Access to care in Georgia: an advocate’s perspective Cindy ZeldinGeorgians for a Healthy FuturePresentation for Trinity Presbyterian ChurchNovember 1, 2015

About Georgians for a Healthy Future

Georgians for a Healthy Future provides a strong voice for consumers and communities on the health care policy issues and decisions that impact their lives.

Overview of today’s discussion

• Access to care: a conceptual framework

• Where does health insurance fit in?

• The Affordable Care Act (ACA): a brief overview of the law’s coverage and access provisions

• Health policy, including the ACA, in Georgia:– Enrollment in new coverage options– The coverage gap

• Opportunities for engagement in health policy issues

Having a hospital in your community?

Enrolling in health insurance?

What is access to care?

Regularly seeing a primary care provider?

Being able to afford needed medications?

Having a source of care in the event of trauma or a major diagnosis?

Receiving recommended cancer screenings?

Access to care

According to the Institute of Medicine:

Access is the timely use of health services to achieve the best possible health outcomes.

Source: Institute of Medicine, Access to Health Care in America, 1993.

Source: Weissman and Epstein Model of Access, “Falling Through the Safety Net: Insurance Status and Access to Care”

Access to Care: A Framework

Health Care System

Access to Health Care

Measured by:Structural, Process, and

Outcome Indicators

Health NeedsPredisposing

Characteristics

Access to Care

How do we measure access to care?• Potential access measures

– number of physicians per capita– usual source of care

• Realized access measures– any physician visit in the last year– cancer screenings

• “Blended” measures (tend to be negative, or signs of unmet need)– Avoidable hospitalizations– ER visit in the last year– diabetic amputation

Access to Care: The Role of Coverage

Strong body of evidence in the health policy literature that:• Health insurance is associated with better health outcomes• The uninsured are less likely to have a usual source of care

and more likely to report not getting the care they need• The uninsured are more likely to experience avoidable

hospitalizations• The uninsured are less likely to get recommended cancer

screenings• The uninsured are less likely to have chronic diseases

appropriately managed

Why Did Health Reform Happen in 2010?• Previous attempts at comprehensive health reform

failed• Incrementalism has historically defined health

policy– rise of employer-sponsored health insurance in the post

WWII era– Medicare & Medicaid in 1965– Children’s Health Insurance Program in 1997– Medicare Modernization Act (drug benefit) in 2003– and many other examples

• And yet…– A growing consensus emerged in the 15 years between

the failure of the Health Security Act (Clinton reform effort) and the development of the Affordable Care Act that the high number of uninsured Americans needed to be addressed and that the status quo was unsustainable

19721974

19761978

19801982

19831984

19861989

19901991

19921993

19941995

19961997

19981999

20002001

20022003

20042005

20062007

20082009

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20142015*

0

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4

6

8

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12

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16

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16.7

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17.5

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10.7

Note: 2015 data is for Q1 only. Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201508.pdf

Uninsured Rate Among the Nonelderly Population, 1972-2015 (slide from Kaiser Family Foundation)

Share of population uninsured:

19721974

19761978

19801982

19831984

19861989

19901991

19921993

19941995

19961997

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20082009

20102011

20122013

20142015*

0

10

20

30

40

50

60

70

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Uninsured Private Public

Note: 2015 data is for Q1 only. Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201508.pdf

Health Insurance Coverage Among the Nonelderly Population, 1972-2015 (slide from Kaiser Family Foundation)Share of population:

Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, 1999-

2012 (slide from Kaiser Family Foundation)

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

38%

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172%

38%

113%

180%

11%

29%

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8%

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38%

Health Insurance PremiumsWorkers' Contribution to PremiumsWorkers' EarningsOverall Inflation

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2012; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2012 (April to April).

Why Did Health Reform Happen in 2010?• Health care costs consistently rising faster than wages and

inflation• Stubbornly high number of uninsured (nearly 50 mil in 2010)• Non-group health insurance market functioned poorly for

consumers• Uneven health care quality• Political window of opportunity• Many lessons learned and best practices from state

experimentation• Health insurance more amendable to public policy

intervention than other social determinants of health• Health reform remains a very polarizing issue, however

Key Coverage Provisions of the ACA

• Guiding philosophy that all Americans should have a pathway to coverage

• Achieved through:– new rules of the road for insurance companies (for

example, no denials for pre-existing conditions)

– health insurance exchanges

– new subsidies/tax credits

– expansion of Medicaid (made optional by SCOTUS ruling in 2012)

– individual mandate

– employment-based health insurance and Medicare maintained

Early Evidence

• Uninsured rate has plummeted, particularly in states that expanded Medicaid

• Insurance gains have been more modest in Georgia, where a “coverage gap” persists

• Kentucky and Arkansas: uninsured rates dropped from more than 20 percent to below 10 percent

• Kentucky (and other states) starting to see an uptick in preventive services utilization

• Newly covered overwhelmingly report they can access care

• Concerns on the horizon: high deductibles; drug costs; narrow networks

NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, MI, PA and NH have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion.SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Current Status of State Medicaid Expansion Decisions (slide from Kaiser Family Foundation)

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT**

MO

MS

MN

MI*MA

MD

ME

LA

KY KS

IA* IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Adopted (31 States including DC)

Adoption Under Discussion (1 State)

Not Adopting At This Time (19 States)

Distribution of Adults in the Coverage Gap, by State and Region (slide from Kaiser Family Foundation)

5 Understanding Medicaid in Georgia and the Opportunity to Improve Itv1 / September 2015

Who Gets Medicaid in Georgia?Several populations are covered and each group has its ownincome eligibility guidelines.

Eligibility levels determine who can receive Medicaidcoverage. States set eligibility levels based onpersonal income and assets. Eligibility levels forchildren, parents, and pregnant women include a5% income disregard.

Georgia has set very restrictive Medicaid eligibility.

Elderly, blind, and disabled people cannot have incomehigher than 75 percent federal poverty level (FPL) or$13,200 for an elderly couple. Income limits are higherfor those needing long-term care.

Parents with minor children must earn an annualincome below 38 percent FPL or $7,600 for a familyof three in order to qualify for Medicaid.

Pregnant women cannot have income higher than225 percent FPL which is $26,500 for an individual or$45,200 for a family of three.

Children are eligible for Medicaid at varying rates as they age, starting at 210 percent FPL for an infant up to age 1, decreasing to 138 percent FPL for children ages 6-19. Children in families beyond these income limits can get coverage through PeachCare for Kids, which covers children up to 252 percent FPL or $50,600 for a family of three.

Adults without dependent children are not eligible for Medicaid in Georgia.

Source: Georgia Department of Community Health, thresholds rounded

Noteligible

50%0% 100% 150% 200% 250% 300%

ADULT WITHOUTDEPENDENT CHILDREN

PARENT

AGED, BLIND, DISABLED

BREAST & CERVICALCANCER

NURSING HOME &COMMUNITY CARE

PREGNANT WOMEN

RIGHT FROM THE STARTMEDICAID FOR CHILDREN

% FEDERAL POVERTY LEVEL

Children Elgibility Levels are Cumulative

Children Ages 6-19Children Ages 1-5Children Ages 0-1PeachCare

For more information on poverty level by family size, see Appendix.

The Federal Poverty Line is$11,770 for an individual and$15,930 for a couple.

10 Understanding Medicaid in Georgia and the Opportunity to Improve Itv1 / September 2015

Georgia’s Health Insurance Coverage GapParents are only eligible for Medicaidif they earn less than 38 percent ofFederal Poverty Level. For a singleparent with one child, this means theparent loses eligibility if they make morethan about $6,000 annually. They donot become eligible for subsidies topurchase private insurance until theymake above $15,930. This leaves alarge insurance coverage gap forlow-income adults trying to accessaffordable health insurance.

A single adult or couple withoutdependent children are not eligible forMedicaid at all. They remain in thecoverage gap unless they make morethan $11,770 or $15,930 respectively.

Many people in the coverage gapwork low-wage jobs where they arenot offered health benefits. A personmaking minimum wage would haveto work more than 30 hours perweek all year to earn enough incometo qualify for subsidies through thefederal health insurance marketplace.

INSURANCEMARKETPLACE

COVERAGE

CURRENTMEDICAID

COVERAGE

VETERANS

WORKINGPARENTS

LOW-WAGEWORKERS

COVERAGE GAP

300,000uninsured Georgians

are now in the coverage gap, where they are ineligible to enroll inMedicaid and do not earn enough to get tax credits on healthcare.gov.

11 Understanding Medicaid in Georgia and the Opportunity to Improve Itv1 / September 2015

The Affordable Care Act (ACA) offersstates an option to increase Medicaideligibility for adults up to 138% FPL.This is equal to an annual income of$16,200 for an individual and $ 27,700for a family of three in 2015.

This expanded eligibility would primarily help parents and other working adults who are not offered coveragethrough their jobs and cannot affordother coverage.

75 138

38 138

138

% FPL

20%0% 40% 60% 80% 100% 120% 140% 160%

CHILDLESSADULT

PARENT

AGED, BLIND, &DISABLED

Using Medicaid to Close the Coverage Gap

Current & Expanded Eligibility

ACA offers states an optionto increase Medicaid eligibility(for adults) up to 138% FPL

= $16,243Annual IncomeIndividual

= $27,724Annual IncomeParent, family of 3

= $16,243Annual IncomeIndividual

138%

Current eligibility

Expanded eligibility

Source: Georgia Department of Community Health, 2015 Financial Limits

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12 Understanding Medicaid in Georgia and the Opportunity to Improve Itv1 / September 2015

Approximately 500,000 Georgianscould enroll in quality, affordablehealth insurance if Georgia closesits coverage gap.

This would drastically reducethe number of uninsured amongstlow-income individuals in the state.

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under 45%

55% and above

50 to 54%

45 to 49%

Communities Across Georgia Stand to Benefit

Percent of uninsured adults who could get Medicaid

ECHOLS

Source: GBPI analysis of U.S Census Bureau data. Specific county-by-county figures available upon request

Enrollment in Georgia: Highlights from Last Year

Open Enrollment 3 is Here!

Open Enrollment 3 is Here!

• In Georgia, 1.5 million still uninsured• Of these Georgians:

– 27% eligible for tax credits/exchange plans– 13% Medicaid eligible– 20% in the coverage gap– 40% ineligible for financial assistance due to

income, ESI offer, or citizenship status• In-person assistance is critical

– Consumers who had in-person enrollment assistance were 2x as likely to enroll

– Many eligible uninsured don’t know they are eligible

What’s Next in Health Policy?

• Closing the Coverage Gap & Enrolling Remaining Eligible Uninsured

• Enhancing value for consumers (containing costs & improving quality)

• Upstream factors & social determinants of health

• And more…

Thank you!Cindy ZeldinExecutive DirectorGeorgians for a Healthy Futureczeldin@healthyfuturega.org

100 Edgewood Avenue, Suite 1015Atlanta, GA 30303Phone: 404-567-5016Fax: 404-935-9885info@healthyfuturega.orghealthyfuturega.org

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