A decade of health care access declines for adults holds implications for changes in the Affordable Care Act

The pending Supreme Court decision on the Affordable Care Act and the fall presidential election raise concerns about what would happen if the insurance expansion promised by the landmark health reform law were to be curtailed. This paper's analysis of national survey estimates found that access to health care and use of health services for adults ages 19-64--the primary targets of the Affordable Care Act--deteriorated between 2000 and 2010, particularly among those who were uninsured. More than half of uninsured US adults did not see a doctor in 2010, and only slightly more than a quarter of these adults were seen by a dentist. We also found that children--many of whom qualify for public coverage through Medicaid and the Children's Health Insurance Program--generally maintained or improved their access to care during the same period. This provides a reason for optimism about the ability of the coverage expansion in the Affordable Care Act to improve access for adults, but it suggests that eliminating the law or curtailing the coverage expansion could result in continued erosion of adults' access to care.     

Policy makers should prepare for major uncertainties in Medicaid enrollment, costs, and needs for physicians under health reform

The Affordable Care Act of 2010 will expand Medicaid to millions of Americans by 2014. How many enroll will greatly affect health care access, demand for clinicians, and the federal budget, yet the precision and validity of enrollment estimates made to date is unknown. We created a simulation model using two nationally representative data sets to determine the range of reasonable projections, estimating eligibility, participation, and population growth using prior research and our data. Our model predicted that the number of additional people enrolling in Medicaid under health reform may vary by more than 10?million, with a base-case estimate of 13.4?million and a possible range of 8.5?million to 22.4?million. Estimated federal spending for new Medicaid enrollees ranged from $34?billion to $98?billion annually, and we projected that 4,500-12,100 new physicians will be needed to care for new enrollees. In the end, Medicaid enrollment will be determined largely by the extent to which federal and state efforts encourage or discourage eligible people from enrolling. Yet our results indicate that policy makers should prepare to handle a broad range of contingencies and uncertainty in Medicaid expansion under health reform.     

How the Affordable Care Act can help move States toward a high-performing system of long-term services and supports

The United States may advance toward a high-performing health care system that offers long-term services and supports for people with disabilities and chronic conditions, or it may retreat from gains achieved in recent years. Since the 1980s, policy makers and advocates for the disabled have sought to move from a system that emphasizes nursing homes and institutional care to one that includes a broader range of care options. The Affordable Care Act of 2010 gives this movement a considerable boost by offering states timely new options and enhanced federal funding to create a care system that meets the diverse needs and preferences of people with disabilities and that also recognizes the role of family caregivers. In this paper we outline the five key characteristics of a high-performing system of long-term services and supports. We describe an emerging "scorecard" that could help measure states' progress toward this goal. And we itemize aspects of the Affordable Care Act intended to support the creation of such a high-performing system for the disabled and those with chronic conditions.     

Small firms' actions in two areas, and exchange premium and enrollment impact

The Affordable Care Act changed the regulations governing small firms' health insurance premiums. However, small businesses can avoid many of the new regulations by self-insuring or maintaining grandfathered plans. If small firms with healthy and lower-cost enrollees avoid the regulations, premiums for coverage sold through insurance exchanges could be unaffordable. In this analysis we used the RAND Comprehensive Assessment of Reform Efforts microsimulation model to predict the effects of self-insurance and grandfathering exemptions on coverage and premiums available through the exchanges. We estimate that Affordable Care Act regulations restricting employers' ability to offer grandfathered plans will result in lower premiums on plans available through the exchanges and will have small negative effects on enrollment in the exchanges. Our results suggest that these regulations are essential to keeping premiums on the Small Business Health Options Program (SHOP) exchanges affordable. Our analysis also found that Affordable Care Act regulations limiting self-insurance will reduce enrollment in the exchanges somewhat, without substantially affecting exchange premiums.     

California's role in ensuring that the potential of health reform becomes reality

The fifty states will play a critical role in implementing the Affordable Care Act, and California is one of the states at the forefront of reform. The act can provide coverage to millions of currently uninsured Californians and offers important benefits in terms of more-affordable coverage, improved access to services, and better health outcomes. As the paper by Peter Long and Jonathan Gruber in this issue of Health Affairs notes, the ultimate effects of health reform in California will be influenced by the policy and program decisions that state lawmakers and administrators make during the next three years. Key issues include revamping cumbersome eligibility determination and enrollment processes that could prevent rapid enrollment in expanded public health insurance--but also affording that expansion in the face of large state budget deficits. California policy makers need to move thoughtfully and strategically to ensure that the potential of federal health reform becomes a reality for state residents.     

Integrating community health centers into organized delivery systems can improve access to subspecialty care

The Affordable Care Act is funding the expansion of community health centers to increase access to primary care, but this approach will not ensure effective access to subspecialty services. To address this issue, we interviewed directors of twenty community health centers. Our analysis of their responses led us to identify six unique models of how community health centers access subspecialty care, which we called Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. We determined that the Integrated System model appears to provide the most comprehensive and cohesive access to subspecialty care. Because Medicaid accountable care organizations encourage integrated delivery of care, they offer a promising policy solution to improve the integration of community health centers into "medical neighborhoods."     

Without the individual mandate, the Affordable Care Act would still cover 23 million; premiums would rise less than predicted

Many policy analysts fear that eliminating the individual health insurance mandate and penalty from the Affordable Care Act of 2010 would lead to a "premium spiral," in which healthy people would drop coverage, premiums would soar, and the number of people with coverage would plummet. However, there are other provisions of the law that would greatly mitigate this effect. For example, the subsidies provided in the law to help people purchase coverage through health insurance exchanges would restrain a premium spiral by absorbing much of the impact of premium increases. We estimate that if the mandate were lifted, premiums in the individual market would increase by 12.6?percent-somewhat less than other estimates-with 7.8?million people losing coverage, versus other estimates for coverage loss of 16-24?million people. In sum, the Affordable Care Act would still cover 23?million people who would have been uninsured without the law. Our study suggests that although the mandate would have important effects on premiums and coverage, it might not be essential to the act's successful implementation.     

Local Health Departments as Essential Community Providers for Health Benefits Exchange Plans

The Affordable Care Act requires health plans’ networks to include “essential community providers” (ECPs). Local health departments (LHDs) can be ECPs, typically for tuberculosis and sexually transmitted disease–related services or family planning. An ECP status may be controversial if it jeopardizes core population health services or competes with community partners. Some LHDs already bill for ECP services, but independent billing functions could exceed projected revenue. Thus, LHDs may wish to investigate contractual arrangements as alternatives to billing multiple issuers.The Affordable Care Act requires health plan issuers to include some essential community providers (ECPs) in their networks to qualify for participation in health benefit exchanges. Essential community providers are entities that help meet the needs of historically underserved areas and populations1; the classification includes federally qualified health centers, critical access hospitals, Ryan White grantees for HIV/AIDS services, and entities that provide services related to tuberculosis and sexually transmitted diseases (STDs), among others. Qualified health plans are required to contract with at least 20% of the ECPs in their service areas and with at least 1 in each service category, or document that doing so is not feasible.2 The rationale for requiring inclusion of ECPs is to ensure continuity of service for newly insured individuals who had received services from ECPs, and to support the health care safety net after Affordable Care Act implementation increases access to third-party coverage.2 The following brief review points to opportunities, challenges, and controversies that the ECP option raises for local health departments (LHDs).     

Washington State exhibits wide regional variation in proportion of Medicaid-eligible children who get needed mental health care

In Washington State, mental health care for Medicaid-eligible children is delivered through thirteen regional support networks. The estimated statewide prevalence rate for serious emotional disturbances in children up to age seventeen is 7 percent; analysis found, however, that the proportion of Medicaid-eligible children who received mental health care ranged from 2.91 percent in the North Central network to 8.16 percent in the Southwest network. The variation was not linked to the racial or ethnic makeup of the local population or the rural or urban nature of the region. Instead, interviews with network administrators indicated a substantial contributor to this regional care variation was the state's Access to Care Standards, which restrict network mental health services to children with the most severe disorders. Other factors contributing to the regional variation included funding, the networks' geographic size, and availability of providers. With the Affordable Care Act expected to bring more children with mental health care needs into the Medicaid system, our findings and recommendations offer policy makers timely information on how to improve children's access to mental health care.     

The role of costs in comparative effectiveness research

The major expansion of federal comparative effectiveness research launched in 2009 held the potential to supply the information needed to help slow health spending growth while improving the outcomes of care. However, when Congress passed the Patient Protection and Affordable Care Act one year later, it limited the role of cost analysis in the work sponsored by the Patient-Centered Outcomes Research Institute. Despite this restriction, cost-effectiveness analysis meets important needs and is likely to play a larger role in the future. Under the terms of the Affordable Care Act, the institute can avoid commissioning cost-effectiveness analyses and still provide information bearing on the use and costs of health care interventions. This information will enable others to investigate the comparative value of these interventions. We argue that doing so is necessary to decision makers who are attempting to raise the quality of care while reining in health spending.     

Polling analysis: public support for health reform was broader than reported and depended on how proposals were framed

The excessive focus of news organizations on "horse race" public opinion polls during the debate about health reform in 2010 left the impression that the public was fickle, as well as sharply divided on whether the government's role in health care should expand. We examined polling data and found that public support for health reform depended very much on how individual policies were described. For example, support for the public insurance option, which was not included in the final version of the Affordable Care Act, ranged from 46.5?percent to 64.6?percent depending on how pollsters worded their questions. Our findings indicate that public support for health reform was broader and more consistent than portrayed at the time. Going forward, policy makers should strive to communicate how health care policy choices are consistent with existing public preferences or should make changes to policy that reflect those preferences.     

More patients, less payment: increasing hospital efficiency in the aftermath of health reform

A major issue for the US health care system will be accommodating the needs of the estimated thirty-two million Americans who will gain insurance coverage under the Affordable Care Act by 2019. For hospitals, a traditional response to this increased demand might be to add resources, such as more staff and beds. We argue that such actions would be unaffordable and unnecessary. Research has demonstrated that large gains in efficiency can be made through streamlining patient flow and redesigning care processes. We argue that once managed efficiently, US hospitals, on average, could achieve at least an 80-90 percent bed occupancy rate--at least 15 percent higher than the current level--without adding beds at capital costs of approximately $1 million per bed. This article outlines a plan for hospitals to accommodate more patients without increasing beds or staff, and for policy makers to require hospitals to make these changes or provide incentives for them to do so.     

Medicare beneficiaries less likely to experience cost- and access-related problems than adults with private coverage

The experiences of people covered by Medicare and those with private employer insurance can help inform policy debates over the federal budget deficit, Medicare's affordability, and the expansion of private health insurance under the Affordable Care Act. This article provides evidence that people with employer-sponsored coverage were more likely than Medicare beneficiaries to forgo needed care, experience access problems due to cost, encounter medical bill problems, and be less satisfied with their coverage. Within the subset of beneficiaries who are age sixty-five or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10?percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems. These results suggest that policy options to shift Medicare beneficiaries into private insurance would need to be attentive to potentially negative insurance experiences, problems obtaining needed care, and difficulties paying medical bills.     

A Path Forward: Mental Health and the U.S. Pandemic Response

The COVID-19 pandemic presents a crisis of mental health in the United States (U.S.) alongside a crisis of infectious disease. Racial inequities in COVID-19 morbidity and mortality have brought health equity to the forefront of public health policy, exacerbating prior inequities in mental health care access and outcomes. This Commentary asserts that policymakers and advocates must prioritize mental health when responding to the pandemic. While the pandemic is an emergency of unprecedented scale, the authors argue that it also is an opportunity to implement broad-based mental health policy reforms in the U.S. that build on the successes of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Guided by innovative state and local policies to promote population-level mental health, we outline a series of empirically grounded strategies for federal and state policymakers to promote mental health equity in the wake of COVID-19.

     

Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization

Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools—accountability measures and payment designs—to improve access to and quality of care for patients with behavioral health needs.     

Quality improvement efforts under health reform: how to ensure that they help reduce disparities--not increase them

Despite persistent evidence of continued racial and ethnic disparities in health care, little explicit attention has been paid to how quality improvement activities might affect disparities. As the nation focuses on the practical realities of implementing health care reform and concurrent quality improvement provisions under the Affordable Care Act of 2010, it is important to recognize that overall improvements in the US health care system might not automatically benefit all segments of the population equally. In this article we highlight challenges to ensuring that quality improvement efforts reduce racial and ethnic disparities. These include making certain that quality improvement efforts measure disparities and improvements in them, notwithstanding providers' reputational concerns; that such efforts not create perverse incentives for providers to avoid serving minority patients; that they be applied to institutions where minority patients are most likely to receive care; and that they fully engage minority patients despite language or other barriers. To assist in these efforts, we argue for the development of disparities impact assessments to measure the effect that the Affordable Care Act's quality provisions will have on reducing disparities.     

Massachusetts's experience suggests coverage alone is insufficient to increase addiction disorders treatment

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.     

Has Massachusetts health care reform worked for the working poor? Results from an analysis of opportunity

PurposeHealth care reform was introduced in Massachusetts (MA) in 2006 and serves as a model for what was subsequently introduced nationally as the Patient Protection and Affordable Care Act. The Boston Area Community Health survey collected data before (2002–2005) and after (2006–2010) introduction of the MA health insurance mandate, providing a unique opportunity to assess its effects in a large, epidemiologic cohort.MethodsWe report on the apparent effects of the mandate on the same participants over time, focusing specifically on the vulnerable working poor (WP). We evaluated differences in subpopulations of interest at pre- and post-reform periods to explore whether MA health care reform resulted in an overall gain in insurance coverage.ResultsMA health care reform was associated with net gains in health insurance coverage overall and among the subgroups studied. Our findings suggest that despite being targeted by health care reform legislation, the WP in MA continue to report lower rates of insurance coverage compared with both the nonworking poor and the not poor.ConclusionsMA health care reform legislation, including the expansion of Medicaid, resulted in substantial overall gains in coverage. Disparities in insurance coverage persist among some subgroups following health care reform implementation in MA. These results have important implications for health services researchers and policy makers, particularly in light of the ongoing implementation of the Patient Protection and Affordable Care Act.     

Creating an effective and efficient publicly sponsored health care delivery system

An effective and efficient publicly sponsored health care delivery system can increase access to care, improve health care outcomes, and reduce spending. A publicly sponsored health care delivery system can be created by integrating services that are already federally subsidized: community health centers (CHCs), public and safety-net hospitals, and residency training programs. The Patient Protection and Affordable Care Act includes measures that support primary care generally and CHCs in particular. A publicly sponsored health care delivery system combining primary care based in CHCs with safety-net hospitals and the specialists that serve them could also benefit from incentives in the Patient Protection and Affordable Care Act for the creation of accountable care organizations, and reimbursement based on quality and cost control.     

Health insurance and subjective well-being: Evidence from two healthcare reforms in the United States

We study the role of access to health insurance coverage as a determinant of individuals' subjective well-being (SWB) by analyzing large-scale healthcare reforms in the United States. Using data from the Behavioral Risk Factor Surveillance System and Panel Study of Income Dynamics, we find that the 2006 Massachusetts reform and 2014 Affordable Care Act Medicaid expansion improved the overall life satisfaction of Massachusetts residents and low-income adults in Medicaid expansion states, respectively. The results are robust to various sensitivity and falsification tests. Our findings imply that access to health insurance plays an important role in improving SWB. Without considering psychological benefits, the actual benefits of health insurance may be underemphasized.