High-Cost Populations, The ACA, And More [From The Editor-in-Chief]

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Policy attention continues to focus on the small share of the population that accounts for the largest share of health spending. This focus is understandable for fiscal as well as quality-of-care reasons. After all, if we can better care for those with the greatest needs, we can improve their lives, and if through prevention, coordination, or attention to social needs we can avert the need for even a small portion of their care, we can save money as well.

Yet as those who have studied the issue or worked with the population know, there are many drivers of high cost. The first step in improving care is understanding the diversity of the high-cost population. This month, as Health Affairs enters its thirty-fifth year of publication, a few papers in the journal contribute to that understanding.

High-Cost Populations

Substance abuse creates its own health problems while exacerbating others. Jan Gryczynski and colleagues examine hospitalization rates and costs across different categories of users of alcohol, marijuana, and other illicit drugs. They find no association between alcohol or marijuana use disorders and hospitalization, but a strong link between other illicit drug use disorders and hospitalization. Notably, marijuana users who do not have a substance use disorder have lower hospitalization rates than those who abstain from the drug completely—a finding that warrants additional exploration, given the loosening of restrictions on marijuana use occurring in states around the country.

Housing instability is associated with poor health outcomes and higher health care costs. Supportive housing, a model that blends housing and health care access, is one intervention designed to address the complex needs of homeless people. Bill Wright and colleagues report findings from a pilot study of a supportive housing program in Portland, Oregon. They find reduced health care costs resulting from reduced use of various forms of hospital care—emergency department visits, inpatient care, and outpatient specialty care—while primary care visits were stable. Unmet health needs declined, and subjective health improved, which suggests promising results from this preliminary report.

Claire de Oliveira and colleagues focus on another group: those for whom mental health services account for at least half of their health care costs. Most of these patients had a diagnosis of a mood disorder or schizophrenia. Analyzing data from Ontario, the authors find that although this patient group had somewhat elevated medical costs, the vast majority of their costs were associated with their mental health condition–primarily psychiatric hospitalizations.

The ACA And Employment

By expanding Medicaid, providing income-based financial subsidies to purchase insurance, and placing coverage obligations on employers, the Affordable Care Act (ACA) has the potential to affect the hiring decisions of employers and the job-seeking behavior of individuals. A recent Congressional Budget Office Working Paper estimates that the ACA will cause the labor force to be two million full-time equivalents smaller in 2025 than would be the case without the law.

Angshuman Gooptu and colleagues compare states that expanded and those that did not expand Medicaid and find no significant differences in the first fifteen months when measuring job losses, job changes, and levels of part-time employment. Asako Moriya and colleagues focus on part-time employment in the first year after large employers were required to provide coverage to full-time employees or pay a penalty. They find no significant increase in part-time employment and no decrease in full-time employment. Our understanding of these issues will improve when analysts can examine data that span a longer period.

Effects Of The Medicaid Expansion

Arkansas took a unique approach to the ACA’s Medicaid expansion. Instead of enrolling those made eligible by the law in a traditional Medicaid program, the state enrolled those who were not in poor health in a silver plan in the new ACA Marketplace, along with wraparound financial protection. This so-called private option has been adopted in modified form by other states and is viewed by some as the basis for a conservative approach to Medicaid expansion. Benjamin Sommers and colleagues compare various measures of access to care among low-income individuals in Arkansas, Kentucky (a traditional expansion state), and Texas (a state that did not expand Medicaid). They find comparable improvements in Arkansas and Kentucky, while performance lagged in Texas.

Finally, Sayeh Nikpay and colleagues analyze hospital payment data from the first two quarters of 2014, just as the ACA’s Medicaid expansions went into effect. They find rapid declines in the share of hospitalizations associated with people without health insurance, and a corresponding increase in the share associated with people covered by Medicaid, in states that adopted the ACA’s Medicaid expansion. No such changes occurred in states that did not expand Medicaid.

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