Presentation to Trinity Presbyterian Church

1. Access to care in Georgia: an advocate’s perspective Cindy Zeldin Georgians for a Healthy Future Presentation for Trinity Presbyterian Church November 1, 2015

2. 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.

3. 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

4. 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?

5. 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.

6. 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 Needs Predisposing Characteristics

7. 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

8. 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

9. 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

10. 16.7 12.0 17.2 16.3 17.5 16.1 18.2 13.3 10.7 0 2 4 6 8 10 12 14 16 18 20 1972 1974 1976 1978 1980 1982 1983 1984 1986 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 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#table01and 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:

11. 0 10 20 30 40 50 60 70 80 90 1972 1974 1976 1978 1980 1982 1983 1984 1986 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 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:

12. Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, 1999-2012 (slide from Kaiser Family Foundation) 38% 109% 172% 38% 113% 180% 11% 29% 47% 8% 24% 38% 0% 20% 40% 60% 80% 100% 120% 140% 160% 180% 200% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Health Insurance Premiums Workers' Contribution to Premiums Workers' Earnings Overall 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).

13. 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

14. 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

15. 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

16. 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 KYKS 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)

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

18. 5 Understanding Medicaid in Georgia and the Opportunity to Improve It v1 / September 2015 Who Gets Medicaid in Georgia? Several populations are covered and each group has its own income eligibility guidelines. Eligibility levels determine who can receive Medicaid coverage. States set eligibility levels based on personal income and assets. Eligibility levels for children, parents, and pregnant women include a 5% income disregard. Georgia has set very restrictive Medicaid eligibility. Elderly, blind, and disabled people cannot have income higher than 75 percent federal poverty level (FPL) or $13,200 for an elderly couple. Income limits are higher for those needing long-term care. Parents with minor children must earn an annual income below 38 percent FPL or $7,600 for a family of three in order to qualify for Medicaid. Pregnant women cannot have income higher than 225 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 Not eligible 50%0% 100% 150% 200% 250% 300% ADULT WITHOUT DEPENDENT CHILDREN PARENT AGED, BLIND, DISABLED BREAST & CERVICAL CANCER NURSING HOME & COMMUNITY CARE PREGNANT WOMEN RIGHT FROM THE START MEDICAID FOR CHILDREN % FEDERAL POVERTY LEVEL Children Elgibility Levels are Cumulative Children Ages 6-19 Children Ages 1-5 Children Ages 0-1 PeachCare 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.

19. 10 Understanding Medicaid in Georgia and the Opportunity to Improve It v1 / September 2015 Georgia’s Health Insurance Coverage Gap Parents are only eligible for Medicaid if they earn less than 38 percent of Federal Poverty Level. For a single parent with one child, this means the parent loses eligibility if they make more than about $6,000 annually. They do not become eligible for subsidies to purchase private insurance until they make above $15,930. This leaves a large insurance coverage gap for low-income adults trying to access affordable health insurance. A single adult or couple without dependent children are not eligible for Medicaid at all. They remain in the coverage gap unless they make more than $11,770 or $15,930 respectively. Many people in the coverage gap work low-wage jobs where they are not offered health benefits. A person making minimum wage would have to work more than 30 hours per week all year to earn enough income to qualify for subsidies through the federal health insurance marketplace. INSURANCE MARKETPLACE COVERAGE CURRENT MEDICAID COVERAGE VETERANS WORKING PARENTS LOW-WAGE WORKERS COVERAGE GAP 300,000 uninsured Georgians are now in the coverage gap, where they are ineligible to enroll in Medicaid and do not earn enough to get tax credits on healthcare.gov.

20. 11 Understanding Medicaid in Georgia and the Opportunity to Improve It v1 / September 2015 The Affordable Care Act (ACA) offers states an option to increase Medicaid eligibility for adults up to 138% FPL. This is equal to an annual income of $16,200 for an individual and $ 27,700 for a family of three in 2015. This expanded eligibility would primarily help parents and other working adults who are not offered coverage through their jobs and cannot afford other coverage. 75 138 38 138 138 % FPL 20%0% 40% 60% 80% 100% 120% 140% 160% CHILDLESS ADULT PARENT AGED, BLIND, & DISABLED Using Medicaid to Close the Coverage Gap Current & Expanded Eligibility ACA offers states an option to increase Medicaid eligibility (for adults) up to 138% FPL = $16,243 Annual Income Individual = $27,724 Annual Income Parent, family of 3 = $16,243 Annual Income Individual 138% Current eligibility Expanded eligibility Source: Georgia Department of Community Health, 2015 Financial Limits

21. TF IE LD HI W R RA Y RS HA HA BE M M U Mc DU FA YE TT FF IE E M ER IW ET H ER SC HL EY MON W TGOW EB ST ER H EE MERLE R Y LA N IE R SE MI NO LE D A SO A RR AR N HOUSTON CKL 12 Understanding Medicaid in Georgia and the Opportunity to Improve It v1 / September 2015 Approximately 500,000 Georgians could enroll in quality, affordable health insurance if Georgia closes its coverage gap. This would drastically reduce the number of uninsured amongst low-income individuals in the state. BIBB TIFT TELFAIR EARLY BURKE GLASCOCK CHATHAM BRANTLEY WARE LEE DOOLY CRISP TAYLOR MACON HARRIS TROUP HENRY JONES LONG PIKE TATTNALL CLAY ELBERT O C JOHNSON MONROE CRAWFORD TERRELL BAKER WORTH IRWIN COFFEE APPLING LOWNDES CHARLTON WAYNE PIERCE BUTTS BULLOCH MILLER D A JACKSON PUTNAM LAURENS E CATOO- SA WALKER CHAT- TOOGA FLOYD FANNIN GILMER PICKENS CHEROKEE GORDON BARTOW RABUN STE- PHENS BANKS N FR KL IN HART MADISON TOWNS UNION WHITE LUMPKIN D W N HALL FORSYTH CL O EE KE OGLE- THORPE GWINNETT DeKALB ROCK- DALE MORGAN TALIA- FERRO WILKES NEWTON GREENE COBB PAULDING DOUGLAS FULTON CLAY- TON POLK HARALSON CARROLL HEARD COWETA SPALDING JASPER BA OW WALTON BALDWIN HANCOCK WASHINGTON WILKINSON JEFFERSON JENKINS SCREVEN EFFING- HAM EVANS TOOMBS EMANUEL TREUTLEN CANDLER DODGE EY WILCOX PULASKI TWIGGS BLE SUMTER TALBOT MUSCO- GEE CHATTA- MARION HOOCHEE STEWART QUIT- MAN CALHOUN MITCHELL DOUGHERTY COLQUITT DECATUR GRADY THOMAS BROOKS BERRIEN COOK BEN HILL JEFF DAVIS ATKINSON BACON CLINCH CAMDEN GLYNN McINTOSH BRYAN LIBERTY WARREN COLUMBIA LINCOLN RICHMOND UPSON LA M A R PE A CH RANDOLPH TURNER 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

22. Enrollment in Georgia: Highlights from Last Year

23. Open Enrollment 3 is Here!

24. 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

25. 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…

26. Thank you! Cindy Zeldin Executive Director Georgians for a Healthy Future czeldin@healthyfuturega.org 100 Edgewood Avenue, Suite 1015 Atlanta, GA 30303 Phone: 404-567-5016 Fax: 404-935-9885 info@healthyfuturega.org healthyfuturega.org FOLLOW & SHARE

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