by Georgia Center for Opportunity | Jul 22, 2014
This is the fifth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, the third explained the impact of uninsurance, and the fourth focused on Medicaid and the Affordable Care Act.
Georgia faces many challenges and barriers to expanding access to quality healthcare for low-income uninsured individuals, particularly for those in the Medicaid expansion coverage gap.
State Fiscal Constraints
Preliminary estimates projected that providing Medicaid to newly eligible adults through the expansion would cost the state approximately $2.1 billion from 2014 to 2023. Since the federal government covers 100 percent of the cost for the first three years and then slowly reduces its contribution until it is set at 90 percent in 2020, expansion is projected to first cost the state about $120 million in 2017. In 2023, the final year of the projection, state costs will have risen to almost $406 million.[i]
Governor Deal and other state leaders maintain that the state cannot afford Medicaid expansion and have expressed serious concerns that the federal government will be unable to live up to its obligations under Medicaid expansion. Therefore, any policy or program that would improve access to healthcare for low-income uninsured Georgians must cost significantly less than Medicaid expansion and must rely upon state-based sources of funding.
Physician Shortage
Georgia ranked 41st in the country in active physicians and 44th in primary care physicians per capita in 2010.[ii] According to the U.S. Department of Health & Human Services, almost 2 million Georgians live in a “Primary Care Health Professional Shortage Area,” meaning there are a low number of primary health professionals relative to the population.[iii] In 2010, 31 of Georgia’s 159 counties did not have an internal medicine physician; 63 did not have a pediatrician; 79 did not have an OB/GYN; and 66 did not have a general surgeon.[iv]
Georgia’s Fiscal Year 2015 budget allocates $2 million in additional funds to develop new graduate medical education programs to train residents.[v] While an important step, the state must continue to pursue efforts to address its shortage of primary care providers. Without more providers, many Georgians may not have access to primary care, even if they have health insurance coverage.
Limits to Nurse Practitioner Scope of Practice
Nurse practitioners (NPs) are an important provider of primary care across the country. In many states, NPs evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments. A literature review by the National Governor’s Association found that most studies show that NPs provide comparable care to physicians and achieve equal or higher satisfaction rates among their patients. The review did not find any studies that raised concerns about the quality of care offered by NPs.[vi]
Georgia’s laws and regulations for NPs are more restrictive than almost any other state. A 2007 study ranked Georgia’s NP regulations 48th in the country because the state’s NP limitations affect patients’ freedom to choose providers and NPs ability to provide primary care.[vii] Georgia’s restrictions include requiring NPs to be supervised by a physician and to have a collaborative agreement with a physician or a physician’s supervisor/delegation in order to prescribe drugs. These limitations do not exist in over one-third of states.[viii]
Fiscal Challenges of Safety-net Hospitals
Hospitals that serve a large number of Medicaid and low-income uninsured patients receive state and federally funded supplemental payments from state Medicaid programs. Called disproportionate share hospital (DSH) payments, the funding offsets the disadvantaged financial situation of hospitals that provide large amounts of uncompensated care to uninsured individuals and serve a substantial number of patients in the relatively low-paying Medicaid program.[ix]
The ACA was expected to reduce the number of uninsured individuals and, therefore, reduce hospital uncompensated care costs. This would create less need for DSH payments. Thus, the ACA required annual aggregate reductions in federal DSH funding from FY 2014 through FY 2020.
In 2011, almost 40 percent of Georgia hospitals lost money. Rural hospitals are in an even worse financial situation as 55 percent had negative total margins.[x] Given their financial struggles, Georgia hospitals have expressed concern regarding the DSH reduction. Since Georgia does not plan to expand Medicaid, the reduction in DSH payments would not be offset by an increase in revenue through having more patients being covered by Medicaid. Thus, the hospitals are likely to receive less funding, while the demand for uncompensated care is expected to persist.
[i] Georgia Department of Community Health, “Preliminary Estimate on the Impact of Federal Health Care Reform on the Georgia’s Medicaid and PeachCare Program,” Handout, April 2012.
[v] Governor Nathan Deal, Office of the Governor, “Deal: Budget includes half a billion dollars in k-12 education,” Press Release, April 28, 2014, accessed May 23, 2014, https://gov.georgia.gov/press-releases/2014-04-28/deal-budget-includes-half-billion-dollars-k-12-education.
by Georgia Center for Opportunity | Jul 18, 2014
This is the fourth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, and the third explained the impact of uninsurance.
Medicaid is the country’s main public health insurance program for low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities. A joint federal/state program, the federal government sets mandatory eligibility groups and general guidelines for benefits, while states establish individual eligibility criteria within federal standards.
The Georgia Department of Community Health projects that over 1.8 million Georgians will enroll in Medicaid and PeachCare in 2014 – 18.56 percent of the state population. The Department estimates that the state will spend $2.85 billion on these programs – 15.57 percent of state revenue. The federal government will cover the remaining $6.65 billion for a total expenditure of $9.5 billion. [i]
In 2010, Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act (Affordable Care Act or ACA). The expansion of Medicaid eligibility to all nonelderly adults who make up to 138 percent of FPL is a major component of the law. In 2012, the Supreme Court found the ACA’s Medicaid expansion to be unconstitutionally coercive of states. As a result of the ruling, expanding Medicaid is now optional for states.
Georgia Governor Nathan Deal and the General Assembly have chosen not to expand Medicaid because of the cost to the state and unsustainability of the federal contribution.
An estimated 534,000 uninsured adults in Georgia making less than 100 percent of the federal poverty level fall in the expansion “coverage gap.” These uninsured individuals would be newly eligible for Medicaid under the expansion but will likely continue to have limited access to affordable health coverage without a change in the state’s expansion decision or other health policy changes. [ii]
GCO’s new healthcare access report focuses on identifying sustainable solutions to improve healthcare for these individuals.
[i] Clyde L. Reese III and Jerry Dubberly, “Georgia Medicaid and PeachCare for Kids,” Georgia Department of Community Health, Presentation to Georgia General Assembly Joint Study Committee on Medicaid Reform, August 28, 2013, 11, 33, http://www.house.ga.gov/Documents/CommitteeDocuments/2013/MedicaidReform/DCH%20PP%20Presentation_Medicaid%20Reform%20Study%20Committee_082813.pdf.
[ii] Genevieve M. Kenney et al., “Opting in to the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could Gain Health Insurance Coverage?,” Timely Analysis of Immediate Health Policy Issues, Robert Wood Johnson Foundation and Urban Institute, August 2012, 18, http://www.urban.org/UploadedPDF/412630-opting-in-medicaid.pdf.
by Georgia Center for Opportunity | Jul 16, 2014
This is the third entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report and the second entry looked at Georgia’s healthcare safety net.
The lack of access to affordable care contributes to many individuals going without important services. Uninsured individuals in Georgia are nearly four times less likely than the insured to have had a routine check-up in the past two years[i] and are more likely to experience avoidable hospitalizations for conditions such as pneumonia, diabetes, and asthma.[ii] In 2011, 36 percent of low-income adults in Georgia reported that they went without care because of cost in the past year. Only two states had a higher percentage of individuals going without care.[iii]
Uninsured individuals are financially costly for taxpayers and the insured as well. In 2013, uninsured individuals across the country spent an estimated $25.8 billion out-of-pocket on medical care and received between $74.9 billion and $84.9 billion in uncompensated care. About 60 percent of the uncompensated care spending was provided by hospitals, 26.4 percent by publicly supported community providers, and 14 percent by office-based physicians who provided in-kind services or charity care.[iv]
Providers also attempt to recover their losses from providing uncompensated care to uninsured patients and those covered by government programs that pay below cost, such as Medicare and Medicaid, by increasing charges for those with private insurance. The higher prices charged to private insurance are passed on to families and business through higher premiums.
Estimates vary on how much cost shifting occurs. One study estimates that cost shifting through increased premiums and other similar strategies accounts for about 2.4 percent of private health insurance costs,[v] while another study estimates that uncompensated care cost shifting makes up 7.7 percent of private insurance costs.[vi] If the higher estimates are accurate, the uninsured population is costing the average Georgia individual $330 and the average family $900 per year in higher premiums.[vii]
[i] Patricia Ketsche et al., The Uninsured in Georgia, Georgia Health Policy Center, Issue Brief, November 2008, http://www.issuelab.org/resource/uninsured_in_georgia_2008.
[ii] John O’Looney, Louis Kudon, interand Glenn M. Landers, Avoidable Hospitalizations in Georgia: An Analysis of the Potential for Strategic Action, Georgia Health Policy Center, January 2005, http://ghpc.gsu.edu/sites/default/files/documents/ghpc/community_public_health/Avoidable_Hospitalizations_11-29-07_FINAL.pdf.
[iv] Teresa A. Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care Was Provided In 2013; ACA Payment Cuts Could Challenge Providers,” Health Affairs 33 (2014): 810, http://content.healthaffairs.org/content/33/5/807.abstract?=right.
[v] Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care,” 812.
by Georgia Center for Opportunity | Jul 11, 2014
This is the second entry in a series of posts highlighting GCO’s new report, Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report .
Unfortunately, 19 percent of Georgians lack health insurance, the sixth highest percentage in the country in 2012.[i] Of the nonelderly uninsured, 56 percent live in households that make less than 139 percent of the federal poverty level (FPL), which is $16,221 for an individual and $33,151 for a family of four.[ii]
While it can be difficult for uninsured individuals to find care – particularly those with low-incomes – some uninsured individuals access care through Georgia’s healthcare safety-net. These providers include community health centers, charity clinics, public hospitals, local health departments, and private office-based physicians who provide limited free care.[iii]
Community Health Centers
The state’s community health centers provide primary and preventive care to many uninsured individuals on a sliding fee scale based on patient or family income. In 2011, Georgia’s Federal Qualified Health Centers (FQHCs) – local, non-profit, community-owned healthcare providers – served more than 317,000 patients at 152 delivery sites across the state. Of the FQHC patients, 51 percent were uninsured. The National Association of Community Health Centers estimates that 13 percent of Georgia’s low-income uninsured population was served by an FQHC in 2011.[iv]
Charity Clinics
Uninsured individuals in 90 of Georgia’s 159 counties have access to a charity clinic as another option to help meet their primary care needs. In 2012, the state’s 96 nonprofit, independent charity clinics served 183,625 unique patients, and 62 percent of these patients were below the poverty level.[v] Due to their volunteer nature, clinics are able to provide an average of $7 worth of services for every $1 invested, and the average cost per patient visit is $29.[vi]The total value of the services provided by Georgia’s charity clinics in 2012 was over $200 million.[vii]
Public Hospitals
In addition to community health centers and charity clinics, many uninsured patients seek care in hospital emergency rooms. Since many low-income uninsured individuals can only afford a small portion of the care they receive and hospitals are required to provide emergency healthcare to anyone needing it, providers are often uncompensated for the services they provide. In 2012, Georgia hospitals provided $1.6 billion in uncompensated care, including $936 million in free, indigent, and charity care and $671 million in care for which the patient did not pay his or her bill and was not qualified for the hospital’s indigent or charity care programs.[1],[viii]
[1] Uncompensated care is an overall measure of hospital care provided for which no payment was received from the patient or insurer. It is the sum of care for which the hospital never expected to be reimbursed and care for which it is unable to obtain reimbursement for the care provided, called “bad debt.” Uncompensated care excludes other unfunded costs of care, such as underpayment from Medicaid and Medicare.
[i] The Henry J. Kaiser Family Foundation, “Health Insurance Coverage of the Total Population,” accessed March 12, 2014, http://kff.org/other/state-indicator/total-population/.
[vi] Georgia Charitable Care Network, “Georgia Charitable Care Network – Partners in Georgia’s Safety Net,” Handout provided by the Georgia Charitable Care Network.
[viii] Georgia Hospital Association, Hospitals 101: A Resource Guide for Elected Officials, Fourth Edition, February 2014, 3, https://publications.gha.org/Portals/4/Hospital101UpdatedApril2014.pdf; American Hospital Association, “American Hospital Association: Uncompensated Hospital Care Cost Fact Sheet,” January 2013, http://www.aha.org/content/13/1-2013-uncompensated-care-fs.pdf.
by Eric Cochling | Jul 7, 2014
Nearly one in five Georgians lacks health insurance, the 6th highest rate in the country. Among those without insurance are an estimated 534,000 adults living at or below 100% of the federal poverty line.
Given the significant need for increased access to healthcare, Georgia’s decision not to expand Medicaid under the Affordable Care Act, and expansion’s long-term unsustainability, it is imperative that viable alternatives for providing healthcare to this portion of the population are identified and implemented.
Today, Georgia Center for Opportunity released a report that adds new ideas and solutions to many of the state’s healthcare challenges. The report, titled Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians, outlines challenges to Georgia’s healthcare system and recommends several policies to start addressing the problems.
The report’s key recommendations include:
- Providing state government support for Georgia’s charity clinics
- Expanding telemedicine
- Modernizing nurse practitioner laws and regulations
- Reinstating the state sales tax exemption for charity clinics
- Replacing lost federal funding for safety-net hospitals
Implementation of these policies offers a strong foundation for expanding care to individuals in need and will ensure that more Georgians have access to affordable healthcare, leading to better outcomes for individuals and reducing the cost of uncompensated care.
Over the next few weeks, we will post a series of blogs that highlight different sections of the report including an overview of the state’s uninsured population and healthcare safety-net, an analysis of many of the state’s healthcare challenges, and an in-depth look at the recommended policies.
View the full report here: Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians,
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