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Health Care in Appalachia

Why Fewer Appalachians Signed Up for Affordable Care Act Coverage in 2019



Dr. Teresa Gardner Tyson, right, during a procedure. Tyson is the executive director of the Health Wagon in southwest Virginia. Credit: The Health Wagon

Fewer residents of Appalachia will have health insurance under the Affordable Care Act in 2019 than the year before. Enrollment numbers are down throughout the region, as they are nationwide, and some advocates say they aren’t surprised.

In 11 of the 13 Appalachian states that enroll residents through the federal website (Maryland and New York administer their own ACA marketplaces), only Mississippi saw a rise in enrollment numbers. West Virginia and Virginia saw the largest declines.

In West Virginia, some 22,600 residents signed up for or renewed health care policies under the ACA, as compared with about 27,400 for 2018, a 17.5 percent drop.

In 2017, 34,045 West Virginians were enrolled.

Of the 39 states that use for enrollment, the only that experienced a steeper decline was Virginia – but that was expected. As allowed for under the Affordable Care Act, Virginia expanded its Medicaid program in 2018, reducing the number of people in need of ACA coverage.

Credit: Kristen Uppercue/100 Days in Appalachia

So if Virginia’s decline was anticipated due to changing health care policies in the state, what happened in West Virginia?

Kat Stoll said the primary factors are a reduction in spending for advertising and assistance, general confusion about the current and future state of the program and a stronger economy. Stoll is the policy director for West Virginians for Affordable Health Care, an advocacy group that works at the state and federal levels on health care issues that affect low-income consumers.  

The advertising budget for the ACA under the Obama administration was more than $100 million a year nationally. The Trump administration slashed that budget by 90 percent.

Stoll believes this has a negative effect.

“People need that reminder,” she said, adding that “with media coverage of the ongoing repeal and replacement debate at the federal level,” the dissemination of information about the program helps clear up confusion.

“I was surprised by how many people thought the [ACA] was gone,” Stoll said.  

She also pointed to the decline in spending for the state’s navigator assistance program, which provides in-person help in determining eligibility and financial assistance for health care coverage.

In 2017 in West Virginia, navigator programs administered by the West Virginia University Research Corporation and First Choice Health Systems received federal grants totaling $600,000. In 2018, those budgets were reduced to $100,000, an 83 percent cut. The Trump administration also cut budgets for navigator programs throughout the country.

Stoll cited a stronger economy as another potential source of the drop in enrollment numbers. The number of West Virginians eligible for Medicaid also declined. Both point to the assumption that more people are working, and may be receiving health care coverage through their employers.

“We were surprised to see the Medicaid enrollment drop,” she said. “We don’t think that was the result of any particular policies at the state level that presented barriers to eligibility for Medicaid. It might actually indicate some uptick in our economy, and that was reflected in some of the revenue estimates from the governor’s office.”

Stoll does not believe the Trump administration’s decision to remove the individual mandate, or the penalty for not having health insurance, was a big factor in the decline in numbers.

“I think people go to the marketplace to get the premium subsidy,” she said. “It’s more of a reward than a penalty system.”

Stoll said about 80 percent of West Virginians in the ACA marketplace receive a premium subsidy.

“I think the key to the marketplace’s success is getting the word out that there are premium subsidies available.”

Stoll cites one final curtailing factor in ACA enrollment: cost.

Cost is a factor for those at the higher-income levels of eligibility who don’t receive a subsidy, she said. And for those of lower-income, “even with generous subsidies, there are still out-of-pocket costs; there are still some premium costs. And when you’re dealing with a family right at that 150 percent of the poverty [level], having to spend perhaps a hundred bucks a month on insurance premiums and knowing you’re going to have copays – that’s a concern.”

“That’s a hard thing to squeeze into your family budget,” she added.

“Affordability has certainly been helped by the Affordable Care Act,” Stoll allowed, “but it’s not solved.”

Nationally, 8.4 million people enrolled or were automatically re-enrolled in an ACA health insurance plan during the 2019 open enrollment period; in 2018, that number was 8.7 million. But the drop wasn’t as precipitous as had been feared after a sluggish start to the six-week open-enrollment period. Enrollment picked up considerably in the final days.

Final enrollment data for 2019 to be released next month will include the results for those states that operate their own marketplace.

Health Care in Appalachia

New Report Outlines Sound Strategies for Healthier Communities in Appalachia



Early Childhood Coordinator Jacki Wimmer reads to pre-K students on Tuesday, May 7, 2013, at Iaeger Elementary School in Iaeger, W.Va. Wimmer works in a program that provides a bag of books to families to encourage reading at home. Wimmer says some students never see a book until kindergarten. The school is located in McDowell County, an area overwhelmed with poverty, unemployment, drug abuse, and teacher shortages. McDowell County on Wednesday was expected to win approval to expand its role to include social services in a county that faces deep economic challenges. The project, called Reconnecting McDowell, brings together medical professionals, telecommunications firms and a teachers' union. Photo: AP Photo/Randy Snyder

As state administrators throughout Appalachia grapple with mounting health care costs, a new resource is offering assistance to policymakers by taking lessons from success stories outside of the health sector.

A healthy community is born of sound policies. That’s the premise of a just-released report from the Washington, D.C.-based nonprofit Trust for America’s Health titled “Promoting Health and Cost Control: How States Can Improve Community Health and Well-being through Policy Change.”

The study examines successful policies outside the health care sector that states, including those in the Appalachian region, have adopted to improve their communities’ health and well-being outcomes while reducing health care costs. Among those included are universal pre-kindergarten, rapid rehousing legislation and housing rehabilitation loans and grants, syringe-exchange programs and tobacco and alcohol taxes.

According to John Auerbach, president and CEO of Trust for America’s Health, the study kept its focus on the state level “because at this juncture, there’s less policy that’s being developed at the federal level.”

The researchers examined 1,600 policies, then honed the list to 13 that met their criteria of addressing pressing issues and proving themselves effective, while being deemed widely feasible.

“We were pleased to see, in terms of looking at these 13, that every state has done at least one of them,” Auerbach said. “We didn’t want to have a list of policies that were aspirational but hadn’t actually been tested in a range of different states.”

Syringe exchange is one such widely replicable policy that has already show positive outcomes in health costs down the road. Appalachian states have been among the hardest hit by the opioid epidemic. The crisis has presented a heightened risk of infectious diseases—including hepatitis C, hepatitis B and HIV—from shared and unclean syringes.

From 2006 to 2012, during the rise of the epidemic in the region, Kentucky, Tennessee, Virginia and West Virginia experienced a 364 percent rise in hepatitis C infections.

These risks translate to real costs for states where abuse is the worst. In North Carolina, the state Department of Health and Human Services reported that between 2011 and 2016 Medicaid charges for hep C treatment spiraled from $3.8 million to $85 million.

Led by the North Carolina Harm Reduction Coalition, which provides support and services to help reduce the harmful consequences associated with drug use, advocates took action. They helped educate law-enforcement and emergency-response agencies on the efficacy of syringe exchange and enlisted law enforcement’s help in crafting legislation that was widely supported. In July 2016, North Carolina passed House Bill 972, legalizing syringe-exchange programs.

In the first year after legalization in North Carolina, nearly 4,000 people were served by a syringe-exchange program. More than 2,500 HIV tests were administered. Program participants also distributed 5,682 kits of naloxone, a treatment that almost immediately reverses opioid overdose. In that first year, syringe-exchange programs were responsible for more than 2,000 reversals.

According to the report, between 1990, when syringe-exchange programs were legalized in New York City, and 2002, HIV prevalence among studied intravenous drug users decreased from 50 percent to 17 percent. The programs delivered one-year savings to the government of $1,300 to $3,000 per client and reduced HIV treatment costs by $325,000 per HIV case averted.

“While establishing programs to increase access to clean syringes can be a politically contentious issue,” the “Promoting Health and Cost Control” authors write, “the evidence supporting the effectiveness of these programs is overwhelming.”

States have taken different approaches to syringe-exchange legalization. According to Auerbach, “The states that have allowed greater flexibility in terms of the development of those syringe-access programs—for instance, where they’re located, under what circumstances they’re located—have had a greater benefit to health and economics.”

As of last year, there are 320 syringe-exchange programs in 40 states, D.C. and Puerto Rico.

The study also found that universal pre-kindergarten—publicly funded preschool available to all 4-year-olds regardless of family income, the child’s abilities or any other eligibility factor—is another initiative that has produced far-reaching effects.

The authors report that investments in high-quality early-childhood education can reduce the risk of chronic illnesses, obesity and eating disorders, behavioral health problems such as depression and anxiety and more. As a 2017 report titled “Creating a Culture of Health in Appalachia” details, the Appalachian region trails the rest of the country in many of these health outcomes.

The authors site a study conducted in Los Angeles that found that approximately half the cost of a pre-K program can be recouped through reduced public spending on Medicaid and other social programs.

In 2002, West Virginia passed legislation requiring that pre-K be made available to all 4-year-olds in the state by the 2012-13 school year. The West Virginia Universal Pre-K program is now available in every county in the state and is one of three state-funded programs that meet all of the National Institute for Early Education Research’s quality benchmarks.

Between 2003 and 2011, the state’s pre-K participation rate more than doubled, and in the 2016-17 school year nearly two-thirds of all 4-year-olds were enrolled in the program. A 2015 assessment found that third-graders who had attended a pre-K program scored four percentage points higher on average in English Language Arts than those who hadn’t.

Auerbach points out that 20 new governors took office in the last election. His ambition is for the “Promoting Health and Cost Control” report to be a resource as they map their health care strategies. The organization plans to monitor policy changes in respect to the report’s findings through regional meetings with state health officials.

“We think these work,” Auerbach said of the policies highlighted in the report, and “they have the added benefit of being effective before someone becomes ill.”

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