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