IMPACT OF MEDICAID EXPANSION

 

Medicaid plays a larger role in providing health coverage to people living in small towns and rural communities than it does in metropolitan areas, a trend that is particularly striking among children, according to an extensive analysis by the Georgetown University Center for Children and Families and the University of North Carolina NC Rural Health Research Program.

About 45 percent of children in small towns and rural areas rely on Medicaid for their coverage, compared to 38 percent in metro areas, according to the report “Medicaid in Small Towns and Rural America: A Lifeline for Children, Families and Communities.” In 14 states, more than half of the children outside of metro areas receive health benefits from Medicaid and the Children’s Health Insurance Program.

 

Among adults, 16 percent of those in small towns and rural America get their coverage through Medicaid, compared to 15 percent in metro areas. In 13 states, at least a fifth of the adults outside metro areas rely on Medicaid.

“Medicaid is of critical importance to people living in small towns and rural America,” said Joan Alker, a Georgetown University research professor who is executive director of the Center for Children and Families. “The trillion dollars in Medicaid cuts that Congress and the White House are considering would have an outsized impact on these communities, many of which are still struggling economically.”

The report also found that the Affordable Care Act’s Medicaid expansion is having a disproportionately positive impact on small towns and rural areas. Researchers from the two universities looked at two sets of data: health coverage in 2008-2009 and in 2014-2015.

In that time frame, the rate of uninsured adults in states that accepted the Medicaid expansion decreased 11 percentage points in non-metro areas of these states. This is larger than the decrease in metropolitan areas of expansion states (9 percentage points) and larger than the decrease in small towns and rural areas in states that did not accept the expansion (6 percentage points).

For children, the data show a clear correlation between increases in Medicaid coverage and decreases in the rate of uninsured kids in small towns and rural areas.

The uninsured rate for children in these areas declined by 3 percentage points nationally during the time period examined. Nevada had the largest decline in the rate of uninsured children – a 14 percentage point drop – in small towns and rural areas. Texas had the largest decline in the number of uninsured children, with 52,000 kids in small towns and rural areas gaining health coverage.

“The declining number of uninsured shown in our research, especially in small towns and rural areas, is striking,” said co-author Jack Hoadley, a research professor at the Georgetown University Health Policy Institute, part of the McCourt School of Public Policy. “It means that more people are protected when they need health care services.”

The report provides a state-by-state breakdown of Medicaid coverage. In addition, interactive maps featuring county-level information will be published on the Center for Children and Families website. This report primarily relies on data from the Census Bureau’s American Community Survey (ACS).

The Center for Children & Families (CCF), part of the Health Policy Institute at the McCourt School of Public Policy at Georgetown University, is an independent, nonpartisan policy and research center with a mission to expand and improve high-quality, affordable health coverage. Founded in 2005, CCF is devoted to improving the health of America’s children and families, particularly those with low and moderate incomes.  

Health care is claiming an ever-increasing share of national wealth. In recent years, healthcare expenditure in Organization for European Cooperation and Development (OECD) countries has been rising at a rate one to two percentage points faster than GDP. If this trend were to continue, healthcare would represent more than 25 percent of France’s GDP—and more than 35 percent of the US’s—by 2050. Clearly, action is needed to bring costs under control.

Moreover, medical errors and other safety lapses persist even in the strongest health systems and are often caused by inconsistencies in care and lack of adherence to good practices. Outcomes vary enormously across healthcare systems and among the care providers within them. For instance, maternal mortality is four per 100,000 births in Italy, but more than three times higher in the US, at 14. Postoperative pulmonary embolisms and thrombosis affect 865 of every 100,000 patients leaving a hospital in France, but just 107 in Belgium, a difference of 706 percent. Regular albumin screening to prevent complications is provided annually for 88 percent of diabetics in the Netherlands, but for fewer than 30 percent of those in France.

Medical errors are the third-most-common cause of death in the US after cancer and heart disease, accounting for more than 250,000 deaths every year. Addressing these issues and the variations in care practices and quality that cause them is another priority for all countries.

As payment and care delivery models shift from episodic, fee-for-service care toward population health and value-based reimbursement, health care leaders are focused more than ever on patient engagement as a key to driving down costs and improving outcomes. And yet, as so many of us know who have attempted to manage our own care or tend to sick family members, the health care system rarely feels like it’s been set up to help us succeed.

What’s needed is a fundamental redesign of the patient’s role — from that of a passive recipient of care to an active participant charged with defined responsibilities, equipped to dispatch them, and accountable for the results. In other words, we need to view the patient’s role as a job and then design that job in such a way as to drive the best health outcomes possible.

The most profound reforms of a public health service may come from initiatives that operate in the shadows with little financial resources because they attract less attention from vested interests. Reform projects that operate away from scrutiny can develop resourcing space that allows for rapid change with little negotiations and minimal coordination cost.

Public health reform initiatives which attract little attention can achieve bigger results because they are relatively shielded from too much interference. Change can come despite, and perhaps even because of, a lack of resources. Usually, organizational change entails a shift in resource control, and this prompts resistance by people who feel this can undermine their resource-derived authority.

Patient advocates and others who have studied the U.S. health care system have catalogued the degree of unpaid, and unsupported, work patients take on in service of their own care. The average, low-risk patient must follow up on referrals to specialists, fill and manage medications, and comply with physical therapy and other regimes. With legacy, pre-internet software systems still the norm in most hospital environments, patients also become unpaid couriers, shuttling critical health data from one provider to the next.

Nearly 30% of patients physically carry x-rays, test results, and other critical health data from one provider’s office to the next. And 55% say their medical history is missing or incomplete when they visit their doctor.

For patients who suffer from chronic or complex conditions, the burden of treatment must be shouldered alongside the burden of illness. The self-management of a chronic illness demands, on average, two hours of patient work each day — work that is often poorly supported, stressful, and frustrating in nature. Rather than having patients as passive recipients of care, they must be active producers of their care, in partnership and coordination with physicians and clinical staff.

We need to acknowledge and account for all the patient work that now goes unrecognized and unsupported. This means grappling with the complexity of tasks patients take on as they seek care across an ever-expanding number of settings — work that varies widely depending on acuity level, disease state, demographics, insurance type, socioeconomic conditions, and so on.

For years, hospitals and medical groups, looking to move the needle on patient satisfaction, have focused largely on managing and optimizing isolated episodes of care. Surveys focus on patient satisfaction with individual encounters within a single institution. But the way we access and experience care has changed. Where we used to have a lifelong relationship with a family doctor, we now switch doctors frequently due to scheduling issues, changes in insurance coverage, and other factors. We’re also more likely to seek care outside the walls of health systems or the boundaries of specific networks — whether it be through urgent care visits, virtual consults, or alternative therapies. And we know that much of what affects our health, for better or worse, happens between visits.

As we shift toward population health, with provider reimbursements tied directly to improved outcomes, we need to move from managing episodes of care to managing the entire patient journey across the full ecosystem of care. The patient journey becomes the operational backdrop against which patients, physicians, and other staff and caregivers must play their respective parts.

If the patient is to have a job in the care-delivery process, we must apply the same principles of intentional work design to their jobs as we do to those of physicians and clinical staff. Only 20% of doctors report high levels of engagement in their jobs. Those who are highly engaged, however, point to a few key drivers: trust in leadership and the system, open communication and feedback, and an operationally effective work environment that allows them to deliver high-quality patient care. It’s not a stretch to suggest that patients would be engaged and motivated by the same drivers.

The roles and responsibilities of patients currently are almost never clearly defined or fully supported. Patients routinely take on frustrating tasks, such as the transfer of vital information from one provider to another, that technology should be designed to handle. They struggle to get access to the information they need to tend to their own care, and get little feedback or satisfaction from seeing their actions move the needle on results. For patients to be satisfied with care, motivated to play their part, attentive to required screenings, and compliant with care, they need the support of a system designed to help them do their jobs effectively.

Saying that the patient has a job to do does not in any way suggest that patients must shoulder the burden of their responsibilities unsupported. Technology is the key enabler of patients’ success, providing the information, visibility, and feedback they need to do their jobs.

The goal should be to understand all the key points of engagement that are needed in order to support the patient before, during, and between visits. Naturally, the patient journey and points of engagement look very different for a healthy 28-year-old than they do for a 55-year-old smoker with diabetes and hypertension. But both have jobs to do that can only be done effectively with the support of surrounding technology.

For example, data aggregated from a multitude of sources — from electronic health records to insurance data — can be used to paint a complete picture of the patient. Smart scheduling systems and patient portals help patients access care on demand. Reminders via text and other modes help the patient arrive on time and prepared. Open data exchange allows personal health information to travel from one provider or encounter to the next so the patient isn’t playing courier.

For high-risk patients, wearable devices and care management apps help them stay compliant and connected to care teams 24/7. Technology can’t do patients’ job for them. They still need to embrace behavior change and take accountability for their own care. But it can make their job easier to do, more likely to be effective, and more satisfying and rewarding.

It’s widely accepted that we will never realize the goals of health care’s Triple Aim — reducing costs, improving the health of populations, and improving the patient experience — without putting patients at the center of their care. To do this effectively, however, health care leaders must do more than retool old mission statements or retrain physicians and frontline staff. They will need to reorient their thinking to acknowledge the critical job of the patient, design it thoughtfully into new operational frameworks, and invest in the networked technology required to support it all. Only when patients, physicians, and staff are all working together, fully engaged and enabled to do what each does best, will we achieve the clinical and financial outcomes we are all aiming for. 

Harnessing the full potential of digital innovations in healthcare could have a profound impact on the quality and financial sustainability of health systems. It would also involve profound changes for care providers and healthcare professionals. To shift mind-sets, healthcare authorities will require a clear and compelling vision and ambitious action. But the benefits for both quality and economics will be well worth it.

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