The latest National Health Interview Survey conducted by the Centers for Disease Control’s (CDC) National Center for Health Statistics, reported some great news this week: Based on early release data, the uninsured rate has fallen to 9.2%, the lowest ever found by a major survey.
“The ACA is proceeding pretty well in states with Medicaid expansion,” said Dr. Harold Pollack, Helen Ross Professor and Deputy Dean for Research and Faculty Development at the University of Chicago. Although several challenges remain and there are some groups still uninsured, Pollack said the fact that it is working well is important not only for individuals but also for health providers to get reimbursed for care.
Dr. Rachel Garfield, a senior researcher at the Kaiser Family Foundation and associate director for the Kaiser Commission on Medicaid and the Uninsured, agreed with Pollack. “There are a lot of goals of the ACA, but one of the main goals was to reduce the number of uninsured Americans. When you look at the recent CDC data, in addition to a lot of other data that’s been coming out over the past year, you are seeing declines in the uninsured rate that are bigger than what we’ve seen for any policy in the past. So, on that outcome, I think it’s fair to say the law is working as hoped and as anticipated.”
Medicaid expansion states showing bigger decline
There are Medicaid expansion programs in 30 states and Washington, D.C., according to the Kaiser Family Foundation. The CDC survey found that uninsured rates fell from 18.4% in 2013 to 10.6% in the first quarter of this year in Medicaid expansion states.
“So what you can draw from that conclusion is that hospitals in those [Medicaid expansion] states are seeing a commensurate increase in revenue from the payers that are covering those people gaining insurance and a corresponding drop in their self-pay or uninsured care as well,” Garfield explained. For non-expansion states, the percentage of uninsured only dropped from 22.7% in 2013 to 16.8% in the first quarter of this year.
As a co-author of a Kaiser Family Foundation study released in April, titled “How Are Hospitals Faring Under the Affordable Care Act?,” Garfield said researchers compared the 161 hospitals across 16 states in Ascension Health’s system. “What we found was that hospitals in states that had expanded Medicaid were seeing big declines in their self-pay or uninsured patients with corresponding increases in patients with Medicaid coverage.”
Overall, there was a 32% decline in visits by uninsured patients compared to a 4% decline in non-expansion states. Also, Ascension’s charity care costs fell 40% in expansion states compared to a 6% decline at facilities in non-expansion states. There was also a 7% increase in discharged patients with costs covered by Medicaid but only a 1% increase in non-expansion states.
A Gallup poll released earlier this week provided more detailed data on the uninsured in Medicaid expanded states. The top two states with the largest reduction in uninsured from 2013 to the first half of this year are Arkansas (22.5% to 9.1%) and Kentucky (20.4% down to 9%).
Also, seven of the 10 states with the greatest reductions in uninsured rates not only expanded Medicaid but also established either a state-based market exchange or a state-federal partnership. An interesting statistic from the poll shows that through the first half of this year, seven states (Connecticut, Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island and Vermont) had uninsured rates below 5%, whereas from 2008 to 2014 only Massachusetts had achieved this rate.
Tenant Health indicated back in May that it would be pulling out of Georgia and North Carolina, both non-expansion states. Although the company didn’t cite this as the reason, Trevor Fetter, Tenant CEO, said, “As we’ve noted in the past, there are markets where we don’t see a path either by acquisition or partnership to develop the scale we believe will be necessary as healthcare delivery continues to evolve.” Hospitals in non-expansion states must cover the full cost for ACA funding.
A 2014 study by the Robert Wood Johnson Foundation reported that the non-expansion states are estimated to cost their hospitals around $15.9 billion in Medicaid revenue for 2016 and a total of $168 billion from 2013 to 2022. For states that expand Medicaid, the report said for every dollar invested in expansion, the state receives $13.41 in federal funds.
Challenges Ahead
Obviously, there are still groups of uninsured Americans. Two of the main populations are the poor and certain immigrant groups (undocumented and those who don’t qualify for Medicaid because they haven’t lived here for a certain time period).
A Forbes article puts the uninsured rate for the poor at 28% and the near-poor rate at 24% compared to 7.5% of Americans who were not poor. However, Garfield said the 28% figure “has come down substantially since the ACA has been enacted – about 10 percentage points – so that’s a pretty significant decline.” She also explained that one of the main challenges in getting those below poverty insurance is that in many states, specifically non-expansion states, “these individuals are unlikely to be eligible for financial assistance or coverage through Medicaid.”
“Also, those below poverty that don’t meet that particular state’s pre-ACA Medicaid rules fall into what we call the ‘coverage gap,’ and have very limited available options," she said.
Another population excluded from coverage, even in Medicaid expansion states, is undocumented immigrants or those who haven’t been in the US long enough to qualify for insurance. “Hospitals see everyone who comes through their door,” Garfield said. “Safety net hospitals, especially ones serving these populations, have some concerns continuing to care for these very vulnerable populations who are very unlikely to have insurance and for whom there is no pathway for them to get coverage under the ACA.”