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The union maintains that uninsured and under-insured patients end up with hospital bills far higher than those with insurance because they're unable to take advantage of dramatic discounts on care negotiated by insurance companies and hospitals. Hospital officials don't dispute the charges and cost amounts used in the union's report, which is to be released during a news conference in Columbus. Millions more patients are "under-insured" and face large medical bills for uncovered expenses, and health experts say more people will fall into that category as employers shift more health-care costs to employees.
The average statewide hospital charge was $12,852 and the average cost per admission was $5,040, resulting in an average markup of 155 percent. In addition, if a patient at 200 percent of the federal poverty level or less has an uncovered hospital bill, Mercy writes off the entire bill, she said.
Ron Wachsman, a top official with ProMedica Health System, the parent company of Toledo Hospital, likewise criticized the report for misleading the public.
Joyce Moscato, policy and program director for Care for Ohio, the union project that conducted the study, said even a discount of 25 percent or more off bill of more than $10,000 does little to help the average patient without insurance. As to the hospitals' statements that they have significant discounts in place for those with unpaid bills, Ms.
Mercy officials provided copies of paperwork they say is sent to all patients that tells them help is available and urges them to contact the hospital if they need financial assistance. What nonprofit hospitals charge the uninsured and under-insured has been under increasing criticism in the past year, as indicated in a Blade report on charity care last August.
Union officials say their report has nothing to do with the lawsuits, but said their concerns mirror those outlined in the lawsuits. Quis autem vel eum iure reprehenderit qui in ea voluptate velit esse quam nihil molestiae consequatur, vel illum qui dolorem? The expansion of Medicaid under federal health reform has greatly reduced the number of Kentuckians without health insurance, but state legislators are wary of its future cost.
Medicaid Commissioner Lawrence Kissner dramatically illustrated the impact of the expansion by showing two county-by-county maps to the latest meeting of the Interim Joint Committee on Appropriations and Revenue. Enrollment in Medicaid has been larger than expected, and Kissner said he did not know how much the new enrollees will cost the state when it has to begin paying 3 percent of their cost in 2017, rising to the law’s cap of 10 percent in 2020. In addition to the studies indicating that expansion would pay for itself, Kissner said, “If you make your population healthier, what happens? Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky. Recent studies suggest that Medicaid expansion will result in health and financial gains.  Older studies also found salutary health effects of expanded or improved insurance coverage, particularly for lower income adults. The Supreme Court ruled in June 2012 that states may opt out of Medicaid expansion, and as of November 2013, 25 states have done so. In this post, we estimate the number and demographic characteristics of people likely to remain uninsured as a result of states’ opting out of Medicaid expansion.
The Supreme Court’s decision to allow states to opt out of Medicaid expansion will have adverse health and financial consequences. Despite the widely held belief that almost all Americans will be insured under the ACA, more than 32 million people will remain uninsured after the law goes into effect. Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage. Predicted national-level consequences of states opting out of Medicaid expansion are displayed in Exhibit 2.
State-level estimates for post-ACA effects of opting out of Medicaid expansion are displayed in Exhibit 3.
We categorized states as opting in or opting out of Medicaid expansion using the Kaiser Family Foundation’s “Status of State Action on the Medicaid Expansion Decision,” which was updated on November 22, 2013.
The patients studied in the OHIE were slightly older than the uninsured poor in opt-out states, and more often female.  While we were able to adjust for these demographic differences in estimating cancer screening rates, it was not possible to do so for other effects. Your map has Vermont as one of the states that opted out , yet your exhibit #1 Table shows Vermont as one of the states that opted in ? No one doubts Medicaid (actual value=99%) is better for family finances than employer-based health coverage (actual value~80%). The AJPH finding of a 40% increase in mortality risk associated with being uninsured is by far the highest in the literature that has directly tried to calculate this value. It’s difficult to believe that the differences in physical health measurement between the Kronick study and AJPH study would account for a 40 percent mortality hazard disappearing.
I stand by my belief that the authors have grossly overestimated potential mortality gains associated with Medicaid expansion.
Michael Bertaut brings up valid concerns about needed financing increases to the Medicaid program, though this was not the focus of our post.
One should also note that states opting for the Medicaid expansion receive a large influx of federal funds that would reduce hospitals’ uncompensated care and serve as an economic stimulus. Professor Conover questions the generalizability of the Wilper AJPH study to Medicaid patients.
Professor Conover notes that in the Sommers study, the observed decline in mortality in Arizona did not achieve statistical significance. As a physician who has taken care of thousands of Medicaid patients in my 35 year medical career, I am acutely aware of the problems we face caring for these people. The second study used to generate the lower bound mortality figure (7,115) is based on Himmelstein and Woolhandler’s own previous work in AJPH. That the authors should bypass a much stronger study showing no mortality benefit from private insurance in favor of a weaker study appearing to show a 40% mortality risk associated with being uninsured is a bit disturbing.

These authors should be well aware that just the act of adding signficant numbers of people, in some states increasing Medicaid populations by 50% or more, will require a heavy investment up-front of state revenue to enact. Anne Mercy Hospital in West Toledo charges uninsured and under-insured patients the highest markup of any nonprofit hospital in Ohio, and several other local hospitals are ranked among the 20 highest statewide, according to a report to be released today. An estimated 45 million Americans, representing more than 15 percent of the population, have no health insurance, and the number is growing annually. But Ohio and local hospital officials contend the report is misleading because it doesn't account for substantial discounts given by hospitals to help many uninsured and under-insured patients. Even those with insurance coverage are indirectly affected by the markups as health care providers try to recoup operating costs from health insurers and employee co-pays. Anne Mercy Hospital in West Toledo, with an average gross charge of $21,341 and an estimated cost per admission of $5,626, resulting in a 279 percent markup. Platzke said, the higher a hospital's charges, the more significant the discounts given to the uninsured or under-insured. That means a patient in a family of four making $38,700 or less would get free care if they had no insurance or couldn't afford their bill.
Wachsman said ProMedica gives free care to those at 200 percent of the federal poverty level or less if they have no insurance or unpaid bills, and has varying discounts for those above that poverty level.
It's easier to find out the true identity of Deep Throat than who is eligible for charity care," Ms. Catholic Healthcare Partners, Mercy Health's parent company, and ProMedica were sued over these issues in federal court, but those charges were dismissed. Hospital officials say it's unfair to blame them for the larger issue: The rise in the number of uninsured and under-insured patients. Steve Beshear has said the expansion will pay for itself by creating more jobs in, and tax revenue from, health care. These opt-out decisions will leave millions uninsured who would have otherwise been covered by Medicaid, but the health and financial impacts have not been quantified.
Applying these figures to estimates of the effects of insurance expansion from prior studies, we calculate the likely health and financial impacts of states’ opt-out decisions.
Based on recent data from the Oregon Health Insurance Experiment, we predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death.
The number of uninsured people in states opting in and opting out of Medicaid expansion is displayed in Exhibit 1. We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104.  Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. In Texas, the largest state opting out of Medicaid expansion, 2,013,025 people who would otherwise have been insured will remain uninsured due to the opt-out decision. We used the Census Bureau’s 2013 Current Population Survey, a nationally representative survey of the non-institutionalized US population, to determine the number of uninsured people in each state before implementation of the ACA.
The OHIE is a randomized study that examined the effects of expanding public health insurance for low-income (less than 100 percent FPL) adults on health, financial strain, health care use, and self-reported well-being.  It found that after an average of 17 months of exposure to Medicaid coverage, improvements occurred in rates of depression (based on the eight-question version of the Patient Health Questionnaire (PHQ-8)), and catastrophic medical expenditures.
For our high estimate, we used the recent study by Sommers and colleagues that compared trends in mortality rates in states with Medicaid expansions (New York, Maine, and Arizona) to trends in states without such expansions.
Our figures, which use the number of uninsured in 2012 as the baseline, differ slightly from Congressional Budget Office figures based on projections of the numbers who would have been uninsured in several future years had the ACA not been passed. Similarly, we did not attempt adjustment for regional differences in depression prevalence, in the uninsured population, although such differences are probably small. I live in Vermont and know that Vermont is an opted in state Please change your Map Graphic to reflect the TRUTH. But at an added cost north of $5,000 per person, Medicaid has to do more than merely reduce out-of-pocket spending to justify its costs. The claim that it likely understates the potential mortality gains from Medicaid expansion lacks credibility, especially since that gain is based on a comparison of the uninsured with those on private insurance.
We did note that a broad Medicaid expansion may indeed strain the limited number of providers accepting Medicaid patients, a problem perpetuated by low reimbursement rates. But he fails to note that the mortality increase in Maine was also non-significant, thus Conover’s comparison of Maine to New York (where Sommers found a significant mortality decrease) is a misapplication of a non-significant point estimate. In light of the mountain of evidence showing the private insurance is vastly superior to Medicaid when it comes to health outcomes, including mortality. It’s notable that on every metric of health risk (obesity, lack of exercise, smoking, drinking) the uninsured led riskier lives (Table 1). That the authors fail to even mention this study or explain their rationale for selecting the one whose results they prefer is equally inexcusable. Had a different, more appropriate comparison state been selected, the estimated beneficial effect of Medicaid expansion might well have disappeared entirely. Toledo Hospital had the fifth-highest markup, with an average gross charge of $18,698, and an estimated cost per admission of $5,630, or a 232 percent markup. She said Mercy gives a minimum 25 percent discount off the charged rate for any patient without health insurance.
Courtney said these discounts - referred to as "charity care" policies - are difficult to understand and patients are often not told about them. Wachsman said ProMedica is developing a more uniform policy for patients that it hopes to have available soon.
Most recently, the Oregon Health Insurance Experiment (OHIE) found a striking increase in emergency department use as well as other outpatient care. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64.

We estimate that Medicaid expansion in that state would have resulted in 184,192 fewer depression diagnoses, 62,610 fewer individuals suffering catastrophic medical expenditures, and between 1,840 and 3,035 fewer deaths. We then projected the number of uninsured people in each state after implementation of the ACA depending on whether the state is opting in or opting out of Medicaid expansion. In addition, the OHIE found that acquisition of coverage led to increased utilization of most types of health care, including several types of care that has been linked to improved outcomes such as diabetics receiving medication to treat their diabetes and clinically indicated mammograms and cervical pap smears (in the past 12 months). We could not take into account several factors that might influence the impact of Medicaid expansion. If anything, the adjusted prevalence of major depression in Oregon appears slightly below the national average. It is listed as an opt-in state, but has a reduction in uninsured (18%) typical of opt-out states. The existing Medicaid program has been opened to single people and others not previously eligible. Much of this evidence also is observational but the best studies, which take into account selection effects, show that private coverage is superior, e.g.
So it is not at all implausible to imagine they are more prone to dying in motor vehicle accidents due to lack of seatbelt use, speeding etc.
This study is structured in the same fashion as the AJPH study but with very different results: Kronick found no statistically significant difference in mortality risk for those who were uninsured compared to those with employer-based coverage. Those with poor insurance coverage also receive substantial discounts to make up for uncovered amounts, she said.
They want state lawmakers to force hospitals to do a better job of telling patients of their charity care policies and issue annual public reports on how much true charity care they're providing.
David Givens, R-Greensburg, asked Kissner how the General Assembly should gauge financial success in the budget-writing process for the 2017-18 biennium,” Wheatley reports.
Because the federal government will pay 100 percent of increased costs associated with Medicaid expansion for the first three years (and 90 percent thereafter), opt-out states are also turning down billions of dollars of potential revenue, which might strengthen their local economy.
Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.
Based on previously published estimates of take-up rates and estimates from the Congressional Budget Office, we assumed that in states opting out, 90 percent of currently uninsured people with incomes below 138 percent of FPL will remain uninsured, as will 75 percent of uninsured people with incomes above 138 percent FPL.
An estimate of the number needed to insure was calculated by dividing the number of newly insured persons by the number of outcomes achieved.
For instance, both the OHIE and Sommers estimates are based on Medicaid expansions that paid doctors pre-ACA reimbursement rates. An older sample population in the OHIE may have resulted in greater improvements in health and screening following Medicaid expansion, leading to a slight overestimate of effects in states with a younger uninsured population, whereas the female predominance in the OHIE may have resulted in a slight underestimate of effects in other states because males are more likely to have diabetes and other chronic conditions. To make room for them, former recipients making over 100% of poverty were moved out and expected to buy insurance through the exchanges.
A recent study by the Kaiser Family Foundation finds that overall state expenditures will be 2.9 percent greater between 2013 and 2022 compared to if all states opted out, whereas federal expenditures will be 26 percent greater.
The AJPH study merely examines the uninsured and privately insured in year 1 and then measures what fraction have died 6-14 years later.
Woolhandler and Himmelstein would not prescribe to their patients a treatment demonstrated to have killed 1 out of every 2 who took it etc.
In states opting in, we assume that 40 percent of currently uninsured people with incomes below 138 percent FPL will remain uninsured, as will 60 percent of uninsured people with incomes above 138 percent FPL. For our low estimate, we used a study based on mortality follow-up of participants in the National Health and Nutrition Examination Study, which found a 40 percent increase in death rates among the uninsured, an effect size approximately 42 percent that found by Sommers. Since the ACA will provide a two-year increase in Medicaid rates for primary care services, it is possible that access to care will improve more than was observed in those studies if more providers start accepting Medicaid.
Table 2 in Sommers shows that the mortality change observed in Maine was statistically signficant from New York’s, but that does not entirely rule out the possibility of a net mortality gain in Maine.
It does not examine the causes of deaths, including many that would have nothing to do with health insurance. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.” Since the AJPH study merely updates the IOM estimate using a different dataset, Kronick’s observation applies to it with equal force. These estimates incorporate the assumption that enrollment of people with incomes above 138 percent FPL through the exchanges will be higher in states that opt to expand Medicaid.
In addition, Oregon’s health costs (and presumably its rates of catastrophic medical expenditures) are slightly lower than national average. The broader expansion under the ACA may put greater strain on the limited capacity of providers who accept Medicaid patients, curtailing utilization. Finally, participants in the OHIE had been uninsured for at least six months, and were concentrated in the Portland area.
The Sommers study examined 3 states and Medicaid was found to have a statistically significant effect in only one.
Yet the Dickman team essentially extrapolated that mortality benefit to EVERY state even though we have no reason to believe that most states would be similar to NY than to ME or AZ. The Dickman methodology concludes that 31 lives would be saved in Maine from Medicaid expansion even though the very study they use to make that extrapolation specifically found that Maine’s Medicaid program had no statistically significant effect on mortality. Given that the Sommers team cautioned specifically against precisely this sort of extrapolation, it’s pretty inappropriate to quote their conclusion without alerting readers to this caveat.

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