This blog is part of a series highlighting recent research illustrating various benefits of expanding Medicaid - from improving health and state budget savings to reducing rates of uninsurance and uncompensated care costs. Previous blogs in this series can be found here, here and here.

Rural hospitals in states that expanded Medicaid were better able to continue being a lifeline for their communities, a new study published in Health Affairs finds. Researchers at the University of Colorado found that the Affordable Care Act’s expansion of Medicaid can be tied to significant reductions in the probability of hospital closures. Since Medicaid expansion helped millions of previously uninsured adults gain coverage for the first time, hospitals in these states saw an increase in patients covered by Medicaid and a corresponding decrease in uncompensated care, which improved their overall bottom lines and helped them keep their doors open.

Overall, hospitals in states that expanded Medicaid were over six times less likely to close than hospitals in non-expansion states. Perhaps the most striking finding, however, is that half of the hospital closures that occurred since 2014 could have been avoided if the respective state had expanded Medicaid. The researchers also found that hospitals in expansion states experienced additional benefits - including significantly better financial performance - than those in non-expansion states.

The decreased closure probability was most significant for rural hospitals in areas with more than 10 percent uninsured rates prior to expansion. Hospitals in these areas were 81 percent less likely to close on average than rural hospitals in non-expansion states.

This research now sits atop a mountain of evidence on the various benefits of expanding Medicaid. In September, a comprehensive literature review of the impacts of expansion found dramatic differences in access to and affordability of coverage, overall health and financial security for residents of expansion states versus non-expansion states. Most recently, a report from the Brookings Institution concluded that Medicaid expansion initiatives, both prior to and as a result of the Affordable Care Act, and be linked to a significant reduction in crime.

With so much to gain from expanding Medicaid, it is disappointing and concerning that 18 states have unfortunately still decided against expanding their programs, leaving their hospitals to bear the burden of uncompensated care and thousands of their residents to remain uninsured. But each new piece of evidence makes the message of expansion louder and clearer. Now is the time for policymakers in non-expansion states to heed that message and do what is best for their state and its residents.

In the first week of the New Year, the Centers for Disease Control and Prevention (CDC) released a report on infant mortality, and the news is not good. Using linked birth and infant death data from 2013-2015, the report breaks down infant mortality rates by state for race and Hispanic origin. The report shows that the stubbornly high rate of infant death for the children of non-Hispanic black women remains a public health crisis across the country while the infant mortality rates for Hispanic women reached double the rate of non-Hispanic white women in some states. These trends are worth diving into as we build out our advocacy priorities for 2018.

Key findings include:

  • For non-Hispanic black women, the infant mortality rates are double that of non-Hispanic white women. Five of the nine highest rates are in Midwestern states, with Wisconsin at the highest rate: 14.28 per 1,000 live births. States that hold rates above the national average include Alabama, Illinois, Indiana, Michigan, North Carolina, Ohio and Wisconsin.
  • For Hispanic women, the infant mortality rate ranges from 7.28 in Michigan to 3.94 in Iowa—eight states were above the national average: Alabama, Connecticut, Indiana, Michigan, Ohio, Oklahoma, Pennsylvania and Texas.
  • Infant mortality rates for non-Hispanic white women are highly variable, but the lowest rates of infant death are in the West and Northeast. Notably, states in these regions also tend to have lower uninsured rates broadly.

The CDC’s findings reinforce that racial and ethnic health disparities are quite stark throughout the country. However, the report does not provide critical data on the high rates of infant mortality for American Indian/Alaska Natives and Asian American/Pacific Islanders and it does not drill down into different rates across ethnicity categories. The CDC should provide further analyses so that we can fully understand mortality rates for all infants.

The report should prompt advocates to dig deeper into the infant mortality rate in your state and include improving birth outcomes in your 2018 policy agenda. Women of color’s lack of access to prenatal and postnatal care is central to changing infant mortality rates. Initiatives like Black Mamas Matter are working to address the broader spectrum of women needs including the social determinants of health and access to community resources such as social networks that support women before and beyond their pregnancies. Layered throughout these needs are the very real and toxic effects of racism—both in everyday life and across the health and human service systems.

From where we sit, the CDC’s report is a reminder of the importance of programs like Medicaid and the Children’s Health Insurance Program (CHIP) in keeping the coverage door open to women throughout their life, enabling them to care for themselves and their infants. At the start of 2018, both programs remain at risk with CHIP in a particularly precarious state.

As we continue our work in the new year, we need make it a priority to amplify the persistent racial disparities for women and infants of color. Working to reduce those disparities should be central to our efforts to secure health and wellness for all.

Over the last year, Republican leaders pushed several attempts at partisan repeal of the Affordable Care Act and repeatedly attacked the Medicaid program. Thanks to all of you, we banded together to stop multiple repeal bills and, more recently, celebrated voter-passed Medicaid expansion in Maine. We were able to save coverage for millions and extend access to care. However, in addition to new challenges to come as a result of the GOP’s tax bill, we must be prepared to defend our progress against further threats in 2018.

Trump already has taken it upon himself to destabilize the insurance markets through executive action, and GOP leaders dealt a blow to the ACA with repeal of the law’s individual mandate disguised as tax reform. Plus, Congress has yet to pass comprehensive legislation to re-authorize CHIP funding, putting nine million kids at risk nationwide. While the ACA remains largely intact for now, House Speaker Paul Ryan continues to call for slashes to Medicaid and Medicare, and Trump has hinted at another anti-ACA health care push in 2018.

Our collective successes in warding off Congress’ attempts to repeal the ACA and Medicaid expansion were due not only to the tireless work of consumer health advocates across the country, but also to the extraordinary efforts of grassroots activists from a diversity of perspectives and issue interests. As we brace for the next phase of this fight, it’s important to reflect on the partnerships that grew and developed as part of this national campaign, and recognize the work needed to maintain and foster these relationships as we grow a movement focused on health access, coverage and equity.

No matter which version of the ACA repeal bill was being debated, grassroots activists brought deeply personal experiences into the public view. Groups like Liberated People, National Council on Independent Living, ADAPT, National Nurses United labor union, MoveOn, ACT UP, National Congress of American Indians and Little Lobbyists organized days-long sit-ins in the offices of their congressmen — including those who refused to hold public town halls — and mobilized massive demonstrations in Washington, D.C. and around the country.

The media was captivated by the images of people in wheelchairs being physically removed from the Capitol by police. Legislators — to some extent — did ultimately take heed of the activists camped out in their offices, greeting them at airports and filling their town hall meetings. However, it is upon us to remember that many of these activists put their own safety at substantial risk to protect the ACA. People of color, LGBTQ people, people with disabilities, parents of children with chronic health issues, people who care for aging family members, and others who face disproportionate health disparities put their lives on the line, risking arrest and public scrutiny for the common good of protecting the ACA and defending Medicaid.

In the coming year, we will once again need to come together to defend the Affordable Care Act and Medicaid. Trump’s decision to withdraw cost-sharing reduction payments to insurers nearly guarantees that people across the country will see double-digit premium hikes, and the GOP's recently passed tax bill puts billions of Medicaid dollars at risk. As we continue in our fight to thwart additional cuts and changes to the ACA and Medicaid, it is also important that we support those new partners we collaborated with over the past eight months. A continued partnership can mean seats at a coalition table, invitations to events, membership on boards, and more, but it also needs to be an active engagement in the other issues important to these partners.

Going forward, consumer health advocates should continue to feel a stake in other fights that contribute to larger social justice movements. We should take this time to reflect on the connections between health care and intersectional racial justice, reproductive justice, immigrant justice, climate justice, justice for people with disabilities, and beyond. Fighting for justice of any kind is hard. Each intersection of different identities and policies comes with its own set of nuance, and it’s impossible to expect anyone to be perfectly versed in all of it. But that’s why we all should work together. Grassroots activists are mobilizing to fight back against the Trump administration’s DACA rollback, climate change deniers and emboldened white supremacists. We should all be prepared to contribute in the ways we best can to resistance movements against these attacks on human rights and social justice, as well.

Health care was the first of many fights to come. We are just one piece of a much larger puzzle of resistance. Grassroots organizers often bring to the table expertise in very nuanced social justice issues, while advocates can bring policy expertise and organizational space, for instance. We should continue to brainstorm new and creative ways to partner with organizations, and use our positions of privilege to contribute however we can to movements beyond our health care sphere.

State consumer health advocates have been at this fight for years, and have shown particular strength over the last ten months. We had some big wins this year, but the fight isn’t over. If we make a conscious effort to work together with non-health care groups on these multifaceted issues beyond health care, we can use our strengths to lift each other up and work together to pursue justice for all.

Tori Bilcik hails from Connecticut and is a recent graduate of Emerson College. She is an intern with the Communications team at Community Catalyst and a freelance writer.

As the 2017 congressional session staggers to a conclusion – capped off last night with only a short-term fix of partial funding of the Children’s Health Insurance Program and Community Health Centers coupled with  a raid on the ACA Prevention Fund – let’s take a few minutes to consider what has happened during this first year of the Trump presidency, and what it suggests for health care policy and politics in the year ahead.

First, the agenda of governing Republicans is abundantly clear to anyone who is not deluding themselves. Their top priority is the further concentration of wealth at the very top of the income pyramid, accompanied by continuous undermining of the health and economic security of middle- and lower-income households. In health care policy terms, this has translated into an unrelenting assault on the Affordable Care Act (ACA) and Medicaid. (While Speaker Ryan continues to eye Medicare somewhat wistfully, cutting Medicare remains an aspirational goal, as even he seems to sense it would be politically suicidal – at least for now).

The health care assault has been both administrative and legislative. On the administrative front, the Trump administration has cut support for ACA marketplace enrollment, cancelled payments for cost- sharing reductions (CSRs), initiated the expanded sale of insurance plans that don’t meet ACA standards, and weakened consumer protections in marketplace plans in areas ranging from access to providers to overseeing rates and more.

With respect to Medicaid, Trump’s HHS department has clearly signaled its intent to approve state Medicaid waivers that would place financial and administrative barriers in the way of coverage. These barriers may include work requirements, increased cost sharing or other measures that will make it harder for people to enroll in Medicaid, keep their coverage or afford care when they need it.

On the legislative front, thanks to a massive organizing effort, repeated attempts to weaken the federal funding commitment to Medicaid, reduce ACA premium tax credits or strip away protections – like guaranteed issue, no pre-existing condition exclusions or limits on age rating – have failed. Unfortunately, the ACA’s individual mandate did not fare as well. After repeated failures to repeal the ACA outright, Republican leaders were finally able to achieve limited success by repealing this least popular aspect of the law – the individual mandate – to help them pay for all the goodies for special interests, their wealthy donors and pet issues for members in the $1.5 trillion deficit-increasing tax bill they were determined to jam through.

On the political front, we have seen that congressional Republicans are undeterred from their course of action despite the fact that both their ACA repeal bills and their tax cut bill have been wildly unpopular.

We have also seen that members appear not in the least troubled by their logical inconsistency in pursuit of their agenda. Two logic gaps have been particularly notable. First, Republicans denied that repealing the mandate would actually cause people to lose coverage, while still claiming that it would save money (apparently, the savings would appear by magic). In addition, even with the GOP assertions that mandate repeal would not have much effect, many were arguing at the same time that its removal would so destabilize the ACA that repeal would become inevitable.

Similarly congressional Republicans seemed to have no trouble simultaneously holding the view that we can afford $1.5 trillion in tax cuts that will disproportionately benefit the rich while at the same time asserting that we cannot afford health care for children, older adults, people with disabilities and low-income adults.

Looking Ahead to 2018

Early next year, advocates should expect initial GOP moves to set up the return of some variant of Graham-Cassidy in the form of a block grant that would combine funding from insurance tax credits and Medicaid expansion coupled with a financial restructuring of the pre-ACA Medicaid that would progressively short-change the program over time. As we saw this year, there will be an effort to move this agenda forward through the budget reconciliation process in order to bypass the need for any Democratic votes. At same time, advocates are going to have to address new state-level problems created by the combination of individual mandate repeal and expanded sale of short-term insurance.

But while it would be foolish not to expect and prepare for further assaults on health security in 2018, there are four reasons why we should enter into the coming debate with some optimism:

  • First and most importantly, we have beaten this agenda in the past. That proves it can be done. The lack of popular support for repeal, the strong support for Medicaid and the continued strong enrollment in the Exchanges despite Trump administration sabotage efforts are all positive signs for the future.
  • Second, by winning the Senate seat special election in Alabama, Democrats have cut the Republican margin to two in the chamber – leaving almost no margin for error in any repeal bill.
  • Third, it is an election year and that may make enacting big cuts in Medicaid and ACA tax credits an even harder lift in the House that it was this year.
  • Finally, taking on Medicaid is much tougher than repealing the individual mandate. More people than ever now like Medicaid. They don’t like the mandate. Undermining Medicaid affects tens of millions of people including not only beneficiaries, but also their families, their providers and many other sectors of the economy that depend on state funding and that would be adversely affected by state budget cuts if federal Medicaid funding were reduced.

However, optimism is not certainty. Winning is not self-executing. It will require every bit as much effort as it did in 2017. It will require an “all-of-the-above strategy” that deploys policy arguments, personal stories, grassroots mobilization and building alliances with multiple stakeholders, including many with whom there is only limited agreement. Even though the road to repeal is narrow, we cannot forget that repealing the ACA and cutting Medicaid is absolutely the default aspirational position of the large majority of the Republican caucus in both the House and the Senate. And, as we have just seen with the tax bill, the votes of Senators Collins, Murkowski and McCain cannot be taken for granted.

Winning next year will be challenging. We have done it before and we can do it again, but only if we are prepared to fight.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

In my clinical work, I get to meet and work with an incredibly devoted set of family caregivers. These are parents caring for their special needs child, often while also caring for an aging parent. Or a spouse, sibling or friend who helps out with care coordination for someone with a mental illness or cognitive impairment. Or the friend who steps in with last-minute transportation help for someone who might be mobility impaired. My clinical colleagues and I rely every day on the proverbial “village” of caregivers as we work to maintain or improve health. 

In my own family, I’m grateful for my mom and her siblings, who lovingly cared for my grandfather at the end of his life, and who continue to care for my grandmother. Our Center team is a team of caregivers too, and we pause during National Family Caregivers Month (#NFCMonth) and in this season of gratitude to share our thanks for the caregivers in our own families and our wider communities. Here is a sampling of reflections on caregiving from members of our team:

  • “As I watch my dad look after my 96 year old grandmother, I really am in awe. He has done such a good job of making sure she’s safe and well cared for while still maintaining his own life and not drowning in her needs. I hope I can do as well when he is 96!”
  • “My mother is 80 years old and doesn’t speak English. She needs my help at her medical appointments as she prefers to have a family member translate from Spanish for her. She doesn’t like strangers hearing about her medical conditions, so even when a provider offers a staff translator, she is uncomfortable without me accompanying her.”
  • “I’m grateful for my father, who was a gentle, loving and committed caregiver for my mother during her many illnesses and, in particular, over the last year of her life. He navigated appointments with a dizzying array of doctors, nurses, social workers and home health aides, all the while managing most of the responsibilities at home. The physical and emotional toll it took on him was enormous, but he remained steadfast by her side throughout.”
  • “Having an engaged and responsive local pharmacist who prepared a weekly bubble-packed card for all my mother’s daily medications – organized by morning, noon, evening and bedtime – relieved a great deal of stress for me about her safety, and allowed my mom to remain in charge of taking her own pills for as long as was possible, which was very important to her sense of autonomy.”
  • “An important aspect of caregiving I’ve experienced is to be at the bedside when my mother has been hospitalized, both to provide comfort and to observe and advocate for her. Recently, after she fractured her leg in a fall, she had a truly alarming episode of post-operative delirium following the repair surgery. While the nursing staff were attentive, they reacted to this as fairly routine. My family and I pushed ourselves to be assertive, requesting steps to manage and quiet her room, to help speed the resolution of my mother’s delirium. She’s doing much better now.”

But in addition to our gratitude, there’s much we can do to support caregivers. Let’s make sure that the health care system: recognizes their importance and includes them in care teams; addresses caregiver burnout, including the provision of respite care; ensures caregivers have peace of mind that their loved ones will ALWAYS have access to the health care coverage they need; and is a system that is easy to navigate so we can spend less time sorting out the bureaucracy of health care and instead be able to spend time together celebrating what matters most in our families’ lives.

Happy holidays, and thank you to all of the caregivers out there.