Health care innovations for homeless families: Emerging opportunities under Medicaid and the Affordable Care Act

Prior to the Patient Protection and Affordable Care Act of 2010 (the ACA), the US health care system left many low-income families facing limited access to medical care, struggling with high-health costs, or lacking health insurance altogether. The ACA aims to increase access to care, improve the quality of care, and lower total health care costs. While the ACA can benefit all individuals and families, it has significant potential for expanding and improving services for those experiencing homelessness. This paper describes specific opportunities under the ACA and Medicaid that can be used to strengthen services for homeless families and provides examples of efforts under way. It also offers guidance for how homeless service agencies can effect change in their respective states. The examples described here are promising approaches to strengthening homeless services. Pursuing these ideas for homeless families will require initiative, creativity, and perseverance, but recent progress is encouraging.     

The role of the health care sector in the U.S. economy

This Issue Brief discusses factors that contribute to the growth of health care expenditures and the reasons that many individuals, employers, and policymakers consider health expenditures too high. In addition, it describes various industries that make up the health care delivery system and their role in the U.S. economy as employers, producers, exporters, and suppliers of research and development. The report also discusses the economic implications of rising health care expenditures for individuals, employers, and the federal government and the potential impact of proposed health care reform on the health care sector and the U.S. economy as a whole. Health care delivery industries such as pharmaceuticals and medical equipment suppliers have higher than average research and development levels, in addition to a positive balance of trade. Moreover, while the total number of jobs in the private sector declined between 1990 and 1993, the number of jobs in the relatively high paid health services sector continued to grow. In aggregate, employer spending on health care represents only 6.6 percent of total labor costs. In comparison, wages and salaries represent 83 percent of total labor costs. Consequently, the growth rate of health care expenditures has a smaller impact on the growth rate of total compensation than does the growth rate in wages and salaries. Using job multipliers developed by the U.S. Department of Commerce, it is estimated that the 18,600 health care services jobs in Rochester, Minnesota in 1993 created another 32,000 jobs in the area. Any contraction of the health care sector in cities that have a large concentration of employment in health services would result in reduced employment in restaurants, retail stores, janitorial services, and other local businesses. EBRI's simulations estimated that between 200,000 and 1.2 million workers could become unemployed as a direct result of a mandate that employers provide health benefits to their employees, assuming that wages and salaries did not adjust at all. Others find that approximately 50,000 individuals would lost their jobs, assuming that wages and other labor costs adjust downward to completely account for increased costs. As is apparent, the estimates of job loss (and of the total costs of the policy) are extremely sensitive to the assumptions used in the simulation.     

The Patient Protection and Affordable Care Act: A Dissenting Opinion

This paper asks whether the Patient Protection and Affordable Care Act achieves its goals of significantly expanding health insurance coverage, while reducing costs and increasing the quality of the care provided. An examination of the early results and current future projections suggests that while PPACA will increase the number of Americans with health insurance, it will fall significantly short of universal coverage. In addition, PPACA fails to control health care costs, and will likely result in higher costs for government, as well as many businesses, and individuals. The author concludes that PPACA is not the most effective vehicle for achieving US health care reform, and that a more market-oriented approach offers a better alternative.     

Foster care and Medicaid managed care

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.     

Addressing intimate partner violence in primary care: lessons from chronic illness management

Though many studies have documented the high prevalence, morbidity, mortality and costs attributable to intimate partner violence (IPV), it is still unclear how our health care system should address this major public health problem. Many have advocated for routine screening, yet there is still insufficient evidence that routine IPV screening can lead to improved outcomes. Though recognition of IPV is very important, a screening paradigm may not be the optimal way to approach IPV within the health care system. For many patients, exposure to violence is a chronic condition, characterized by long-term abusive relationships, histories of childhood and community violence, multiple associated chronic symptoms, and extra barriers to addressing their other chronic illnesses. Thus, there may be important lessons to be learned from work being done in the area of chronic care. We explore how Wagner's Chronic Care model may guide efforts to improve health care for IPV survivors and may serve as a framework for future research studies.     

Power and change: primary health care at the crossroads in Sweden.

This paper is based on in-depth interviews with members of Sweden's medical interest groups involved in a national effort to control health care costs. Sweden is faced with escalating costs due primarily to a growing high technology hospital sector. Simultaneously, consumer demand for primary care services and for gerontological care is rising rapidly. The Swedish way of changing the health care system is described and an analysis of the power struggle between physicians, health care bureaucrats and politicians is presented.     

The effectiveness of health care cost management strategies: a review of the evidence

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.     

Health care reform: managed competition and beyond

Since the election, the health care reform debate has focused on three broad features: implementation of managed competition, changes in the tax treatment of health insurance, and the imposition of budget caps or targets. The basic element of managed competition is the creation of sponsors who act as collective purchasing agents for large groups of individuals. One of the potentially most politically difficult issues in implementing any health care reform proposal is likely to be defining the minimum standard benefit package. It will determine the costs society bears, the income of providers, the health of many individuals, and the attributes of a workable health care reform package. Managed competition is intended to foster competition among health plans on the basis of cost and quality. The measures of quality actually employed in the health care system will determine in large part the incentives faced by insurers, providers, and consumers. The problem of adverse selection is potentially the most important issue in reforming the health insurance market. If individuals can opt not to purchase health benefits, poorer risks will be more likely to purchase health insurance than good risks, and at minimum the price of these benefits will be higher than would otherwise be the case. Managed competition requires that individuals share at least some of the financial consequences of their choices among health plans. As a result, most managed competition proposals change the tax code by limiting the exclusion of employer contributions to health insurance from worker's taxable income. Changing the health insurance market, mandating employer health benefits, and changing the tax code may have significant effects on the health care delivery system, but they are unlikely to reduce health care cost inflation in the near term. One of the proposals for restraining the growth in health care costs is the imposition of a budget on the amount spent on health care services. The combination of the constraints placed on federal governmental action by the budget and the significant political problems involved in reaching a consensus on the important elements of health care reform may limit the ability of the federal government to implement national health care reform in the near term. As a result, individual states may be encouraged by the federal government to continue to experiment with their own health reform programs.     

When Home Is Still Unsafe: From Family Reunification to Foster Care Reentry

Reuniting children with their families is the preferred outcome of foster care, yet many children reunited with their families reenter foster care. This study examined how parental substance abuse and mental health problems, and the time allotted for reunification, are associated with reentry risk. We used a complete cohort of children who entered the Texas foster care system in fiscal years 2008 and 2009 to identify the risk of foster care reentry within 5 years of reunification using selection‐adjusted multilevel survival analysis. Approximately 16% of reunified children reentered care within 5 years. Substance abuse and mental health problems predicted higher rates of reentry. Reunification after 12 months was associated with increased reentry risk overall, but not among children commonly exempted from federal permanency timelines. Permanency guidelines that restrict the length of time to achieve reunification may have the unintended consequence of pushing reunification before maltreatment risks have been resolved.     

EMERGING TRENDS IN THE PROVISION AND CONSUMPTION OF HEALTH SERVICES

Health services are examined in terms of emerging trends for the new millennium. On the one hand, centralization is increasing as payers tighten control over disbursements through managed care and more restrictive health insurance. On the other hand, health services are decentralizing as patients acquire more information and take more control of some aspects of treatment. Health services markets now also show signs of becoming global in nature, possibly benefiting both bulk purchasers of care and individual consumers. Any tendencies toward increased patient control are likely to be ephemeral, however: In the absence of reforms sparked by yet-to-be-experienced crises, advances in technology, particularly in medical informatics, will likely be used to strengthen the profit positions of insurance providers, not to provide more comprehensive health care services for patients.     

Social context and personal expenditures for health care: federal policy and the experience of older adults in the 1970s

The relationship between the intent and the outcome of legislated social policy is discussed. Specifically, this study documents some effects of federal health reimbursement and income policy in the late 1960s and early 1970s on health care behavior and expenditures in the decade 1970-1980. The Longitudinal Retirement History Study (LRHS), containing information on a panel of 6,270 men and unmarried women aged 58 to 63 in 1969, was used to provide information on the personal health expenditures in this decade. Medicare and Medicaid and the indexing of Social Security became operational at the beginning of the study, which permitted the exploration of intended and observed effects of legislation designed to make health care more accessible and affordable for older adults. As policy intended, utilization increased over the decade as indicated by both increases in the number of panelists with health care bills and increases in the size of total bills (constant dollars). Consistent with federal policy to reduce personal costs, out-of-pocket expenditures and the proportion of total bills paid out of pocket decreased. However, the effects of these federal policy initiatives were constrained by reimbursement rules and the social location of users. For instance, even at the end of the 1970s, out-of-pocket health care expenditures across subpopulations persisted. The 1980s and early 1990s have brought increased concern over the cost of health care and renewed concern over access. Data suggest that future proposals aimed at providing universal coverage along with high out-of-pocket costs may not result in equitable programs, and are likely to have a limited impact on constraining health care costs. The LRHS data indicate that utilization increased despite continued high out-of-pocket costs for all except the lower-income groups, who may be limited in their ability to purchase increasingly costly care.     

Informal Care Intensity and Caregiver Drug Utilization

Providing informal care has negative health consequences for informal caregivers. If these health consequences increase drug utilization among caregivers, estimates of health care savings from informal care—mainly realized through reductions in utilization among care recipients—should consider the increased drug costs incurred by informal caregivers. This paper evaluates whether more intensive informal caregivers have higher drug utilization than less intensive caregivers, controlling for initial health status and other factors. We find that informal care intensity is associated with higher drug consumption. An increase of 10% of total informal care per day is associated with a 0.7% increase in drugs. The small magnitudes indicate that, in this application, it is not important to consider caregiver drug utilization when quantifying the net savings to the health care system of informal care. For individual caregivers, such as those who take multiple drugs per month and/or have no drug coverage, the increase in drug utilization associated with intensive caregiving is likely to be costly.     

Social Context and Personal Expenditures for Health Care: Federal Policy and the Experience of Older Adults in the 1970s

The relationship between the intent and the outcome of legislated social policy is discussed. Specifically, this study documents some effects of federal health reimbursement and income policy in the late 1960s and early 1970s on health care behavior and expenditures in the decade 1970-1980. The Longitudinal Retirement History Study (LRHS), containing information on a panel of 6,270 men and unmarried women aged 58 to 63 in 1969, was used to provide information on the personal health expenditures in this decade. Medicare and Medicaid and the indexing of Social Security became operational at the beginning of the study, which permitted the exploration of intended and observed effects of legislation designed to make health care more accessible and affordable for older adults. As policy intended, utilization increased over the decade as indicated by both increases in the number of panelists with health care bills and increases in the size of total bills (constant dollars). Consistent with federal policy to reduce personal costs, out-of-pocket expenditures and the proportion of total bills paid out of pocket decreased. However, the effects of these federal policy initiatives were constrained by reimbursement rules and the social location of users. For instance, even at the end of the 1970s, out-of-pocket health care expenditures across subpopulations persisted. The 1980s and early 1990s have brought increased concern over the cost of health care and renewed concern over access. Data suggest that future proposals aimed at providing universal coverage along with high out-of-pocket costs may not result in equitable programs, and are likely to have a limited impact on constraining health care costs. The LRHS data indicate that utilization increased despite continued high out-of-pocket costs for all except the lower-income groups, who may be limited in their ability to purchase increasingly costly care.     

MODERNIZATION,GENDER EQUALITY,AND MORTALITY RATES IN LESS DEVELOPED COUNTRIES

Although greater accessibility to health care and increasing levels of education among residents of less developed countries have clearly contributed to mortality decline, few theoretical models to date have adequately explained the relationship. A comprehensive model of mortality decline should document both the factors that directly drive down mortality rates and the underlying structural dynamics that give rise to such direct effects. The present article draws on fundamental diffusion concepts and a psychosociological model of modernization that attempts to explain how less developed countries increase their availability of health care services and reduce gender inequality. Two diffusion mechanisms are argued to be operating: the transfer of raw material goods and technology through the international capitalist exchange system and the transfer of modern values, ideas, practices, and knowledge through the mass media. The model was tested with data on four measures of mortality for a sample of 43 less developed countries circa 1993. Partial support is found for the model, and suggestions for future research are made.     

The Hidden Costs of Informal Elder Care

Demographic, socio-economic, and political trends throughout the developed world have contrived to make elder care an issue of utmost policy importance. They also have led to sharp reductions in health and social program expenditures. Policymakers are looking to communities to help meet growing care needs because community care is believed to be better and cheaper than institutional care. However, these beliefs become untenable when costs beyond public sector costs are considered. In fact, informal care carries a number of hidden costs that seldom are considered in health and social policy discussions. This article introduces a taxonomy of the costs of informal elder care, which can be categorized as out-of-pocket expenditures, foregone employment opportunities, unpaid labor, and emotional, physical and social well-being costs. Then, an illustration is provided regarding how the taxonomy can be applied to understanding the incidence, magnitude, and distribution of these costs among stakeholder groups. This taxonomy can help inform ongoing debate about health and social policy reform.     

Characteristics of the nonelderly with selected sources of health insurance and lengths of uninsured spells

This Issue Brief examines the characteristics of individuals with selected sources of coverage and combinations of sources of coverage over a 12-month period. In addition, it examines the characteristics of individuals who experience spells without health insurance and the lengths of these spells. It uses the most recent 12-month period from the Survey of Income and Program Participation and builds on previous research on the lengths of spells with and without health insurance. Analysis of individuals' health insurance coverage from October 1994 to September 1995 showed that approximately 77.6 percent of the nonelderly had health insurance coverage during this entire period. In addition, 22.4 percent of the nonelderly were uninsured for at least one month during this period, and 7.4 percent of the nonelderly were uninsured for the entire period. Of those with health insurance coverage for the entire year, approximately 83 percent were covered by private health insurance, with at least 81 percent of this group receiving the coverage from employment-based sources. Eighty-five percent of the spells without health insurance with an observed beginning and end lasted for 4 months or less, and 99 percent lasted for 8 months or less. When examining the spells with either an observed beginning or end, 55 percent of these spells were found to last for 4 months or less, and 87 percent were found to last for 8 months or less. However, investigation of all spells without health insurance showed that approximately one-half of all spells without health insurance coverage lasted for 8 months or longer. This report found that two-thirds of spells without health insurance last for less than one year, confirming previous research that a majority of these spells are for less than a year. However, this report also confirms the existence of a significant number--approximately one-third of all individuals with a spell of noncoverage--of chronically uninsured individuals. These individuals are the most likely to delay seeking treatment for illnesses and to use the emergency room as their only site of care. Because they are in poverty or near poverty, much of this care is uncompensated. Thus, to the extent that providers can shift these costs onto other payers, all individuals and employers share in these costs through higher health insurance premiums or higher taxes to finance public hospitals and public insurance programs. Recent major health insurance legislation has addressed access to health insurance, and in many cases focused solely on continued access to employment-based coverage, but has done very little to address the affordability of coverage. However, as this report demonstrates, many individuals experiencing spells without health insurance have low incomes. Thus, to obtain coverage, individuals need not only increased access to health insurance but also the ability to afford this health insurance.     

“They Treat us Like Pests:” Undocumented Immigrant Experiences Obtaining Health Care in the Wake of a “Crackdown” Ordinance

This article presents findings from a qualitative study of Latino immigrant experiences seeking health care services in the wake of an anti-immigrant “crackdown” ordinance similar to Arizona's SB 1070. Prince William County, Virginia's 2007 “Rule of Law” ordinance escalated law enforcement efforts that targeted this population for deportation and ordered staff to ensure that no one receive social services other than those required by federal law. This article sought to answer the questions: (1) Were undocumented immigrants able to obtain health care? (2) How do immigrants characterize their experiences with health providers? Data were gathered via semi-structured interviews (n = 57) with Latinos in a low-income neighborhood. Analysis of Spanish-language narratives found that many were dissuaded from seeking care because of high costs as well as lack of familiarity with the health care system. Others perceived that they were treated with insensitivity or outright hostility—and believed this treatment was a deliberate effort to discourage them from seeking help.     

Inequitable Access to Health Services for Older Adults with Diabetes: Potential Solutions on a State Level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.