STUDY OF THE IMPACT OF THE AFFORDABLE CARE ACT (ACA) IMPLEMENTATION IN KENTUCKY

STUDY OF THE IMPACT OF THE AFFORDABLE CARE ACT (ACA) IMPLEMENTATION IN KENTUCKY Webinar April 27, 2017, 1:00 PM CDT You will be connected to broadcast audio through your computer. You can also connect via telephone: (888)-504-7949, Conference ID 368192 Slides and handouts at: http://www.shadac.org/kywebinar

Technical Items For those dialing in: Phones automatically muted Submit questions using the chat window at any time during the webinar Problems: Call Readytalk s help line: (800) 843-9166 Ask for help using the chat feature Download the slides at http://www.shadac.org/kywebinar Webinar archive will be posted on SHADAC s website E-mail notice will be sent to participants 4/27/2017 2

Introduction Gabriela Alcalde Foundation for a Healthy Kentucky Lynn Blewett SHADAC Colin Planalp SHADAC 4/27/2017 3

Study of the Impact of the ACA Implementation in Kentucky: One Foundation s Approach Gabriela Alcalde, MPH, DrPH

(New) Mission and Vision Mission To address the unmet health needs of Kentuckians by developing and influencing policy, improving access to care, reducing health risks and disparities, and promoting health equity. Vision A Kentucky where every individual and community reaches their highest levels of health.

Promoting Response Health Policy (PRHP) An initiative aimed at making public policy more responsive to the health and health care needs of the people of Kentucky, with a focus on four (4) policy priorities: 1. Increasing access to care 2. Strengthening local public health 3. Improving children s health 4. Increasing the proportion of Kentuckians living in smokefree jurisdictions To advance these priorities, the Foundation makes grants, invests in research and data efforts, convenes stakeholder groups in forums and meetings so they can share information and work together, and supports relationship- and capacitybuilding activities.

Purpose of Study Significant health policy change provides an unprecedented opportunity to analyze the impacts of this system change on coverage, access, cost, quality, and outcomes; particularly for historically underserved populations, during the first years of implementation. As the only southern state to expand Medicaid and establish a statebased health benefit exchange, Kentucky offers a unique case study. Plan for the study findings and reports to be made accessible to key state health policy makers and other civically engaged parties. To serve as a credible, nonpartisan expert resource for health and health care stakeholders in Kentucky.

Purpose of the Study (continued) To serve as a resource to other states wishing to compare and learn from other states experiences in implementing the ACA, as well as lessons for federal level in designing health policy to be implemented by the states. To report knowledgeably on trends in coverage, access, quality, cost, and outcomes and to identify elements of the implementation process that were important to the identified impacts, whether positive or negative. To result in an objective, mixed methods study analyzing key effects of implementing the Affordable Care Act (ACA) in Kentucky, over a three-year period.

Reports and Deliverables Baseline report Special reports: Impact on Children s Coverage High Deductible Health Insurance Substance Use and the ACA Emergency Department Utilization Annual and semi-annual reports Quarterly data snapshots Final report All available on Foundation s website, www.healthy-ky.org/research

Thank you Questions? Email: GAlcalde@healthy-ky.org

STUDY FINDINGS Colin Planalp, MPA Research Fellow, SHADAC 12

Kentucky s Implementation of the ACA Patient Protection and Affordable Care Act signed into law Kentucky expands Medicaid and launches Statebased Marketplace (SBM) State switches to Healthcare.gov platform, and submits Section 1115 waiver to modify Medicaid expansion 2010 2011 2012 2013 2014 2015 2016 U.S. Supreme Court upholds ACA, but effectively makes Medicaid expansion a state option New governor elected after campaigning to reverse Medicaid expansion and close SBM 4/27/2017 13

Kentucky s Implementation of the ACA Pre-ACA baseline ACA implementation 2010 2011 2012 2013 2014 2015 2016 4/27/2017 14

About our study Multi-year study of the impacts of the ACA in Kentucky Focused on 5 key domains: Coverage Access Cost Quality Health Outcomes 4/27/2017 15

Coverage Since 2012, Kentucky s uninsurance rate has dropped by more than half Insurance Coverage by Type for Kentucky and the U.S., 2012 & 2015 (all ages) 100% 80% Employer Individual Medicaid/CHIP Medicare Uninsured 13.6% 17.4% 6.1%* 18.9%* 14.7% 15.4% 9.4%* 16.5%* 60% 13.4% 19.8%* 13.4% 15.7%* 4.4% 5.3%* 5.2% 7.1%* 40% 20% 51.2% 50.0% 51.4% 51.4% 0% 2012 2015 2012 2015 Source: SHADAC analysis of ACS KY *difference is statistically significant at the 95% level U.S. 6

Coverage Uninsurance dropped among whites, African Americans Uninsured Rates by Race/Ethnicity for Kentucky, 2012-2015 (all ages) 2012 2015 30% 25% 28.7% 24.2% 20% 15% 12.6% 17.3% 16.9% 12.5% 15.5% 10% 8.2%* 5% 5.3%* 5.5%* 0% Hispanic/Latino White African American/Black Asian Other/Multiple Source: SHADAC analysis of ACS *difference is statistically significant at the 95% level 8

Coverage Uninsurance declined significantly among all ages Uninsured Rates by Age Category for Kentucky, 2012-2015 (ages 0-64) 30% 25% 26.5% 2012 2015 22.6% 20% 16.9% 15% 10% 5% 6.4% 4.5%* 11.2%* 10.0%* 6.5%* 11.4% 4.5%* 0% 0-18 19-25 26-44 45-54 55-64 Source: SHADAC analysis of ACS *difference is statistically significant at the 95% level 9

Coverage All income categories saw declines in uninsurance Uninsured Rates by Income as Percent of Federal Poverty Guidelines for Kentucky, 2012-2015 (all ages) 30% 2012 2015 25% 25.0% 20% 17.5% 15% 10% 9.4%* 8.3%* 8.1% 5% 5.1%* 2.9% 1.9%* 0% 0-138% 139-200% 201-400% 401%+ Source: SHADAC analysis of ACS *difference is statistically significant at the 95% level 10

Coverage Cost cited as most common reason for being uninsured Main Reason Cited for Being Uninsured, 2016 Reason Percent Too expensive/ could not afford 56.2% Do not need health insurance 10.0% Unemployed/ not working 8.7% Will get insurance soon 6.9% Don t want government involved in their health care 5.3% Not eligible/ health condition 5.3% Spiritual/ natural healing 2.4% Do not know how 2.3% Never looked into it 2.0% Other 1.0% Source: 2016 Kentucky Health Reform Survey 21

Coverage Cost cited as most common reason for being uninsured Main Reason Cited for Being Uninsured, 2016 Reason Percent Too expensive/ could not afford 56.2% Do not need health insurance 10.0% Unemployed/ not working 8.7% Will get insurance soon 6.9% Don t want government involved in their health care 5.3% Not eligible/ health condition 5.3% Spiritual/ natural healing 2.4% Less than 1 in 5 cited reasons suggesting opposition to coverage Do not know how 2.3% Never looked into it 2.0% Other 1.0% Source: 2016 Kentucky Health Reform Survey 23

Coverage Marketplace plan selections ranged from about 80,000 to 105,000 each open enrollment period Marketplace Plan Selections, OEP 1-3 Source: ASPE Health Insurance Marketplace reports 25

Coverage Marketplace plan selections ranged from about 80,000 to 105,000 each open enrollment period Marketplace Plan Selections, OEP 1-3 29% Source: ASPE Health Insurance Marketplace reports 26

Coverage Marketplace plan selections ranged from about 80,000 to 105,000 each open enrollment period Marketplace Plan Selections, OEP 1-3 12% Source: ASPE Health Insurance Marketplace reports 27

Coverage Enrollment increased in expansion and traditional Medicaid since first quarter of ACA implementation Quarterly Medicaid Enrollment, 2014-2016 600,000 500,000 400,000 Expansion Traditional income-based 506,317 300,000 260,535 200,000 100,000 116,421 144,550 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2014 2015 2016 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services 29

Coverage Enrollment increased in expansion and traditional Medicaid since first quarter of ACA implementation Quarterly Medicaid Enrollment, 2014-2016 600,000 500,000 400,000 Expansion Traditional income-based 94% 506,317 300,000 260,535 200,000 100,000 116,421 144,550 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2014 2015 2016 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services 30

Coverage Enrollment increased in expansion and traditional Medicaid since first quarter of ACA implementation Quarterly Medicaid Enrollment, 2014-2016 600,000 500,000 400,000 Expansion Traditional income-based 506,317 300,000 200,000 100,000 260,535 116,421 24% 144,550 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2014 2015 2016 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services 31

Coverage Younger adults lead Medicaid enrollment Total Enrollment by Age, Quarter 3 of 2016 Expansion Traditonal income-based 19-25 108,839 39,086 26-34 128,221 53,787 35-44 111,284 38,539 45-54 96,388 11,683 55-64 61,585 1,455 0 50,000 100,000 150,000 200,000 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services 32

Coverage Drop in employers offering coverage driven by small firms Employer Offer Rates by Private Sector Employers for Kentucky, 2012-2015 100% 2012 2015 98.7% 98.3% 80% 60% 54.4% 47.8%* 40% 20% 36.4% 26.6%* 0% All private sector employers Firms with less than 50 employees Firms with 50 or more employees Source: SHADAC analysis of MEPS-IC *difference is statistically significant at the 95% level 24

Coverage Since 2012, Kentucky had the second-largest decline in its uninsurance rate after only West Virginia Uninsurance, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) Source: SHADAC analysis of ACS *difference is statistically significant at the 95% level 35

Coverage More low-income concerned about losing coverage Concern About Losing Current Coverage by Type and Income, 2016 30% 25.8%* 20% 18.5%* 11.4% 12.6% 10% 5.8%* 3.9%* 0% Total Public Private <138% FPG 138-200% FPG 200+% FPG Source: 2016 Kentucky Health Reform Survey *difference is statistically significant from total at the 95% level 28

Access Significantly more Kentuckians reported a usual source of care Usual Source of Care by Age Category, Kentucky, 2012-2015 2012 2015 100% 80% 82.3% 89.7%* 93.8% 96.6% 75.6% 84.4%* 60% 40% 20% 0% All 0-18 19-64 Source: SHADAC analysis of NHIS *difference is statistically significant at the 95% level 29

Access Fewer elderly Kentuckians responded to drug-cost barriers Skipping, Delaying, or Altering Prescription Drug Use Due to Cost, Kentucky, 2012-2015 (ages 19-64 & 65+) 40% 34.1% 2012 2015 30% 27.2% 26.2% 20% 13.6%* 10% 0% 19-64 65+ Source: SHADAC analysis of NHIS *difference is statistically significant at the 95% level 31

Access Breast cancer screenings covered by Medicaid have continued to increase since 2014 Quarterly Breast Cancer Screenings, 2014-2016 Expansion Traditional income-based 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 8,920 5,453 1,082 1,223 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2014 2015 2016 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services 44

Access Substance use treatment services increased for traditional and expansion Medicaid enrollees Quarterly Substance Use Services, 2014-2016 Expansion Traditional income-based 14,000 12,000 12,319 10,000 8,000 6,000 4,000 4,472 2,000 0 1,504 1,268 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2014 2015 2016 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services 45

Access One in four Kentuckians used Emergency Department Emergency Department Visits in the Past Year, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) Source: SHADAC analysis of NHIS *difference is statistically significant at the 95% level 46

Access One in four Kentuckians used emergency department Emergency Department Visits in the Past Year, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) Source: SHADAC analysis of data from the Kentucky Hospital Association 47

Access One in four Kentuckians used Emergency Department Emergency Department Visits in the Past Year, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) 30.2% Medicaid 46.9% Source: SHADAC analysis of data from the Kentucky Hospital Association 48

Access One in four Kentuckians used Emergency Department Emergency Department Visits in the Past Year, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) Self-pay and charity care 23.2% 5.9% Source: SHADAC analysis of data from the Kentucky Hospital Association 49

Access One in four Kentuckians used Emergency Department Emergency Department Visits in the Past Year, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) 5% Source: SHADAC analysis of data from the Kentucky Hospital Association 50

Cost Fewer Kentuckians reported trouble paying medical bills Trouble Paying Medical Bills, Kentucky Compared to Neighboring States and U.S. Rate, 2012 & 2015 (all ages) Source: SHADAC analysis of NHIS *difference is statistically significant at the 95% level 51

Cost Delayed and forgone care declined significantly Delayed or Went Without Needed Care Due to Cost by Age Category, Kentucky, 2012-2015 20% 2012 2015 16.9% 15% 14.4% 10% 5% 11.7% 6.5%* 10.0% 4.9%* 9.0%* 7.3%* 0% Delayed care Went without care Delayed care Went without care All 19-64 Source: SHADAC analysis of NHIS *difference is statistically significant at the 95% level 43

Cost Hospital charity care and self-pay charges declined Hospital Charity Care and Self-Pay Charges in Dollars (millions), Kentucky, 2012-2015 $3,000 $2,500 $2,396 $2,570 $2,000 $1,500 $1,000 $942 $786 $500 $0 2012 2013 2014 2015 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services Kentucky Hospital Administration Claims Data 56

Cost Hospital charity care and self-pay charges declined Hospital Charity Care and Self-Pay Charges in Dollars (millions), Kentucky, 2012-2015 $3,000 $2,500 $2,396 $2,570 $2,000 $1,500 $1,000 $500 $942 $786 67% $0 2012 2013 2014 2015 Source: SHADAC analysis of data from the Kentucky Cabinet for Health and Family Services Kentucky Hospital Administration Claims Data 57

Cost Lower 2016 Marketplace Plan Costs Than Neighbors Median Silver Plan Premium for 30-year-old Couple with Two Children, 2016 Source: SHADAC analysis of Robert Wood Johnson Foundation and Manatt, Phelps & Phillips HIX Compare 2015 2016 58

Cost Kentucky APTCs Were Smaller, Fewer Received Them Percentage of Marketplace Enrollees Receiving Advanced Premium Tax Credits (APTCs) and Average Monthly APTC, U.S. and Kentucky, 2015 & 2016 Source: CMS Effectuated Enrollment Snapshots, 2015 & 2016 59

Quality Racial disparities continued in low birth weight Low Birth Weight for Births by Race/Ethnicity, Kentucky, 2012-2015 (all births) 2012 2015 15% 13.8% 13.9% 10% 8.7% 8.7% 8.2% 8.2% 6.8% 6.5% 5% 0% All Non-Hispanic White Non-Hispanic Black Hispanic Source: National Vital Statistics Reports 60

Quality Breastfeeding grew to more than two-thirds of births Breastfeeding Initiation Rates, Kentucky, 2012-2015 (newborn infants) 75% +5.9pp 70% 68.7% 66.4% 65% 62.8% 63.9% 60% 2012 2013 2014 2015 Source: Kentucky Department for Public Health Note: Data are still preliminary for 2014 and 2015. 61

Health outcomes Nearly one in four Kentucky adults report fair or poor health Poor/Fair Health, Kentucky Compared to Neighboring States and U.S. Rate, 2012-2015 (ages 18+) Source: SHADAC analysis of BRFSS *difference is statistically significant at the 95% level 62

CONCLUSIONS 64

Conclusions Commonwealth has experienced clear improvements in coverage since before ACA Some improvements seen in access and cost domains Quality and health outcomes have remained largely stable 65

THANK YOU! Colin Planalp, MPA Research Fellow cplanalp@umn.edu State Health Access Data Assistance Center (SHADAC) University of Minnesota, Minneapolis 4/27/2017 66

Lynn Blewett SHADAC QUESTIONS? Gabriela Alcalde Foundation for a Healthy Kentucky Colin Planalp SHADAC Submit questions using the chat window. 4/27/2017 67

Contact Information Direct inquires to Colin Planalp, cplanalp@umn.edu or shadac@umn.edu 4/27/2017 www.shadac.org @shadac