Better Safety Net Programs for the Uninsured:
G tti to
Getting
t Universal
U i
l Access
A
Mark A
A. Hall
Hall, J
J.D.
D
Professor, Social Science & Health Policy
Wenke Hwang,
Hwang Ph.D.
Ph D and Alison Snow Jones,
Jones Ph.D.
Ph D
AcademyHealth, Boston MA | MAY 12, 2009
23 Million Uninsured
23 Million Uninsured
• Citizen scofflaws
• Illegal aliens
Illegal aliens
• Earn $90,000 ‐ $120,000
Massachusetts Uninsured
Massachusetts Uninsured
•
•
•
•
•
•
•
Noncitizen
7%
Penalized
Penalized 18%
Income <150% FPL 46% (33%)
Unins. < 3 months 17%
Religious exemption 2%
Religious exemption 2%
Ins. unaffordable 15%
Income >400% FPL 20%
Percent
PPACA Gap Between Mandate and S b idi
Subsidies
Medicaid
Medicaid
Income for a Family of Four % FPL (Annual Income)
% FPL (Annual Income)
Study Design
In-depth study of four model safety net programs for uninsured:
Asheville NC; Denver,
Asheville,
Denver CO; Flint,
Flint MI; and San Antonio,
Antonio TX
Each has a well-constructed program providing low-income
p
service
uninsured access to comprehensive
Public
hospital
Asheville
Denver
Flint
San
Antonio
Mainly
community
providers
Little/ No
patient
cost-sharing
Substantial
patient costsharing
Serves
undocumented
immigrants
Diversity of Location Characteristics, 2008
Community Hospital Programs
Asheville, NC
Buncombe County
Flint, MI
Genesee County
Public Hospital Programs
Denver, CO
Denver County
San Antonio, TX
Bexar County
County Demographics
Population
Minority
(US=35%)
Adults (US=17%)
Adults <200%
poverty
t (2006)
229,047
428,790
598,707
1,622,899
14%
25%
49%
68%
County Uninsured
18.60%
11.10%
24.70%
24.50%
16 171
16,171
46 432
46,432
162 591
162,591
16 086
16,086
Diversity of Program Structures
ASHEVILLE, NC
FLINT, MI
DENVER, CO
SAN ANTONIO, TX
Project Access
Genesee Health Plan
Denver Health
CareLink
6,000
21,669
26,118
41,252
35%
100%
56%
25%
Employed
Employed
p y
Public
Medicare rates
Medicare rates
Medicaid rates
$7-$35
$22 900
$22-900
2.5%-6.7% of
income
Size
Adults p
per month
Proportion of county
adults <200% FPL
enrolled
Payment
Primary care
Specialists
p
Hospital
Cost Sharing
Physician
Hospital
Employed
Charity
y
$0-$50
none
Medicaid +14%
Medicaid +4%
Charity
$3-$5
varies
aries b
by facilit
facility
San Antonio Payment Schedule
Poverty Level Monthly Payment
<75 %
2.5% of income
Average Payment
$ 15.52
<100 %
3.37% of income
<150 %
5% of income
<200 %
6 7% of income
6.7%
$103 89
$103.89
<300 %
10% of income
$192.19
$ 43.30
Better Safety Nets: Access without Insurance
•
•
•
•
Enrollment
Medical home
Medical home
Hospital, specialists, Rx
Feels like insurance coverage
– may not even realize uninsured
may not even realize uninsured
Service Use Per Adult Member, San Antonio
Office visits
ER visits
LLow‐income
i
Uninsured
74
7.4
0.36
Commercial
C
i l
Health Plan
49
4.9
0.32
R ti
Ratio
1.5
1
5
1.1
Monthly Cost for Covering Uninsured Nonelderly Adults, 2008
Safet
Safety
Net
Actual
Costs
Risk-adjusted
Comparison
Medicaid
Private
Ratio
high/low
Ratio
low/high
2.03
0.49
1 54
1.54
0 65
0.65
1.37
0.73
Asheville
NC
$149
Flint MI
$141
Denver
San
Antonio
$200
$273
$155
$267
$347
2.2
0.46
M
Mean
$1
$155
$281
$282
1 82
1.82
0
0.55
$302
$217
Conclusions/Implications
 For ¼ to ½ less than comprehensive insurance,
adequate
d
safety
f net programs can be
b constructed
d that
h
provide access that is at least minimally decent
 Safety net programs can be adapted for middle-income uninsured,
using substantial copayments that increase in income (as done in
Denver San Antonio).
Denver,
Antonio)
 Safety net programs can be constructed for smaller communities
(Asheville Flint) as well as metropolitan areas.
(Asheville,
areas
PPACA Policy Levers
PPACA Policy Levers
• Disproportionate Share Hospital (DSH) p y
payments
• Hospital charity care standards
• Various waiver/demonstration projects V i
i /d
i
j