Reports & Analysis

This report provides a review of safety-net systems across the country, identifying their experiences, lessons, and successes in adapting and responding to health care reform. The purpose is to capture transformations occurring across systems varying financially, while also caring for a large number of low-income patients, to document their actions and innovations as well as implications and potential considerations for the California safety net. As such, this study intends to build on and add a unique dimension to the existing body of work on safety-net hospital systems transformations nationally and in California.

State policymakers increasingly recognize that improving health outcomes is as much about addressing the social determinants of poor health as it is about providing high-quality medical care. Medicaid accountable care organizations (ACOs), or other ACO-like models, offer a prime opportunity to meld population health and payment and delivery system reforms. This brief explores state strategies for promoting population health through Medicaid ACOs. It provides background information on population health approaches and Medicaid delivery system reforms and describes various state strategies to inform ACO design and governance structures, program components, metrics, and information-sharing mechanisms. It also includes some promising early examples from three states — Minnesota, Oregon, and Vermont — working to embed population health strategies in Medicaid ACO program requirements.

DSRIP initiatives are part of broader Section 1115 Waivers and provide states with significant funding that can be used to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries. This analysis provides an early look at the impact of DSRIP waivers on Medicaid payment and delivery systems. It is based on interviews conducted with state officials, providers and advocates in three states that have adopted the Medicaid expansion (California, Massachusetts, and New York) and one state that has not adopted the expansion (Texas).  While each of the four programs is different, a number of major themes emerged across the four states that highlight the opportunities and challenges with DSRIP.

Since the Great Recession peaked in 2010, the economic picture has steadily improved, and in 2013, GDP increased relative to 2012 and the unemployment rate fell but remained fairly high at 7.4 percent. In addition, the uninsured rate decreased slightly (0.1 percentage point) in 2013, continuing the trend from 2011 and 2012. Despite these improvements, rates of coverage through employer sponsored insurance have declined since 2010, though more slowly in recent years than at the height of the recession. Gains in coverage since 2010 have been largely due to increases in coverage through public programs such as Medicaid and the Children’s Health Insurance Program (CHIP). This brief further examines coverage patterns for the nonelderly population from 2008 through 2013 using data from the American Community Survey.

Since the ACA’s first open enrollment period began in late 2013, there has been rapid enrollment growth in Medicaid and in private health insurance plans purchased through the new Marketplaces. However, administrative data on Medicaid enrollment and enrollment in Marketplace health plans do not show how health insurance coverage is changing under the ACA, because not all of those enrolling were previously uninsured. Household survey data are needed to track changes over time in the share of the population that is uninsured. This report uses the Urban Institute’s Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage since the first quarter of 2013. According to HRMS data, the uninsurance rate among nonelderly adults has declined 7.5 percentage points between September 2013 and March 2015, representing 15 million fewer adults without health insurance.

Opponents of Medicaid expansion claim that states need flexibility to promote personal responsibility, ensure appropriate use of health care services, and require work. These critics seek to impose premiums, cost-sharing charges, and work requirements that go well beyond what the Medicaid statute allows. States can, however, use Medicaid to employ a number of strategies to promote personal responsibility and work and ensure appropriate use of health care, which would also help lower Medicaid spending and improve beneficiary health outcomes. These alternatives focus on improving the delivery of care instead of imposing harsh requirements that prevent people from getting care in the first place. Many states have already taken advantage of Medicaid’s existing flexibility to move in this direction.

To develop this dataset, researchers collecting data simulated a typical shopping experience on healthcare.gov. The dataset captures 25 design aspects of the marketplace websites, which include, but are not limited to, whether websites ask for pregnancy and disability status and whether consumers can view quality ratings for certain plans. This dataset is featured in the data brief entitled, "Window Shopping on Healthcare.gov and the State-Based Marketplaces: More Consumer Support is Needed."

The Affordable Care Act (ACA) set new standards for the adequacy of health insurance, including limits on out-of-pocket cost-sharing and requirements that insurers cover a minimum set of health benefits. Yet while we know that access to health insurance has improved, our understanding of consumers’ experiences with plans’ cost-sharing, provider networks, and benefit design is lacking. One source of information about consumers’ coverage experiences are the state-run Consumer Assistance
Programs (CAPs) call centers, which receive calls from consumers on a wide range of issues, from those seeking coverage to those with coverage that is not meeting their needs. These programs provide a unique lens on consumer experiences with coverage both before and after the ACA went into full effect in 2014. They can help us understand how consumers have benefited from the insurance reforms, and where there may still be gaps or problems with their insurance coverage.
 

Across the country, states are exploring the viability of Medicaid accountable care organizations (ACOs) that align provider and payer incentives to focus on value instead of volume, with the goal of keeping patients healthy and costs manageable. To date, eight states have launched Medicaid ACO programs, and nine more are actively pursuing them. This fact sheet walks through current progress for Medicaid ACOs. It describes how emerging state programs are seeking to drive accountability through three key activities: (1) implementing a value-based payment structure; (2) measuring quality improvement; and (3) collecting and analyzing data. It also provides a glimpse of some early state successes.

Health disparities persist in the United States, with disadvantaged groups disproportionately bearing the burden of poor health outcomes and shortened lifespans. States cannot effectively control healthcare costs or improve quality without addressing health disparities. Fortunately, state and federal policymakers can work together to build an equitable health care delivery system by aligning payment models, creating new partnerships, and building infrastructure and data systems to reduce health disparities. This brief reflects on a discussion of health equity held at a meeting of state and federal leaders convened by the National Academy for State Health Policy, and includes examples of several states’ efforts to promote health equity.