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Pennsylvania health insurance

‘Keystone State’ ranked 29th on health factors. Can ACA help?

  • By
  • contributor
  • September 2, 2014

Public health and access to affordable health care are important factors in long term health outcomes and quality of life. Here’s a summary of Pennsylvania residents’ overall health, access to health insurance, and state leadership’s approach to healthcare reform:

Pennsylvania health ratings

Pennsylvania ranked a little above average on The Commonwealth Fund’s Scorecard on State Health System Performance in 2014. The state came in 22nd out of the 50 states and DC, down from 14th place in 2009. The Pennsylvania Scorecard provides details showing how the rating was determined; the state scored better than average for prevention and treatment metrics, but lower than average on the “healthy lives” section, which includes factors such a specific disease incidence, tobacco use, and obesity.

In 2013, America’s Health Rankings placed Pennsylvania slightly lower than the Commonwealth Fund, giving the state a ranking of 29th out of the 50 states in terms of overall health. The state’s rating is helped by a strong high school graduation rate, high immunization coverage among adolescents, and a low percentage of the population without health insurance (11 percent in 2013).

Pennsylvania’s challenges include high rates of drug deaths and air pollution, and relatively low per capita public health funding. Just over 29 percent of the state’s adult population is obese, and although tobacco use decreased by 5 percent between 2012 and 2013, more than 2.1 million adults in Pennsylvania still smoke.

Trust for America’s Health has summarized a variety of public health data pertaining to Pennsylvania in their 2014 edition of Key Health Data, which contains information on specific diseases, health factors, and outcomes.

The Robert Wood Johnson Foundation also analyzed public health data at the county level, ranking Pennsylvania’s counties on this interactive map. The southeast part of the state has some of the highest ranking counties for both health factors and outcomes.

Pennsylvania and the Affordable Care Act

In 2010, both of Pennsylvania’s U.S. Senators, Democrats Robert Casey and Arlen Specter, voted in favor of the ACA. In the U.S. House, eleven Democrat Representatives voted yes, while seven Republicans voted no. Specter has since been replaced in the Senate by Republican Pat Toomey, and the U.S. House now includes just five Pennsylvania Democrats, and 13 Republicans.

At the state level, the overall population in Pennsylvania has a Democratic majority, but the Governor is a Republican and Republicans also hold a majority in the state’s House and Senate. Governor Tom Corbett is not an ACA supporter, and HHS is running the exchange in Pennsylvania.

But unlike many Republican governors, he pursued the possibility of Medicaid expansion under the ACA.  Corbett submitted his proposal for a modified version of Medicaid expansion – dubbed “Healthy Pennsylvanis” – to HHS in February.  It took half a year of negotiations, but on August 28, Corbett and HHS announced that they had reached an agreement, and Pennsylvania became the 28th state (including DC) to accept federal funding to expand Medicaid to cover residents with incomes up to 138 percent of poverty.  Enrollment will begin on November 15 – coinciding with open enrollment for private plans in the exchanges – and coverage will become effective on January 1, 2015.  Although hundreds of thousands of residents are in the coverage gap in Pennsylvania in 2014, their situation will improve next year when the coverage gap is eliminated in the state.

How did the ACA help Pennsylvania Residents?

Before the ACA was implemented, the uninsured rate in Pennsylvania was 11 percent, the seventh-lowest rate in the nation. Despite the fact that Pennsylvania has not yet expanded Medicaid, the uninsured rate had fallen slightly – to 10.1 percent – by the middle of 2014. About 360,000 people obtained coverage, including Medicaid/CHIP and private plans, through the Pennsylvania exchange during the first open enrollment.

Pennsylvania enrollment in QHPs

In the fall of 2013, the Kaiser Family Foundation estimated that 1,276,000 Pennsylvania residents could potentially buy coverage through the exchange, and that 715,000 of them would qualify for premium subsidies. By the end of the first open enrollment period, 318,077 people purchased private plans in the Pennsylvania exchange, and 81 percent received premium subsidies.

Nine carriers are offering plans in the Pennsylvania exchange: Aetna, Capital Blue Cross, Blue Cross of Northeastern Pennsylvania, Geisinger Health System, HealthAmerica PA, Highmark Health Services, Independence Blue Cross, Keystone Health Plan (a subsidiary of Independence Blue Cross), and the University of Pittsburgh Medical Center Health Plan.

Pennsylvania Medicaid/CHIP enrollment

Pennsylvania is the most recent state to move forward with Medicaid expansion, announcing a compromise with HHS in late August 2014.  Eligible residents will be able to apply starting on November 15, and coverage is set to become effective on January 1, 2015.  Rather than simply expand the existing Medicaid program to cover all legal residents with incomes up to 138 percent of poverty, Governor Corbett proposed using federal Medicaid funds to subsidize private coverage, and requiring small premium contributions from some insureds. Corbett also wanted unemployed enrollees to be actively searching for work.

The eventual compromise with HHS looks much more similar to straight Medicaid expansion than Governor Corbett’s original proposal.  Of the twenty four modifications that Corbett requested, four were approved by HHS.  There will be no premiums charged in 2015, but starting in 2016 Healthy Pennsylvania will be able to charge small premiums for residents with incomes between 100 percent and 138 percent of poverty level.  The premiums are capped at two percent of income, which is the same cap used in the exchanges (for a Silver plan) for this income demographic in states that have not expanded Medicaid.

Corbett’s requirement that able-bodied adults be actively searching for work was rejected, but the state is implementing a voluntary job training and career coaching program and may eventually tie participation in the program to reductions in cost sharing for the Healthy Pennsylvania program.

Healthy Pennsylvania will utilize a private coverage option (PCO), which is basically Medicaid managed care provided by private insurance carriers.  Nine carriers submitted successful applications to participate in the Healthy Pennsylvania PCO, and will begin enrolling applicants in December.  Although this aspect of the expansion is being called a win by those who favor private insurance over straight Medicaid expansion, the funding is still from the same source (federal government initially, with gradual state contributions that will reach 10 percent by 2020).  And private carriers operating Medicaid managed care programs is common in many states, including Pennsylvania’s existing Medicaid program.

Since Medicaid expansion in Pennsylvania doesn’t take effect until 2015, there are currently 281,290 people – about a quarter of the state’s uninsured population – in the Pennsylvania coverage gap, and the exchange only enrolled 42,335 people in the existing Medicaid program by mid-April.  Up to 600,000 people will be eligible for coverage under Healthy Pennsylvania, although not all of them are currently uninsured.  Those with incomes between 100 percent and 138 percent of poverty are currently eligible for subsidies to purchase private insurance in the exchange, but will instead be eligible for Healthy Pennsylvania in 2015.

Medicaid enrollment in 2014 still utilizes Pennsylvania’s existing strict eligibility guidelines: Non-disabled adults with no dependent children cannot receive Medicaid coverage regardless of income, and parents with dependent children are only eligible if their household earnings doesn’t exceed 33 percent of poverty (about $656 a month for a family of four – certainly not a livable income).  Starting next year, Healthy Pennsylvania will provide a much-needed safety net for low income residents who don’t meet the current eligibility guidelines.

State-based health reform legislation

Here’s a summary of recent Pennsylvania legislation related to public health and healthcare reform: