It’s becoming more and more apparent that the struggle to expand insurance coverage in Iowa through Medicaid was well worth the effort. As these pages have recently noted, coverage is up and uncompensated care is down in both Iowa and other states that expanded Medicaid. That trend has impacted more than medical care and finances; it has helped smooth Iowa’s mental health system reform and contributed to Iowa ranking as best in the nation for children’s health.
In other parts of the nation, the positive impacts are also being documented, including actual lives saved. In Massachusetts, which adopted insurance expansion in 2006, a study published last spring determined that mortality declined almost 3 percent relative to control counties in the four years after the state’s health expansion was rolled out. Mortality related to health care-amenable conditions fell by 4.5 percent.
As IHA’s successful campaign stated and restated in 2013: coverage matters.
Unfortunately, it also matters for the 24 states that have so far turned their backs to Medicaid expansion (though a few are on the fence). An Urban Institute survey found that the uninsured rate among adults under 65 had declined by 6.1 percentage points in states that expanded, compared with only 1.7 percentage points in those that didn’t.
The situation in these states has put hospitals in peril. Carolinas HealthCare System, which has some 900 care locations including 7,640 licensed beds in North and South Carolina, reported an astounding 53 percent drop in earnings. Had North Carolina expanded Medicaid, it would have covered 500,000 additional people and brought an additional $413 million to the state. Meanwhile, Fitch Ratings had this blunt assessment: “We expect providers in states that have chosen not to participate in expanded Medicaid eligibility to face increasing financial challenges in 2014 and beyond.”
What’s more, many of these states, by many measures, were among the least healthy in the nation long before the Affordable Care Act (ACA) became law. Look at the Kids Count Survey which Iowa led and you will see Louisiana, Alabama, Mississippi and other far-southern states struggling with every sort of children’s health issue, from low-birth weight babies and infant mortality to childhood immunization rates and the number of children struggling with mental health issues. Amazingly, seven of the 10 states with the highest uninsured rate (for total population) are not moving forward with Medicaid expansion.
On top of all this, the United States Court of Appeals for the District of Columbia Circuit ruled last week that ACA does not allow the federal government to offer financial assistance to people buying insurance in states not running their own insurance marketplaces. If that ruling stands (keep in mind another federal court ruled the subsidies are fine), it could mean that millions of residents in 36 states, including Iowa, would lose access to insurance through ACA.
Having expanded Medicaid, Iowa remains well-positioned for the future. However, many states (including four of the six bordering Iowa) have declined the offer, leaving millions of Americans even more on the fringes of the health care system. In that way, ACA has fallen short as a national solution for providing health care access to uninsured Americans.
The need remains – in fact, it has only become greater. The question is, given the unexpected curves and bumps thrown in front of ACA’s otherwise admirable progress, what can or should be done to get states that have been left behind back on track? Furthermore, how will their lack of progress impact states like Iowa that have done the right thing and continue to make great strides in providing high-quality, high-value health care?
The concept of patient-centered care has long recognized the value of each patient’s family and friends as an integral part of both the healing process and wellness in general. It’s arguable that this support system is as important as the care services themselves.
With that in mind, many hospitals in Iowa and around the nation have done away with “visiting hours” and replaced them with 24/7 visitation policies that are presented something like this: “We encourage family and friends to be with their loved one while in the hospital. We view family and friends as our partners in the patient’s care and we support their presence and participation in the patient’s caretaking and decision-making, but only to the extent that the patient would like.”
Visiting hours may be as ancient as hospitals themselves – or maybe not, since early hospitals depended greatly on family members as caregivers. More likely, visiting hours are a lingering contrivance of “modern” medicine and professionalization of providers, ostensibly designed to benefit the patient but able to hang on because of staff preferences.
With a greater focus on patient-centeredness and safety, the necessary involvement and encouragement of “care partners” has been duly recognized. By reducing fear and anxiety, they support the healing process. By serving as scribes and advocates, they increase understanding (for both providers and patients) and help reduce the likelihood of errors or readmissions.
In a 2014 Health Research & Educational Trust survey of U.S. hospitals, about 58 percent of hospitals report that they have a policy or guidelines that exist across all units in the hospital that facilitate unrestricted access to the patient by families or partners in care, according to patient preference. This is good news for patient-centeredness, but there is clearly still work to be done.
For the majority of hospitals that have set aside restrictions, perhaps the next step is to formally eliminate the concept of “visitors.” Some hospitals have done this by transforming their visitor policies and developing an official “welcoming policy.”
One of the leaders in this development has been Contra Costa Regional Medical Center (CCRMC), a public hospital in Martinez, California. The hospital’s website explains the policy: “We have implemented a new Welcoming Policy to make the hospital accessible 24 hours a day to family and loved-ones of those receiving care in the medical center. Recognizing that family and loved-one presence supports safe and high quality care, we have worked over the last year to replace our ‘visitor policy’ with this Welcoming Policy.”
Implementing the policy was a rigorous process at CCRMC that involved physicians and nurses as well as front-line staff, security personnel, patients and families. Anna Roth, the hospital’s CEO, noted that a 24/7 welcome policy is not without boundaries; safety, security and patient preference remain priorities. The hospital is tracking the policy with data; since implementation, more than 5,000 after-hours (8 p.m.-7 a.m.) “welcome moments” have been recorded with zero complaints.
Roth explained, “Our old policies treated family members like visitors, until we realized that we are the visitors in people’s lives, not the other way around. This was a huge cultural shift, and one that the staff here was courageous enough, bold enough and caring enough to undertake.”
A national survey that each year measures major trends affecting children’s well-being ranks Iowa as the top state for health and in the top three overall.
The 2014 Kids Count Data Book released this week by the Annie E. Casey Foundation lists Iowa No. 1 for health, third place for children’s economic wellness and third overall. The survey compares data from 2005 to 2012, the most recent year that statistics are available. Iowa also moved up from seventh place to third in the nation for overall children’s well-being.
Four indicators were used to measure the health of those up to 19 years old: low-birth weight babies, children without insurance, child and teen deaths per 100,000 and teenage abuse of alcohol and drugs.
From the Quad-City Times:
Marcus Johnson-Miller, who works in the early childhood program run by the Iowa Department of Public Health, pointed to the state’s efforts to encourage better care for low-birth weight babies.
In the past year, the state has worked on a regional system that pairs up low-birth weight babies with the hospitals that can best care for them.
In other words, he said, “High-risk deliveries are now done at the facilities that can handle the high-risk babies.”
Further, the state is examining ways to ensure that women carry their babies to full-term, or 40 weeks, he said. The rate of early elective deliveries in Iowa has at least stabilized or gone down slightly, he said.
Actually, Iowa hospitals have been working diligently to reduce the number of early elective deliveries – and with great success. Reports from the Iowa Healthcare Collaborative show these deliveries have been reduced by more than 90 percent.
Iowa hospitals do constant work to keep children healthy, from providing free bike helmets to teaching babysitting classes to helping parents properly install child seats in their cars. Hospitals also help sponsor “safety fairs,” like this one in Vinton and this one in Iowa City.
Hospitals also work hard to make sure children are properly immunized, as the Times noted:
To Dr. Louis Katz, Iowa’s lofty ranking is because of the hard work done by many public health workers.
Katz, the longtime medical director of the Scott County Health Department, mentioned the many screening and immunization programs now available, saying that they are central to good health and finding potential medical problems early.
One example is the Flu-Free Quad-Cities initiative of Genesis Health System that offered free inoculations to almost 10,000 schoolchildren in Scott, Clinton and Rock Island counties last year.
Finally, another big reason Iowa’s children are healthier than others is insurance. The Kids Count data shows only 4 percent of Iowa children were uninsured – almost half the national average. As the Des Moines Register reported:
Iowa has long had some of the lowest uninsured rates in the nation. Marcus Johnson-Miller, who oversees early childhood programs for the Iowa Department of Public Health, noted that state officials have aggressively worked in the past few years to let parents know about options such as Medicaid and Hawk-I. The publicly subsidized insurance plans are for children from poor or moderate-income families. Johnson-Miller said the Hawk-I enrollment efforts have been supplemented this year with expansion of other types of insurance under the Affordable Care Act. The rate of uninsured children has probably declined even further since 2012, he said.
In Iowa and across the nation, the positive effects of Medicaid expansion are now being quantified. More than 105,000 people are now enrolled in the Iowa Health and Wellness Plan, where they are receiving health screenings, primary care management and overall access to the health care system—many for the first time in their lives. Hospital charity care is moderating and the number of self-pay patients is declining. It is doing the things that hospital advocates knew it would.
And now there’s further evidence that Medicaid expansion is working. As part of Iowa’s behavioral health care system redesign, counties had to enter into formal regional alignments to provide mental health care programs across the state. The new system became operational July 1.
Many feared that the new regional system would lead to service cuts as county per capita mental health tax levy rates were equalized. But as the Des Moines Register recently reported, not only have those cuts not materialized, but many regions are now adding new programs to better meet the needs of Iowans. The Register noted, “the (new) programs include efforts to keep people from deteriorating to the point where they end up hospitalized or jailed because of behaviors related to mental illness.”
And to what do we attribute that success? Medicaid expansion. As the Register explained, Medicaid expansion covers behavioral health care, meaning counties have now been relieved of many of the costs of psychiatric care, counseling visits, prescription medications and even inpatient psychiatric care for individuals previously covered only by county taxpayer funds. Not only do these people now have more service options, but care can now be provided in earlier stages of distress, avoiding more expensive acute care episodes. Medicaid expansion is the underpinning of the new regional system; without it, the success of redesign would have been far more problematic.
Other media outlets across the state are also reporting that the new system is working in all 15 regions, although to varying degrees. Universally, however, things are moving forward and much of the credit is due to Medicaid expansion.
Although the topic of the Affordable Care Act remains a political hot potato, particularly at the federal level, there’s no denying that Medicaid expansion is working in Iowa. The Iowa Health and Wellness Plan is not only providing coverage to thousands of Iowans previously left outside the boundaries of the health care system, it is quickly proving to be financially prudent at the state, county and hospital-specific levels.
It’s hard to believe that fully half of the states in America have not seen the wisdom of following Iowa’s lead in expanding Medicaid coverage to their poorest citizens. It’s yet another example of how Iowa’s health care system can be a model for the rest of the nation.
And positioned squarely in the middle of that equation are Iowa’s community hospitals, which not only provide high quality care at conservative costs, but whose leaders are visionary when it comes down to the bottom line of caring for people. At the end of the day, that’s what matters the most.
(IHA is closely monitoring the impact of the Affordable Care Act and, in particular, Medicaid expansion, which is being implemented through the Iowa Health and Wellness Plan. As we have shared, preliminary studies indicate early success in meeting the essential goals of health care reform. With that in mind, IHA is one of 24 state hospital associations working with the Robert Wood Johnson Foundation [RWJF] on its Hospital ACA Monitoring Project, which is described below, to further study progress. Reprinted with permission.)
To monitor the impact of health reform on hospital utilization, the Robert Wood Johnson Foundation has embarked on an important surveillance project, working in collaboration with 24 state hospital associations. The RWJF Hospital ACA Monitoring Project, or HAMP, collects data each quarter on all inpatient admissions and emergency department (ED) visits by payer. HAMP also collects some information on a subset of diagnoses and procedures that are believed to be sensitive to insurance status.
Clearly, there are a variety of ways in which health reform may affect hospital utilization. Conventional wisdom might suggest that coverage expansion will result in fewer preventable hospitalizations, and less use of the ED for ambulatory care sensitive conditions. However, we saw in the Oregon Medicaid experiment that increased Medicaid enrollment resulted in more ED use. Another possibility is that increased demand for primary care may overwhelm the ambulatory care system, resulting in increased use of the hospital for primary care treatable conditions, even among those who were previously insured.
The potential financial impact of health reform on hospitals is also unclear. While the reduction in uncompensated care is clearly a plus, there may be significant increases in utilization by patients who have payers that reimburse at relatively low rates. Further, there is a possibility of increased bad debt from patients with Marketplace plans, which require significant cost-sharing. Additionally, there are reductions in DSH payments and other simultaneous changes in Medicare payments.
The HAMP effort is designed to shed light on some of the effects of health reform on hospitals and provide extremely timely data to researchers, policymakers and hospital leaders. Seventeen state hospital associations submitted information from individual hospitals, while seven others submitted state-level data. There are approximately 1,700 hospitals included in this data set, which is roughly one-third of all hospitals in the country. The participating states and the number of individual hospital submissions are shown in Table 1.
The individual diagnoses and procedures being collected include three reasons for inpatient hospitalization that are considered to be preventable, and have been defined as such by the federal Agency for Health Research and Quality (AHRQ). These include short-term complications of diabetes, hypertension and urinary tract infection. Additionally, HAMP is monitoring admissions for knee replacement—an inpatient procedure that may be sensitive to insurance status. It is also monitoring ED visits for three specific diagnoses that are considered primary care treatable or at least ambulatory care sensitive: upper respiratory infection, urinary tract infection and headache. More details about these specific conditions are shown in Table 2.
The types of hospitals that participate in this project are shown in Table 3. While about 65 percent are acute care hospitals, there are a number of critical access hospitals, particularly in Western states and rural areas. The distribution of participating hospitals is shown in Table 4.
Baseline Data Offers Trends to Watch
Data from 2013 from participating states show great variation in the number of inpatient admissions and ED visits, as shown in Tables 5 and 6. Tables 7 and 8 show the payer mix in the inpatient and ED setting. There are clearly differences between the two. While only about 6 percent of inpatients are reported as being “self-pay”, about 20 percent of ED visits are attributable to the uninsured. The state variation in the percentage of admissions and visits which fall into the “self-pay” category are significant. This range can be seen in Tables 9, 10 and 11. It is clear that certain states have a relatively high share of uncompensated care. For example, 30 percent of South Carolina’s ED visits are in the “self-pay” category, as compared to about 11 percent of those in Nebraska. Inpatient admissions range from about 2 percent self-pay in Minnesota to about 12 percent in Wyoming. Table 11 makes clear that states with a high percentage of self-payers in the inpatient setting tend to also have a high share of self-pay patients in the ED. Tables 12-14 show similar patterns for Medicaid.
One thing that is clear from these tables is that some of the participating states that have expanded Medicaid were exposed to relatively little uncompensated care in 2013. This is the case for Minnesota, Michigan, Connecticut and New York. However there are also a number of expanding states (New Jersey, Nevada, Colorado and Kentucky) that in 2013 had a significant amount of self-pay utilization both in the inpatient and ED settings. Depending on the degree of eligibility and take-up among these uninsured patients, these states may experience a fairly significant change in utilization patterns upon expansion. Early reports from national hospital chains suggest increases in Medicaid utilization and decreases in uncompensated care in expanding states—and no change in Medicaid and increase in uncompensated care in non-expanding states. Similarly, data released by the Colorado Hospital Association showed similar trends in Medicaid and uncompensated care as a percent of charges in Q1 2014 in expanding versus non-expanding states.
Future posts will provide more information about payer mix and utilization by state and variation within states and for more specific diagnoses and procedures. Data for Q1 2014 are expected by the end of the summer.
Katherine Hempstead is RWJF Coverage team director and senior program officer.