The Center's work on 'Insurance Coverage' Issues


What to Know About Next Week’s Health Coverage Data

September 11, 2014 at 4:25 pm

The Census Bureau will release estimates Tuesday of the number and share of Americans without health coverage in 2013, based on its annual Current Population Survey (CPS).  While the CPS is the most widely used source of health coverage information, significant changes in its health coverage questions instituted for 2013 — the result of a multi-year Census initiative to improve the reliability and accuracy of the survey’s health coverage estimates — mean that the 2013 results cannot be compared to those for prior years, as we explain in a new report.  Moreover, because the CPS estimates are for 2013, they will not show the effects of health reform’s major coverage expansions, implemented starting in January 2014.

Analysts and policymakers should therefore look to other available data sources as well, including other federal and private surveys.  For example, the Census Bureau also will issue Tuesday the health coverage results from its American Community Survey (ACS).  Unlike the CPS, the ACS health insurance data for 2013 will be a part of a consistent data series back to 2008 and hence will allow analysis of changes in health coverage over recent years.

Preliminary results from the Centers for Disease Control and Prevention’s (CDC) National Health Interview Survey provide important clues about the upcoming Census estimate (under the ACS) of the change in health coverage in 2013.  The CDC data show that the share of Americans without health coverage remained stable between 2012 and 2013, as did rates of private coverage, Medicaid coverage, and coverage for particular groups of Americans.  These data show the uninsured rate rose from 14.5 percent in 2007 to 16.0 percent in 2010, then fell to 14.7 percent by 2012, and remained essentially unchanged (in statistical terms) at 14.4 percent in 2013.

Click here to read the full report.

Damaging House Bill Would Undo Health Reform Protections and Raise Small Business Premiums

September 9, 2014 at 2:02 pm

The House this week is scheduled to consider a bill sponsored by Rep. William Cassidy (R-LA) that would allow insurance companies, through 2018, to continue to offer to any small employer the health insurance plans in the small group market that the insurers were selling in 2013.

In short, the bill is another attempt to undermine health reform and try to ensure it doesn’t succeed, as we explain in a new analysis:

Under the bill, such plans would not have to comply with the Affordable Care Act’s (ACA) market reforms and consumer protections that otherwise apply to all health insurance plans offered in the small group market, starting in 2014.

The bill would go well beyond the existing Administration transition policy that permits states to allow insurers to continue — through 2016 — to offer non-ACA-compliant plans in the individual and/or small group market to individuals and employers who were previously enrolled in such plans. . . [T]he Cassidy bill would likely have serious adverse effects both on premiums in the small group market — causing them to rise substantially for many small firms — and on health reform’s consumer protections, such as the reform that prevents insurance companies from charging higher premiums to firms with older, less healthy workforces.

Click here to read the full paper.

Hospitals Benefiting From Medicaid Expansion, Report Finds

September 5, 2014 at 10:52 am

Hospitals in states that have expanded Medicaid as part of health reform are seeing a large drop in uninsured patients and higher-than-expected revenues, a new report from the PricewaterhouseCoopers (PwC) Health Research Institute finds.  It’s the latest evidence of the Medicaid expansion’s benefits for states, their businesses, and their residents.

Examining financial data for the first half of the year from the country’s three largest health care providers, PwC found a 47 percent drop in admissions of uninsured patients at affiliated hospitals in Medicaid expansion states.  This suggests a sizable drop in uncompensated care — consistent with a nationwide survey of hospitals by the Colorado Hospital Association after the first quarter of the year.  PwC also found that the rise in the share of patients with health coverage boosted providers’ revenues even more than they had anticipated.

Meanwhile, the Urban Institute projects that hospitals in the 23 states that have not yet expanded Medicaid (see map) will lose out on $157 billion in reimbursements between 2013 and 2022.

This PwC report is one of several indicators of the growing gap between states that have expanded Medicaid and those that haven’t.  The Medicaid expansion is driving large gains in health coverage, while states that haven’t expanded risk forgoing those gains as well as millions of dollars in savings.

Wisconsin and Wyoming Tally Fiscal Cost of Rejecting Health Reform’s Medicaid Expansion

August 28, 2014 at 12:00 pm

Recent budget reports from Wisconsin and Wyoming show that their failure to adopt health reform’s Medicaid expansion is costing them millions of dollars in forgone budget savings.

In Wisconsin, the legislature’s nonpartisan Legislative Fiscal Bureau estimates that the expansion, which covers non-elderly adults with incomes up to 138 percent of the poverty line, would have saved the state $206 million in the 2014 and 2015 fiscal years combined.

Governor Scott Walker chose instead to extend Medicaid coverage to adults only up to 100 percent of the poverty line through a separate waiver.  This means that the federal government is paying for the expanded coverage at the state’s regular Medicaid matching rate of 59 percent, rather than the much higher matching rate for health reform’s Medicaid expansion.  (For states that expand to 138 percent of poverty, the federal government will pick up 100 percent of the cost through 2016 and no less than 90 percent thereafter.)  The difference in matching rates is the main reason for the $206 million in forgone savings.

Wisconsin could still save between $261 million and $315 million over the 2016 and 2017 fiscal years by adopting the expansion during next year’s legislative session, the report estimates.  Gov. Walker has justified his opposition to it by arguing that the federal government would ultimately renege on its financial commitment, but those fears are unfounded.

In Wyoming, the state health department projects that the Medicaid expansion would save the state $50 million a year on other health programs for low-income uninsured residents.  As a result, Governor Matt Mead is moving to advance the Medicaid expansion during the coming legislative session.  More than 17,000 uninsured residents would gain access to coverage under the expansion, the Urban Institute estimates.

The 27 states (including Washington, D.C.) that have adopted the Medicaid expansion are already seeing dramatic gains in health coverage and reductions in the cost of providing uncompensated care to the uninsured.  Wisconsin, Wyoming, and the other 22 states that have not done so could realize similar benefits.

States Seeking to Expand Medicaid Through Waivers Can Learn From Arkansas, Iowa, and Michigan

August 22, 2014 at 11:05 am

The federal government is considering proposals from Pennsylvania and Indiana to adopt health reform’s Medicaid expansion through a demonstration project, or waiver, and New Hampshire will soon submit its own.  The experience of the three states — Arkansas, Iowa, and Michigan — that have expanded through a waiver suggests that while the federal government will work with states to craft reasonable expansion plans, there are limits to the programmatic flexibility it will grant, as we explain in a new paper.

Waivers provide states with additional flexibility in how they operate their Medicaid programs, but they cannot be used to impose onerous requirements that make it difficult for eligible individuals to gain and maintain Medicaid coverage.  This principle has informed how the Department of Health and Human Services (HHS) has responded to waiver proposals so far.

Among the takeaways:

  • States may not disenroll people with incomes below the poverty line for non-payment of premiums.  While Iowa has received approval to charge beneficiaries with incomes between 50 and 100 percent of the poverty line modest premiums starting in 2015, the state will waive premiums for individuals who complete health risk and wellness assessments or attest to financial hardships.  Importantly, the state cannot disenroll individuals from coverage if they do not pay their premiums.
  • States may not require individuals to pay cost-sharing charges above what is allowed under Medicaid rules.  Medicaid cost-sharing rules provide states with significant flexibility while providing significant protections for beneficiaries that are intended to minimize barriers to necessary health care services.  The rules include special protections barring cost-sharing for children and pregnant women and for certain services such as family planning, emergency services, and maternity care.  People with incomes above the poverty line may be charged higher amounts, and providers cannot deny services to people with incomes below the poverty line who cannot afford to pay.  States must apply these protections to the newly eligible adults regardless of whether states expand Medicaid through a waiver.
  • States may not overly restrict certain benefits.  States have significant flexibility regarding benefits for newly eligible adults and can largely align their benefits with the benefits that private market plans provide.  Still, HHS has provided very limited waivers of Medicaid benefits.  And in Arkansas and Iowa, which are enrolling some or most of their expansion populations in private plans offered in the health insurance marketplaces, HHS has required that states augment marketplace benefits to ensure beneficiaries have access to the same benefits than if they were enrolled in regular Medicaid.
  • States can’t condition Medicaid eligibility on employment or participation in work search activities.  In December 2013, Pennsylvania Governor Tom Corbett proposed a Medicaid expansion waiver that would require anyone working fewer than 20 hours a week to register with the state’s unemployment compensation program and engage in 12 work search activities per month to remain eligible for Medicaid coverage.  Those judged not to be in compliance would have their health coverage revoked.  Gov. Corbett subsequently submitted a revised proposal to HHS that would charge beneficiaries differential premiums based on whether they are working or engaged in work search activities.  In response to Pennsylvania’s proposal, HHS has indicated that it is unlikely to approve waivers that condition either Medicaid eligibility or premium amounts on compliance with work search or other work-related activities.

Click here to read the full paper.