Taking Stock of the Impact of Post-ACA Health Coverage in Ohio

Amy Rohling McGee, Health Policy Institute of Ohio

The uninsured rate for working-age Ohioans has dropped by more than half since 2010, primarily because the state decided to expand Medicaid eligibility under the Affordable Care Act.

Prior to Jan. 1, 2014, adults without dependent children were not eligible for Medicaid coverage in Ohio. Parents with incomes below 90 percent of the Federal Poverty Level (FPL), children and pregnant women with incomes below 200 percent FPL, people with disabilities with incomes below 64 percent FPL and workers with disabilities with incomes below 250 percent FPL were eligible for Medicaid. At that time, there were about 2.4 million Ohioans enrolled in Medicaid.

In 2010, 19 percent of working-age Ohioans did not have health insurance. Just five years later, that number dropped to less than 9 percent. The primary driver behind the dramatic reduction is expanded Medicaid eligibility for adults to 138% FPL.

Now more than 3 million Ohioans – over a quarter of the state’s population – are enrolled in Medicaid.

Most of the growth in the program has been in the new eligibility category, also referred to as Group VIII. In March 2016, 673,519 Ohioans were enrolled in the Group VIII category.

The covered families and children (CFC) category – which includes parents of children under age 19, children and pregnant women – has also grown, to an average of 1.8 million to date in SFY 2016 compared to an average of 1.6 million in SFY 2015. Conversely, the aged, blind or disabled (ABD) category has decreased from an average of 422,076 in SFY 2015 to an average of 395,401 to date in SFY 2016.

Enrollment of people who are newly eligible has exceeded multiple projections. Several factors have likely contributed to higher than anticipated enrollment, including a streamlined eligibility system, enrollment efforts of providers and navigators and the individual mandate.

More than half of the adults enrolled in the newly eligible category are working or have a spouse who is working. Adults who are older are less likely to be working than younger adults.

The decrease in the number of people enrolled in the ABD category may indicate that some people with disabilities are choosing to enroll through Group VIII, rather than through the disability determination process. This may change in the future as Ohio shifts to a single disability determination system.

Utilization among Medicaid expansion population

The Ohio Department of Medicaid has tracked a number of utilization metrics for Group VIII. Initially the newly eligible Medicaid expansion population utilized inpatient services at a much higher rate than the Covered Families and Children (CFC) population, likely due to previously unaddressed health conditions. Both inpatient and emergency department outpatient rates almost immediately came down and are now at or below levels for families and children. Overall, both the newly eligible and CFC groups utilize much less health care than the elderly and disabled population.

One area where the newly eligible population utilizes services at a higher rate than the CFC population is behavioral health. The fact that behavioral health utilization has been higher for Group VIII suggests that there may be a higher incidence of mental health conditions and addiction in this population.

Coverage gains outside Medicaid

Gains in coverage through other sources have been less dramatic. About 55 percent of working-aged Ohioans have coverage through employer-sponsored insurance, a rate that has remained consistent from 2010 through 2015.

And Ohio’s marketplace enrollment has not been robust. At the end of 2015, only about 25 percent of the estimated number of potential 2015 marketplace enrollees in Ohio had enrolled, placing Ohio in the bottom quartile compared to other states. More recent data from the 2016 open enrollment period shows that Ohio has the highest average monthly premium after advance premium tax credits are applied, despite a relatively high number of carriers offering plans in the state. Only 243,715 Ohioans enrolled in coverage though the marketplace for 2016 coverage; the number that pays their premiums and maintains coverage is likely to be lower.

Impact of Medicaid coverage on health

It is clear that expanded Medicaid eligibility has been the primary driver of the decrease in the number of uninsured Ohioans. But has this policy change led to better health outcomes?

The Ohio Medicaid Assessment Survey shows modest improvement from 2012 to 2015 for adults below 138 percent of FPL (both those enrolled in Medicaid and those who are not) for the percent who report fair or poor health, smoking and misuse of pain medications. On the other hand, there has been an increase in obesity in the same time frame and no change in percent of people with diabetes. The statistical significance of these changes from 2012 and 2015 has not been assessed and it’s likely that it will take more time, data and analysis to determine whether the impacts on access, financial well-being and health are similar to findings in other states, such as Kentucky and Oregon.

Other impacts on health

Notably, there is a sizeable gap between the percent of adults who report fair or poor health who are under 138 percent FPL (34 percent) versus those between 138 and 150 percent FPL (13 percent). A person living in poverty may have access to health coverage, but likely experiences many other barriers to good health.

Researchers have estimated that our health is influenced by a number of modifiable factors, with 20 percent attributed to clinical care, including access to and quality of care, 40 percent to social and economic environment, 30 percent to behaviors and 10 percent to physical environment. High-quality health care is critical for people who are sick, injured or have a chronic health condition, but clinical care alone will not improve health outcomes.

To put it another way, access to care is necessary, but not sufficient, to achieving good health.

For this reason, HPIO’s work focuses on policy options both inside and outside of the healthcare system, examining opportunities to invest in prevention and strategies that impact the social determinants of health.

HPIO created a Health Value Dashboard to track the many factors that impact population health outcomes, including, but not limited to, measures related to access to care. It is our hope that a more comprehensive view of the data and a sharp focus on our state’s most pressing health challenges will lead to more nuanced conversations regarding policy options.