When the Kaiser Family Foundation released its new report about enrollment and spending trends in Medicaid earlier this week, the most reported on findings probably didn’t shock anyone: as a result of increased enrollment associated with the ACA, the rate of growth of overall Medicaid spending increased. We covered more people, and spending went up as a result – this isn’t a particularly interesting story. But the data actually tells a far more intriguing story, buried just a little deeper in the report.

To see it, you have to look beyond what happened to overall Medicaid spending, and dig into happened to state Medicaid spending. Remember: Medicaid is a jointly-financed program between the states and the federal government, with the federal government picking up the entire tab for newly-eligible Medicaid beneficiaries for the first three years. So while overall (federal plus state) Medicaid spending growth increased as a result of coverage gains associated with the ACA, state Medicaid spending growth didn’t, even in expansion-states. Indeed, state spending growth on Medicaid since the coverage expansions were implemented in 2014 is in line with growth levels from previous years.

An even more interesting story appears when you compare state Medicaid spending growth in states that closed the coverage gap with states that have not: in Fiscal Year (FY) 2014, states that closed the gap saw their state Medicaid spending grow at about the same rate (6.6%) as state Medicaid spending in states that didn’t close gap (6.1%). And in FY2015, states that closed the coverage gap are actually projecting less growth in state Medicaid spending (4.4%) than states refusing to close the gap (6.8%).

Let’s just review that one more time, because it’s a little counterintuitive: some states chose to accept federal dollars to provide coverage to more people. Not only did they see a significant drop in the number of uninsured residents as a result, but they also did not experience jump in their Medicaid spending growth – and, in fact, they are projecting slower growth for this coming year than states that didn’t close the coverage gap. Other states have refused to close the coverage gap. They have higher uninsured rates – causing harm to both their economies and the health of their families – and their Medicaid spending grew at about the same rate as states that did close the coverage gap. And next year these states are projecting even faster state Medicaid spending growth than states that closed the gap.

The numbers from the Kaiser report focus only on spending and savings in the Medicaid program itself. States that closed the coverage gap have reported savings elsewhere in their state budgets as a result of the drop in uninsured residents, such as reductions in mental health, correctional health, and state-funded programs for the uninsured and uncompensated care. These savings are not accounted for in the Kaiser report, which means this report underestimates the fiscal benefits of closing the coverage gap. Indeed, the Kaiser report just added more evidence to what we already knew: closing the coverage gap is a win-win proposition for states.

Prior to the Affordable Care Act (ACA), individuals with pre-existing conditions and chronic illnesses routinely faced discrimination in the individual market in the form of higher premiums or, even outright denials for coverage through a tactic known as medical underwriting. That meant that children with asthma or a woman in remission from breast cancer could be denied health insurance.  Thanks to the ACA, we now have limits on this industry practice which prohibit insurers from charging higher premiums or imposing coverage exclusions based on factors such as health status, use of health services, or gender. 

During our Consumer Voices for Coverage Annual Meeting in September, Community Catalyst facilitated a workshop on advocacy strategies to address discrimination in health plans.  In this blog we will focus on how stronger network adequacy standards can play a role in addressing discrimination concerns, and later in part 2 we will highlight how discrimination in health plans affects people living with HIV/AIDS, as one example. 


Picture from New York Times: After Surgery, Surprise $117,000 Medical Bill from Doctor He Didn’t Know

Part 1:  Narrow provider networks—keeping the sick and chronically ill out-of-network.  While narrow networks might be seen as an attempt to reduce premium rates, they can also create barriers to accessing care. People with chronic illnesses often face discrimination because their providers are more likely to be excluded from a network due to the high cost of treatment. We have seen cases where many cancer care centers and children’s hospitals are excluded from the provider networks of a significant number of health plans. When provider networks are inadequate, consumers may unexpectedly seek care outside their health plan’s network and potentially face a surprise charge of thousands of dollars due to a practice known as balance billing.

New York – paving the way for stronger protections.  Recently, New York passed a law to end balance billing and protect consumers from surprise out-of-network medical bills, passing the strongest protections of its kind in the nation. This is a significant victory for New Yorkers (Click here for a complete list of the advocacy strategies.). The new law strengthens standards for network adequacy, requires transparent information about out-of-network providers and reimbursement levels, expands consumers’ appeal rights for treatment decisions, and creates an independent arbitration process when the health plan and provider can’t agree on cost. Elisabeth Benjamin, co-founder of the Health Care For All New York coalition (HCFANY), shared that it is important to work among allies to identify and quantify problems, choose the right solutions, as well as raise awareness through media.  Additionally, she offered that compelling stories are a key to winning legislators’ hearts.  

It took us three years to get the job done,” Elisabeth concluded, “but time is on [our] side and the cause is righteous!”

What can advocates do? Consumer advocates can play an important role in elevating consumer concerns and informing policy decisions to protect consumers, especially the sick and chronically ill, from out-of-network costs. There are several avenues of advocacy that we believe will help ensure that new insurance options provide adequate coverage for consumers.

  • Advocates can utilize their state’s legislative and regulatory process as well the Marketplace to either strengthen existing laws or enact new legislation to limit balance billing practices, enhance transparency in health plans, and improve provider directories.  Advocates should identify allies in the state who can use their influence to move reform forward.   
  • At the federal level, states can continue to push the administration to release guidance on important transparency and civil rights protections in the ACA (sections 1557 and 2715A).
  • The upcoming open enrollment presents an opportune time for navigators and enrollment assisters to collect stories from consumers who are returning to the marketplace for a second time.  Understanding firsthand how narrow networks are affecting consumers is vital to understanding the depth of the problem and supporting legislative and regulatory initiatives. 


If you have questions or ideas for future materials on network adequacy, please contact Quynh Chi Nguyen, Program & Policy Associate; Staff Lead, Health Equity at qnguyen@communitycatalyst.org.

Authors: Ashley Blackburn and Quynh Chi Nguyen


Since today is the last day of National Hispanic Heritage Month, we are celebrating the gains in health care coverage for Latinos since the Affordable Care Act (ACA) went into effect. According to a new report by the Commonwealth Institute, the uninsurance rate for Latinos, the racial and ethnic group that has had the least health care coverage, dropped from 36 to 23 percent. While we celebrate this progress, we also acknowledge the disproportionate impact of the Medicaid coverage gap on Latinos. Despite the impressive gains in coverage for Latinos nationally since the ACA went into effect, the uninsurance rate of Latinos has remained statistically unchanged in states that have not yet accepted federal dollars to raise their Medicaid eligibility levels.

The ACA’s new affordable health coverage options through Medicaid and the health insurance Marketplaces are two major cornerstones to closing the gap on the uninsured Latino population. Here are highlights from this report:

  • Latinos with incomes below 138% of the Federal Poverty Level (FPL) had the greatest uninsured rate decline of all groups, from 35% to 17%
  • Latinos were more likely than whites to find and enroll in an affordable plan on the marketplace
  • Most Latinos who enrolled in the marketplace were previously uninsured 
  • California, which has the largest Latino population, saw half of previously uninsured Latinos gain coverage through expanded coverage options

These successes are true strides in improving access to coverage and care for Latinos. However, these gains were only available in the 25 states, along with the District of Columbia, that accepted the federal dollars to provide coverage to individuals with incomes below 138% FPL. For states that did not accept federal funds to raise their Medicaid eligibility levels, the 33% uninsured rate among Latinos remains statistically static. We still have work to do.

The following graph from the report, illustrates the gains in health care coverage for Latinos as well as the differences between states with and without a coverage gap.


Policymakers in non-expansion states have an opportunity to put health care coverage within reach of the 22% uninsured (or 1.3 million) Latino adults who currently fall into the coverage gap. These states can accept federal funding to close the gap anytime. According to a Robert Wood Johnson Foundation report, doing so will yield great strides in reducing health disparities for Latinos and other communities of color.

Looking ahead, besides offering expanded health care options, the report illustrates other critical steps needed to lower the insurance rate for Latinos:

  • Ensuring marketplace website functionality and effective Spanish translation
  • Reaching the remaining uninsured, young and poor through effective outreach, enrollment and education
  • Raising awareness of the marketplaces among Latinos, especially those who primarily speak Spanish

In meeting these goals, we are hopeful that the coming enrollment period will yield even more reasons to celebrate at next year’s National Hispanic Heritage Month.

-Amber Ma, Policy Analyst

Last week’s release of nationwide information about drug and device manufacturer payments to doctors was the beginning of a new era of sunshine and transparency. The information, which is made public under a provision of the Affordable Care Act, shows the  millions of ways that drug and device manufacturers try to influence doctors, using gifts, free meals, free travel and other payments of some value.

How much is industry paying our doctors?

An initial look at the data by Pro-Publica showed that total payments made by industry to more than 546,000 physicians (including dentists, podiatrists, chiropractors, and optometrists) during the last five months of 2013 totaled more than $3.4 Billion.

Bringing sunshine and transparency to the previously murky and highly suspect financial dealings between drug and device makers and our nation’s doctors is a huge victory for consumers! It reveals how extensively industry interacts with our nation’s physicians.The fact that industry payments or gifts touched more than half of all U.S. doctors in just the last five months of 2013 raises serious concerns.

According to Pro-Publica, this transparency revealed that industry paid for more than 3.5 million free meals for doctors, and for more than 200,000 trips to nearly 80 different countries. Overall, industry spent nearly $93 million on free meals to doctors, and another $74 million on travel. The drug and device industry also spent more than $202 million hiring doctors to give promotional talks to help sell their products, and $158 million hiring doctors as consultants. An article in the NY Times last week found that a small number of doctors – about 130 based on the data available so far – each earned more than $100,000 for either consulting or public speaking.

All the data is not yet identified by name of physician or teaching hospital, however. In an abundance of caution, the Centers for Medicare and Medicaid Services (CMS) has withheld the names of physicians or teaching hospitals that received payments if CMS was unable to accurately match these payments to the correct physician. This problem was due to differences in existing databases that track doctors by their prescriber id numbers or state license numbers. In these cases, CMS has temporarily released this data without identifying the recipient. Altogether, payments without recipient identifiers account for 40 percent of the number of payments, but more than 60% of the total $3.4 billion. In terms of dollars, most of these funds are reportedly for research, which covers a broad range of activities, from giving medical or scientific advice on a product in development, to conducting actual studies or clinical trials.

Based on analysis by ProPublica.

Consumers and their doctors

The CMS website lets a viewer download the data, but it does not yet allow consumers to look up their own physicians. The agency has said that will be a future enhancement to the site, to make this information more accessible to the public. In the meantime, there are two other resources that consumers can use now to find out if their own doctor has received payments from the drug industry.  

First, the website dollars-for-docs, hosted by the non-profit organization Pro-Pubica, allows consumers to look up doctors that have received payments from industry going back to 2010. While the recently released data from CMS is not included in the dollars-for-docs database yet, it is expected the site will do so soon.

In the meantime, TIME magazine has put the newly released data in an on-line search tool, where consumers can look up any doctor by name and town, and see what payments they received from August 1 to December 31, 2013.


For consumers, these disclosures can be empowering. Consumers have the right to know if their doctor is receiving money from a manufacturer of a drug that their doctor prescribes. However, this information can be confusing to patients, as well. Patients may assume that getting paid by a drug maker is a sign that their doctor is a valued expert, when in reality the payments are made to influence the physician. Alternatively, some patients may distrust their doctor for receiving any payments, even if the doctor is performing valuable medical research that contributes to a new drug, device or a new manner of medical care.

Many patients will start to question – correctly – whether these payments may have affected their care. But raising these questions with your doctor is a lot harder than it might sound. If your doctor has these interactions with industry, then asking them about accepting free meals, travel, consulting or other payments implies a question of whether the doctor is being influenced by these industry payments – a question that goes right to the doctor’s objectivity, professionalism, and personal integrity.

Unfortunately, most doctors think that they cannot be influenced by free meals, or other small gifts. But this is a myth. Research definitively shows that doctors are just like all of us — we generally feel a sense of obligation when we accept gifts from others, whether consciously or subconsciously. This effect has been shown to influence how doctors think about the drug companies that gave them the gifts, and about the drug or device products they promote.

This is an important example of the broader need for patients to be empowered to work with their doctors on a more equal level, but it’s going to take a lot of work to get there. Recent surveys show that a majority of patients don’t feel comfortable telling their doctors when they cannot afford the medicines they are prescribed. If these surveys reflect how comfortable patients are raising issues about prescribing decisions and drug choices in general, then serious work needs to be done to empower patients and consumers.

Advocates can help by raising concerns about how industry is paying doctors in their state or region, while also working to empower consumers to raise these issues individually with their doctors. 

More and more, we are learning that an engaged patient makes a healthier patient. But what makes a patient “engaged?”

Researchers are answering this question and blazing a trail to help health care providers, consumers and advocates better understand patient engagement and how to achieve it. In the September/October issue of Family Practice Management, John Wasson, MD, and Eric Coleman, MD, MPH, posit that the key to unlocking the door to patient engagement is to ask patients directly how confident they are about controlling and managing their health problems. By asking patients this fundamental question, health care providers can initiate a dialogue with their patients about what information, training and/or services they need to better understand and improve their health. Wasson and Coleman call this an “action query” – an assessment that results in more than a number on a scale because it leads patients to perform activities that increase their engagement and ultimately improve their health. These findings are consistent with the research of Judith Hibbard, PhD, who led the development of the Patient Activation Measure, a tool that assesses the confidence, knowledge, and skills needed to manage one’s health and health care.

Essentially, the more patients know, the more skills they acquire, and the more resources they can access to assist them, the more confident and engaged they will be and the healthier they will become. Take, for example, the case of Mrs. M, a 90-year-old widow with congestive heart failure. She had been hospitalized three times and had four emergency department visits, seven office visits and 21 telephone conversations with her primary care physician over a six-month period. Subsequently, Mrs. M’s physician measured her confidence and knowledge related to her condition and worked with her to improve both of these areas. As a result, she went from a 4 to an 8 in confidence and from a 1 to a 9 in knowledge, leading to fewer hospital and office visits and allowing her to resume her usual activities.

Additional questions that patients can answer to gauge their health confidence are available in a free, web-based tool developed by Dr. Wasson and available at Health Confidence.org. Offered by Dartmouth Medical School since 1994, the tool has been used effectively with hundreds of clinics, nationwide and internationally, to better address patient needs, increase patient engagement and improve procedures within medical practices.

In Massachusetts, Community Catalyst’s partner, Health Care For All (HCFA), recently launched a campaign to build health confidence in at least three regions of the state. The first community-based organization to partner with HCFA will be the South Shore Community Partners in Prevention (SSCPP), a Community Health Network Area serving 11 towns in southeastern Massachusetts. SSCPP will promote the use of Wasson’s health confidence tool to its residents through their connections to hospitals, service agencies, schools, businesses and boards of health. Patients using the tool will open up a much-needed dialogue with their providers as they work together to better align patient needs to provider and community resources.

Patient engagement is one of the most successful ways to improve the health, and ultimately the quality of life, of our sickest and most frail citizens, calling on more and more health care providers, delivery systems and communities to say, “Dear Patient: Let’s get engaged!”