The Journal — September 2017
Tex Med. 2017;113(9):e1.
By Carlos Ramos Gomez-Rejon, JD, PhD; Charles E. Begley, PhD; Luisa Franzini, PhD; and Henry S. Brown III, PhD
Dr Ramos Gomez-Rejon, health policy analyst, The MITRE Corporation and Adjunct Faculty at Texas A&M University-Kingsville; Dr Begley, The University of Texas Health Science Center at Houston School of Public Health; Dr Franzini, University of Maryland School of Public Health; and Dr Brown, The University of Texas School of Public Health Austin Regional Campus. Email correspondence to firstname.lastname@example.org.
The author's affiliation with The MITRE Corporation is provided for identification purposes only and is not intended to convey or imply MITRE's concurrence with, or support for, the positions, opinions, or viewpoints expressed by the author.
Under the Affordable Care Act, Texas could expand Medicaid to low-income adults. However, the state has not done so and relies on safety net programs to meet the needs of this population. The policies of President Trump's administration favor flexibility for states to design Medicaid programs. This may lead to expansions that integrate safety net components. Using data from a 2010 survey conducted in Houston, Harris County, we provide evidence on access to care differences between low-income nonelderly adults with Medicaid and those obtaining services through the Harris County Hospital District's Gold Card safety net program. We compared Medicaid and Gold Card access to that of the uninsured using five measures. After controlling for personal characteristics, access was similar for Gold Card and Medicaid beneficiaries, and access for both was significantly better than that for uninsured adults. This suggests that well-structured safety net programs and Medicaid can improve access.
Numerous studies have shown how Medicaid coverage has improved access to care for some populations like low-income children and women.1-5 However, due to limitations in eligibility in most states before the Affordable Care Act (ACA), we see less evidence of long-term benefits of Medicaid coverage for nonelderly (aged 19-64 years), nondisabled adults, who are targeted under the ACA's Medicaid expansion option.6-13 Critics argue that because of low payment rates and limited provider participation, expanding Medicaid will not be effective in increasing access for this population.14,15
Low-income adults who do not qualify for Medicaid frequently rely on local safety net programs. These programs vary enormously around Texas but typically include public hospital and clinical care at local health department and community clinics. Many of these programs currently receive federal supplemental funding support through a Social Security Act Section 1115 Medicaid waiver titled Texas Healthcare Transformation and Quality Improvement Program. This waiver includes a Delivery System Reform Incentive Payment (DSRIP) Pool and an Uncompensated Care (UC) Pool.16 The DSRIP funding consists of performance-based payments to incentivize "hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality of care, the cost-effectiveness of care provided, and the health of the patients and families served."16 The UC payments are "designed to help offset the costs of uncompensated care provided by the hospital or other providers."16
Historically, Medicaid waivers have been used for different purposes such as expanding "coverage to populations who were not otherwise eligible, changing benefits packages, and instituting delivery system reforms."17 Post-ACA, 1115 waivers have become an important financial vehicle for states to deal with "the interplay of financial needs of hospitals, the rise of Medicaid managed care, and CMS [Centers for Medicare & Medicaid Services] interest in moving toward performance-based accountability."18 Waiver funds can be significant. For example, the net worth of Texas's 1115 waiver for the 2012–16 period was $29 billion (all funds).19 Post-ACA, the role of these Medicaid supplemental funds has been in part to support and strengthen local safety net programs in achieving the Triple Aim goals: improving population health, enhancing outcomes and the experience of patients, and reducing cost of care.17
Concerns about the rising cost of medical care and the growing number of enrollees have led many states to turn to capitated managed care as the predominant delivery model for Medicaid. Under this model, the state pays private managed care organizations (MCOs) a fixed rate per enrollee per month, and the MCOs are responsible for the cost of delivering services through a network of doctors, hospitals, and other providers. The evolution from fee-for-service to the capitated MCO model in Texas Medicaid began in the early 1990s and went through several periods of expansion to different parts of the state and Medicaid eligibility groups. In 2013, a total of 71% of the Medicaid population was enrolled in MCOs, whereas by 2015, MCOs covered 87%.20-22
The interplay of safety net programs and Medicaid expansions was a source of debate between states and President Obama's administration as evidenced in the approval or extension of these waivers. For example, the Low Income Pool (LIP) program (part of Florida's 1115 waiver) was intended to temporarily support providers delivering uncompensated care while Florida's Medicaid program moved from fee-for-service to managed care.23 Upon Florida applying for renewal of the LIP program, a debate between the state and CMS ensued with CMS explaining that "coverage is the best way to secure affordable access to health care for low-income individuals and uncompensated care pool funding should not pay for costs that would be paid for in a Medicaid" expansion.24 Thus, while CMS was attempting to improve access to care by expanding Medicaid, Florida preferred addressing the problem through an 1115 waiver that would expand funding for local safety net systems.
Ultimately, CMS renewed the Florida waiver but did so for only 2 years (instead of the usual 3-year term).23,25 In addition, while President Obama was still in office, CMS set three principles to guide the review of 1115 waiver applications: "1) uncompensated care pool funding should not pay for costs that would be covered in a Medicaid expansion, 2) Medicaid payments should support services provided to Medicaid beneficiaries and low-income uninsured individuals, and 3) provider payments should promote provider participation and access, and should support plans in managing and coordinating care."23,25
Medicaid waivers are a product of the Executive Branch and, as such, their scope and durability depends largely on the priorities and values of the presidential administration.18 After the 2016 election, the role of 1115 waivers in supporting the safety net could change dramatically. Tom Price, the US Health and Human Services Secretary, and Seema Verma, the CMS administrator, seem to embody a different policy approach to one of the principles that guided the review of 1115 waiver applications under the Obama administration. Specifically, the new administration appears to support policies that would allow 1115 waiver funds to pay for costs that would be covered in a Medicaid expansion. In a letter signed jointly by Secretary Price and Administrator Verma (March 2017), the administration reaffirmed its "commitment to support and complement the various federal, state, and local programs that have demonstrated success in assisting eligible low-income adult beneficiaries" in part through the use of 1115 waivers. This is important for states like Texas that did not expand Medicaid as renewal or expansion of 1115 waivers that support the safety net is more likely under President Trump's administration.
To supplement what is known about the performance of Medicaid and local safety net programs in Texas, the objective of this study was to determine how access to care differs among low-income adults who are Medicaid beneficiaries, safety net users, or uninsured non-safety net users. To be clear, this study does not necessarily equate safety net access to insurance coverage. Some benefits associated with insurance coverage that were not analyzed in this study do go beyond access to care. Among others are economic protection, linking individuals to care, reducing out-of-pocket costs, and improving health outcomes (eg, improved rates of self-reported health status, longer life expectances, and decreased mortality rates).26-28 However, by analyzing access to care of Medicaid and safety net users, this study informs the relative effectiveness of public insurance and local safety net programs.
We compared Medicaid and Gold Card adults' access with that of their uninsured counterparts using five self-reported access measures. The study is of importance for states like Texas that have not expanded Medicaid as many uninsured adults continue to rely on the safety net. However, the study is also relevant for states that expand Medicaid as even after a potential expansion, some populations still do not qualify for Medicaid coverage and will continue relying on the safety net.29
Texas's Medicaid and the Harris Health System's Gold Card Program
To qualify for Medicaid in Texas, nonelderly adults must meet a federal poverty level (FPL) threshold and fall within a "categorically" eligible group.20 The FPL threshold varies depending on the person's "category" (eg, has a disability, is pregnant, is a parent of a child in Medicaid). In Texas, the FPL threshold for a nondisabled adult with dependent children is 15% of the FPL.20 This translates to less than $300 per month for a two-parent household. Nondisabled, nonelderly adults without children cannot qualify for Medicaid no matter how low their income is.20
Uninsured adults residing in Houston, Texas, who do not qualify for Medicaid can obtain services at the Harris Health System (HHS), a local public safety net program. HHS is a county-tax-supported system of three public hospitals and more than 20 community health clinics and centers. The HHS offers free or discounted medical services through its Financial Assistance Program, formerly known as "Gold Card" due to the color of the benefit card. Given that a large portion of the data used for this study30 predates 2010 and that the program operated for many years as Gold Card, which is how Houstonians frequently know it, we use the term Gold Card in this paper.
Under Gold Card, a person's level of subsidy is determined by a sliding FPL scale.31 Those people at or below 200% of the FPL obtain substantial discounts and are responsible for minimum copayments; however, they are not liable for additional costs. In contrast, those who are at >200% of the FPL experience higher copayments and are liable for part of the cost of services.32 Thus, Gold Card is a subsidy allowing patients to obtain services at discounted prices but is not insurance.
The HHS finances uncompensated costs not covered by Gold Card beneficiaries through a combination of local taxes, research dollars, foundation support, and federal supplemental funds. Since 2011 ― the year Texas's 1115 waiver was approved ― HHS has received about $600 million in 1115 waiver funds.33 To clarify, this does not necessarily mean that the $600 million were used to support uncompensated care costs incurred by Gold Card beneficiaries given that HHS obtained waiver-funds for different projects.
Methods of Comparison
The Behavioral Model created by Aday and Andersen guided this study.34,35 This model classifies variables into one of three categories: individual determinants, community characteristics, and health care access and outcomes. The individual determinants category is divided further into three variable groups to predict utilization: Predisposing variables, Enabling variables, and Need variables.
Predisposing variables are those that describe the tendency to use a service (eg, gender, marital status, age, employment, education, race, and ethnicity). Enabling variables describe means that facilitate access including income, insurance, and having a usual source of care (USC). Need variables capture health status or illness that could trigger use of services.
We conducted a cross-sectional analysis of data from the 2010 Health of Houston Survey (Survey), a multimodal, population-based survey designed to capture information about unmet health needs (eg, health status, utilization of services, and socioeconomic information) of adults and children residing in the greater Houston metropolitan area.36 The Survey team randomly selected households and used computer-assisted telephone interviews, interactive web questionnaires, and hardcopy mail. The content of the Survey was designed specifically to meet the data needs of the health sector.36 To assure a representative sample, the Survey divided Harris County "into seven areas corresponding to the US Census 1% Public Use Microdata Areas (or PUMAs) and employed an address-based sampling design with special selection features to insure that minorities and lower income residents" — the groups of interest in this study — were accurately represented.36 The Survey was administered in English, Spanish, and Vietnamese.36 The size of the final household sample was 5116, and information on an equal number of adult interviewees (aged 18 years or older) was collected.
Some people were excluded from this study. First, the privately insured were excluded as they are not expected to rely on Medicaid or Gold Card. Second, the elderly (≥ 65 years) were excluded as Medicare covers a large percentage of this population. Third, dual eligibles (persons simultaneously covered by Medicaid and Medicare) were excluded because mixed coverage prevents analyzing the isolated effect of Medicaid. Fourth, persons with incomes >400% of the FPL were excluded as they do not qualify for Medicaid, for ACA health insurance exchange subsidies, or generally for Gold Card subsidies. Lastly, because beneficiaries sometimes confuse Medicaid and the Children's Health Insurance Program (CHIP), to avoid accidental inclusion of CHIP beneficiaries in the study, adults younger than 19 years were also excluded as people in Texas are not eligible for CHIP at age 19 years. After the exclusions criteria were applied, 1286 subjects remained in the study. Table 1 provides the characteristics of the population in this study stratified in accordance with the type of insurance reported.
Five access measures were analyzed. Three perceived access measures relied on the following yes/no questions: Thinking about the past 12 months, was there any time that due to cost or lack of insurance you delayed or could not (1) fill a prescription for medicine for yourself, (2) see a doctor when you needed, or (3) get specialist care? A fourth measure analyzed if subjects had a USC. The fifth measure explored if a participant reported at least one medical visit in the previous 12 months.
The primary independent variable of interest was lack of coverage or type of coverage, which was captured by asking, "Are you CURRENTLY covered by any of the following types of health insurance or health coverage plans? Please tell me 'yes' or 'no' for each type of insurance." The interviewer read a list (eg, Medicaid, Medicare), and subjects selected one or more options. Subjects could also select "Other" and write the name of their insurer (if not listed). Subjects who reported Medicaid and no other coverage were classified as Medicaid. Those who selected "Other" and wrote "Gold Card," "Harris County Hospital District," or a variation of these answers were classified as Gold Card if they did not report other coverage. To clarify, Gold Card beneficiaries are uninsured persons who are identified as safety net users. This classification permits a direct analysis of the impact of the safety net among safety net users. This stratification is more precise than that of studies using the general uninsured population as a proxy of the safety net without identifying if the uninsured persons are actual safety net users.
The subjects were dichotomized into low-FPL (≤138%) and mid-FPL (>138%-400%) groups. The low-FPL group matches the general ACA Medicaid eligibility threshold. Although some people in the mid-FPL group are not always eligible for Medicaid in Texas, this group was intentionally included for two reasons. First, some eligibility groups such as pregnant women qualify for Medicaid even if their incomes are above the 138% FPL threshold.37 Second, according to a study, incomes are highly variable during the year, particularly for people at "the lower end of the income-distribution spectrum."38 Income fluctuations can occur due to shifts in employment like losing a job, changing employers, or moving to a part-time job.38 Since this study used cross-sectional data, some subjects with Medicaid coverage reported incomes in the mid-FPL group.
Subjects were classified as having a USC if they reported having one or more personal doctors/health care providers, reported one or more places they usually went to when they were sick or needed advice about their health, and did not report emergency rooms as places they usually went to when sick or needed services.
Multivariate logistic regressions were used to analyze the association of type of coverage and each of the five measures of access while controlling for other individual socioeconomic characteristics including self-perceived health status and common chronic conditions (diabetes, heart disease, high blood pressure, or asthma). All analyses were conducted using Stata version 11.2. Two-tailed P values less than or equal to .05 were considered statistically significant.
As described in Table 2 for the USC measure, when compared with the uninsured, Medicaid and Gold Card beneficiaries were significantly more likely (2.56 and 1.90 times, respectively) to report having a USC.
Similarly, for the delay/forgo medication measure, Medicaid and Gold Card beneficiaries were significantly less likely (57% and 47%, respectively) to report foregoing medications due to cost or lack of insurance when compared with the uninsured. For the delay/forgo seeing a doctor measure, when compared with the uninsured, Medicaid and Gold Card beneficiaries were significantly less likely (60% and 56%, respectively) to report delaying or forgoing seeing a doctor in the previous 12 months due to cost or lack of insurance. Likewise, for the delay/forgo seeing specialist measure, Medicaid and Gold Card beneficiaries were significantly less likely (43% and 55%, respectively) to report delaying or forgoing seeing a doctor in the previous 12 months due to cost or lack of insurance.
Finally, for the medical visit measure, when compared with the uninsured, Medicaid and Gold Card beneficiaries were significantly less likely (66% and 75%, respectively) to report not seeing a doctor in the past 12 months.
This study yielded three major findings. First, in all measures, Medicaid adult
beneficiaries enjoyed significantly better access when compared with uninsured adults, which is consistent with other studies analyzing access for publicly insured adults.4-6,8-13,26 Second, in all measures, adults in Gold Card also enjoyed significantly better access when compared with uninsured adults. Third, the magnitude of the access improvements was similar for Gold Card and Medicaid beneficiaries.
A surprising finding was that the magnitude of improved access to specialists reported by Gold Card beneficiaries when compared with the uninsured was comparable to Medicaid. A possible explanation is the level of integration within the HHS system to which Gold Card holders have access. In HHS, providers share the same electronic record system, are colocated in the same facilities, and are likely to have set patterns of referral and consultation. In addition, the HHS system includes institutions exempted from the "corporate practice of medicine" law in Texas and, therefore, HHS can directly employ physicians.39,40 As such, HHS is likely to have more standardized policies and systems for coordinating care.
Possibly, Gold Card enrollees could have sought specialist care outside of HHS; however, this is unlikely as the subsidized nature of the program is one of the main reasons people enroll in Gold Card. Also, until 2009, only HHS was serving Gold Card beneficiaries; after that year, some federally qualified health centers also began accepting Gold Card holders. Thus, the access to specialist care observed in Gold Card is more likely the result of improved care coordination and not the result of a larger number of specialist providers accepting Gold Card.
Also notable is the finding that Medicaid and Gold Card beneficiaries were more likely to report having a USC when compared with the uninsured. Multiple studies show that having a USC is an important predictor of access.41-43 Likewise, studies show that Medicaid beneficiaries are more likely to have a USC when compared with their uninsured counterparts.9,26 However, the role of the safety net in helping uninsured persons establish a USC is not well understood. Some studies suggest that the safety net improves access to a USC;44 others, that it does not;45 and others show inconclusive results.46 As mentioned, unlike other studies that used the general uninsured population as a proxy of the safety net (without identifying actual safety net users), through the Gold Card classification, this study directly identified users and analyzed their access to care. Thus, differences in the definition of "safety net" in this and the other articles may be in part responsible for the discrepancies in the USC results. A second possibility is that HHS is outperforming other safety net programs. Although the questionnaire did not capture the reason for lacking a USC, the uninsured are frequently less likely to seek a USC due to financial problems when compared with patients who have insurance.47
As previously mentioned, this study does not necessarily equate Gold Card to Medicaid coverage. The study did not analyze factors (eg, potential increases in population-wide insurance coverage) besides improvements in access. Per a Kaiser Family Foundation report, if Texas expanded Medicaid, the state's uninsured population could decrease by 27%.48 In addition, this study did not measure health outcome differences among Medicaid and Gold Card beneficiaries. Lastly, this study did not compare a critical aspect: cost. Significant federal matching funds are available to assist states in Medicaid expansion that are not available for local safety net systems, and under the ACA, supplemental funds to pay for uncompensated care costs of safety net providers (eg, disproportionate share hospital payments) are expected to decline after 2018.49 Other alternatives like subsidizing Medicaid and private coverage expansion for low-income uninsured adults (eg, Ohio's hybrid Medicaid expansion or Arkansas' private option approach) appear to have potential for bridging the gap.
These results suggest that Medicaid and well-structured safety net programs, such as the Gold Card program in Harris County, can lead to significant improvements in access to care for low-income nonelderly adults. These findings are particularly important for states like Texas that did not expand Medicaid as many uninsured adults will continue relying on the safety net to obtain services. However, they are also relevant for states that expanded Medicaid as some populations still will not qualify for Medicaid and will continue to rely on the safety net; for example, undocumented immigrants, legal residents exempt from the mandate for lack of affordable options, and those with intermittent coverage coming in and out of Medicaid.29
Some limitations should be considered when interpreting these results. First, the analysis is based on cross-sectional data that predates the ACA. However, this should be inconsequential since Texas has not expanded Medicaid, and the Gold Card program has not changed dramatically.
Second, because interviewers did not expressly inquire if the subjects had Gold Card, some might have reported being uninsured even if they had Gold Card. This is improbable, however, given that a high number of subjects reported Gold Card as "insurance" without being prompted. It has been documented in another study that even though safety net programs similar to Gold Card are not insurance per se, people often perceive them and report them as such.46 More importantly, the misclassification (if any) does not weaken the analysis. Gold Card outperformed the uninsured in all measures. Consequently, if Gold Card beneficiaries were misclassified as uninsured, the study likely underestimated the low access to care for the uninsured population. This in turn strengthens our conclusion that when compared with the uninsured, Medicaid and Gold Card improve access to health care.
Third, it is possible that uninsured beneficiaries could experience poorer health when compared with the other groups. However, given that in the medical visit model, measures of visits were dichotomized as zero or one-or-more, the impact of a person's health on this measure should be minimal. In the other models, any possible bias associated with poorer health is only indirect because access is measured in accordance with having a USC or reporting delaying or forgoing care, and none of these variables measure access in number of refills or encounters. More importantly, the model adjusted for self-perceived health status and commonly reported chronic conditions. Fourth, because of data constraints we could not determine if subjects had the same type of insurance during the previous 12 months.
The results of this study show that Medicaid and well-structured safety net programs such as Gold Card can effectively improve access to care for low-income nonelderly adults. Post-ACA, the role of the safety net — particularly in states like Texas that did not expand Medicaid — remains critically important. Compared with President Obama's administration, President Trump's administration seems more supportive of the use of 1115 waivers to federally fund safety net providers who serve the uninsured and underinsured. Furthermore, the recently proposed "repeal and replace" bill titled the American Health Care Act (AHCA) included provisions aimed at strengthening the safety net, for example, eliminating ACA disproportionate share hospital payments cuts, and providing $10 billion in safety net funding for nonexpansion states.50 The AHCA did not gather sufficient support in the Senate, and additional health care reform efforts in that chamber came to a dramatic stop in July. However, the effect of similar safety net-related provisions (if adopted by Congress) or President Trump's administration's views of 1115 waivers could profoundly influence the role and design of safety net programs across the nation.
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