The study’s “alarming” findings are seen as having the biggest impacts on patients and hospitals in certain states.

Jan. 31—While the Affordable Care Act (ACA) helped reduce the U.S. rates of uninsured, considerable gaps remain among patients with chronic conditions, a new study found.

The study of 606,277 adults ages 18 to 64 with at least one chronic condition, which was conducted by physician researchers from the Cambridge Health Alliance, only covered the first year of ACA implementation, 2014. It found that the coverage gaps were more pronounced among racial minorities and people living in states that did not expand Medicaid. Twenty percent of African-Americans and one third of Hispanics with chronic disease were uninsured that year, compared to 15 percent of those with chronic conditions in the general population.

The ACA increased insurance coverage among those with chronic conditions by nearly 5 percent. The study, which was published Jan. 24 in the Annals of Internal Medicine, found under the ACA fewer people with chronic conditions (2.5 percent) forewent physician visits and 2.7 percent reported increases in physician checkups. The percentage reporting a personal physician did not change post-ACA implementation.

The study also found that the U.S. prevalence of chronic disease increased steadily in the past decade, with half of U.S. adults now having at least one chronic medical condition, defined as diabetes, heart failure and other serious disease.

The 2014 insurance coverage increased in nearly all states, but varied a gain of 12.7 percent in West Virginia to a 0.7 percent loss in Idaho. The gains were greater in Medicaid expansion states---an average of a 5.6 percent increase, compared to non-expansion states average increase of 4.3 percent. Massachusetts, a Medicaid expansion state, saw a post-ACA insurance rate of 95.1 percent while Texas, a non-expansion state, had 73.7 percent covered.

Elizabeth Poorman, a primary care physician with the Cambridge Health Alliance and a study coauthor, said the new research should make hospital financial executives “very nervous about the future of healthcare in America. Our study demonstrates that people who need care need that care right now, and if they don’t have it, then their conditions worsen.”

Minorities started out with large gap in the percentage of uninsured, which the ACA narrowed, Poorman said.

Rachel Garfield, senior researcher for the Kaiser Family Foundation, said that while the study’s numbers are alarming, she’s not surprised to find people with substantial health needs falling through the cracks, particularly in states that did not accept the Medicaid expansions. 

“These people don’t have a clear pathway towards coverage right now,” Garfield said in an interview.

Garfield said in non-Medicaid expansion states, affordability of care assumes even greater significance.

“Many simply could not afford care,” she said. “We’re also seeing many people signing up for coverage selecting the lowest premium plan with the highest deductible and not using that coverage because of the cost. They’re still avoiding going to the doctor unless it’s absolutely necessary.”

ACA Marketplaces

A 2017 Health Insurance Exchange analysis by consulting firm Avalere Health found ACA marketplace plans will be more expensive, offer narrower provider networks, and be harder to find in the coming year. The study found fewer insurers participating in the marketplaces than in previous years, with increases in premiums, particularly among the popular, low-cost silver plans, which saw price hikes of 12 percent to 25 percent.  Out-of-pocket costs increased 20 percent to an average of $3,703 for silver plan deductibles. Avalere also found coinsurance payments for specialty drugs rose by 31 percent or more in bronze and silver plans.

Recent insurance premium hikes among ACA marketplaces show that “America is a lot sicker than we thought,” Poorman said. “This is a highly fragmented system of care with a lot of bureaucracy and there’s so much more we can do. We still have the ability to negotiate drug prices, for example. But as long as we’re just cobbling different pieces together we will have continual rises in prices and continued waste.”

Tom Miller, a resident fellow with the American Enterprise Institute, said a mismatch between what insurers expected or were encouraged to expect in cost structure accounts for some of the premium rate hikes in recent years.

“There’s some catch-up pricing and sometimes there was political pressure to suppress rates,” Miller said. “Insurers made some mistakes and were giving better prices to get greater market share. Some were impaired by the recalculation of rates. But it’s a wide landscape: some markets had cost increases and some didn’t. What may have seemed like a good idea didn’t work out the way it was hoped.”

Sara Rosenbaum, professor of health policy at the George Washington University School of Public Health and Health Services, said the study showed that health insurance affordability is important.

“The answer is if we had more young, healthy people in the individual insurance markets the price increases would have been mitigated,” Rosenbaum said in an interview.

Rosenbaum said there are only limited tools to bring down insurance premium costs, citing narrow provider networks or fewer, less generous benefits.

“The whole point of the ACA was to give people access to real, meaningful insurance that they can afford to purchase and use,” Rosenbaum said. “The premium subsidies were not generous enough and as a result, to hold down premium prices, the deductible went way up and networks narrowed beyond what people wanted.”

Medicaid Impact

Poorman said that Medicaid is one of the most cost-effective insurance programs in the U.S. and expanding it into non-expansion states will show gains and close coverage gaps.

“A larger solution would be to explore something like a public option or the ability to buy into Medicaid to offer a consistent safety net that is not so difficult to get into or pay for,” she said.

Medicaid changes Poorman urged included easing insurance enrollment and renewal, with the addition of an auto–enrollment system.

Poorman said an ACA repeal would “negatively impact hospitals and health systems, particularly safety net hospitals.”

The ACA cut most of hospitals’ disproportionate share hospital (DSH) funding to pay for the coverage expansions and Miller was uncertain whether they’ll fare better than insurers moving forward.

“There are too many questions without answers,” Miller said in an interview. “Hospitals over time will see their rates depressed. The marketplace enrollment has bottomed out. And while they saw more Medicaid patients, the reality is they still lose money on Medicaid.” 

Garfield said the positive news for hospitals and health providers is that the ACA delivered big gains in coverage.

“It’s really striking to see the difference in payer mix in states that did expand Medicaid versus those that didn’t. The states that did saw big drops in charity care and uncompensated care and increases in paying Medicaid patients,” she said. “In hospitals within states that did not expand Medicaid, they did not see those effects. If the ACA is repealed, hospitals will have a lot to lose, from the coverage gains to their payer mix and bottom line.”

Mark Taylor is a freelance writer based in Chicago. 

Publication Date: Tuesday, January 31, 2017