Lecture on access to care in Georgia and nationally with a focus on the Affordable Care Act

1. Access to care in Georgia: an
advocate’s perspective
Cindy Zeldin
Georgians for a Healthy Future
Presentation for Trinity Presbyterian Church
November 1, 2015

2. About Georgians for a Healthy Future
Georgians for a Healthy Future provides a strong voice for
consumers and communities on the health care policy issues and
decisions that impact their lives.

3. Overview of today’s discussion
• Access to care: a conceptual framework
• Where does health insurance fit in?
• The Affordable Care Act (ACA): a brief overview of the law’s coverage
and access provisions
• Health policy, including the ACA, in Georgia:
– Enrollment in new coverage options
– The coverage gap
• Opportunities for engagement in health policy issues

4. Having a
hospital in
your
community?
Enrolling in
health
insurance?
What is access to care?
Regularly seeing a
primary care provider?
Being able to afford
needed medications?
Having a source of
care in the event of
trauma or a major
diagnosis?
Receiving
recommended
cancer
screenings?

5. Access to care
According to the Institute of Medicine:
Access is the timely use of health services to
achieve the best possible health outcomes.
Source: Institute of Medicine, Access to Health Care in America, 1993.

6. Source: Weissman and Epstein Model of Access, “Falling Through the Safety Net: Insurance Status and Access to Care”
Access to Care: A Framework
Health Care
System
Access to Health
Care
Measured by:
Structural, Process, and Outcome
Indicators
Health Needs
Predisposing
Characteristics

7. Access to Care
How do we measure access to care?
• Potential access measures
– number of physicians per capita
– usual source of care
• Realized access measures
– any physician visit in the last year
– cancer screenings
• “Blended” measures (tend to be negative, or signs of
unmet need)
– Avoidable hospitalizations
– ER visit in the last year
– diabetic amputation

8. Access to Care: The Role of Coverage
Strong body of evidence in the health policy literature that:
• Health insurance is associated with better health outcomes
• The uninsured are less likely to have a usual source of care and more
likely to report not getting the care they need
• The uninsured are more likely to experience avoidable
hospitalizations
• The uninsured are less likely to get recommended cancer screenings
• The uninsured are less likely to have chronic diseases appropriately
managed

9. Why Did Health Reform Happen
in 2010?
• Previous attempts at comprehensive health reform failed
• Incrementalism has historically defined health policy
– rise of employer-sponsored health insurance in the post WWII era
– Medicare & Medicaid in 1965
– Children’s Health Insurance Program in 1997
– Medicare Modernization Act (drug benefit) in 2003
– and many other examples
• And yet…
– A growing consensus emerged in the 15 years between the failure
of the Health Security Act (Clinton reform effort) and the
development of the Affordable Care Act that the high number of
uninsured Americans needed to be addressed and that the status
quo was unsustainable

10. 16.7
12.0
17.2
16.3
17.5
16.1
18.2
13.3
10.7
0
2
4
6
8
10
12
14
16
18
20
1972
1974
1976
1978
1980
1982
1983
1984
1986
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015*
Note: 2015 data is for Q1 only.
Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01and
http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201508.pdf
Uninsured Rate Among the Nonelderly Population, 1972-
2015 (slide from Kaiser Family Foundation)
Share of population uninsured:

11. 0
10
20
30
40
50
60
70
80
90
1972
1974
1976
1978
1980
1982
1983
1984
1986
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015*
Uninsured Private Public
Note: 2015 data is for Q1 only.
Source: CDC/NCHS, National Health Interview Survey, reported in
http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and
http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201508.pdf
Health Insurance Coverage Among the Nonelderly Population, 1972-
2015 (slide from Kaiser Family Foundation)
Share of population:

12. Cumulative Increases in Health Insurance Premiums, Workers’
Contributions to Premiums, Inflation, and Workers’ Earnings,
1999-2012 (slide from Kaiser Family Foundation)
38%
109%
172%
38%
113%
180%
11%
29%
47%
8%
24%
38%
0%
20%
40%
60%
80%
100%
120%
140%
160%
180%
200%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Health Insurance Premiums
Workers' Contribution to Premiums
Workers' Earnings
Overall Inflation
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012. Bureau of Labor Statistics, Consumer Price Index, U.S. City
Average of Annual Inflation (April to April), 1999-2012; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment
Statistics Survey, 1999-2012 (April to April).

13. Why Did Health Reform Happen
in 2010?
• Health care costs consistently rising faster than wages and inflation
• Stubbornly high number of uninsured (nearly 50 mil in 2010)
• Non-group health insurance market functioned poorly for consumers
• Uneven health care quality
• Political window of opportunity
• Many lessons learned and best practices from state experimentation
• Health insurance more amendable to public policy intervention than
other social determinants of health
• Health reform remains a very polarizing issue, however

14. Key Coverage Provisions of the ACA
• Guiding philosophy that all Americans should have a
pathway to coverage
• Achieved through:
– new rules of the road for insurance companies (for example, no
denials for pre-existing conditions)
– health insurance exchanges
– new subsidies/tax credits
– expansion of Medicaid (made optional by SCOTUS ruling in 2012)
– individual mandate
– employment-based health insurance and Medicare maintained

15. Early Evidence
• Uninsured rate has plummeted, particularly in states that
expanded Medicaid
• Insurance gains have been more modest in Georgia, where
a “coverage gap” persists
• Kentucky and Arkansas: uninsured rates dropped from more
than 20 percent to below 10 percent
• Kentucky (and other states) starting to see an uptick in
preventive services utilization
• Newly covered overwhelmingly report they can access care
• Concerns on the horizon: high deductibles; drug costs;
narrow networks

16. NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, MI, PA and NH have
approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA
expansion.
SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015.
http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
Current Status of State Medicaid Expansion Decisions
(slide from Kaiser Family Foundation)
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI
PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV
NE
MT**
MO
MS
MN
MI*
MA
MD
ME
LA
KYKS
IA*
IN*IL
ID
HI
GA
FL
DC
DE
CT
CO
CA
AR*AZ
AK
AL
Adopted (31 States including DC)
Adoption Under Discussion (1 State)
Not Adopting At This Time (19 States)

17. Distribution of Adults in the Coverage Gap, by State
and Region (slide from Kaiser Family Foundation)

18. 5 Understanding Medicaid in Georgia and the Opportunity to Improve It
v1 / September 2015
Who Gets Medicaid in Georgia?
Several populations are covered and each group has its own
income eligibility guidelines.
Eligibility levels determine who can receive Medicaid
coverage. States set eligibility levels based on
personal income and assets. Eligibility levels for
children, parents, and pregnant women include a
5% income disregard.
Georgia has set very restrictive Medicaid eligibility.
Elderly, blind, and disabled people cannot have income
higher than 75 percent federal poverty level (FPL) or
$13,200 for an elderly couple. Income limits are higher
for those needing long-term care.
Parents with minor children must earn an annual
income below 38 percent FPL or $7,600 for a family
of three in order to qualify for Medicaid.
Pregnant women cannot have income higher than
225 percent FPL which is $26,500 for an individual or
$45,200 for a family of three.
Children are eligible for Medicaid at varying rates as
they age, starting at 210 percent FPL for an infant
up to age 1, decreasing to 138 percent FPL for children
ages 6-19. Children in families beyond these income
limits can get coverage through PeachCare for Kids,
which covers children up to 252 percent FPL or
$50,600 for a family of three.
Adults without dependent children are not eligible
for Medicaid in Georgia.
Source: Georgia Department of Community Health, thresholds rounded
Not
eligible
50%0% 100% 150% 200% 250% 300%
ADULT WITHOUT
DEPENDENT CHILDREN
PARENT
AGED, BLIND, DISABLED
BREAST & CERVICAL
CANCER
NURSING HOME &
COMMUNITY CARE
PREGNANT WOMEN
RIGHT FROM THE START
MEDICAID FOR CHILDREN
% FEDERAL POVERTY LEVEL
Children Elgibility Levels are Cumulative
Children Ages 6-19
Children Ages 1-5
Children Ages 0-1
PeachCare
For more information on poverty level by family size, see Appendix.
The Federal Poverty Line is
$11,770 for an individual and
$15,930 for a couple.

19. 10 Understanding Medicaid in Georgia and the Opportunity to Improve It
v1 / September 2015
Georgia’s Health Insurance Coverage Gap
Parents are only eligible for Medicaid
if they earn less than 38 percent of
Federal Poverty Level. For a single
parent with one child, this means the
parent loses eligibility if they make more
than about $6,000 annually. They do
not become eligible for subsidies to
purchase private insurance until they
make above $15,930. This leaves a
large insurance coverage gap for
low-income adults trying to access
affordable health insurance.
A single adult or couple without
dependent children are not eligible for
Medicaid at all. They remain in the
coverage gap unless they make more
than $11,770 or $15,930 respectively.
Many people in the coverage gap
work low-wage jobs where they are
not offered health benefits. A person
making minimum wage would have
to work more than 30 hours per
week all year to earn enough income
to qualify for subsidies through the
federal health insurance marketplace.
INSURANCE
MARKETPLACE
COVERAGE
CURRENT
MEDICAID
COVERAGE
VETERANS
WORKING
PARENTS
LOW-WAGE
WORKERS
COVERAGE GAP
300,000
uninsured Georgians
are now in the coverage gap, where they are ineligible to enroll in
Medicaid and do not earn enough to get tax credits on healthcare.gov.

20. 11 Understanding Medicaid in Georgia and the Opportunity to Improve It
v1 / September 2015
The Affordable Care Act (ACA) offers
states an option to increase Medicaid
eligibility for adults up to 138% FPL.
This is equal to an annual income of
$16,200 for an individual and $ 27,700
for a family of three in 2015.
This expanded eligibility would primarily
help parents and other working adults
who are not offered coverage
through their jobs and cannot afford
other coverage.
75 138
38 138
138
% FPL
20%0% 40% 60% 80% 100% 120% 140% 160%
CHILDLESS
ADULT
PARENT
AGED, BLIND, &
DISABLED
Using Medicaid to Close the Coverage Gap
Current & Expanded Eligibility
ACA offers states an option
to increase Medicaid eligibility
(for adults) up to 138% FPL
= $16,243
Annual Income
Individual
= $27,724
Annual Income
Parent, family of 3
= $16,243
Annual Income
Individual
138%
Current eligibility
Expanded eligibility
Source: Georgia Department of Community Health, 2015 Financial Limits

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12 Understanding Medicaid in Georgia and the Opportunity to Improve It
v1 / September 2015
Approximately 500,000 Georgians
could enroll in quality, affordable
health insurance if Georgia closes
its coverage gap.
This would drastically reduce
the number of uninsured amongst
low-income individuals in the state.
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under 45%
55% and above
50 to 54%
45 to 49%
Communities Across Georgia Stand to Benefit
Percent of uninsured adults who could get Medicaid
ECHOLS
Source: GBPI analysis of U.S Census Bureau data. Specific county-by-county figures available upon request

22. Enrollment in Georgia: Highlights from Last Year

23. Open Enrollment 3 is Here!

24. Open Enrollment 3 is Here!
• In Georgia, 1.5 million still uninsured
• Of these Georgians:
– 27% eligible for tax credits/exchange plans
– 13% Medicaid eligible
– 20% in the coverage gap
– 40% ineligible for financial assistance due to income,
ESI offer, or citizenship status
• In-person assistance is critical
– Consumers who had in-person enrollment assistance
were 2x as likely to enroll
– Many eligible uninsured don’t know they are eligible

25. What’s Next in Health Policy?
• Closing the Coverage Gap & Enrolling
Remaining Eligible Uninsured
• Enhancing value for consumers
(containing costs & improving quality)
• Upstream factors & social determinants of
health
• And more…

26. Thank you!
Cindy Zeldin
Executive Director
Georgians for a Healthy Future
czeldin@healthyfuturega.org
100 Edgewood Avenue, Suite 1015
Atlanta, GA 30303
Phone: 404-567-5016
Fax: 404-935-9885
info@healthyfuturega.org
healthyfuturega.org
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