Question

Suggest a health policy that would help your community. Health policies do not need to be complex--it can changing current law or policy, it can be asking for funding for a health program or policy--or they can be more complex--laws that mandate a behavior, laws that mandate the stopping of behavior, laws that mandate policies for companies (e.g., safety, environmental), laws that create entirely new policies (Affordable Care Act).

Briefly (4-5 sentences) propose a new policy for a community. Identify the health issue this policy will address, and how the policy may impact it.

Answer 1

HEALTH POLICY

The Patient Protection and Affordable Care Act

The ACA has changed the financing, organization, and delivery of U.S. health care services in a number of important ways. It not only expands private and public health insurance but also reforms how Medicare and Medicaid services are delivered and revises the tax code in important ways that encourage nonprofit hospitals to invest in their local communities in new ways. The following section briefly reviews selected features of the ACA and discusses both how these features affect communities and how federal policy could be changed to affect health equity at the community level.

The ACA has expanded access to Medicaid coverage and private insurance to millions of individuals. Nationally, since 2010, rates of uninsured have dropped from 16.0 percent in 2010 to 9.2 percent in 2015 (Cohen and Martinez, 2015). Significantly, in part because 32 states expanded their Medicaid programs and 19 did not, the rates of uninsured among the nonelderly population varies significantly from a low of 5 percent in Massachusetts to a high of 19 percent in Texas (Kaiser Family Foundation, 2015, 2016). State decisions regarding Medicaid expansion were controversial and highly politicized in many states (Jacobs and Callaghan, 2013). Yet, these state decisions have important implications for communities. The variation in uninsured rates is more dramatic across metropolitan areas; among the 25 largest metropolitan areas the rates range from 4 to 19 percent (U.S. Census Bureau, 2015). On average, urban and rural counties have higher rates of the uninsured than suburban counties. Moreover,

geographically uninsured whites are more likely to live in areas with high poverty census tracts, whereas minorities are more likely to be uninsured wherever they live (REACH Healthcare Foundation, 2016).

State policy around health insurance, particularly through Medicaid decision making, has serious implications for health and other disparities. On the one hand, the impact of health insurance on health outcomes has been found to be mixed, at least in the short run. For instance, while biometric measures of health were not found to improve in a study of the Oregon Medicaid expansion, self-reported health was found to improve. Other studies have also found improvements in self-reported health (Sommers et al., 2012), but not consistently (Wherry and Miller, 2016). On the other hand, health insurance is seen as a potential mechanism for increasing use of preventive and other medical care services. Although health insurance lowers the cost of care to individuals, other factors may also be important and counter lower costs, such as wait times for appointments, distances to services, and the perceived discomfort of the care itself. The empirical literature has found overwhelmingly that insurance expansions improve access to medical care .Additionally, greater health insurance plays an important financial role by shielding individuals from out-of-pocket medical costs and improving their overall financial status (Hu et al., 2016). The annual cost of inpatient care for a person between the ages of 18 and 64 who was hospitalized in 2012 was approximately $15,000, and the annual cost of all types of care for that person in the same year was $25,000 (Hu et al., 2016). Individuals without health insurance often have difficulty paying medical expenses and may need to borrow money or forego other necessities such as food, heat, or rent. They are more likely to be contacted by collection agencies and are more likely to declare bankruptcy. Thus, medical bills play a large role in individuals’ overall financial picture, including their ability to save and make other investments. The expansions of Medicaid, including expansions under the ACA, have been found to substantially reduce the financial burden of medical care on low-income individuals and to increase their financial well-being.

Hospital Community Benefit

Another important provision of the ACA for communities relates to charitable or nonprofit hospitals (in 2014, 78 percent of approximately 5,000 U.S. hospitals were nonprofit, exempt from most federal, state, and local taxes [Berwick et al., 2008; James, 2016]). In particular, the ACA changed the Internal Revenue Code such that all charitable hospitals must conduct community health needs assessments (CHNAs) and adopt an implementation strategy that addresses the needs identified in that assessment. Furthermore, the process must include “persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health.” Moreover, regulations issued in 2014 specify that the CHNA should include “the need to address financial and other barriers to accessing care, to prevent illness, to ensure adequate nutrition, or to address social, behavioral, and environmental factors that influence health in the community” and it was later clarified in an executive update that this includes some forms of housing improvements. Nonetheless, federal reporting forms and instructions have caused some confusion related to community benefit, investments in improving the social determinants of health, and CHNAs. As health insurance coverage has expanded, the level of uncompensated care provided by hospitals has declined, leaving hospitals to consider other areas and ways to invest community benefit dollars. Some hospitals have shown greater interest in community-wide health investments and the underlying factors that affect population health rather than maintaining the more narrow focus on health care services and funding offsets (Rosenbaum and Choucair, 2016). Howard and Norris wrote that by “addressing these social determinants of health through their business and non-clinical practices (for example, through purchasing, hiring, and investments), hospitals and health systems can produce increased measurably beneficial impacts on population and community health”. Examples of efforts that have used community benefit investments to build, hire, and invest in the local community include Kaiser Permanente in California and elsewhere and Promedica in Cleveland