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The Health Care “Safety Net” in a Post-Reform World
Mark A. HallWake Forest University
Sara RosenbaumGeorge Washington Univ.
Other Authors
• Robert W. Mickey, Univ. Michigan• Thomas R. Oliver and Richard Rieselbach, et
al., Univ. Wisc. • Peter D. Jacobson, et al., Univ. Mich.• Frank J. Thompson, Rutgers, Pub. Policy• Gloria J. Bazzoli and Sheryl Garland, Va.
Cmwlth.• Jack Needleman & Michelle Ko, UCLA
Alison Snow Jones, 1949 – 2011
Challenges• Reform will reduce by the number of
uninsured by more than half– But, newly insured will face access challenges– And, perception of no need for remaining
uninsured, or not deserving of suppot
• The composition of the remaining uninsured will change substantially
Medicaid Eligibles36.5%
Undocumented Immigrants
24.5%
With Affordabil-ity Exemption
16.2%
With Affordable Subsidized Op-
tion7.5%
With Affordable Unsubsidized Op-
tion15.3%
Distribution of Nonelderly Uninsured Adults under ACA
UNIVERSAL ACCESS
Safety Net Deficiencies
Access without Insurance
• Potential access: Structural measures– Enrollment Card– Primary care medical home– Referrals to specialists, Rx, hospital
• Perceived access:– Still face greater barriers to care– But, feels like insurance coverage
Realized Access: Utilization Measures Average annual visits per person to:
Had at least one annual visit to Dr.
Any Dr. office
Primary care ER
Hospital stay
National Population Survey, 2007 (NHIS)
All adults 83% 3.2 1.8 0.39
National Medical Records, 2006 (NAMCS, NHDS)
Privately Insured 3.9 1.7 0.25
Medicaid 3.6 2.7 0.53
All adults 2.9 1.5 0.37 0.1
Overall 3.1 1.8 0.41
Case Study Uninsured Adults
Denver Program, 2008 4.7 2.6 0.38
Flint Program, 2007-2008 3.0 2.5 0.44 0.04
Asheville Program, 2008 5.4 3.9 0.5 0.05
Texas Program, 2005 70% 7.4 0.36
Boston area, 2002 65%
Buncombe County, 2008
Low-income uninsured
clinic
Medicaid, risk adjusted
Primary care 3.9 4.6
Hospitalization 0.05 0.10
Asheville: Annual Visits Per Nonelderly Adult
Create a sense of community-wide need
• Recognize unavoidable gaps in coverage for low-income eligibles
• Include middle income people still facing “unaffordable” premiums– Consider fee sliding scale
Duration of Uninsured Spells
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