what’s the matter with the medicaid gap in kansas? kathryn schartz, msn, rn, cpnp
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WHAT’S THE MATTER WITH THE MEDICAID GAP IN KANSAS?
Kathryn Schartz, MSN, RN, CPNP
U.S. HEALTH CARE SYSTEM
• High costs/low quality• Services restricted/rationed• Inexplicable range of costs• Innovation/diffusion of best practices very slow
• “Competition . . . currently exists at the wrong level.”
http://ucatlas.ucsc.edu/spend.php
HEALTH CARE COVERAGE PRIOR TO ACA
• Employer-subsidized plans – 59%
• Uninsured – 19%• Individual – 6%• Government – 23%
(2009)
http://www.mypremiermd.com/Rates%20&%20Insurance.html
WHO ARE THE UNINSURED?
• 41.3 million non-elderly• 86% were adults• 27% below poverty• 80% are US citizens• 85% low- or moderate-income
families• 71% in families with one or
more FT workers • 14% with PT workers• Rates affected by occupation,
race, state of residence
UNINSURED EMPLOYEES• Employee-sponsored coverage offered
by 57% of companies• 80% of eligible employees participated• Half of those covered were employees/half were
dependents
• Two-thirds of adult uninsured were workers
• Didn’t work enough hours• Employer didn’t offer
• Employers cited cost as the main barrier to offering insurance to employees
• Availability of employer-sponsored insurance eroded over time, even in a strong economy
Majerol, M. Newkirk, V. & Garfield, R. (December 2014).
FINANCIAL IMPLICATIONS OF UNINSURANCE -- INDIVIDUAL
• Most uninsured do not receive care free or at reduced charge
• Hospitals charge 2-4 times what 3rd party payers pay• Often must pay “up front”• Total expenditures less than for those with insurance, but
out-of-pocket much higher• Increased risk of amassing unaffordable medical bills• Few savings and assets to use for health care costs• Risk difficulty paying off debt
BURDEN OF UNCOMPENSATED CARE
• $84.9 billion in 2013• $53.3 billion paid to providers to
help offset costs
• Burden by provider:• 60% by hospitals• 26% by community-based
providers• 14% by office-based physicians
• Burden to consumer• Increased premiums (>$1,000/yr)• Increased out-of-pocket costs
NON-GROUP HEALTH INSURANCE COVERAGE
• Private insurance purchased on individual market
• Very few covered prior to ACA (5%)
• Obtaining coverage difficult• Pre-existing conditions• Older adults• High rates if covered• 41% reported policy too
expensive, 6% were denied coverage at any price
Patient Protection and Affordable Care Act
• “ACA” or “Obamacare”
THE AFFORDABLE CARE ACT
• Individual mandate• Employer mandate• Medicaid expansion• Premium & cost-sharing
subsidies• Health insurance
exchanges
THE AFFORDABLE CARE ACT
• Changes to private insurance• Temporary high-risk pool• Dependent coverage up to age 26• 80% of premiums spent on direct care• No pre-existing conditions, life-time
caps• Must cover preventive care such as
immunizations• Health care choice compacts and
national plans
THE AFFORDABLE CARE ACT
• New regulations on payers/employers
• Some incentives to change at provider level – new health care delivery models
• Incentives/requirements for some innovations (EMR)
MEDICAID EXPANSION
• ACA required expansion of Medicaid to legal residents up to 138% of FPL
• Goal of ACA -- extend coverage to 32 million people by 2019
• CBO projected that 16 million would get coverage through Medicaid expansion
• Supreme court ruling reduced this trajectory to 12 million
IMPACT OF INSURANCE EXPANSION ON UNCOMPENSATED CARE COSTS
• Volumes of uninsured less, especially in Medicaid-expansion states• Inpatient admissions• ED visits
• Volumes of Medicaid patients increased in Medicaid-expansion states
• UCC estimated to be $5.7 billion lower in 2014
DeLeire, T., Joynt, K., and McDonald, R. (2014). Impact of insurance expansion on hospital uncompensated care costs in 2014. Department of Health and Human Services, September 24, 2014. Retrieved on January 6, 2015 from: http://aspe.hhs.gov/health/reports/2014/uncompensatedcare/ib_uncompensatedcare.pdf
WHAT IS THE MEDICAID GAP?
• In states that do not expand Medicaid (currently 21), most childless adults below 100% of FPL will not have access to coverage
• 4 million people nationally are in the coverage gap with income:• greater than Medicaid eligibility• below lower limit for Marketplace
premium tax credits
/
http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update
The ACA in Kansas
• Kansas has one of the lowest standards for Medicaid eligibility
• For non-pregnant, non-elderly adults, income must be less than 38% of the FPL
• Must be between 100% and 400% of FPL to qualify for subsidies for insurance on the exchanges
The Medicaid Gap in Kansas
• Most childless adults in Kansas (unless disabled or elderly) do not qualify for Medicaid
• 182,000 Kansans are in the ‘Medicaid Gap’ – • too poor for tax credits• too ‘well-off’ for Medicaid.
12700
0
132200
171700
38700
126200
With Medicaid Expansion Without Medicaid Expansion
Medicaid Credits/Subsidies No assistance
Henry J. Kaiser Family Foundation. (January, 2014). How will the uninsured in Kansas fare under the Affordable Care Act? Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on February 3, 2015 from: http://kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-kansas/
KanCare Expansion• KHA lobbying for a “Kansas-based” solution• KanCare 2.0 – a statewide demonstration program to provide
coverage for all individuals < 138% of FPL• Utilize 100% federal match – provision to opt out if this drops below
90% • Helps keep Kansas taxpayer dollars in Kansas• Preservation of Kansas health care system
• Focus on health delivery reform initiatives• Improving health status/quality of care• Promoting patient-centered medical homes• Reducing ED utilization• Increase use of prenatal care• Reduce infant mortality rates
KHA. (2015) Guiding principles for KanCare 2.0, Kansas Hospital Association. Retrieved on January 29, 2015 from: http://www.kha-net.org/CriticalIssues/KanCareExpansion/
Estimated costs to hospitals in Kansas without KanCare expansion
• SVRHC -- $7,626,712.00• St. Francis -- $3,587,120.00• All hospitals -- $106,075,220.00
RESOURCES – EDUCATE YOURSELVES!
• http://www.nursingworld.org/healthcarereform• American Nurses Association
• http://kff.org/health-reform/• Henry J. Kaiser Family Foundation
• http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/• Henry J. Kaiser Family Foundation
• http://www.kha-net.org/• Kansas Hospital Association
• https://www.healthcare.gov/• HealthCare.Gov
• http://www.aha.org/• American Hospital Association
• http://www.khi.org/• Kansas Health Institute
References
• AMA News Room. (2013). AMA analysis lists states where one private health insurer rules. Retrieved from http://www.ama-assn.org/ama/pub/news/news/2013/2013-11-07-study-anticompetitive-market-conditions.page
• Cauchi, R & Landess, S. (2012). Out-of-state health insurance: allowing the purchase, Retrieved from http://www.ncsl.org/research/health/out-of-state-health-insurance-purchases.aspx
• DeLeire, T., Joynt, K., and McDonald, R. (2014). Impact of insurance expansion on hospital uncompensated care costs in 2014. Department of Health and Human Services, September 24, 2014. Retrieved on January 6, 2015 from: http://aspe.hhs.gov/health/reports/2014/uncompensatedcare/ib_uncompensatedcare.pdf
• Henry J. Kaiser Family Foundation (April 25, 2013). Summary of the Affordable Care Act. Henry J. Kaiser Family Foundation. Retrieved on January 28, 2015 from: http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/
• Henry J. Kaiser Family Foundation. (January, 2014). How will the uninsured in Kansas fare under the Affordable Care Act? Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on February 3, 2015 from: http://kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-kansas/
• http://www.acep.org/News-Media-top-banner/The-Uninsured--Access-To-Medical-Care/• Huang, C.C & Smith, S. (2014). Number of uninsured Kansans in 2013 unchanged from 2012: Trend shows more people receiving public coverage. Kansas
Health Institute. December 17, 2014. Retrieved on February 7, 2015 from: http://www.khi.org/policy/article/rate-uninsured-kansans-unchanged-2012-trend-shows-
• Institute of Medicine. (2013). Consequences of uninsurance, IOM Retrieved on January 31, 2014 from: http://www.iom.edu/Activities/HealthServices/InsuranceStatus.aspx
• Keckley, PH, Coughlin, S, Korenda, L, & Rice, E. (2011) The impact of health reform on the individual insurance market: a strategic assessment. Deloitte Issue Brief. Retrieved from http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Health%20Reform%20Issues%20Briefs/us_chs_HealthReformAndTheIndividualInsuranceMarket_IssueBrief_101011.pdf
• KHA (2015). KanCare expansion, Kansas Hospital Association. Retrieved on January 29, 2015 from: http://www.kha-net.org/CriticalIssues/KanCareExpansion/• KHA (2015). KanCare expansion, Kansas Hospital Association. Retrieved on January 29, 2015 from: http://www.kha-net.org/CriticalIssues/KanCareExpansion/• Majerol, M. Newkirk, V. & Garfield, R. (December 2014). The uninsured: A primer. Key facts about health insurance and the uninsured in America. Henry J.
Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on January 29, 2015 from: http://kff.org/uninsured/report/the-uninsured-a-primer/
• Porter, ME & Teisberg, EO. (2013). Redefining competition in healthcare, Harvard Business Review. Retrieved from http://hbr.org/web/extras/insight-center/health-care/redefining-competition-in-health-care
• Rockefeller Institute of Government. (2014). Kansas: Baseline report. State-leve field network study of the implementation of the Affordable Care Act, State University of New York, December 1, 2014, Retrieved on February 7, 2015 from: http://www.issuelab.org/resource/kansas_baseline_report__state_level_field_network_study_of_the_implementation_of_the_affordable_care_act
• Stoll, K. and Bailey, K. (2009) Hidden health tax: Americans pay a premium, Families USA, May, 2009. Retrieved on January 31, 2015 from: http://familiesusa.org/product/hidden-health-tax-americans-pay-premium
• UC Atlas (2011) Health care spending, US Atlas of Global Inequality. Retrieved on January 31, 2015 from: http://ucatlas.ucsc.edu/spend.php
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