How Would Medicaid Losses in Approved Section 1115 Medicaid Work Experiment States Affect Community Health Centers? Geiger Gibson / RCHN Community Health Foundation Research Collaborative Jessica Sharac, MSc, MPH Peter Shin, PhD, MPH Sara Rosenbaum, JD About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long- standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at https://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at www.rchnfoundation.org. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 Executive Summary This brief estimates the potential effects of Medicaid work experiments on community health centers and their patients. Our analysis focuses on seven states with approved experiments and uses data from the federal government’s 2017 Uniform Data System. We find that across the seven states, between 120,000 and 169,000 adult health center patients could be expected to lose Medicaid coverage during the initial experimental year. As a result of declining Medicaid enrollment, health centers in these states would lose between $89 and $125 million in Medicaid revenue in the first year alone, which in turn could be expected to result in an overall drop in patient care capacity of between 104,000 and 147,000 and staffing reductions of between 815 and 1,145 FTE staff members. Michigan; we also provide updated estimates for Arkansas. Background (Because Ku and Brantley conclude that projected losses Recently, a number of states have sought to make Medicaid for Utah and Wisconsin are uncertain, estimates of health eligibility for adults conditional on proof of employment or center patient impact cannot be determined for these two other forms of community engagement. As of June 2019, approved states). the Trump administration has approved § 1115 Medicaid Table 1 shows selected characteristics for community work experiments in nine states: Arizona, Arkansas, health centers in the seven states. In 2017 (the latest year Indiana, Kentucky, Michigan, New Hampshire, Ohio, Utah for which UDS data are available), the 179 health centers in and Wisconsin. A tenth approved state (Maine) has decided these states served 3,263,935 patients, of whom nearly 60 not to proceed with its approved demonstration. percent (1,934,685) were adults age 18 to 64. Among the Previously, we have used analyses prepared by Leighton Ku 1,655,431 health center patients enrolled in Medicaid, and Erin Brantley estimating projected reductions to 906,787 (55 percent) were adults age 18 and older. Total Medicaid coverage in three approved states (Arkansas, patient visits to all health centers in these seven states Kentucky, and New Hampshire) to project the potential surpassed 12.5 million in 2017, and the health centers impact of these losses on community health centers and employed more than 26,000 full-time equivalent staff. their patients. In order to calculate impact, we used data from the 2017 Uniform Data System (UDS), a nationwide Methods data-reporting system containing detailed information on Based on the latest Ku and Brantley estimates, we show in community health center patients, services, staffing and Table 2 the estimated population of adult Medicaid health other information. center patients who would be subject to work requirements In this blog, we update our work to apply newly-reported in each of these states, along with the estimated decrease estimates by Ku and Brantley on Medicaid enrollment in Medicaid enrollment for those enrollees targeted for losses across multiple approved states. Specifically, we participation in the experiment. In Arizona, Michigan and broaden our analysis to include Arizona, Ohio, and Ohio, Medicaid coverage losses are projected among Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 Source: GW analysis of 2017 UDS data patients who are members of the ACA expansion center patients (115,026), adjusted for age. population, since the experiment is limited to ACA For all four states, the figures were adjusted to account for expansion adults. In Indiana, all non-elderly adult the age range of adults subject to work requirements by beneficiaries, both ACA expansion and traditional, must calculating the age distribution of non-elderly adult health- participate unless exempt. center patients in each state (ages 19-64 in Arizona, To estimate the number of Medicaid expansion adults Michigan, and Ohio, to match the Medicaid expansion age served by health centers in these states, we applied the range, and 18-64 for Indiana) and excluding the percentage state-specific percentage of Medicaid expansion adults of adults outside the work requirement age range (age 50- from the most recent Medicaid enrollment data available 64 for Arizona and Ohio, age 60-64 for Michigan, and age 18 (2017, 3rd quarter) for Arizona (22 percent), Michigan (42 and 60-64 for Indiana). (It was assumed that elderly percent) and Ohio (22 percent) to total regular (non-CHIP) patients with Medicaid coverage are dually eligible for health center Medicaid enrollees in 2017. In Indiana, where Medicare and would thus be reported under Medicare, as projected losses occur among both expansion and the UDS requires). traditional adult populations (as is also the case in Kentucky), the estimated target population of 102,734 was based on the number of regular Medicaid adult health- Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 Source: GW analysis of 2017 UDS data for Arizona, Indiana, Michigan, and Ohio; Medicaid.gov enrollment numbers for 2017, 3rd quarter; previously reported figures for Arkansas, Kentucky, and New Hampshire; Ku & Brantley, 2019 Results Arkansas (Table 2) remains the same as it was in our earlier analysis, but health-center impact (Table 3) differs from our Table 3 below presents the projected first-year Medicaid earlier projections as a result of the updated enrollment loss coverage losses among health center patients subject to estimates. work requirements in the seven states. New estimates are Applying the projected declines in Medicaid enrollment provided for Arizona, Arkansas, Indiana, Michigan and Ohio, overall, we then estimate the projected drop in the number and previously-reported estimates are provided for and percent of health center Medicaid patients in the first Kentucky and New Hampshire. The losses in Table 3 shown year of the experiment (Table 3). Assuming a proportional for Arkansas differ from those in our prior Arkansas loss of Medicaid enrollment to Medicaid revenue, the estimate, since Ku and Brantley revised their initial estimated loss of Medicaid revenue (shown in Table 4) is projections of Medicaid enrollment declines, from its then applied to determine the loss of total revenue (Table 3) previous range of 19 percent to 30 percent (on which our and the resulting loss of total patients and staff (Table 4). original estimates were based), to an updated range of 26 percent to 30 percent. The target population size for Across seven states, the number of health center patients Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 expected to lose Medicaid coverage ranges from 2,520 in revenue losses could reach a total of $125 million across all New Hampshire to 39,892 in Michigan. Low-end total losses seven states, surpassing $37 million in Kentucky and $38 of coverage among health center patients stand at 119,820. million in Michigan. Across all seven states, we estimate a At the high-end of the estimate range, 169,335 patients total reduction in health center patient capacity of between could lose coverage, and the state range jumps to between 103,991 and 147,217 patients and a total staffing reduction 3,779 (New Hampshire) and 49,865 (Michigan). Decreases ranging between 815 to 1,145 health center FTE staff. in total Medicaid enrollment could reach as high as 23 percent (Kentucky). As patients lose coverage, health centers lose Medicaid revenue, and as revenue declines, so does patient care capacity (Table 4). At the high end, health center Medicaid Source: GW analysis of 2017 UDS; previously reported figures for Kentucky, and New Hampshire; Ku & Brantley, 2019 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 Source: GW analysis of 2017 UDS data; previously reported estimates for Kentucky and New Hampshire; Ku & Brantley, 2019 growing numbers of uninsured patients, and Conclusion uncompensated care and bad debt grow. Staffing and services get scaled back, which can take several forms— The Institute of Medicine, in a landmark study of health layoffs, reduced hours, shuttered locations, and elimination insurance and its effect, concludes that health insurance of services that may be more costly to provide but generate coverage patterns can have a community-wide impact. In little in the way of revenue. communities with more limited access to coverage at the individual level, services can be affected community-wide It is also important to note that this issue of community- since health care providers located in these communities wide impact is one that typically is systematically lack the financial means to maintain strong systems of care. overlooked, both in federal guidance governing § 1115 Just as the expansion of health insurance led to overall evaluations and in the evaluations themselves. Evaluation economic strengthening that benefits all patients, coverage of the impact of coverage loss for community-wide access losses can adversely affect access to care for all patients, should be viewed as a basic element of any § 1115 not just those immediately losing coverage. As coverage experiment designed to achieve large-scale shifts in declines, economic losses mount; providers must treat coverage. 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