Researchers at Harvard, Massachusetts Institute of Technology and Oregon Health Sciences University jumped at the opportunity to analyze the effect coverage expansion really has not only on access to care, but also on the health and financial outcomes for enrollees. What did they find?
Coverage expanded utilization. Not surprisingly, and consistent with all we have seen with Obamacare, coverage increases utilization. Comparing the covered with the uncovered: Outpatient care was 35 percent higher, hospitalization was 30 percent higher, prescription use was 15 percent higher. And 18 months after implementation, ED visits were up 40 percent. The study found: “Overall, the increased health care use from enrollment in Medicaid translates into about a 25 percent increase in annual health care expenditures.”
Prevention improved. Coverage improved preventive practices, with cholesterol monitoring up 50 percent and mammograms in those 40 and older doubling.
Beneficiaries were better off, financially. Catastrophic financial consequences of health care were eliminated for the covered population, and the financial burden to enrollees was sharply reduced.
Health improvement proved more elusive. The study found that in the first one to two years of coverage, Medicaid improved self-reported health and reduced depression, but had no statistically significant effect on several measures of physical health. In particular, the study found that:
“Medicaid increased the probability that people reported themselves in good to excellent health (compared with fair or poor health) by 25 percent.
“We did not detect significant changes in measures of physical health including blood pressure (systolic or diastolic), cholesterol (HDL or total), glycated hemoglobin, or a measure of 10-year cardiovascular risk that combined several of these risk factors. Nor did we detect changes in populations thought to have greater likelihood of changes, such as those with prior diagnoses of high blood pressure of the portion of our population over age 50.
“Rates of depression dropped by 9.2 percentage points, or a 30 percent reduction relative to the control group rate of 30 percent.”
On balance, coverage did have an effect on self-reported health status and on depression, but did not have any measurable effect on objective measures of physical health, which many observers would argue is the ultimate goal of the health care system and of expanding health care coverage.
The Chain of Coverage Expansion to Health and Its Impact on Policy and Politics
Iowa is upon us — and then who knows who will be running the country?
If Republicans are ascendant in 2016, they will seek to chip away at Obamacare and roll back subsidies and Medicaid expansion, jeopardizing the coverage gains made for 20 million Americans. The candidates and their advisers have said as much. Less money for subsidies and more block grants and flexibility will, in turn, have a major impact on reducing utilization and revenue for hospitals and health systems that have benefited economically from expanded coverage.
If Democrats prevail, their focus likely will be on expanding coverage to the still uncovered; minimizing the economic damage of cost-sharing to all who have coverage, including those with employer-sponsored coverage; and minimizing the economic damage that consumers face from high-priced outliers. A good example of what may lie ahead is the No Surprises Law in New York, where providers have to give the consumer a heads-up that they are going to be screwed by the second assistant surgeon who is out of network. Nice try, but it doesn’t really solve the problem. If Democrats prevail, hospitals and health plans will feel pressures on margins from attempts to box them in on price, either directly through regulated prices or indirectly through requirements on network adequacy and standardization of benefit design.
So, pick your political poison: pressure on the top line or the bottom line. Depending on your mission, vision and values, you’ll make it all work one way or another. That’s your job, and I have confidence in you all.
Implications for Hospitals
No matter who is running the country, hospitals can learn from what we know about the connection among coverage, affordable care and health outcomes. And we should use these insights to encourage us to find new ways to deliver care that are more affordable to cover and are more effective in outcome. In particular:
Don’t expect massive expansion in coverage. Even if Democrats prevail, don’t expect massive coverage expansion from 2015 levels. Exchanges will do well to have the same number of enrollees who have paid their premiums by the spring, as they did at the end of 2015. Why? Overcoming the 30 percent churn is an enormous headwind, given that the low-hanging fruit have signed up and an improving economy has meant that employer-sponsored coverage has remained stronger than expected in a tightening labor market. Further Medicaid expansion is possible in some states, but many of the more conservative state legislatures still will resist Medicaid expansion as they resist Syrian refugees (even if Hillary is president).
Ask whether medical care is just overrated. I must confess that I find it a bit of a buzzkill to find that the whole connection of coverage expansion to health outcomes falls apart at the end of the story with the results from the Oregon Medicaid experiment. Is medical care just overrated as a contributor to human health? Is it just so for low-income people? Do we have the right delivery models to truly connect the dots? I think we have to use this as a learning opportunity to rigorously explore models of care delivery that improve outcomes, not just provide access to medical services.
Focus on delivery model innovation for Medicaid and low-income populations. A specific subset of this problem is finding sustainable, affordable and effective delivery models for low-income, economically vulnerable enrollees in Medicaid and beyond (even in employer-sponsored coverage). High-deductible, narrow-network insurance is not a coverage panacea for the bottom half of the income distribution, no matter who pays for their coverage, nor perhaps is episodic fee-for-service delivery. But what? Kaiser may help us to find solutions as it takes on more Medicaid patients, and other health systems are exploring targeted delivery innovations focused on lower-income patient segments. We need more solutions, including new delivery models. FQHC 2.0 perhaps?
Be accountable for health outcomes. In all our dalliances with accountable care, we must remember to be accountable for health, not just tick all the boxes of service delivery. As the Commonwealth Fund state scorecard shows, we are making significant progress on all fronts across the entire country. Let’s build on that progress and connect the dots better from coverage expansion to health creation. And most of all, please let’s not get distracted by political demonization and demagoguery that undermines or reverses the substantial gains we have made and the significant improvement that will lie ahead if we are smart and focused on our important work.
Ian Morrison, Ph.D., is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.
