Since Obamacare, officially known as the Affordable Care Act (ACA), passed in 2010, Congressional conservatives have tried to repeal the health care law more than 50 times. The most current attempt, in late 2015, was the first time both the House and Senate passed such legislation and sent it to the President’s desk. As expected, Obama vetoed the bill on Jan. 8.
But while Congress continues to battle the law, the national uninsured rate has dropped below 10 percent, and 17.6 million people have gained health insurance since the law began to take effect. In Colorado, the uninsured rate has fallen to 6.7 percent from an all-time high of 15.8 percent in 2011. According to the 2015 Colorado Health Access Survey conducted by the Colorado Health Institute, a health policy research institute in Denver, 4.9 million Coloradans now have health care coverage, a historical high.
“We call Colorado an all in state when you look at the Affordable Care Act because we expanded Medicaid here, established our own co-op, established a health insurance exchange and all of those things contributed in varying degrees to the drop in the uninsured rate,” says Jeff Bontrager at the Colorado Health Institute.
“But it’s really looking like the Medicaid provision was the biggest driver in the drop in the uninsured rate.”
293,000 Coloradans have signed up for Medicaid since the expansion of the program compared to 150,000 people who have enrolled in private insurance through Connect for Health Colorado, the state insurance exchange. Colorado HealthOP enrolled 40 percent of the population using the exchange in 2015, although due to financial reserve concerns, the company folded and no longer offers health plans.
Medicaid is a federal matching health care program for low-income citizens who meet certain eligibility requirements. The federal government matches states’ Medicaid expenses approximately 50 percent for populations the program has historically covered, such as children, pregnant women and people with disabilities.
One of the provisions of the ACA was expanding Medicaid to include not only the traditionally covered populations, but also adults without dependent children. For this specific population, the federal government would pay 100 percent of Medicaid claims for the first several years and then taper off to a 90/10 percent cost sharing model with states by 2020. As the health care reform was challenged in the Supreme Court early on, the Medicaid expansion provision became optional for states, but not required.
Colorado had already begun expanding its Medicaid program with the passing of 2009 legislation (HB 09-1293) that introduced hospital provider fees to help fund the program without draining the general fund. Gov. Hickenlooper signed legislation in 2013 authorizing the further expansion of the program through the ACA provision.
“We were slowly kind of opening the floodgates for new expansion populations with our own money and then when the federal money was authorized that is when we really went full tilt,” says Susan Birch, executive director of the Colorado Department of Health Care Policy and Financing.
Additionally, the provision increased the income thresholds for eligibility to Medicaid. Pursuant to the 2009 legislation, Colorado covered adults earning $90 a month or less without dependent children through Medicaid. Now the state covers adults with an annual income of just under $16,000 or roughly $32,000 a year for a family of four. “When we talk about expansion, what we did was expand the upper end of the income range so that folks could get qualified,” Birch says.
In Colorado, Medicaid covers roughly 1.3 million people. Of that, 44 percent are low-income kids and adolescents, 42 percent are adults without kids, 7 percent are those with disabilities and 4 percent are older adults who are often utilizing both Medicaid and Medicare. Adults without dependent children have seen the most increase in Medicaid coverage since the expansion of the program.
“This is not the old traditional Medicaid. The way we are doing Medicaid is really a movement towards cost containment and improving health outcomes. …” Birch says. “What’s different now is that our systems are being redesigned so more people are getting physicals, more people are getting screenings and there is a lot more attention towards prevention and wellness.”
Part of this new model is the Accountable Care Collaborative model, which focuses on cost containment practices such as prevention and wellness, coordinated care between different health partners and community-based care to keep people out of hospitals and assisted living facilities. This program has achieved “$285 million in gross savings, $77 million in net, which goes back into the general fund,” Birch says. “We’ve demonstrated real success with returning investments back to the state on how we are delivering on this new accountable care model.”
For Boulder County specifically, the uninsured rate has dropped from 11.8 percent in 2013 to 5.2 percent in 2015. The local government has taken the lead to enroll citizens both in private and public health insurance programs. “Boulder County really does come at this from a holistic approach,” says Patrick Kelly with the Department of Housing and Human Services (HHS). “We are looking at this as being well-suited as a county to have the infrastructure to assist clients in getting through the application process. … We can troubleshoot cases, help get clients through to determination and then either shop or utilize their Medicaid benefits.”
Medicaid enrollment for people over the age of 21, mostly adults without dependents, has increased 176 percent since 2012 in Boulder County. But this growth comes with increasing Medicaid claims over the last two years (69 percent), and it is becoming increasingly difficult for health providers to keep up with demand. One of the challenges of the Medicaid expansion is finding providers to accept the government insurance, as it tends to pay less than other insurers.
So in addition to providing services for those enrolling in Medicaid, the County is also working with health care providers to educate them about taking on Medicaid clients and Medicaid reimbursements.
“Not only are we helping clients through the process but we’re also trying to help increase the number of providers around the community that take Medicaid and then support them in that process,” says Alison Brisnehan with of the Community Support Division of HHS. “Just to make sure that we know as we are enrolling all these people there are providers out there that are helping to see these clients.”
As both local governments and the State continue to focus on Medicaid expansion as well as enrolling people in the private marketplace and driving down the uninsured rate, it is unlikely that Colorado, or any other state for that matter, will be 100 percent covered. Undocumented immigrants who don’t qualify for public insurance and conscientious objectors will prevent that from happening. But with 94 percent coverage, Colorado ranks higher than most states.
Which is why both Birch and Kelly agree that repealing the federal health care law, specifically the Medicaid expansion provision, wouldn’t be beneficial. The hospital provider fee will continue to cover the state’s portion of Medicaid, even as federal financing wanes and repealing the law wouldn’t save any general fund money, Birch says. “Our premise is that if you pull back the Affordable Care Act, the federal government would pull back on the funding mechanisms … it would create more expensive modeled care,” she says. “We think it’s much smarter to stay on this path.”