One in 5 million Americans now covered by Medicaid

By Claire Thayer, July 7, 2014

The Affordable Care Act (ACA) has had a huge impact on Medicaid enrollment and spending since the expansion of Medicaid eligibility to include almost all adults with incomes at or below 138% of the federal poverty level effective January 1, 2014. The Kaiser Family Foundation recently released, Medicaid Moving Forward, a concise fact sheet summarizing current enrollment, spending and other trends for the Medicaid program.  Lots of data is packed into this fact sheet, here are a few of the important highlights:

Who Does Medicaid Cover?

  • Over 66 million Americans now receive their health coverage through the Medicaid

  • Medicaid and Children’s Health Insurance Program (CHIP) cover more than 1 in every 3 children

  • In June 2013, over 28 million children were enrolled in Medicaid and 5.7 million were enrolled in CHIP

  • The ACA expanded Medicaid to nearly all adults under age 65 with income at or below 138% FPL, effective January 1, 2014.

  • As of June 2014, 27 states, including DC, were expanding Medicaid, three states were actively debating the issue, and 21 states were not moving forward

What does Medicaid Cover?

  • inpatient and outpatient hospital services;

  • physician, midwife, and nurse practitioner services;

  • early and periodic screening, diagnosis, and treatment (EPSDT) for children up to age 21;

  • laboratory and x-ray services;

  • family planning services and supplies;

  • federally qualified health center (FQHC) and rural health clinic (RHC) services;

  • freestanding birth center services (added by ACA);

  • nursing facility (NF) services for individuals age 21+;

  • home health services for individuals entitled to NF care;

  • tobacco cessation counseling and pharmacotherapy for pregnant women (added by ACA);

  • non-emergency transportation to medical care

How do Medicaid Beneficiaries Get Care?

  • Most Medicaid beneficiaries obtain care from private office-based physicians & other health professionals.

  • Safety-net health centers and hospitals also play a major role in serving the Medicaid population.

  • Over half of Medicaid beneficiaries nationally, mostly, children and parents, are enrolled in comprehensive managed care organizations (MCO) that contract with states on a capitation, or risk, basis to deliver Medicaid services

  • A smaller but still significant number of beneficiaries are enrolled in Primary Care Case Management (PCCM) programs

How much does Medicaid cost and how is it financed?

  • In FY 2012, Medicaid spending on services totaled about $415 billion

  • Administrative costs accounted for 5% of overall program spending.

  • Two-thirds of all spending on services was attributable to acute care

  • 30% of all spending on services was associated with long-term care.

  • Supplemental payments to hospitals that serve a disproportionate share of Medicaid and uninsured patients, known as “DSH,” accounted for about 4% of spending

  • Medicaid payments for Medicare premiums and cost-sharing on behalf of dual eligible beneficiaries totaled 3.5%.

Source: Medicaid Moving Forward, The Henry J. Kaiser Family Foundation, June 17, 2014.

Additional Issue Briefs that might be of interest:

Katherine Young and Lisa Clemans-Cope and Emily Lawton and John Holahan, Medicaid Spending Growth in the Great Recession and Its Aftermath, FY 2007-2012, The Henry J. Kaiser Family Foundation, Issue Brief, July 3, 2014.

Samantha Artiga and Robin Rudowitz, Medicaid Enrollment Under the Affordable Care Act: Understanding the Numbers, The Henry J. Kaiser Family Foundation, Issue Brief, January 29, 2014.



Marketplace: 57% of New Enrollees Were Uninsured Before Signing Up

By Cyndy Nayer, July 1, 2014

Kaiser Family Foundation--KFF-- issued a new summary on the enrollees in the insurance marketplaces, which MCOL has summarized.  In short, most of the enrollees in the #ACA were uninsured before the rollout, and most of the 57% had been without coverage for 2 years.

The chronicles of the value-based movement have shown that when costs for acquisition (copays and co-insurance, often called out-of-pocket costs) are reduced, more people become engaged and adherent in their health care.  This is important in the management of chronic disease.

But if we are determined to build a culture of health in the US, then the engagement and adherence of newly-insured to prevention strategies as well as lifestyle change will be critical. The efforts in incentive-based designs (value-based for beneficiaries and for service providers, such as physicians, health plans, care coordinators, and more) must retool to encourage 24/7 improvement.  Focusing on appropriate choices whenever possible, adding 10-minute exercise breaks, and identifying friends and relatives who encourage and join in the exercise, screenings, and healthy foods are goals that we can all achieve.

Thank you to MCOL for its continued data vigilance so that, together, we can build the healthiest US.  [image courtesy of KFF]

Breakdown of Marketplace enrollees prior to purchasing current plan;

Covered by a different non-group plan 16%
Covered by Medicaid/other public program 9%
Covered by an employer/COBRA 14%
Other/Don't Know/Refused 4%
Uninsured 57%

Source: Kaiser Family Foundation


May I Speak to the Doctor's Computer? 

By Kim Bellard, June 25, 2014

There's a new provocative study in Computers in Human Behavior that suggests we may be more likely to tell the truth about personal matters, such as health problems or medical history, when talking to a virtual human instead of to an actual human.  I'm not sure if these findings threaten to set back the patient-physician relationship 10,000 years, or promise to advance it fifty years.

The article -- It's Only a Computer, by Lucas, Gratch, King, and Morency -- tested participants' willingness to disclose information to a "virtual human" on a computer screen.  When the participants believed the virtual human was fully automated instead of being controlled by a human, they reported lower fear of self-disclosure, were less likely to shade the truth in order to create a good impression ("impression management"), and were rated as being more willing to disclose information.  The key to the behavior was their belief that no human was involved, whether or not a human was actually acting behind the scenes.

The virtual human idea is not pie-in-the-sky, good only for research studies.  Versions of it are already being tested, such as by, whose digital health avatar was profiled by MIT Technology Review a year ago.  It captures patient information via an avatar, which can respond to patient statements or data and can even answer questions.  

Clearly, we're entering a new world.

The kind of artificial intelligence that might power these avatars/virtual humans can also be used to assist physicians instead of competing with them.  IBM, of course, has been touting Watson in health care for several years now.  As Wired recently reported, there are a number of AI efforts out there to assist physicians. 

Wired also notes that companies are trying to keep their products viewed as offering recommendations instead of making decisions, which would push them over into FDA approval and regulation.  We probably will get there, but that step will be a big gulp.

Some experts believe people will improve their health behaviors -- e.g., get more exercise or lose more weight -- if they know they are being monitored.  Others fear people will end up forgetting about their trackers and will slide back to their previous behaviors. 

The plethora of tracking devices poses issues not only with the sheer volume of data generated, but also with integrating the disparate data from multiple operating systems into a unified record. 

The idea that health information is only collected at a medical office or lab, and that patients should wait to act on it until a human can talk to them, is simply no longer viable.  The data are increasingly going to be available 24/7, and when it means something important there have to be mechanisms to act upon it in real-time.   Maybe that is through alerts to physicians, who then initiate contact with patients, or maybe the wearable ecosystem can trigger its own alerts and advise the user what is going on using avatars and other automated mechanisms.

A recent op-ed by Dominic Basulto in The Washington Post stated that "Google and Apple want to be your doctor, and that's a good thing."  Mr. Basulto concluded:

Companies like Apple and Google can help to break down the notion that health has to be something offered by a monolithic company with a confusing set of rules and terms. It might just be the case that mobile health care facilitated by wearable tech will turn out to be better than traditional doctors.

I think it is a stretch to say that mobile health will be "better" than traditional doctors, but I think these and other technological options can certainly radically change when, why and where people need to see physicians or other health care professionals.  And that's good.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Enrollment in Federal Marketplace & 2014 Premium Tax Credits

By Claire Thayer, June 23, 2014

Last week, the Department of Health and Human Services published an in-depth research brief that examined 19,000 Marketplace plans for 2014 and analyzed data on the change in the premium cost associated with the tax credit for Marketplace plan selections made through the Federally-Facilitated Marketplace (FFM) during the initial open enrollment period.


Study highlights and selected charts are provided below:

For additional information, download the full research report, PREMIUM AFFORDABILITY, COMPETITION, AND CHOICE IN THE HEALTH INSURANCE MARKETPLACE, 2014. Interested in learning more about public and private health insurance exchanges? Health Policy Publishing’s Health Insurance Marketplace Newsmight be just what you’re looking for! Request a complimentary sample issue:


Goldman Exec: Economy is Growing, but…

By Cyndy Nayer, CEO, Center of Health Engagement, June 18, 2014

Goldman's top economist, Jan Hatzius, believes that the US economy is now growing at an above-trend pace. This is great news regarding economics and income security. For most.

But Hatzius calls out the high student debt and overall slow pace of job creation as a hindrance to the recovery and expansion of the marketplace.  

And there is still the issue of those without health care coverage or those with income insecurity--making less than the cost of living, managing multiple jobs, or at risk of losing their pensions.  

A video was recently published on the relationship of poverty to readmissions, featuring the Detroit Henry Ford health system. When there is low income, lack of access to pharmacies and healthy food, and poor public transportation, patients discharged from hospitals are often readmitted due to poor compliance in follow-up recommendations. They skip drugs, they eat poorly and they miss regularly scheduled physician checkups. Many are readmitted to emergency rooms and inpatient stays.

This, then, becomes not only a patient risk (for both increased costs and poorer outcomes) but also a health system risk (since CMS is penalizing health systems for avoidable readmissions). Costs go up for the patient (copays, deductibles, new prescriptions, more outpatient visits). Costs go up for payers (avoidable medical and drug costs, among others; absence management if the payer is the self-insured employer). Costs go up for the community (unreimbursed medical costs go up, tax dollars are used for some of these and needed infrastructure, education, and job creation are left behind).

A new study from Mannatt and Commonwealth Fund clearly lays out the advantages of clinicians helping patients to get the community services needed to overcome these inequities.

"Before physicians can substantially cut costs and improve outcomes, they must first address patients' social needs, including whether a patient has a home or heat or access to healthy food, according to findings from a new report," says the report.

This is another opportunity for value-based reimbursements to those entities that can coordinate care beyond clinical intervention. The study calls for patient-centered medical homes (PCMH) to onboard these tasks.  

But ACOs, public health and even business entities can become allies in this effort to identify resources to improve access to healthy food, needed pharmaceuticals, expanded consumer debt counseling and educational resources.

Using value-based reimbursement strategies, payers, health systems and public entities could benefit by providing clear increases to those clinical practices that use care coordination and document better health and health cost outcomes.

Sometimes, health is achieved through non-clinical, social determinants (influences) that are improved by using the trusted resources in a patient's life. The physician, nurse, and pharmacist are 3 of the most influential.


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