Geiger Gibson Program in Community Health Policy Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Research Brief # 33 Assessing the Potential Impact of the Affordable Care Act on Uninsured Community Health Center Patients: A Nationwide and State-by-State Analysis Peter Shin, PhD, MPH Jessica Sharac, MSc, MPH Sara Rosenbaum, JD The George Washington University School of Public Health and Health Services Department of Health Policy October 16, 2013 About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the School of Public Health and Health Services at The George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation, founded in October 2005, is a not-for-profit foundation whose mission is to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the country dedicated to community health centers, the Foundation builds on health centers’ 40-year commitment to the provision of accessible, high quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at http://sphhs.gwu.edu/projects/geiger-gibson-program or at rchnfoundation.org. 2 Executive Summary In this brief, we estimate the number of uninsured community health center (CHC) patients who would gain coverage under the Affordable Care Act using data from the 2009 HRSA Survey of CHC patients and 2011 Uniform Data System. We find that were all states to implement the Affordable Care Act Medicaid expansion, an estimated 5 million uninsured health center patients – or two-thirds of all uninsured patients served by CHCs nationally – would be eligible for coverage. However, over one million uninsured patients – 72% of whom live in southern states -- who would have been eligible for coverage will remain uninsured because of states’ decisions to opt out of the expansion. The spillover effects of the decision to opt out of the Medicaid expansion are likely to be significant. Health centers in opt-out states can be expected to struggle, falling further behind their expansion state counterparts in terms of service capacity, number of patients served (both insured and uninsured), and in their ability to invest in initiatives that improve the quality and efficiency of health care. 3 Introduction The Affordable Care Act (ACA) can be expected to provide access to affordable health insurance coverage to most low income Americans. The Act achieves this aim through a combination of two approaches. The Act expands Medicaid to cover all nonelderly adults with incomes up to 138% of the federal poverty level (FPL). The Act also creates new Health Insurance Marketplaces that make subsidized private insurance coverage through Qualified Health Plans (QHPs) available for people with family incomes between 100 and 400% of the FPL. The most significant level of assistance is available to people with family incomes up to 200% FPL, who are eligible for subsidies that reduce the cost of coverage under a reasonably comprehensive insurance plan to 5% of family income or below. For example, a family of 4 with $40,000 in income in 2014 would qualify for a $6,325 subsidy toward a health plan purchased in the Marketplace, which otherwise would cost $8,290 – a discount of more than two-thirds. 1 Health Insurance Marketplace subsidies were designed to work in tandem with Medicaid. With the exception of certain recently-arrived legal U.S. residents who qualify for subsidies even with poverty-level incomes, eligibility for Marketplace subsidies does not begin until family income exceeds 100% FPL. In states that expand Medicaid to cover all low income adults, Medicaid coverage will extend to 138% FPL and Marketplace subsidies will begin only above this point. In any state that opts out of the Medicaid expansion, 2 the poorest uninsured adults – those with incomes below 100% FPL – will remain completely uninsured unless they can qualify for coverage under the state’s traditional program. Traditional Medicaid eligibility rules for nonelderly adults are far more restrictive, however. Eligibility is limited to adults who are pregnant, persons with disabilities, or parents; furthermore, financial eligibility standards for low-income parents average well below 138% FPL. 3 As a result, in a state that opts out, a poor adult who does not fall into a traditional category cannot qualify for Medicaid coverage at any income level, while parents may be unable to qualify unless their incomes are extremely low. As of September 30, 2013, 26 states had elected to opt out of the Medicaid expansion. 4 On October 10th, 2013, Ohio received federal approval for its Medicaid expansion, and final state action is expected by the end of October. 5 1 Kaiser Family Foundation, subsidy calculator, Available at: http://kff.org/interactive/subsidy- calculator/#state=&zip=&income-type=dollars&income=40%2C000&employer-coverage=0&people=4&adult- count=2&adults%5B0%5D%5Bage%5D=21&adults%5B0%5D%5Btobacco%5D=0&adults%5B1%5D%5Bage%5D=21&a dults%5B1%5D%5Btobacco%5D=0&child-count=2&child-tobacco=0 (Accessed online October 8, 2013). 2 This option was not part of the original law but was instead created by the United States Supreme Court’s decision in NFIB v Sebelius, which held that states could not be compelled to expand their existing programs to encompass all non-elderly low income adults. 3 Kaiser Family Foundation State Health Facts. (October 1, 2013). Medicaid Income Eligibility Limits for Adults at Application, Effective January 1, 2014. Available at: http://kff.org/medicaid/state-indicator/medicaid-income-eligibility- limits-for-adults-at-application-effective-january-1-2014/ 4 Centers for Medicare and Medicaid Services (CMS). (September 30, 2013). State Medicaid and CHIP Income Eligibility Standards Effective January 1, 2014. Available at: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward- 2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels-Table.pdf 5 Higgs, R. (October 11, 2013). Ohio gains federal approval to expand its Medicaid program to cover state's working poor. 4 http://www.cleveland.com/open/index.ssf/2013/10/ohio_gains_federal_approval_to.html In 2011, the nation’s 1,128 community health centers (CHC) operating at more than eight thousand medically underserved urban and rural sites provided health care to over 20.2 million patients. 6 An additional 100 “look alike” health centers served another 1 million patients that year. Health center patients are extremely poor. As a result, health center patients are extremely sensitive to state Medicaid eligibility decisions. Nationally, 72% percent of all patients who receive care at health centers have family incomes below 100% of the federal poverty level ($19,530 for a family of 3 in 2013), while 92% have family incomes below twice the FPL ($58,590 for a family of 3 in 2013). In 2011, 36% of all patients (7.4 million people) were uninsured. As their uninsured patients gain coverage, health centers in turn can be expected to realize significant growth in financial resources, a crucial consideration in light of the fact that health centers by law serve all community residents, regardless of their insurance status. Despite the insurance expansions resulting from the ACA, health centers can be expected to continue to see large numbers of patients who remain uninsured on either a short-term or long- term basis. They will also serve as a source of care for patients who are covered but unable to afford the deductibles and coinsurance that are part of qualified health plans sold in the Marketplace, even at the reduced levels made possible through the cost-sharing assistance also available under the ACA. The added revenues realized from the coverage expansions, however, will enable health centers to expand into new communities, to increase the number of patients served, to add badly needed services such as adult dental and mental health care, and to increase clinical staffing levels. Previous research has documented the favorable spillover effects on health centers of expanding insurance coverage to the poor. Studies have demonstrated the link between higher levels of insurance coverage among adult patients and improved health center capacity as measured by the level and scope of health care, the number of patients served, the number of service locations, clinical staffing levels, and health care quality. 7 Other research, which focused on the unique experience of Massachusetts’s health centers, shows how comprehensive health reform affects health center capacity for both insured and uninsured patients. 8 Massachusetts’s 2006 health reform law helped fuel a significant expansion in health centers’ service capacity; at the same time, while the overall proportion of uninsured patients served by health centers declined significantly in the years following health reform, the proportion of CHC patients without health insurance stood at 21.3% in 2011, more than 6 times 6 Bureau of Primary Health Care. (2012). Uniform Data System (UDS) Report 2011. Washington, DC: Health Resources and Services Administration, US Department of Health and Human Services. Available at: http://bphc.hrsa.gov/uds/doc/2011/National_Universal.pdf 7 Kaiser Family Foundation. (2012) Medicaid and community health centers: The relationship between coverage for adults and primary care capacity in medically underserved communities. Available at: http://kff.org/health-reform/issue- brief/medicaid-and-community-health-centers-the-relationship/ 8 Ku, L., Jones., E., Shin, P., Byrne, F.R., and Long, S.K. (2011) Safety-net providers after health reform: Lessons from 5 Massachusetts. Arch Intern Med, 171(15): 1379-84. the statewide average of 3.4%. 9 Furthermore, while the overall proportion of uninsured patients fell, the actual number of uninsured residents receiving care at Massachusetts health centers increased by 6% between 2007 and 2011. 10 In sum, the ACA insurance expansions can be expected to strengthen health centers’ overall operations, while also growing their capacity to treat the remaining uninsured residents. Estimated Impact Because of the ACA’s income eligibility rules for Medicaid and for substantial premium subsidies and cost sharing assistance, three distinct income ranges become important in estimating the potential effects of state coverage choices on health centers and patients. The first is the number of patients with incomes at or below 138% FPL, the Medicaid eligibility upper income limit in states that expand. The second key income range is the number of patients with incomes at or below 100% FPL, the population that will remain ineligible for Marketplace premium subsidies and cost-sharing assistance in states that opt out of the Medicaid expansion. The third pertinent income range is the number of health center patients with incomes between the Marketplace threshold (either 100% or 138% FPL) and 200% FPL, where premium subsidies and cost-sharing assistance are sufficiently generous to make a significant difference in patients’ ability to afford care. Using data from the 2009 Health Center User Survey and the 2011 Uniform Data System (UDS), we estimated the potential impact of the ACA on uninsured CHC patients both nationally and by state. We present results in Tables 2 and 3, which display estimates for states that expand Medicaid as well as for those that opt out of the expansion. The 2009 survey, which was administered by the Health Resources and Services Administration (HRSA), represents the most current patient-level information available on CHC patients nationally. 11 Because the proportion of low income non-elderly adults nationally who are uninsured appears to have changed little (0.2% increase) from 2007-2011, 12 the survey 9 Bureau of Primary Health Care. (2012). Uniform Data System (UDS) Massachusetts Rollup Report 2011. Washington, DC: Health Resources and Services Administration, US Department of Health and Human Services. Available at: http://bphc.hrsa.gov/uds/doc/2011/UDS_2011_Rollups_MA_Universal.pdf ; US Census Bureau. (2012). Current Population Survey, Annual Social and Economic Supplement. http://www.census.gov/cps/data/cpstablecreator.html 10 Number of uninsured in MA increased from 123,388 in 2007 to 131,141 in 2011. Bureau of Primary Health Care. (2008). Uniform Data System (UDS) Massachusetts Rollup Report 2007. Washington, DC: Health Resources and Services Administration, US Department of Health and Human Services. Available at: http://bphc.hrsa.gov/healthcenterdatastatistics/statedata/2007/MA/07rollup_statema_08jul2008.pdf; Bureau of Primary Health Care. (2012). Uniform Data System (UDS) Massachusetts Rollup Report 2011. Washington, DC: Health Resources and Services Administration, US Department of Health and Human Services. Available at: http://bphc.hrsa.gov/uds/doc/2011/UDS_2011_Rollups_MA_Universal.pdf 11 The CHC survey estimates are based on 4,562 CHC patients that represent a weighted total of over 16.5 million CHC patients. The survey included questions on family income and family size that were combined with 2009 poverty guidelines to categorize federal poverty levels. 12 Kaiser Commission on Medicaid and the Uninsured. (2013). Reversing the Trend? Understanding the Recent Increase in Health Insurance Coverage among the Nonelderly Population. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/04/8264-02.pdf 6 continues to be a source of reliable information in estimating the impact of the ACA on uninsured CHC patients. The 2011 UDS data consist of organizational, financial, patient mix, and utilization summaries submitted to HRSA by each federally-funded health center. Table 1 shows the income distribution of uninsured CHC patients by various eligibility levels. For states expanding Medicaid, the key ranges consist of Medicaid assistance up to 138% FPL coupled with Marketplace premium assistance between 138% and 200% FPL. (Because of Medicaid’s 5-year waiting period, legal residents generally would receive help through Marketplace premium assistance regardless of income). For states that opt out of the Medicaid expansion, the critical ranges are incomes up to 100% FPL and 100%-200% FPL. Table 1 shows, not surprisingly, that the majority of CHC patients who are uninsured are poor and are most likely to qualify for Medicaid. Table 1. Uninsured health center patients by federal poverty level Income range Distribution of Estimated number of uninsured CHC patients uninsured health center ≤100% FPL 53% 3,903,005 (2009), by income patients (2011)* 101-200% FPL 31% 2,282,890 201-400% FPL 13% 957,341 >400% FPL 3% 220,925 ≤138% FPL 70% 5,154,913 139-400% FPL 27% 1,988,323 ≤400% FPL 97% 7,143,236 *Calculated by multiplying 2nd column percentages by the 7,364,161 uninsured reported in the 2011 UDS Source: 2009 CHC User Survey, HRSA and the 2011 UDS, HRSA Tables 2 and 3 present state-level data on the overall size of the health center patient population and the number of health center patients who are uninsured. In order to illustrate the impact of states’ Medicaid expansion decisions on health center revenues, we also estimate, separately for non-expansion/opt-out and expansion states, the potential state- specific revenue gains and losses under a full Medicaid expansion scenario as compared with a non-expansion scenario. 13 This was calculated by multiplying the number of uninsured health center patients who were expected to gain coverage by the average per capita Medicaid revenue received by health centers in 2011. Because the 2011 UDS does not report on uninsured patients by income, we applied the Urban Institute’s estimated share of uninsured residents who are expected to gain 13 Eligibility levels in effect as of January 1, 2014 based on information current as of September 30, 2013, provided to CMS by states either for purposes of FFM programming of state-specific Medicaid/CHIP rules, through state plan amendments, or 7 by direct request from CMS. These levels are subject to change. coverage in opt-out and opt-in states (see Table A2 in Appendix). 14 Using the Urban Institute formula, we find that approximately 5 million CHC patients nationwide could be expected to gain coverage were all states to expand Medicaid. Health centers in the opt-out states Table 2 shows that health centers in the 25 non-expansion states serve approximately 3.1 million uninsured patients. Based on the Urban Institute statewide projections, we estimate that about 1.2 million CHC patients in these opt-out states can be expected to become eligible for coverage. This means that an estimated one million patients in the opt-out states who would have gained coverage will remain uninsured. Approximately 72% of health center patients who would have gained coverage but will remain uninsured live in southern states 15 (AL, FL, GA, LA, MS, NC, OK, SC, TN, TX, VA). Some patients might be expected to qualify for Medicaid under traditional eligibility rules (i.e., pregnancy, disability, or status as parents of minor children), but since eligibility levels for parents average below 50% FPL in the opt-out states, the number who qualify on traditional eligibility criteria will be relatively low. At the same time however, the number of eligible health center patients who fail to gain insurance coverage as a result of living in non-expansion states represent approximately half the expected number who would have gained coverage had these states expanded Medicaid. The actual share of health center patients who remain uninsured may be higher than the overall share of the state low income population that remains uninsured in the opt-out states, given the fact that health centers are by law located in the poorest communities with higher concentration of potentially Medicaid-eligible residents. 16 Opting out of the Medicaid expansion can be expected to have significant spillover effects on health center operations. Had expansion occurred in the opt-out states, health centers would have been expected to generate approximately $1.2 billion in 2014, adjusted for inflation. Under an opt-out scenario, health centers in these states are expected to receive approximately half that amount, shown on Table 2. 14 Buettgens, M., Kenney, G.M., Recht, H., & Lynch, V. (2013). Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States. Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf408158 15 Based on the U.S.Census Bureau regions. 16 Kaiser Family Foundation (2013) Community Health Centers in an Era of Health Reform: An Overview and Key Challenges to Health Center Growth. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8098-03.pdf; Rosenbaum, S., Jones, E., Shin, P. and Ku, L.(2009) National Health Reform: How Will Underserved Communities Fare? Geiger Gibson/RCHN Community Health Foundation Research Collaborative. Available at: http://www.rchnfoundation.org/?p=864; Ku, L., Shin, P., and Rosenbaum, S. (2009) Estimating the Effects of Health Reform on Health Centers’ Capacity to Expand to New Medically Underserved Communities and Populations. Geiger 8 Gibson/RCHN Community Health Foundation Research Collaborative. Available at: http://www.rchnfoundation.org/?p=866 Table 2. Estimated Impact on Uninsured Patients and Health Center Revenues in States that Opt Out of the ACA Medicaid Expansion Uninsured Uninsure Number Uninsured Potential revenue Potential revenue Total CHC eligible d eligible of CHC gained in 2014 gained in 2014 State patients with without CHCs patients under Medicaid without Medicaid (2011) Medicaid Medicaid (2011) (2011) expansion expansion expansion expansion Alabama 14 320,044 152,414 121,931 57,917 $55,006,620 $26,128,144 Alaska 25 91,020 32,216 24,162 13,853 $29,452,818 $16,886,283 Florida 44 1,080,695 504,432 343,014 186,640 $188,666,714 $102,656,888 Georgia 27 317,299 162,305 113,614 56,807 $41,472,145 $20,736,072 Idaho 11 126,354 65,318 48,989 27,434 $41,565,975 $23,276,946 Indiana 19 273,536 102,076 79,619 43,893 $42,721,645 $23,551,676 Kansas 13 147,489 75,668 54,481 31,024 $29,088,881 $16,564,502 Louisiana 24 223,095 86,976 66,102 33,921 $33,426,925 $17,153,290 21 324,046 134,212 106,027 48,316 $34,849,947 $15,880,989 Maine 18 181,171 26,385 20,844 13,984 $14,806,379 $9,933,393 21 420,130 145,288 114,778 61,021 $79,115,667 $42,061,494 Mississippi 15 101,406 50,835 41,176 23,892 $23,444,078 $13,603,354 Missouri Montana Nebraska 6 63,532 33,674 24,245 13,806 $11,406,865 $6,495,576 New 10 65,466 19,267 14,643 9,441 $9,590,343 $6,183,248 Hampshire North 28 411,015 214,217 147,810 81,402 $73,440,392 $40,445,433 Carolina Oklahoma 17 135,272 54,478 39,224 22,336 $29,228,346 $16,643,919 Pennsylvani 35 637,928 164,857 126,940 70,889 $66,923,667 $37,372,957 a South 20 326,829 129,838 98,677 50,637 $50,887,002 $26,113,067 Carolina South 6 58,003 21,328 17,062 8,531 $9,223,857 $4,611,928 Dakota Tennessee 23 372,360 150,413 114,314 61,669 $49,637,726 $26,778,247 11 $35,245,488 $20,732,640 Texas 64 975,509 501,327 315,836 170,451 $180,192,888 $97,246,956 25 $36,786,082 $19,725,870 Utah 112,794 62,782 42,692 25,113 16 $42,776,643 $24,202,574 Virginia 285,359 108,328 74,746 40,081 5 $2,421,402 $1,500,587 Wisconsin 281,591 67,793 51,523 29,151 Wyoming 18,022 7,512 5,334 3,305 Total 518 7,349,965 3,073,939 2,207,782 1,185,514 $1,211,378,495 $656,486,033 9 Health centers in the expansion states Table 3 shows that health centers in expansion states will potentially see 2.8 million patients gain coverage and, as a result, will generate a potential revenue increase of over $2 billion. Again, the number of CHC patients eligible for new coverage is likely underestimated given the higher prevalence of poverty among CHC patients than the general population. Table 3. Estimated Impact on Patients and Health Center Revenues in States that Implement the ACA Medicaid Expansion Uninsured Uninsured Potential Potential Uninsured Number Total CHC eligible eligible revenue gained revenue gained CHC State of CHCs patients with without in 2014 with in 2014 without patients (2011) (2011) Medicaid Medicaid Medicaid Medicaid (2011) Arizona 16 408,737 118,255 73,318 40,207 $65,195,104 $35,752,154 expansion expansion expansion expansion Arkansas 12 156,159 65,858 49,394 26,343 $23,070,616 $12,304,329 California 121 3,104,183 1,287,447 823,966 450,606 $637,033,588 $348,377,743 Colorado 15 474,241 191,596 126,453 72,806 $88,070,409 $50,707,205 Connecticut 13 315,992 73,956 48,071 28,103 $39,839,839 $23,290,983 Delaware 3 38,861 15,074 10,401 6,331 $5,132,612 $3,124,199 D.C. 4 122,891 20,124 13,282 6,238 $7,329,804 $3,442,786 Hawaii 14 137,266 33,911 26,111 11,869 $21,340,024 $9,700,011 Illinois 37 1,098,483 339,834 224,290 115,544 $108,105,419 $55,690,671 Iowa 13 179,120 61,935 47,071 26,013 $27,540,900 $15,219,971 Kentucky 19 278,242 105,406 85,379 43,216 $56,382,656 $28,539,369 Maryland 16 282,831 61,633 39,445 21,572 $33,264,557 $18,191,554 Massachusetts 36 615,708 131,141 85,242 85,242 $59,550,775 $59,550,775 Michigan 29 546,245 178,903 144,911 73,350 $96,842,052 $49,018,816 Minnesota 15 165,474 65,113 46,881 27,999 $28,909,207 $17,265,221 Nevada 2 57,987 27,730 17,747 9,706 $7,423,394 $4,059,669 New Jersey 20 454,243 196,515 115,944 68,780 $61,669,906 $36,583,842 New Mexico 15 285,700 111,181 76,715 38,913 $49,372,208 $25,043,874 New York 52 1,489,141 373,617 246,587 141,974 $204,705,824 $117,860,929 North Dakota 4 32,404 8,975 7,090 4,308 $3,502,831 $2,128,302 Ohio 17 33 484,631 162,444 131,580 68,226 $60,346,341 $31,290,695 Oregon 25 289,731 110,401 80,593 46,368 $93,573,777 $53,836,967 Rhode Island 8 123,095 39,004 26,133 15,602 $17,796,267 $10,624,637 Vermont 8 121,682 12,362 9,272 6,305 $7,024,584 $4,776,717 Washington 25 794,485 278,369 194,858 111,348 $198,253,434 $113,287,677 West Virginia 27 379,702 91,295 73,949 38,344 $44,822,471 $23,241,281 Total 582 12,437,234 4,162,079 2,824,683 1,585,313 $2,046,098,599 $1,152,910,377 17 Ohio was added to the expansion group based on Governor Kasich’s recent submission of a federally approved expansion 10 plan to his state budget control board for final approval. Approximately 63,354 eligible patients would have remained uninsured had Ohio not expanded Medicaid. Discussion These estimates illustrate the potential impact of the Affordable Care Act on uninsured health center patients and health center capacity. In the states that expand Medicaid, the number of patients expected to be eligible for coverage through Medicaid and premium assistance is approximately 2.8 million. In these states, health centers can expect to gain approximately $2 billion (adjusted to 2014 dollars) in additional revenues from Medicaid and payments by qualified health plans. Because patient cost-sharing under qualified health plans will be higher, even with cost-sharing assistance, total revenues received may be slightly lower than estimated here, but since more than 90% of health center patients have incomes below twice the FPL, health centers can nonetheless be expected to realize significant revenues from insurance reform, similar to the experience of Massachusetts health centers. By contrast, the 518 health centers in states that do not couple Marketplace premium subsidies with Medicaid expansions–nearly half (46%) of all grantees in 2011–can be expected to struggle. Over one million uninsured patients in these states who would have been eligible for coverage are likely to remain uninsured, and health centers in these states stand to lose nearly $555 million in revenues in 2014 dollars. Health centers in the opt-out states will be able to qualify some of their patients under traditional Medicaid eligibility rules, but we anticipate that this number will be modest, since most of those previously eligible would have been identified and enrolled because of health centers’ outreach and enrollment assistance efforts that predate health reform. With the opt-out states representing the nation’s highest proportions of uninsured poor, 18 the Medicaid expansion becomes especially vital. It is the residents of these states who, research shows, bear the greatest burden of illness and poor health and stand to gain the most from the health care access improvements that Medicaid produces. 19 Because of the close association between high concentrations of uninsured poor populations and medical underservice – the key indicator of need used to determine where health centers will be located – health centers in these opt-out states already face especially deep challenges. Health centers in opt-out states can be expected to fall further behind over time compared to those in expansion states in terms of number of patients served (both insured and uninsured), expanded service capacity, recruitment and retention of clinical staff, expansion of service sites, and the introduction of further improvements in clinical quality. In the coming years, more states may expand Medicaid. But in the near-term, health centers in non-expansion states can be expected to confront more significant growth challenges, more limited service capacity, and more limited ability to invest in the types of system reforms that improve quality and efficiency. Assessing the Affordable Care Act’s impact on health centers and their communities thus emerges as a principal means of enabling policymakers to understand how health insurance reform ultimately enables the types of community health system transformations that extend beyond the immediate receipt of care at an individual patient level and affect health and health care on a community-wide basis. 18 Tavernise, S. & Gebeloff, R. (October 2, 2013). Millions of Poor Are Left Uncovered by Health Law. The New York Times. Available at: http://www.nytimes.com/2013/10/03/health/millions-of-poor-are-left-uncovered-by-health-law.html 19 Commonwealth Fund, Health Care in the Two Americas 11 http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/Sep/1700_Schoen_low_income_score card_FULL_REPORT_FINAL_v4.pdf (Accessed online October 12, 2013) Appendix Table A1 shows the breakdown of health centers by income status and the proportion of each income group of patients who are uninsured. Approximately 97% of all CHC patients have incomes below and at 400% of FPL. In general, the majority of CHC patients have incomes less than 100% (and 138%) of FPL. A1. Income Profile of CHC Patients Income range Proportion of all Proportion of CHC patients patients within income level who are uninsured ≤100% FPL 54% 35% 101-200% FPL 32% 36% 201-400% FPL 11% 42% >400% FPL 3% 38% ≤138% FPL 73% 35% 139-400% FPL 24% 41% ≤400% FPL 97% 36% Source: 2009 CHC User Survey, HRSA. 12 Table A2 is derived from the Urban Institute’s report which examined how many uninsured would be eligible for Medicaid, the Children’s Health Insurance Program and subsidized private insurance. A2. Uninsured Eligible for Coverage, By State With Without With Without State Expansion Expansion State Expansion Expansion Alabama 80% 38% Montana 81% 47% Alaska 75% 43% Nebraska 72% 41% Arizona 62% 34% Nevada 64% 35% Arkansas 75% 40% New Hampshire 76% 49% California 64% 35% New Jersey 59% 35% Colorado 66% 38% New Mexico 69% 35% Connecticut 65% 38% New York 66% 38% Delaware 69% 42% North Carolina 69% 38% District of 66% 31% North Dakota 79% 48% Columbia Florida 68% 37% Ohio 81% 42% Georgia 70% 35% Oklahoma 72% 41% Hawaii 77% 35% Oregon 73% 42% Idaho 75% 42% Pennsylvania 77% 43% Illinois 66% 34% Rhode Island 67% 40% Indiana 78% 43% South Carolina 76% 39% Iowa 76% 42% South Dakota 80% 40% Kansas 72% 41% Tennessee 76% 41% Kentucky 81% 41% Texas 63% 34% Louisiana 76% 39% Utah 68% 40% Maine 79% 53% Vermont 75% 51% Maryland 64% 35% Virginia 69% 37% Massachusetts 65% 65% Washington 70% 40% Michigan 81% 41% West Virginia 81% 42% Minnesota 72% 43% Wisconsin 76% 43% Mississippi 79% 36% Wyoming 71% 44% Missouri 79% 42% Source: Buettgens, M., Kenney, G.M., Recht, H., & Lynch, V. (2013). Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States. Robert Wood Johnson Foundation. 13 The following tables (A3-A4) show the distribution of CHC patients by income less than or equal to 100% FPL. The source for all estimates is the 2011 UDS data. A3. CHC Patients with Incomes Less than 100% FPL in Non-Expansion States Reported number Pct. Of CHC of CHC patients No. of CHC patients patients 202,237 226,027 State Total CHC patients ≤ 100% FPL ≤ 100% FPL* ≤ 100% FPL 21,394 47,243 Alabama 320,044 70.6% 626,933 759,554 Alaska 91,020 51.9% 173,229 225,899 Florida 1,080,695 70.3% 64,985 80,624 Georgia 317,299 71.2% 156,147 216,140 Idaho 126,354 63.8% 83,014 103,433 Indiana 273,536 79.0% 117,589 170,450 Kansas 147,489 70.1% 57,810 81,418 Louisiana 223,095 76.4% 324,046 203,480 235,477 72.7% Maine 181,171 44.9% 420,130 249,652 316,772 75.4% Mississippi 101,406 49,861 63,649 62.8% Missouri 32,693 42,472 Montana 28,252 34,669 Nebraska 63,532 66.9% 237,794 312,153 New Hampshire 65,466 53.0% 68,709 94,105 North Carolina 411,015 75.9% 323,087 418,130 Oklahoma 135,272 69.6% 192,874 253,390 Pennsylvania 637,928 65.5% 18,265 31,617 South Carolina 326,829 77.5% 214,404 306,960 South Dakota 58,003 54.5% 599,230 717,432 Tennessee 372,360 82.4% 65,950 84,586 Texas 975,509 73.5% 100,609 165,968 Utah 112,794 75.0% 135,608 181,516 Virginia 285,359 58.2% 6,345 10,886 Wisconsin 281,591 64.5% 7,349,965 4,030,151 5,180,571 Wyoming 18,022 60.4% Total for non-expansion states 70.5% *This was calculated by adding the reported number of patients <=100% FPL in the UDS with the number of patients with unknown income multiplied by the percentage of those <=100% FPL 14 A4. CHC Patients with Incomes Less than 100% FPL in Expansion States Reported number of Pct. CHC patients No. of CHC patients reported 196,932 308,023 State Total CHC patients ≤ 100% FPL ≤ 100% FPL* ≤ 100% FPL 70,551 103,068 Arizona 408,737 75.4% 2,174,229 2,445,913 Arkansas 156,159 66.0% 317,026 354,809 California 3,104,183 78.8% 179,452 207,332 Colorado 474,241 74.8% 18,933 22,844 Connecticut 315,992 65.6% 73,068 93,523 Delaware 38,861 58.8% 81,541 102,547 District of Columbia 122,891 76.1% 672,932 844,626 Hawaii 137,266 74.7% 72,620 126,581 Illinois 1,098,483 76.9% 124,003 164,941 Iowa 179,120 70.7% 120,125 177,555 Kentucky 278,242 59.3% 296,337 403,895 Maryland 282,831 62.8% 269,346 363,935 Massachusetts 615,708 65.6% 71,928 118,462 Michigan 546,245 66.6% 25,227 42,958 Minnesota 165,474 71.6% 303,646 358,172 Nevada 57,987 74.1% 129,684 190,957 New Jersey 454,243 78.9% 654,197 1,018,864 New Mexico 285,700 66.8% 10,487 21,344 New York 1,489,141 68.4% 199,882 342,416 North Dakota 32,404 65.9% 182,700 221,493 Ohio 484,631 70.7% 43,681 83,527 Oregon 289,731 76.4% 15,842 37,483 Rhode Island 123,095 67.9% 473,696 539,288 Vermont 121,682 30.8% 125,167 194,120 Washington 794,485 67.9% 6,903,232 8,888,674 West Virginia 379,702 51.1% Total for expansion states 12,437,234 71.5% *This was calculated by adding the reported number of patients <=100% FPL in the UDS with the number of patients with unknown income multiplied by the percentage of those <=100% FPL 15