By Kristin Jones
An astounding 93 percent of Coloradans now have health insurance, according to the latest count by the Colorado Health Access Survey, up from 86 percent in 2013. The biennial tally, released Tuesday, provides the best look yet at how well policies to expand Medicaid and private insurance are working in our state.
“Colorado is a state that has done what it set out to do, and that is to get more people insured,” says Michele Lueck, president and chief executive of the Colorado Health Institute, which administers the survey with funding from The Colorado Trust.
At the same time, the survey highlighted continuing disparities statewide across income, race and geographic lines in regards to the number of people insured, the affordability of health care and the overall health of Coloradans.
Some of the people who have benefitted the most from the insurance expansion are Colorado’s poorest residents. Around 450,000 more people enrolled in Medicaid in the past two years, accounting for by far the biggest leap in the number of Coloradans with insurance.
Medical providers say they can see the effects in their practices.
“There are many more people receiving primary care services, and this is a wonderful positive,” says Gisela Garrison, who directs the Northwest Colorado Health, which provides nursing, home health and other services in Routt and Moffat counties.
The percentage of those with insurance in these northwestern counties are the lowest of anywhere in the state, at 87 percent. Still, that’s up from 75 percent two years earlier.
Garrison says undocumented immigrants account for some who remain uninsured; they don’t qualify for Medicaid, and can’t buy insurance from the exchange. For others, the resistance is philosophical, and has to do with western, rural culture, says Garrison.
“People have a strong feeling that ‘the government should not interfere with my life, period,’” she says. “There are still many families who would be eligible for Medicaid because their income is low enough, and they are documented, but they don’t want to go through giving information to a government agency.”
That could change as the penalty for being uninsured increases. In 2015, the penalty was 2 percent of a person’s yearly income, or $325 per person—whichever is higher. Next year, it will be 2.5 percent of annual income, or $695 per person.
Growing number of underinsured
Another pressing problem is the affordability of health care, even for people who have insurance. Around one in 10 Coloradans said they didn’t see a doctor because of cost in 2015, down 15 percent from 2013.
The survey also documented what’s known as underinsurance—in which people have insurance but face prohibitive costs for medical treatment, typically benchmarked at spending more than 10 percent of one’s income on health care.
The number of those who are underinsured has actually increased since 2013, the survey revealed.
Around 16 percent of Coloradans are now underinsured, up from 14 percent in 2013. About one in four of the Coloradans who bought insurance on the individual market are underinsured.
Robin Dickinson, MD says she sees a lot of those patients in her private practice in Englewood, Community Supported Family Medicine. Most of her patients make between 200 and 400 percent of the federal poverty level, so they don’t qualify for Medicaid. Tax subsidies help many of them pay for insurance, but the more affordable plans are the bronze- and silver-level ones that come with high deductibles and maximum out-of-pocket costs. Per-person deductibles of $2,000 to $4,000 are typical of the silver-level plans on the market; deductibles at the bronze level are even higher.
“If your daughter is playing soccer, and twists her knee, or you get a urinary tract infection—all that stuff you’re now paying out-of-pocket because you have insurance,” and no longer qualify for discounted care, says Dr. Dickinson. These costs can add up. “If you’re making $40,000, you don’t have $8,000 sitting around” for unexpected medical expenses, she points out.
Her practice offers these patients a workaround; she simply doesn’t take insurance. Instead, her patients—many of whom are actually insured—pay a monthly fee of $30 to see her as many times as they like. Dr. Dickinson performs skin biopsies, stitches up cuts, helps manage diabetes, diagnoses and treats depression, and provides other primary care services to people who would otherwise find it hard to afford that treatment.
“People blame the patient: ‘You shouldn’t have bought such a crappy insurance plan.’ But they can’t go buy a nice plan because then they can’t do other things that are important to them,” says Dr. Dickinson.
She speaks from experience. Dr. Dickinson herself had a high-deductible plan three years ago, and had saved to pay out-of-pocket expenses when her daughter was born. What she hadn’t planned on was having two strokes shortly afterward, incurring out-of-pocket medical costs before a $5,800 deductible.
“I was lucky to have family that could pay it off,” she says. “Many people don’t.”
When her patients need specialty care, Dr. Dickinson sometimes advises them to cut back on their work hours so that they qualify for Medicaid.
But a growing number of those considered underinsured are Medicaid clients, according to the Colorado Health Access Survey. Eighteen percent of Medicaid and Child Health Plan Plus clients were underinsured in 2015, up from 13 percent in 2013. The survey revealed that those most likely to be underinsured were those who were least able to afford it.
In rural areas, notes Garrison of the Northwest Colorado Health, Medicaid clients often have additional obstacles.
“The challenge is that many patients who finally now have access to primary care are being diagnosed with long-neglected medical issues, and now have to access specialty care,” says Garrison. “They are being referred four and a half hours out to St. Mary’s Hospital in Grand Junction, or to Denver.”
Garrison considers this a kind of underinsurance, too, and her care coordinators are working to find more specialists in the region willing to take Medicaid.
Across the state, advances in coverage have so far left intact the state’s deep health disparities, according to the survey.
Lower-income Coloradans were more than twice as likely to report physical health problems as those in the highest income bracket. They were three times as likely to have mental health or oral health problems.
More than one in five black Coloradans report having dental problems. That’s compared to just 13 percent of whites and 14 percent of Hispanics.
And one in five Hispanic Coloradans reported having physical health problems, compared with 11 percent of whites.
In the San Luis Valley, more than one in four residents who responded to the survey said they were in fair or poor physical health—the worst rate in the state. Donna Wehe is the patient access manager at the San Luis Valley Health regional medical center. She says that patients she sees are suffering from diabetes, chronic obstructive pulmonary disease, hypertension—chronic conditions not easily fixed with a few visits to a doctor.
“It’s hard to make those lifestyle changes to eat better, exercise, stop smoking,” says Wehe.
And even behavior is often only secondary to other social determinants of health that the Affordable Care Act can’t address on its own.
“Poverty, education, child care, geography—those are all pieces of the larger puzzle,” says Brooke Powers, program and policy manager for ClinicNet, which advocates for safety-net health services. “Coverage is a piece of it.”