Christie Mettenbrink, MSPH,GISP Denver Public Health Who Got Covered: Assessing Medicaid Enrollment after Medicaid Expansion Christie Mettenbrink, MSPH,GISP Denver Public Health Thank you for coming. My name is Christie Mettenbrink, I’m an epidemiologist with Denver Public Health Department and I was asked to come and speak all of you today on an analysis that we worked on examining Medicaid Expansion as an result of the ACA. Denver Outreach Partners Meeting 9 June 2016

Denver uninsured | Pre-ACA Impacts of Medicaid expansion Objectives Denver uninsured | Pre-ACA Impacts of Medicaid expansion Who and where are the remaining uninsured? I’m going to start today’s talk with a bit of a background of the uninsured population in Denver prior to ACA implementation. The bulk of my talk today will center around the impacts of Medicaid expansion- looking at who got enrolled, where do those newly enrolled people live, and how Medicaid enrollments compare post-ACA to pre-ACA. And finally, we’ll talk a bit about the remaining uninsured population. Who they are demographically and where they live.

Uninsured in Denver: Pre - Patient Protection and Affordable Care Act (ACA) implementation So let’s jump right in and look briefly at Denver’s uninsured population before the ACA went into effect.

Uninsured Rate by Demographic Group| Pre - ACA Overall, in 2013 (pre-aca) approximately 18% of Denver’s population was uninsured. Source: 2015 Colorado Health Access Survey administered and analyzed by the Colorado Health Institute

Uninsured Rate by Demographic Group| Pre - ACA While lack of health insurance is common throughout our community, it’s particularly high among young adults, males, and Hispanics. Source: 2015 Colorado Health Access Survey administered and analyzed by the Colorado Health Institute

Uninsured in Denver | Pre - ACA So where did the uninsured live in Denver? This map estimates the percentage of uninsured by Denver census tracts. The darker colors represent areas where there are higher numbers of uninsured while the light blue colors are areas with low numbers of uninsured. If you’ve ever seen maps of Denver depicting disparities, you may have heard the term ‘inverted L’. This is oftentimes the trend in Denver, with the bulk of those in need living in the northern and western parts of Denver. Source: American Community Survey 2009-2013

Impact of the ACA in Denver Now let’s move to the ACA implementation. There were a lot of different parts to the ACA

Impact of the ACA in Denver Medicaid Expansion , but today we’re going to concentrate on one particular piece which is Medicaid Expansion.

Denver Medicaid Enrollment | Pre ACA Before we go down that road, let’s first take a step back and look at what Medicaid enrollment in Denver looked like before Expansion.

Denver Medicaid Enrollment | Pre ACA Not surprisingly, the majority of those enrolled in Medicaid were Hispanic, Female, and under 18.

Trends in Denver Medicaid Caseload | 2013-2016 And then Medicaid expansion hit. This graph shows the trends of Medicaid caseload in Denver from Jan, 2013 through Jan, 2016. Up until Medicaid, caseloads in Denver remained stable, but once we hit January of 2014 we see a pretty dramatic jump in caseload with the most dramatic rise occurring in those members 21 and over who are now eligible for Medicaid under the new eligibility requirements. Most of the expansion enrolled were newly eligible for the program. However we also saw what we call “Welcome Mat” enrollees, which means they were already eligible under pre-expansion criteria but weren’t aware of it or just hadn’t signed up.

Denver Medicaid Enrollment | Pre and Post ACA Going back to Medicaid enrollment and comparing pre ACA with post ACA, we see slightly more older individuals enrolled post-ACA and more males than before, but overall, there are no drastic differences between the demographics of the two groups. So, how do we know the true impact of Medicaid expansion and that it reached those individuals we intended it to?

Denver Medicaid Enrollment | Pre and Post ACA To do so, we need to tease out those who are eligible and enrolling for Medicaid under the new expansion rules and that’s what this slide shows.. MAGI- Modified Adjusted Gross Income- it’s basically those qualifying for Medicaid based on your income alone. This allows us to see the huge differences in those qualifying for Medicaid due to Medicaid Expansion. From this we can see that Medicaid Expansion worked – we have significantly more individuals over 18 enrolling in Medicaid- and a large proportion of those male. We did not see a single racial/ethnic group enrolling in Medicaid due to expansion efforts compared to any other group.

Denver Medicaid Enrollments| Total Enrollments The next thing we wanted to look at was where those newly enrolled in Medicaid lived in Denver. This map is all Medicaid enrollments from Jan 2015 through June 2015. The darker blue areas are higher enrollment areas, and the lighter blue are lower areas of enrollment. We still see our inverted L here- but this way in a good way. Those individuals were highest in disparities and most likely to not have coverage.

Denver Medicaid Enrollments| Adult Enrollments We can also tease out adult enrollments vs. children. Adult enrollments (those over 18) follow the same pattern that the overall enrollment map showed, with the highest numbers of enrollment falling to the northern and western parts of Denver.

Denver Medicaid Enrollments| Child Enrollments Those enrolled who were under 18 followed a similar pattern although we notice slight difference. For instance, with regards to children, the highest enrollments occurred in the north eastern part of Denver in the Montbello and Gateway/green valley ranch area.

Who and where are the remaining uninsured? And finally, let’s take a look at who remains uninsured in Denver.

Uninsured Rate | Pre and Post ACA We looked at this same graph earlier- showing those uninsured in Denver prior to Medicaid Epansion. With such a huge uptake of Medicaid it’s important to look at how the face of the uninsured has changed. Source: 2015 Colorado Health Access Survey administered and analyzed by the Colorado Health Institute

Uninsured Rate | Pre and Post ACA As you can see, it changed quite a bit! Overall, the percentage of Denver residents who are uninsured decreased over 44% compared to 2013. There’s no doubt that Medicaid expansion drove the reduction in uninsured. Age and gender disparities in uninsured decreased, although we still see a high disparity of ethnic disparities. Source: 2015 Colorado Health Access Survey administered and analyzed by the Colorado Health Institute

Uninsured Rate | Pre and Post ACA As you can see, it changed quite a bit! Overall, the percentage of Denver residents who are uninsured decreased over 44% compared to 2013. There’s no doubt that Medicaid expansion drove the reduction in uninsured. Age and gender disparities in uninsured decreased, although we still see a high disparity of ethnic disparities. Source: 2015 Colorado Health Access Survey administered and analyzed by the Colorado Health Institute

Uninsured Rate | Pre and Post ACA As you can see, it changed quite a bit! Overall, the percentage of Denver residents who are uninsured decreased over 44% compared to 2013. There’s no doubt that Medicaid expansion drove the reduction in uninsured. Age and gender disparities in uninsured decreased, although we still see high ethnic and racial disparities. Source: 2015 Colorado Health Access Survey administered and analyzed by the Colorado Health Institute

The Remaining Uninsured| Where are They? The map on the left is the one we looked at earlier- the estimated uninsured in Denver prior to Medicaid expansion and is depicted using estimates from the American Community Survey.. The map on the right is the estimated uninsured after expansion. To get this, we used Medicaid enrollments in each census tract and subtracted that number from the estimated uninsured. The goal in Denver was to turn the map blue. Or in other words, have less that 10% uninsured in each Denver census tract. And as the map shows, we’ve definitely made progress toward that goal! The map on the Two things to point out: We still have some work to do.. We still see a pockets of uninsured in the north eastern part of Denver as well as to the southwest, which gives us areas to concentrate further enrollment efforts. You’ll notice there are certain census tracts hashed out. This is where the number of Medicaid enrollments were higher than the estimated number of uninsured. We know that Medicaid expansion resulted in higher enrollments than we anticipated- which makes the hashed out areas not surprising. These are most likely the areas where our estimates were off.

The Remaining Uninsured| Barriers to Insurance We’ve talked about the new ‘face’ of the uninsured in Denver (again, highest in 19-39 year olds, Males, and all racial/ethnic groups) We also know in general where our uninsured population lives in Denver. The question remains as to why these individuals remain without healthcare. We estimate that most of the remaining uninsured are the working poor, with an income above the Medicaid eligibility threshold. The ACA provides help for such persons – they can buy insurance through Colorado’s online marketplace – Connect for Health Colorado – and receive support from the federal government to pay for premiums and reduce the cost of care.  Enrollment through Connect for Health Colorado is limited to the open enrollment periods, except if there are certain qualifying events such as getting married or having a child.   Private insurance is more complicated for patients than Medicaid – there are more plans to choose from and more challenges to know how to navigate premiums, co-pays, and co-insurance. Therefore, we suggest that patients interested in Connect for Health Colorado get help from enrollment specialists at Denver Health or a community-based enrollment assistance sites.

The Remaining Uninsured| Barriers to Insurance Making health insurance affordable, especially for those with low and moderate incomes is a primary goal of the ACA. The law tries to do this in many ways including offering tax credits for premiums and subsidies for out-of-pocket costs to those who qualify. Unfortunately, the income gap still remains. Many higher earners who make too much to qualify for Medicaid or eligible for tax credits to buy insurance through the marketplace remain uninsured. For them, the cost of obtaining insurance is still too high.

The Remaining Uninsured| Barriers to Insurance Over 20% of those without insurance say that they don’t need health insurance because they’re in good shape and don’t expect that to change. There’s also a large percentage of this population who don’t need coverage because they don’t believe in Obamacare.

The Remaining Uninsured| Barriers to Insurance And finally, over 13% state that they don’t know how to get insurance. We’ve found that uninsured Hispanics are more likely to report this than uninsured non-Hispanics

Thank you! Christie.mettenbrink@dhha.org