The Legacy of the War on Poverty’s Health Programs for Non-Elderly Adults and Children

1. The Legacy of the War on Poverty’s Health Programs for Non-Elderly Adults and Children Barbara (Bobbi) Wolfe June 12, 2012

2. Major Components of the War on Poverty’s Health programs • Medicaid • Expanded to Children's Health Insurance Program • Neighborhood Health Centers • National Health Service Corp added to attract providers

3. Pre War on Poverty • Public sector – • public hospitals, military health care, Public funding for medical research, school health programs, programs to promote maternal and infant health, worker’s comp for health • ~one percent of GDP • Private insurance covered < 30% of private health spending. Employers provide as cost of business so tax subsidized.

4. A Picture of Health Differences by Income pre War on Poverty

5. Medicaid • Became law in 1965; a Demand side program that provides coverage to eligible persons • Joint federal-state program • Federal – minimum benefit package; majority of financial resources (match based on average per capita income in state: range 50-83 percent.) Mandatory groups- single-parent family members, quickly expanded to pregnant women • Minimum benefits for children 1967, Early & Periodic Screening, diagnostic and Treatment • State – option to cover additional groups (medically needy) and services and set income-eligibility for mandatory groups (tied to AFDC eligibility). • Major Eligibility Expansions: • 1986-pregnant women and infants with income <100% FPL as state option; 1988 mandatory. 1989: expanded to cover up to 133% FPL. & up to age 6. • 1990: All children to age 18 up to 100% FPL • 2010: ADA – all under 133% FPL

6. Personal Health Expenditures and Medicaid, 1960 to date

7. Core problems with Medicaid • Zero-one nature re eligibility. “Notch” • Negative labor market incentive • Negative private coverage incentive (increases uninsured) May change use of care in way that influences health • Coverage varies by state: inequality • Crowd-out. • Low reimbursement especially for specialists and oral health providers limits access • Cost of program esp. to states

8. Evaluation tied to core issues • Wisconsin Badgercare • Eligibility to 185% FPL, no asset test, family coverage • Premiums for higher income families • State subsidy for ESI for those eligible for BadgerCare (tied to income) • outreach • Outcomes: increased coverage. Evidence that bridged gap between public and private provision. Estimates of crowd out about 25% • Medicaid Managed Care Program- (Kaestner, DuBay and Kenney) • evaluate effect of MMC on prenatal care usage and infant health. • Find no tie to adequacy of prenatal care; or health outcomes. • Community Care of NC (KFF study) • Medical home model-MDs, hospitals, county health & social service agencies coordinate care. 24/7 access on call • Improved care and cost savings.

9. ACA –lessons from Experience of Medicaid • Makes eligibility more uniform across states • Raises importance of smooth transition from Medicaid to private coverage • Subsidy plan; administration and implementation • Providers who participate • Access – will providers participate? Reimbursement • Medical or health homes to improve care for chronically ill

10. (State) Children’s Health Insurance Program • 1997: SCHIP 2009: CHIP • Joint federal state program to expand coverage beyond Medicaid to low income children. extensive leeway to states. • Coverage varies from 160% up to 400% FPL. • Targeted on children but states have option to expand to parents. • Federal government pays Medicaid rate + 15% • Issues – low take-up rate, churning enrollment and crowd out.

11. Evaluation • Focus on Take-up rates and strategies to increase (2009=84.8%) • Outreach • Simplify enrollment • Longer periods of eligibility • Focus on Crowd-out and ways to reduce • Use of waiting periods; lock-outs • Premiums • Improvements in coverage for children? • CPS data show drop in uninsured children < 250% FPL while adults increase rate • Improvements in access? • Greater utilization if have Medicaid/Chip but disparities continue in quality, and access to specialty care including time to appointment • Managed care networks not serve both Medicaid/CHIP and privates

12. Neighborhood Health Centers • Concept: provide health and social services in poor and medically underserved areas and promote community empowerment. Established in 1965 as part of War on Poverty. • Slow growth – perceived threat and only benefit those in geographical areas would be served (supply side approach that differed from private insurance.) • Early 19070s only ~ 100. Now 1,124 and under ACA expected to double capacity • 2010 served 19.5 million • 93% < 200% FPL; 72% <FPL • FQHC-1989 on • 90% federally qualified; • all can receive cost-based reimbursement from Medicaid and Medicare (since 1989). • FQHC covered for malpractice. • Medicaid accounts for 37% of funding; federal grants 25%, state & local grants 12%

13. CHC - evaluation • Most compare CHC to other providers • Quality of care; access; disparities; cost-effectiveness • Mostly favorable • Reduced infant mortality rate and low birth weight • More up to date on cancer screening than comparable women • More pediatric patients have recommended preventive care • Lower rate or ambulatory care sensitive hospitalizations • Lower cost than comparable care—Medicaid covered CHC patients lower hospitalizations rates and fewer annual hospital days

14. Issues-CHCs • Current issue – insufficient funding to serve population • 1985-2006 real / ca appropriations steadily decreased • Staffing • Funded vacancies esp. in rural areas • Access to specialty services • Can they expand to meet expected increase in demand?

15. Measures of Success of These Programs-insurance coverage • In 1965, >70% of population had hospital coverage; 67% surgical care but little else. >25% had no coverage. By 1970, 15% had no coverage*. • Records of actual coverage only begin in 1982 (earlier count policies.)

16. Indicator of success of Medicaid and S-CHIP on covering children

17. High rates of Uninsured among Non-elderly adults remain

18. Indicator of Success-utilization disparities

19. Indicator of Success – infant mortality rates by race

20. Final thoughts • Bulk of evidence clearly suggests that the combination of Medicaid/Chip/CHC /NHSC have increased health insurance coverage, access (as captured by utilization) to medical care for the poor and decreased gaps in health status. • ACA if enacted will extend these benefits though clearly major issues remain in terms of actual access to beneficial care • It is also clear that evaluations in this area are complicated; beyond asking limited questions (for ex., take-up, crowd out, costs of care, labor market incentives, infant mortality) the profession has not done well at understanding the full benefits of this set of programs • Endogeneity of take up of Medicaid and use of CHCs • Inaccuracy of numerous measures of health and limited scope of others (mortality, infant mortality) • Long term nature of health and effectiveness of medical care. • Role of risk taking behaviors/knowledge/exposures with health consequences • Difficulty in conducting experiments that might deny coverage or access to care.