Credble Numbers on Obamacare: And Why is the 16.3% Prevalence of Persons Without Health Insurance Good News?

The signed Affordable Care Act

We finally have some credible numbers on what's happened to insurance enrollment under Obamacare. The paper can be found here.

The authors used the ongoing Gallup-Healthways survey that questions representative samples of the U.S. population about their health insurance status. Since it began, this repeat survey has assessed changes in the coverage of adults 18 to 64 years of age. The authors used these data to assess the trends in insurance status that were associated with the roll-out of Obamacare between January 2012 to June 2014.

For all of 2012 and the first part of 2013, the nation's uninsured rate was 20% to 21%.  Following the star-crossed open enrollment period that began in the fall of 2013, the uninsured rate began to drop.  By April of 2014, it fell to 16.3%. 

Depending on the underlying statistical assumptions, the absolute percent increase in Americans with insurance ranged between 4.2% to 7.1%. States that took the Feds up on their offer to underwrite Medicaid expansion saw a absolute decline of 6%  of low-income Americans having no insurance.

The Population Health Blog predicted that the 2014 outcomes from Obamacare would have something for everyone.  For the news outlets (like this and this) with a reputation of being sympathetic to the Administration, positive spin abounded. In the meantime, more skeptical reporters tried to poke some holes in the data, saying the increase in insurance coverage was really thanks to gains in employment or was in reality a lousy deal thanks to narrow networks.

The PHB's take?

It's struck by the relatively modest decline in the percent of uninsured Americans. Considering the heavy price we've paid, that lingering 16.3% rate is a lot.

That price?  It includes not only the hit to our national fisc, but paralyzing partisan rancor, endless and unpredictable litigation and the precedents of White House 'pen and phone' fiat by regulation. The latter will almost certainly be used by a future Presidents on both sides of the aisle.

And so it goes.

America's Uninsured. A Reality-Based Six Point Counter Proposal

In a prior post, the Disease Management Care Blog reviewed an Annals of Internal Medicine report by Wilper and colleagues on the 25% prevalence of chronic illness among America’s uninsured. An accompanying editorial (subscription necessary, but don't bother - you'll see why soon) by Marshall Chin of the University of Chicago's Land of Make Believe dismisses the idea that extending health insurance to this group as necessary but insufficient.

Drawing on the science of quality improvement, reports from the Robert Wood Johnson Foundation and experience from the Health Disparities Collaboratives from community health centers, Dr. Chin recommends instead that every practice, every hospital and every health plan also 1) analyze quality performance data by race, language and socioeconomic and insurance status, 2) implement training programs in responding to diverse populations, 3) routinely measure reductions of inequities of care, 4) adopt clinic-based models of care that have been shown to improve care for vulnerable patients, 5) smartly align incentives that reward providers and organizations for providing care to vulnerable populations 6) allocate the resources by paying providers, especially those have a disproportionate share of uninsured persons, including ‘efforts to create and certify patient centered medical homes….’

The DMCB thinks the editorial itself is well intentioned yet insufficient. Here’s why:

While the devil is in the details underlying the content and delivery of any quality improvement activity, its impact on (for example) provider behavior, diabetes control or quality of care for the elderly is far from a sure thing. The DMCB also had little trouble finding references here and here suggesting the impact from 'collaboratives' outside of community health centers is less of a slam dunk that its advocates would have you believe. The other recommendations above are worn out nostrums of dubious evidence based on an antiquated focus on physician-centric care.

Disappointed yet undaunted by the inability of my academic colleagues to cross over from their parallel universe of contented salaried physicians, grants and tenure tracks, the DMCB would like to offer its own, if admittedly politically naïve, 6 point approach to meeting the goal of the Annals editorialist: improving care and outcomes of uninsured persons with chronic disease….'now’:

1) Develop a stripped down insurance benefit that covers that which is patently medically necessary. One could start by covering services recommended by the U.S. Preventive Health Services Task Force along with a representative standard benefit, probably with mental health parity. Assuming local or regional insurers take this on, the Feds or some other entity may need to help with reinsurance.

2) Pull out all the stops of utilization management including pre-authorization, concurrent review and denials of payment for services that require approval, specifically targeting the usual suspects: those notorious outpatient procedures, high dollar radiology and the biologicals.

3) Accept the high likelihood that extending insurance coverage to a group with a 25% prevalence of chronic illness is likely to result in costly health care utilization that will be borne by the taxpayer or add to deficit spending no matter what you do. While this is a stretch, Governor Rendell of Pennsylvania teaches us that taxpayers will accede if a) you’re up front with them and b) they believe they are getting their money’s worth.

4) Deploy disease management programs, especially ones with the years of experience in Medicaid, to temper the inevitable demand for health care services by coaching patients to use the most cost-effective care options, including self-care. And face the ugly truth: the patient centered medical home is just getting off the ground and doesn’t have the mass or scalability to carry this out. Helloooo, it's also being 'piloted' everywhere because it's unproven.

5) Start out by paying the primary care physicians, and we're not talking penurious RVUs either. Since primary care is in short supply in many areas of the United States, programs that offer alternate levels of care including non-physician practices and retail clinics will be necessary. Without it, emergency room use for persons with their new-found insurance will not only increase, it will go through the roof.

6) This is an area ripe for trying even more novel approaches to care such as upside gain sharing, combined disease management-patient centered medical home strategies, community-based lay educators, consumer incentives and private-public partnerships.

The Annals of Internal Medicine Tells Us About the Burden of Chronic Illness Among the Uninsured (and it's not pretty)

The Aug 5th issue of the Annals of Internal Medicine has an interesting article by Wilper et al from Harvard titled ‘A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults.’ The authors drilled into six years’ worth of National Health and Nutrition Examination Survey (‘NHANES’) data involving individuals between 18 and 64. Since NHANES is representative of the U.S. population, the authors were able to extrapolate the data and obtain a snapshot of the health status of the 36 million Americans in this age group who don’t have health insurance.

Their findings indicate that about one third or 11 million of these individuals have at least one chronic condition. They include cardiovascular disease (1.3 million), hypertension (5.9 million), diabetes (1.4 million), hypercholesterolemia (4 million), lung disease (3.5 million) or previous cancer (1.1 million). 23% of these persons have not seen a physician in the last year and 26% were unable to identify a particular health clinic that they rely on.

The Disease Management Care Blog’s only criticism of the study is that it’s not clear that ‘hypercholesterolemia’ is such an awful disease, since high lipids, in the absence of other risk factors, doesn’t usually warrant ‘treatment.’

Yet, this was an eye-opening study. Until this publication came alone, the DMCB underestimated the prevalence of chronic illness among the uninsured. It also needs to rethink the uninsureds’ reputation of being healthy and well-off enough to ‘risk’ going without health insurance. Last but not least, the reassurance of the ‘non-collapsing’ health care system safety-net apparently means little to the over two million uninsured persons with a chronic condition who are not making an appointment to see a doctor.

What is the solution for these millions of Americans with diabetes, high blood pressure, heart disease, lung disease and cancer in remission? The DMCB believes there merit to the notion that we need a mix of mandated participation (play or pay) plus public funding for a ‘bare necessities’ insurance product. Given the preponderance and escalating costs of chronic illness, risk pools and the individual market are not up to the task: good coverage is simply unaffordable and the death spiral will rule.

Based on Massachusetts’ experience, we are also learning that simply providing health insurance is not enough. We know that the primary care system is a key ingredient in providing cost-effective care for persons with chronic illness and that in many areas of the country, there are insufficient numbers of PCPs to meet the pent-up demand.

More on the implications of this in a future post.