Health Care Outcomes In States Influenced By Coverage, Disparities


By Kimberly Leonard

Health investment contributes to better medical outcomes, but social determinants also play a role.

Enjoying longer, healthier lives than the average American, and with strong medical coverage and access to care, Hawaiians rank No. 1 in the country for health care, according to n analysis of federal data supporting the Best States rankings. But Hawaii has more than a mild climate and residents who share a proclivity for outdoor activities to contribute to its success. The state had a significant head start: a four-decade jump on health care reform.

"It was a really wonderful exciting time and one that's kind of forgotten by the rest of America," says Dr. Jack Lewin, who oversaw the state's implementation of the Prepaid Health Care Act as health agency director.

As a result of the law's passage, Hawaii became the first state in the country to implement a nearly universal health care system for its residents, enforcing a mandate for all employers whose employees work a minimum of 20 hours a week. The model, originally proposed by President Richard Nixon, would later become the inspiration for Hillary Clinton's unsuccessful attempts at national health care reforms in her role as first lady in the 1990s.

Though never implemented nationally, the law in Hawaii, as well as measures in other states that have been particularly proactive, provides strong evidence that increasing access to health care coverage has contributed to wellness, according to the data compiled for Best States.

In Hawaii, residents have steady access to preventive care such as screenings and doctor visits, and are among the least likely to report that they skipped needed medical care because of cost. Mortality rates are the lowest in the country, giving Hawaiians the longest life expectancy in the U.S. Their obesity and infant mortality rates also are among the lowest in the country.

Experts say the Hawaiian experience helps give credence to those who say health care coverage is fundamental to reforming the American health care system, noting that people who are uninsured often skip needed testing, care or medicines because of concerns about cost.

"There is a large body of research showing that people who have health insurance are likely to access care and to get appropriate care like cancer screenings, and that leads to ultimately better health outcomes," says Rachel Garfield, associate director for the program on Medicaid and the Uninsured at the Kaiser Family Foundation, which studies health care.

The rankings examine not only how well residents are, but whether they can access medical care and how good that care is. Each of these three components is given equal weight for a final score. The results appear to suggest some parallels across states that tend to be more engaged.

"Higher performing states have huge efforts over time to reform or improve their health care system, and government plays a very important leadership in that," says Douglas McCarthy, senior research director of the Commonwealth Fund, a foundation that releases studies on health care issues. "The stakeholders are very engaged and created a culture of collaboration. It's really about bringing everyone to the table."

These states can offer insight and inform policy at a time when the nation is facing a crossroads on health care reform. In Washington, President Donald Trump and Republicans are vowing to repeal President Barack Obama's health-care law, the 2010 Affordable Care Act, with a great deal at stake for some states.

Though Hawaii is Obama's native state, his law was modeled more closely after the 2006 health care law in Massachusetts – the commonwealth that ranked second in the Best States health care index. Both laws expanded coverage through the individual mandate, which requires people to obtain coverage or pay a penalty, and offer tax subsidies to help people buy plans. Obama's law also expanded government-funded Medicaid to low-income people.

Though the Affordable Care Act, also known as Obamacare, was written to standardize health care across the country, state lawmakers resisted the one-size-fits-all approach. Several Supreme Court decisions, as well as the extent to which state governments were engaged, resulted in uneven implementation across the country.

Nineteen states haven't expanded Medicaid under the law, and for the most part – though not entirely – those states also rank lower on the health care index.

Dr. Donald Schwarz, vice president for programs at the Robert Wood Johnson Foundation, which has been studying the impacts of Obamacare, says that its studies have shown that Medicaid expansion has made the greatest difference in state performance in recent years.

"That is a particular intervention that is one of the most powerful and most important," he says.

Still, while the Best States rankings are closely correlated with insurance rates, experts say that social determinants of health, such as access to jobs, education, housing and transportation, also have a strong impacts.

For instance, Texas has the highest rate of people who are uninsured, at 23.25 percent, though it still ranks higher than some states that expanded Medicaid, including Illinois, Kentucky, Nevada, New Mexico and West Virginia. In non-expansion Florida, Georgia, Mississippi and Oklahoma, nearly one in five people remain uninsured. Nationally, the uninsurance rate is under half that. In Massachusetts, it's 3.92 percent.

But many of these disparities began before Obamacare, experts say.

"The states that expanded generally had lower uninsurance rates to start with," Garfield says. "They had more generous programs even before the Affordable Care Act. Now you do see that difference even more starkly."

Garfield also believes economic factors play a role: The more low-income residents, the more likely residents are to be uninsured.

Amy Lischko, who was director of health care policy under Massachusetts Gov. Mitt Romney, says she believes coverage has an effect but also notes the impact of state wealth. She believes the rankings would be very similar even if all states had expanded Medicaid.

"I think even though you'd have more insured if you did the same rankings, you would have the same states popping up in that order," she says. "It's built in because of the income disparity issue. The state just doesn't have enough revenues to put into public health and education."

Lischko, who is now a public health and community medicine professor at Tufts University, says states with lower insurance rates can still perform well through investment in safety-net programs or community health centers. The main difference noted with more widespread coverage, she says, is increasing access to screenings which can affect health in the long term.

McCarthy says states can take measures other than insurance expansion to improve health outcomes through focusing on quality, whether by improving transparency or working with hospital associations to reduce readmissions, for instance.

According to the Best States rankings, which uses hospital readmission data in Medicare, Hawaii's readmission rates are among the lowest in the country, but states such as Alaska, Idaho, South Dakota and Utah, which haven't yet expanded Medicaid, also performed well.

Further, the rankings suggest that expanded access to public or private health coverage can only go so far when not enough providers are available, as is perhaps best indicated by outcomes in mental health.

"Generally across the board states don't fair well on mental health," says Theresa Nguyen, vice president of policy and programs for Mental Health America. "Access to services is really poor."

Studies have shown that a shortage of mental health workers or problems navigating the health care system provide significant barriers to both access and outcomes.

According to the Best States rankings on mental health, which use data from the Centers for Disease Control and Prevention, Oregon had the highest rate of those who reported poor mental health in any of the last 30 days at the moment of the interview, at 41.05 percent. South Dakota had the lowest, at 27.59 percent.

Data on suicide rates, from the WONDER database at the CDC, showed that Montana has the highest suicide rate, at 24.4 per 100,000 people, but other states aren't far behind, including Alaska, New Mexico, Wyoming, Colorado and Nevada – all with rates above 20 per 100,000 people. New York had the lowest suicide rate in the country, at 8.6 per 100,000 people, though at 8.8, New Jersey and Massachusetts followed closely.

And as is true with other factors, social determinants of health contribute to mental health outcomes.

"Researchers more and more are looking at factors like access to quality nutrition, drinking levels, lead, maternal benefits, early childhood education and access to employment," Nguyen says.

These factors – social determinants, limited providers and uneven insurance coverage – can leave some states better off than others.

Even places like Hawaii and Massachusetts struggle, particularly when it comes to costs. To finance the health care program in Hawaii, costs of goods and services – whether buying a burger or getting a shirt dry cleaned – are higher than in other parts of the country. Massachusetts is struggling to get its health care costs under control. The trend of health care spending growing faster than the economy has been a challenge for decades even nationally, and is one of the reasons some cash-strapped states have been reluctant to get more involved in health care.

But Lewin, who implemented Hawaii's system and is now chairman of the National Coalition on Health Care, also sees a mindset at play in states that are more hands-on. "These states have that philosophical difference in which they believe health care is something appropriate to offer … that it should be provided as a societal benefit," he says.

While that attitude was also part of the culture in Hawaii, in which various health constituencies came together, even it faced challenges with implementation.

"The struggles we went through to get this passed were every bit as much contentious as everything that happened with the Affordable Care Act," Lewin says. "It was not an easy process."

Lischko made similar observations about state philosophies in states that have been particularly successful, including in New England or in places like Hawaii and Minnesota.

"There is not as much of an 'us versus them' mentality," she says. "The attitude is more: We've created these environments where health matters and health insurance matters. All the participants in the society have made a commitment to that.

"There's that little bit of solidarity going on."


Articles in this issue:


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