STUDY OF THE IMPACT OF THE ACA IMPLEMENTATION IN KENTUCKY

Quarterly Snapshot: April - June 2016

The Study of the Impact of the Affordable Care Act (ACA) on Health Coverage,

Access, Quality, Cost, and Outcomes in Kentucky, funded by the Foundation for

a Healthy Kentucky, is a three-year mixed methods study conducted by the State

Health Access Data Assistance Center (SHADAC), a health policy research institute

at the University of Minnesota. As part of the Study, the research team produces

Quarterly Snapshots to track ACA implementation indicators in a timely way.

Sources and technical notes are included on page 5. Please visit us at:

http://healthy-ky.org or follow us on Twitter @healthyky and @shadac.

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In 2015, Kentucky’s uninsurance rate (all ages) was the lowest among its neighboring states and the U.S. — tied at 6% with West Virginia. Of these states, the four that implemented tradi-tional Medicaid expansions (IL, KY, OH, WV) had the lowest un-insurance rates, between 6% and 7.1%. The states that haven’t expanded Medicaid (MO, TN, VA) or expanded Medicaid via an 1115 waiver (AR, IN) had higher uninsurance rates, between 9.1% and 10.3%.

COVERAGE AND COST 2nd Quarter 2016

This is the sixth Quarterly Snapshot produced under the Study of the Impact of the ACA Implementation in Kentucky. All sections have been updated with new data and/or data points since the previous Quarterly Snapshot. Data sources are included at the end of this brief in a Technical Notes section.

Historical Uninsurance RatesUninsurance in 2015

Emergency Department Visits

Before 2014, Kentucky’s uninsured rate (all ages) followed a similar trend to the rest of the U.S.. Since implementation of the ACA coverage expansion, uninsurance in Kentucky has dropped below the U.S. rate. In 2015, Kentucky’s uninsurance rate was 3.4 percentage points lower than the U.S. rate.

Since implementation of the ACA, the number of Emergency Department (ED) visits has not followed a clear trend. In 2014, Kentucky hospitals reported 2.1 million ED visits — nearly identical to the number of visits in 2012. ED visits did, however, increase to 2.2 million in 2015. When 2016 data become available, our study will examine whether ED visits have increased or just fluctuated from year to year. Starting in 2014, the health coverage type for ED visits has changed: Charity and self-pay ED visits have dropped from 23.2% in 2012 to 5.9% in 2015, and Medicaid coverage of ED visits has increased from 30.2% to 46.9%.

13.2%*14.5%*

15.3%14.4%* 13.9%* 14.3%

8.5%*

6.0%*

14.6% 15.1% 15.5% 15.1% 14.8% 14.5%

11.7%

9.4%

0%

5%

10%

15%

20%

2008 2009 2010 2011 2012 2013 2014 2015

KY U.S.

* Statistically significant difference from U.S. at 95% level.

IL

7.1%*MO

9.8%*

AR

9.5%*

TN 10.3%*

KY

6.0%

WV

6.0%

IN

9.6%*

OH

6.5%*VA

U.S.

9.1%*

9.4%*

Kentucky

Non-expansion StatesUnited States

Medicaid Expansion States

* Statistically significant difference from KY at 95% level.

MedicaidSelf-pay/charity careMedicareCommercialOther

100,000

0

200,000

300,000

400,000

500,000

2012 2013* 2014 2015Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4

30.2%

23.2%

17.7%

26.0%

2.8%

42.7%

8.8%

19.2%

26.6%

2.7%

46.9%

19.4%

25.4%

5.9%

2.5%

*Because SHADAC uses 2012 as our baseline year, we have excluded 2013 Emergency Department data from the chart.

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Fulton

Hickman

Carlisle

BallardMcCracken

GravesCalloway

Marshall

Livingston

Lyon

Christian

Trigg

Hopkins

MetcalfeWarren

Allen

Muhlenberg

HartButler

Ohio

Logan

Simpson

McLeanWebster

Caldwell

Todd

Crittenden

Edmonson

JohnsonBreckinridge

Floyd

Henderson

Marion

Washington

Nelson

Daviess

MeadeHancock

UnionHardin

Larue

Monroe

Barren

Grayson

Lee

Breathitt

Leslie

Owsley

Harlan

Bell

Knox

Clay

JacksonRockcastle

LaurelPulaski

Casey

WhitleyMcCreary

Wayne

Clinton

Cumberland

Russell

Adair

Taylor

Green Perry

Morgan

Magoffin

Menifee

Letcher

Wolfe

Knott

Harrison

Nicholas

Bourbon

Clark

Fayette

Nicholasville

Mercer

Boyle

Lincoln

Garrard

Madison

Powel

Estill

Martin

Pike

Robertson

Fleming

Lewis Greenup

CarterBoyd

Lawrence

Elliott

RowanBath

Montgomery

Franklin

Anderson

Woodford

Mason

Scott

Kenton Campbell

Pendleton

Owen

Grant

Gallatin

Carroll

Trimble

Jefferson

OldhamHenry

Shelby

SpencerBullitt

Boone

Bracken

0-9.9%10-19.9%

30%+20-29.9%

MEDICAIDACA Expansion Enrollment

This map shows the distribution of ACA Medicaid expansion enrollees across Kentucky (ages 19-64) in 2015. The largest share of Medicaid expansion enrollees was in Eastern Kentucky.

Medicaid Services

During the past quarter (April-June 2016), Medicaid paid for thousands of needed services for traditional income-based and ACA Medicaid expansion enrollees ages 19-64.

2nd Quarter 2016

Breast Cancer Screenings

30.7% lived in Eastern Kentucky 25.8% lived in Western Kentucky 19.6% lived in Greater Louisville 16.4% lived in Greater Lexington7.5% lived in Northern Kentucky

Preventive Dental Services

43,463

Substance Use

15,234

ENROLLMENT METRICS

Breast Cancer screenings were covered by Medicaid for traditional income-based and expansion enrollees ages 19-64.

ACA Medicaid Expansion 3,754Traditional Income-Based Medicaid 2,066

Breakout of Hepatitis C ScreeningMedicaid Enrollment by Age

Enrollment by Age and Medicaid Category

Newborn Births

6,620

9,848

Colorectal CancerScreening

6,289

In the second quarter of 2016, Medicaid covered nearly 636,000 adult Kentuckians (19-64) through traditional in-come-based and ACA Medicaid expansion eligibility. The ACA Medicaid expansion was particularily important for new coverage of young adults (ages 19-34).

*These data exclude children and elderly adults, and people enrolled through other eligibility categories.

Expansion Traditional income-based

27.9%22.9%

16.7%

9.8%22.7%19-25

26-3435-44

45-5

4

55-64

60,721

94,652

108,206

124,654

104,966

1,388

11,264

37,579

52,913

39,404

55-64

45-54

35-44

26-34

19-25

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2nd Quarter 2016

KYNECT

Health Status of kynect EnrolleesAmong people who shopped for coverage through kynect, more than half used in-person assistance, such as help from kynectors (52.3%). Using the kynect call center was next (41.7%), followed by the website (38%).

Compared to the Kentucky population, people who obtained coverage through kynect reported being less healthy. They were significantly more likely to report poor or fair health and significantly less likely to report excellent or very good health. This includes people who obtained both public and private cov-erage through kynect.

Use of kynect Resources

Kentuckians enrolling in insurance coverage through kynect, the Commonwealth’s State-based Marketplace, were most likely to have enrolled in Medicaid. Only 5% of people who obtained health insurance through kynect enrolled in private individual-market coverage.

In 2016, approximately 26% of Kentuckians reported obtaining insurance coverage through kynect, with some variation by region. Those in Northern Kentucky had a significantly lower rate of enrollment through kynect, and those in Eastern Kentucky had a significantly higher rate.

Indicators on this page are from the 2016 Kentucky Health Reform Survey, conducted by SHADAC and the University of Cincinnati Institute for Policy Research specifically for the “Study of the Impact of the ACA Implementation in Kentucky.” All data presented below are for non-elderly adults in Kentucky (ages 18 - 64).

kynect Coverage Types kynect Coverage by Region

Public Coverage 95%

Private Individual-market Coverage 5%

GreaterLexington

WesternKentucky

GreaterLouisville

NorthernKentucky

EasternKentucky

Regional rates compared to overall Kentucky ratesSignificantly Lower Not Significantly Different Significantly Higher

of Kentuckians reported obtaining coverage through kynect in 2016.

ACCESSING COVERAGE THROUGH KYNECT

16.5%*

28.4%*

25.2%

22.4%*

7.4%*

10.7%

17.5%

28.3%

29.8%

13.7%

0% 5% 10% 15% 20% 25% 30% 35%

Poor

Fair

Good

Very Good

Excellent

Overall population kynect population

WEBSITE

CALLCENTER

IN-PERSONASSISTANCE

33.9% lived in Eastern Kentucky 27.8% lived in Western Kentucky 22.5% lived in Greater Louisville21.9% lived in Greater Lexington16.0% lived in Northern Kentucky

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2nd Quarter 2016

This is the sixth Quarterly Snapshot produced under the “Study of the Impact of the ACA Implementation in Kentucky”. All sections have been updated with new data and/or data points since the previous Quarterly Snapshot.

COVERAGEUninsurance in 2015: SHADAC analysis of data from the 2015 American Community Survey. Note: The estimates presented here are for individuals of all ages in the total civilian non-institutionalized population. While Indiana is indicated as a Medicaid-expansion state, its expansion did not begin until February 2015, compared to the expansions that began in January 2014 in Arkansas, Illinois, Kentucky, Ohio, and West Virginia.

Historical Uninsurance Rates: SHADAC analysis of data from the 2008-2015 American Community Survey. Note: The estimates presented here are for individuals of all ages in the total civilian non-institutionalized population.

Emergency Department Visits: SHADAC analysis of data from the Kentucky Hospital Association (KHA) for 2012-2015. Notes: Payer assignments reflect the primary payer at the time of discharge. Due to rounding, data do not add to 100%. Where possible, SHADAC uses 2012 as the pre-ACA baseline year for our study, including the Emergency Department claims data. Because we use 2012 as our baseline year, we have excluded 2013 ED data from the chart.

MEDICAIDMedicaid Enrollment and Services Indicators: SHADAC analysis of data provided by the Kentucky Cabinet for Health and Family Services (CHFS). Notes: For the map, we include only ACA expansion Medicaid enrollees ages 19-64. For service utilization counts, we include only traditional income-based Medicaid and ACA expansion Medicaid enrollees ages 19-64. We exclude special enrollee categories: Medicare-Medicaid dual eligible; foster, former foster, and kinship care; intermediate care facility, nursing home, and hospice populations; Medicare savings and special populations; SSI recipients; waiver populations, or incomplete claims that do not show enrollee category. Dental services represent preventive dental visits only; other dental visits are excluded. While the label for dental services has been updated in this snapshot to indicate these are preventive services only, these data are consistent with prior snapshots. Services are calculated based on claims data with dates of service from 4/1/16-6/31/16, retrieved on 10/11/16 by CHFS.

KYNECTkynect Indicators: SHADAC analysis of the 2016 Kentucky Health Reform Survey (K-HRS) data. The K-HRS was conducted by SHADAC and the University of Cincinnati Institute for Policy Research from March-May 2016. The survey was conducted specifically for the Study of the Impact of the ACA Implementation in Kentucky. The dual-frame (landline and cell phone) survey sampled non-elderly adult Kentuckians for a total of 1,639 interviews. Notes: Estimates presented here are for non-elderly adults in Kentucky. Health status may not add to 100% due to rounding. Use of kynect resources does not add to 100% because respondents can report using multiple resources.

For more information on other findings from the 2016 Kentucky Health Reform Survey and additional details on the methodology, read the September 2016 Semi-Annual Report of our Study of the Impact of the ACA Implementation in Kentucky: https://www.healthy-ky.org/res/uploads/media/FINAL-Sept-2016-Semi-Annual-report.pdf.

Quarterly Snapshot Technical Notes