Commonwealth Fund study shows insurance gaps remain
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify potential risk factors and interventions for patients who still don’t have health insurance under the Affordable Care Act
While some 26 million Americans have gained insurance since the Affordable Care Act (ACA) became effective in 2010, another 24 million U.S. adults are still living without coverage, according to a new report by the Commonwealth Fund, a private, nonprofit organization that supports health policy research and reform.
This is a concern because not only are uninsured adults likely to skip needed health services due to the cost, but a lack of insurance is also a risk factor for preventable hospitalizations and health declines due to chronic diseases, according to the Henry J. Kaiser Family Foundation (http://ow.ly/Bs3a304bJR7).
So who are these uninsured Americans? According to The Commonwealth Fund survey (http://ow.ly/I8uZ304cB2b), 88% are Latinos under the age of 35 who earn less than $ 16,243 and/or work for a small business. "Half (51%) of the remaining uninsured live in one of the 20 states that had not yet expanded Medicaid at the time of the survey," states a press release issued by the Commonwealth Fund (http://ow.ly/gqsB304bJZk).
Case managers should take note of the survey findings.
"The Commonwealth Fund analysis is beneficial to all case managers, because the uninsured population compromises our most at high-risk groups of patients," says June Stark, RN, BSN, Med, director of care coordination at St. Elizabeth’s Medical Center in Boston. "Most hospitals today seem to be the primary source of healthcare provision to the patients in their communities. Expanding the case manager’s understanding of this population can contribute to the development of successful strategies for managing this group."
About the study
The study, called The Commonwealth Fund Affordable Care Act Tracking Survey, consisted of 15-minute telephone interviews. Interviewers conducted the interviews in two languages, either English or Spanish, between February and April 2016. The data was collected by calling a random, nationally representative sample of nearly 5,000 adults ages 19?64.
Since the ACA went into effect, the uninsured population shifted from mostly white adults to Latinos, according to the Commonwealth Fund press release. Results also show that renewed efforts to help uninsured individuals gain coverage might also be in order.
"The ACA held promise for many, especially those with incomes that could bear new market sticker prices, and as can be seen from the study, diverse populations benefitted from targeted reform marketing efforts," says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the director of case management and bed management for RWJBarnabas Health in Toms River, New Jersey. "Yet it is very apparent that while there has been success with some at-risk populations, those with the lowest incomes who do not qualify for Medicaid are still struggling."
This study, she says, shows it may be time for a revival of the initial efforts to enroll Americans in health plans, which have become less prominent over time. There may also be a role for case managers and social workers to help guide uninsured patients they encounter in the hospital to seek coverage.
"The case manager has an active role in helping patients acquire insurance coverage," says Stark. "A mainstay of the traditional case manager role is, during the admission assessment, to determine if the patient has insurance and if so, to validate if it is correct and active. This is accomplished by interviewing the patient, viewing their insurance card, and checking further with the help of the hospital’s financial counselors."
If a patient is uninsured, case managers should refer him or her to financial counselors to determine the patient’s eligibility and to help him or her secure insurance during the hospital stay, she adds.
"The case manager’s efforts to secure insurance is essential, as the specific insurance benefits drive what discharge options are available for the patient, and therefore, helps secure a safe discharge plan," says Stark.
Social workers, too, play a role.
"It is often the social work partner in a case management relationship who provides the under-insured and uninsured the counseling, available tools and resources, and sometimes the hands-on, step-by-step training to explore with patients and families their income/assets/spending and eligibility for entitlement programs or market products," says Kates. "It is a continuous conversation that has been rooted in a long history of patient intervention by social work. Possessing expert knowledge in federal and state eligibility requirements, financial/social access limits, and having strong relationships with county and state providers, the social worker will connect services with patients."
In their role as patient advocates, case managers and social workers can help to break down cultural and social barriers, such as language and access based on geography, she adds.
Action points from the Commonwealth Fund
The Commonwealth Fund study authors agree with Kates that enhancing efforts to reach the uninsured and help them enroll in health plans should be a goal based on these findings. Only 62% of people without insurance said they knew about insurance marketplaces.
They also recommend a number of other steps that they say could help more of these uninsured individuals gain coverage. Their recommendations are as follows:
- Expand state eligibility for Medicare coverage, a move that Commonwealth Fund authors say would "immediately extend health insurance to millions of uninsured people." Twenty states had not yet expanded Medicaid coverage at the time of the survey. If they had, one-third of all adults without insurance would qualify for Medicaid coverage. "This especially affects uninsured young adults, of whom 38% or an estimated 4 million, have incomes that would qualify them for Medicaid but live in non-expansion states," states the press release.
- Enhance subsidies and lower cost-sharing in marketplace plans to help more people afford insurance. Many people without insurance believe they can’t afford it?even if they might qualify for financial help under the ACA. Some 85% of those without insurance who did shop for a plan said they couldn’t find an affordable option. "A large majority of this group, who were also uninsured, had incomes qualifying them for subsidies or Medicaid, though some may not have been eligible due to their immigration status," states the press release.
- Promote immigration reform. Changing immigration rules would help more people gain insurance coverage. "A loosening of the law’s restrictions on eligibility for undocumented immigrants would also help," states the Commonwealth Fund press release. While the survey data didn’t definitely prove that this is the case, study authors suspect that many Latinos lack insurance coverage because they may be undocumented and not eligible for coverage under the ACA. Other risk factors that may also be at play: Latinos make up nearly half of adults who are earning less than 138% of the poverty level?$ 16,243 for one person or $ 33,465 for a family of four.
Ultimately, using a combination of local and federal interventions can help the U.S. move closer to its goal of helping get coverage for all its citizens.