In most articles about the looming expiration of the enhanced premium tax credit (EPTC) associated with the Affordable Care Act (ACA), the authors tend to focus on how many people are at risk of losing their insurance. While a central feature of the debate over whether or not to keep these tax credits, it only tells part of the story.

I've seen this information sliced and diced and repackaged lots of ways. But in a recent Commonwealth Fund issue brief, the authors go farther than most, analyzing the broader impact on hospitals, care providers, insurers, health workers, and so on. They even look at the impact on businesses on the periphery of healthcare that will be affected when, for instance, rural hospitals have to shut down due to a lack of funding as a direct result of dipping Obamacare enrollment numbers.

Going even further, the authors of the data brief also forecast the impact of these potential changes on economies, employment, and tax revenue on every state plus the District of Columbia. It's a holistic approach that foregrounds the danger to everyone within shouting distance of the healthcare industry of a collapse of the EPTC, and even those outside of the industry.

The EPTC is one of two existing Obamacare subsidies, and it helps low- and middle-income individuals and families who meet certain criteria to buy insurance through the ACA health insurance marketplaces at an affordable rate.

The ball is now in Congress' court to reauthorize EPTC legislation. Needless to say, if these tax credits are allowed to expire later this year, as they are scheduled to do, costs will rise sharply and fewer people will be able to afford to stay on their plan. This will lead to millions of people losing health coverage.

To set a baseline for the discussion, I'll post six graphs that tell the story of the progress that Obamacare has made in the past five years in enrolling steadily (and then drastically!) more people.

For those uninitiated in things like insurance exchanges and tax credits, I only ask that you look at the trend lines for now, which I've provided to give you a sense of how literally everything is moving in the right direction. The charts are broken down by so-called "metal level," which is just another way of saying "insurance plan type." The "metal" comes from their naming convention, such as gold, silver, bronze, and platinum.

Please note that this data comes only from the 31 states that are considered "inside the ACA exchanges." These are states that either have Federally Facilitated Exchanges (FFE) – including states performing plan management functions – and states whose State-based Exchanges rely on the federal information technology platform for QHP eligibility and enrollment (SBE-FP). Put another way, these 31 states use Healthcare.gov as the underlying infrastructure of their plans.

Don't worry about the particulars of this right now, as I'll get into these distinctions a little further down. Just know that this data doesn't represent the entirety of the performance of ACA insurance exchanges. That said, to me it's a good indicator of broader trends at work.

First up, the data for gold plan enrollees:

This is a good graph to start with, because you can very clearly see where enrollment numbers drastically increased in 2024. There are reasons for this, which I'll detail in a minute. Next up, let's look at silver plan enrollees:

You might have noticed a significant jump in the total numbers of enrollees for the silver plan in the year 2024, and there's a good reason for that. That's because incentives have tipped over time toward driving people toward this plan. We'll investigate why in a little bit. Next we have bronze plan enrollees, followed by platinum, catastrophic, and expanded bronze enrollees:

Look at those trend lines! They're all ramping up, no matter the metal level. Keep this in mind as we explore the consequences of making it more challenging for people to enroll in Obamacare.

Before we get started, I think it's important to keep in mind that these enrollees are human beings we're talking about, and their lives will drastically change if these measures aren't extended. It's important to ground the numbers I'll be pointing to in this reality, because this sort of blog post can rapidly become an intellectual exercise if we're not careful. There's a lot on the line here.

Of particular note, the previously-mentioned Commonwealth Fund issue brief notes that consequences of not extending the tax credits would fall most squarely on Black and Latino Americans. In addition, residents of states that haven't expanded Medicaid under the ACA will be disproportionately affected. These two groups – African American/Latino populations and residents of non-Medicaid expansion states – overlap significantly.

Indeed, according to the Center on Budget and Policy Priorities, as of 2024, the following was true:

"Some 38 and 33 percent of Black and Latino people, respectively, reside in non-expansion states, compared to 26 percent of the overall U.S. population…Texas alone, where roughly 1 in 5 Latino people in the U.S. live, is home to 74 percent of Latino people in the coverage gap."

What is this so-called "Medicaid coverage gap"? People facing this issue earn incomes below the federal poverty level, and their income level makes them ineligible for financial assistance through the ACA marketplaces; at the same time, they don’t qualify for Medicaid because they live in one of the states that have not adopted the ACA Medicaid expansion. A total of 1.6 million uninsured adults are stuck in the coverage gap, and African Americans and Hispanics make up a disproportionate percentage of this population.

We'll look at these trends in more depth a little further down, but briefly, in 2024 the Urban Institute found that "Black and Hispanic people will see greater reductions in the percent of uninsured people relative to White people because of enhanced PTCs." The inverse of this is true as well: if the EPTCs go away, an outsized number of these minority groups will feel the negative effects.

It's also worth noting at the outset that any changes to Medicare, no matter their specific target, are deeply unpopular with the American public. While not mentioning the EPTC directly, a recent KFF survey found the following:

"...fewer than one in five (17%) say they want to see Medicaid funding decreased. In fact, most people say funding for Medicaid should either increase (42%) or stay about the same (40%)."

When it comes to Medicaid funding, it should be no surprise that a strong majority (64%) of Democrats favor increasing spending, as do four in ten independents. Sentiment for increasing Medicaid funding also holds true broadly across Republican ranks, and interestingly, about three in four total rural residents and two-thirds of rural Republicans say funding should increase or stay the same.

No matter how you frame it, cutting Medicare and Medicaid benefits are not broadly popular prospects. Before we go any further and start digging into the data, a quick primer on the EPTC is in order.

The EPTCs, which started out as just PTCs (more on that evolution below), are available only to people residing in states that have accepted extended Medicaid benefits. As stated before, the PTCs were established under the ACA, and it helped people previously unable to afford insurance to gain coverage. The tax credits have evolved over the years, most significantly in 2020 and 2022.

The enhanced (sometimes also called "advanced") premium tax credit is based on an individual's estimated income and household size, and it takes into account how much health coverage costs in a given state.

As the Commonwealth Fund notes, "As part of the American Rescue Plan Act of 2020, Congress increased the ACA marketplace premium tax credits (PTCs) to ensure that Americans had access to affordable health insurance during the pandemic. In 2022, Congress extended these enhanced tax credits through 2025 as part of the Inflation Reduction Act."

As the Congressional Budget Office (CBO) puts it, "ARPA reduced the maximum amount eligible enrollees must contribute toward premiums for health insurance purchased through the marketplaces established by the Affordable Care Act, and it extended eligibility to people whose income is above 400 percent of the federal poverty level (FPL)." The Inflation Reduction Act (IRA) extended the ARPA provision for three additional tax years, 2023 to 2025.

Remember how my graphs all showed a significant uptick in enrollment numbers in 2024? This is likely because of the IRA extending ARPA provisions. As the CBPP puts it, "...a record-breaking 21.4 million people had selected a marketplace health insurance plan for 2024. This is a 30 percent increase over last year and is the fourth consecutive year of record ACA marketplace enrollment."

Referencing the IRA and ARPA, the CBPP goes on to say the following:

"Those laws also removed the income cap on premium tax credit (PTC) eligibility (previously set at four times the federal poverty level, or about $58,000 a year for an individual), ensuring that no one pays more than 8.5 percent of their income for the silver-level benchmark plan. These enhancements have driven consistent enrollment growth since 2021."

If you recall the graph at the beginning of this post showing how enrollment in the silver plan has shot through the stratosphere in the ensuing years, this is the likely reason behind it. Now that we're in the final year of that expansion, Congress has to revisit this issue and decide whether or not to extend the tax credits yet again.

Offering these progressively more generous premium tax credits spurred ever-increasing enrollment in ACA marketplace insurance, which contributed to record low uninsured rates. As of 2024, 93 percent of marketplace enrollees – which equates to 19.3 million people – receive premium tax credits, which is a record level of enrollees.

As part of the Affordable Care Act, the framers stipulated two different approaches for lowering monthly insurance premiums. You might have heard them referred to as Obamacare subsidies. The first of these we've already talked about: EPTCs. The second is what is known as Cost-Sharing Reductions, or CSRs.

Similar to EPTCs, CSRs provide extra savings that reduce beneficiaries' out-of-pocket costs. A person must fill out an application online to see if their income level qualifies them to receive out-of-pocket cost savings, and they must enroll in a silver plan (more on the tiered plan structure below). If you cast your mind back to the graphs at the beginning of the post, you'll see mounting evidence for why most enrollees elect for the silver plan.

These savings are achieved by lowering an enrollee's deductible, coinsurance rate, or copays. The out-of-pocket maximum is also limited by this subsidy. Some potential enrollees may be eligible for both the EPTC and CSRs, and this can help them save on annual health plan costs.

I think it's worthwhile to give a very brief overview of how the APA insurance exchanges work, and also to take a general look at the flavors of insurance plans nationwide. It will help to keep in mind the various types of plans when we look at trends a little further down, and how all of this will likely reverse if the tax credits aren't renewed.

When looking at data from the health insurance exchanges, it's important to understand that they fall into three broad categories:

A total of 31 states fit into the first two categories listed above (FFE + SBE-FP) – these are sometimes referred to as being "inside the ACA exchanges." It's data from these exchanges that I used to inform my graphs at the top of this post. On the other hand, 20 states plus the District of Columbia fit into the third category and don't use the federal government platform ​to determine plan eligibility or enact enrollment. These latter states are referred to as being "outside of the ACA exchanges."

I'm not 100% sure about this, but it seems that for the plans inside the ACA marketplace, enrollees must pick one of the four so-called "metal tiers," or gold, silver, bronze, or platinum. In other words, the other two categories aren't available to them. The defining features of these tiers is something called "actuarial value."

Put simply, actuarial value – or actuarial value percentages – represent how much of a typical population’s medical spending is covered by a health insurance plan.

I like the following definition of actuarial value provided by a website called Beyond the Basics:

"The actuarial value is 60 percent for bronze plans, 70 percent for silver plans, 80 percent for gold plans, and 90 percent for platinum plans. The higher the actuarial value, the more the plan covers of a typical population’s costs (and thus the typical population would pay less out-of-pocket). A lower actuarial value means the plan covers less of the costs (and the population pays more). The actuarial value calculation focuses mainly on cost-sharing charges. This means that a bronze plan generally would have higher overall enrollee cost sharing than a gold plan would."

It's worth stopping for a minute and asking why residents of states that haven't expanded Medicaid will be most affected if the tax credits aren't renewed. Earlier we examined how certain minority groups, which are disproportionately represented in non-Medicaid expansion states, would fare worse than other groups if the EPTCs weren't extended. But what's so special about Medicaid that states with less robust versions come out on the short end of the stick? The Commonwealth Fund article provides us with some insight:

"Residents of these states are more reliant on enhanced PTCs, because their legislatures and governors have not taken up the ACA’s Medicaid expansion and there are no other affordable health insurance options."

These states include Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. In addition to many people in these states and others losing their insurance, it's also worth pointing out that the CBO predicts "that not extending the credit will increase the number of people without health insurance and raise the average gross benchmark premiums for plans purchased through the marketplaces."

What are these benchmark premiums that are likely to rise? The Paragon Health Institute tells us that "a benchmark plan is the second lowest-cost silver plan premium in the consumer’s region. The Premium Tax Credit (PTC) related to Affordable Care Act plans is based on the cost of the benchmark plan as it relates to the household income of the insurance enrollee. The higher the benchmark plan premium, the larger the PTC."

The American Hospital Association adds numbers to the mix, stating that "The lack of an extension would also increase gross benchmark premiums by 4.3% in 2026 and by 7.9% on average from 2026-2034." So not only will people lose their insurance, but for everyone else obtaining insurance through the insurance exchange, their premiums will likely rise significantly.

While the knock-on effects of stopping the EPTC are fairly straightforward, it's worth reviewing how the authors of the Commonweath Fund issue brief conceive of them:

"The dynamics of this ripple effect work as follows. As the enhanced PTCs disappear, former recipients will likely either become uninsured or shift to another form of health insurance. Health insurers, in turn, will no longer collect the PTCs (and other insurance payments), causing them to cut payments for patient care to hospitals, doctors’ offices, pharmacies, and other health providers. For their part, health providers will need to cut jobs — some could even close due to loss of revenue. This would lower access to health care overall, even for people who remain insured."

Wait, there's more!

"Providers will also need to reduce payments to businesses in their supply chains, and, in response, those firms will be forced to cut labor and other costs. As employees lose income, they must reduce spending on consumer goods and services. Finally, the loss of individual and business income results in less state and local tax revenue collected."

It's on these last two items – a reduction in consumer spending and loss of state and local tax revenue – that every American should be focused. For me, these concerns represent a wider picture of the repercussions of Congressional inaction. These two eventualities could affect all of us, no matter our medical status. They throw into stark relief the deep consequences of ending these tax credits, particularly in states that haven't expanded Medicaid coverage.

So, telehealth. Over the past couple of decades, it's been a subject of much interest and some controversy in the United States. Before the COVID-19 pandemic, telehealth – or telemedicine, as some call it – was underused and underappreciated. While patients who actually used the technology tended to look favorably on it, many physicians either couldn't bear the red tape associated with it, or flat-out thought it was the catalyst for a race to the bottom when it came to quality.

But then COVID-19 changed everything. The pandemic served as the impetus for passage of the CARES Act and CMS 1135 Waiver, which in turn led to the federal government dropping licensing requirements and other barriers to utilizing telehealth. Patients with routine appointments could now be seen virtually, freeing up hospital space for emergent cases of COVID and avoiding relatively healthy people being exposed to the virus in a clinical setting.

This set of circumstances led to an ever-increasing acceptance of telehealth by the mainstream. In fact, in a 2022 survey administered by the American Medical Association, "74.4% of physicians surveyed reported that telehealth was used in their medical practices—nearly three times the share in 2018."

When any technology is adopted relatively overnight, there are bound to be bumps along the way. This is borne out by a 2024 JD Power telehealth satisfaction survey which found that telehealth user experience has varied significantly across various demographics. Despite this somewhat spotty record, however, most respondents praised the relative convenience of the technology.

This dynamic squares with most other articles I've read about the subject: although barriers persist, most people can at least agree that it's easier to hop on a telehealth call than taking the time to travel to a doctor's office.

Because I keep hearing about the ascendancy of telehealth, I wanted to get a better sense of who exactly is using it. The best data set I have access to is the Medicare Telehealth Trends data, so I'll be relying on it in this post as a proxy for how much telehealth has caught on among different demographic groups. The data set contains numbers for Medicare enrollees between 2020 and the second quarter of 2024.

But first, a few caveats.

Caveat #1: Because this is Medicare data, it has limited utility for this question. For instance, since Medicare is intended to insure mostly older Americans, we won't be able to get a feel for how most younger folks are using telehealth.

Caveat #2: Although the majority of Medicare beneficiaries are ages 65 and older (86%), 14% are younger and qualify for Medicare enrollment because of a long-term disability. Among this group, "(l)arger shares of Black (25%) and Hispanic (19%) beneficiaries are under age 65 compared to White beneficiaries (12%)" which makes comparing the general population to Medicare beneficiaries challenging.

Caveat #3: Medicare Part B and some Medicare Part A enrollees are eligible for telehealth services, but of those Part A beneficiaries who are permitted to use telehealth, most are enrolled in Medicare Advantage plans. For this reason, I'll be focusing only on Medicare Part B beneficiaries in this post.

Caveat #4: Since the latest data available in this data set only runs through Q2 of 2024, we can't get a full picture of current telehealth use.

With all that said, we'll look at trends over the past four years for how Medicare Part B enrollees have been utilizing telehealth services. Let's dive in.

Let's start at what might seem like an obvious place: age. As stated above, keeping in mind that there are some exceptions, the data for Part B beneficiaries necessarily skews to the older crowd. It's fair to assume that the older you get, the more touch points there would be with healthcare services and, thus, more telehealth consumption.

But surprisingly, this assumption is incorrect. As it turns out, Medicare Part B enrollees between 2020 and 2024 tended to use more telehealth services as they aged, but then the trend reversed when with the 75-84 year old cohort. Let's take a look at the data to see what I'm talking about here.

*Important note: all numbers are reflective of the years 2020 - Q2 of 2024

When graphed, it looks like this:

I may go into the reasons for this dropoff as age increases in another blog post, but my initial guess is that older folks tend to have more issues with technology and likely prefer to see doctors in person.

Now let's turn to differences by gender, again keeping in mind that these numbers are reflective of total telehealth use between 2020 and Q2 of 2024.

Between 2020 and Q2 of 2024, 2,424,715 more female than male Medicare Part B beneficiaries used telehealth. Personally, I don't find this very surprising given that, according to the Harvard Business School website, "At an individual level, studies have shown that women utilize more healthcare services" and are "76% more likely than men to have visited a doctor within the past year. At the family level, women control 80% of healthcare decisions…in the home."

Now here's where things get interesting. I've done a few things differently here to try to provide better context for what's going on: I've averaged telehealth use by race for the years 2020 - 2024, and added two additional new columns – one for numbers of each racial group enrolled in Medicare as of 2023, and then I averaged the mean number of enrollees in each racial category and the number enrolled in Medicare Part A and B as of 2023.

As it turns out, American Indian/Alaska Native enrollees top the list of average use of telehealth. Given all of the challenges facing that community, including lower overall access to high-speed internet, I was pleasantly surprised to find that they are relatively comfortable with using telehealth.

This is in keeping with research that shows that as of 2021, "Non-Hispanic White (39.2%) and non-Hispanic American Indian or Alaska Native (40.6%) adults were more likely to use telemedicine compared with Hispanic (32.8%), non-Hispanic Black (33.1%), and non-Hispanic Asian (33.0%) adults."

Happy New Year! For my first post of 2025, I'd like to talk about an innovative approach to healthcare delivery that recently appeared on my radar. Toward the end of 2024 I attended several events on Capitol Hill related to healthcare. The days before and immediately after the U.S. presidential election were an exciting yet exhausting time filled with snap reflections and bold predictions.

In other words, the boundless optimism of the healthcare policy crowd wasn't in short supply.

On "team optimism" I ran across a group of healthcare providers-turned-policy-advocates from the appropriately-named Advocate Health, a nationwide healthcare system, who'd traveled to the Hill from Charlotte, North Carolina to advocate for the continuation of a program called the Acute Hospital Care at Home (AHCAH) initiative.

Featured prominently among the speakers on Capitol Hill was Colleen Hole, a Person-Centered Healthcare Advisor working on the front lines of delivering value-based healthcare. The Advocate Health team was advocating for the continuation of CMS waivers (which I'll explain in more detail below) beyond the end of 2024. I subsequently interviewed Colleen for a forthcoming episode of the Dragon Tree Podcast, so I'll update this post when the video is available.

Spoiler alert: the aforementioned waivers were extended by the American Relief Act, 2024, through March 31, 2025; however, without action by Congress to extend the initiative further, CMS will no longer accept waiver requests for participation in the initiative.

But I'm getting ahead of myself.

When I first read the advertisement for the Capitol Hill briefing, the whole concept of acute care patients receiving equivalent medical care at home seemed alien to me. I suppose I'd heard of Hospital at Home (HaH) care before, but the event announcement made it seem like, at least for certain patients who would under most circumstances have to seek care in a brick-and-mortar hospital, they could now receive care in the friendly confines of their homes.

According to a recently-released report (PDF file) on the AHCAH, the concept has its roots in the UK: "The first trials, held in the United Kingdom (UK) in the late 1970s for patients experiencing acute myocardial infarctions, found that hospitalizations conferred no benefits over home-based acute care. Since then, HaH programs have been established in the UK, Italy, Australia, Canada, Israel, and other countries with government-run health systems."

The report goes on to say that similar studies were made in the U.S. in the 1990s, but the approach doesn't seem to have been adopted to any significant extent here. So it stands to reason that, while HaH has been used to good effect elsewhere, I was new to the AHCAH, a CMS-sanctioned care delivery approach that takes this brand of home care to the next level.

The initiative, which was authorized by CMS in the Acute Hospital Care at Home Individual Waiver in the opening days of the COVID-19 pandemic, served as a way to relieve pressure on overstretched care facilities. It allowed certain hospitals to begin treating patients with inpatient-level care at home, with a goal of improving their outcomes and experience, while at the same time reducing hospital costs.

This waiver covers Medicare patients at Atrium who are eligible for enrollment into the AHCAH. Regarding Medicaid patients, however, an AMA Future of Health Case Study (PDF file) spotlighting Advocate's HaH program notes that, "as of November 1, 2023, North Carolina Medicaid covers this program under the existing diagnosis-related group (DRG) methodology."

The case study notes that coverage for Medicaid patients was meant to run through the end of 2024, and I was unable to find out if, like the plan covering Medicare patients, this, too was extended. I'll update this post if I find further information. But whatever the case may be, AHCAH proved a revolutionary approach to care delivery during the pandemic, when brick-and-mortar hospitals were becoming overrun by COVID patients. Many will remember that especially during 2020, the prospect of someone with non-emergent issues stepping foot inside a care facility was met with serious skepticism.

Despite a short runway for takeoff, the AHCAH initiative proved a big success in places like Charlotte. In that city, Atrium Health – which is part of Advocate Health and is an integrated nonprofit health system operating the Atrium Health Hospital at Home (AH-HaH) program, a version of the AHCAH – has achieved impressive results (PDF file). To date, they've enrolled over 8,400 patients across 10 counties in the Charlotte region. This has resulted in nearly 30,000 bed days saved since March 2020.

The goal of Advocate Health's AHHaH program, which is a strategic partnership between a traditional brick-and-mortar health system and a technology company, is to "build and scale a program that enables patients to continue their care and recovery at home." There was good reason at the outset to think the program would prove useful in stemming the flow of patients flooding hospitals in 2020, and that, if properly implemented, it could continue once COVID rates started falling.

And Advocate Health's optimistic outlook is shared by other HaH participants, including Mt. Sinai. The New York-based healthcare system recently reported that it has doubled the number of providers involved in its program. Part of the reason for their success is that they began providing home-based care a decade ago. From the article:

"The health system already has one of the oldest hospital-at-home offerings in the country, starting in 2015, before the CMS waiver that propelled many health systems to launch the care model. So Mount Sinai has learned to provide acute inpatient care at home in the face of regulatory uncertainties."

These "regulatory uncertainties" have likely put a damper on wider, nationwide uptake of the AHCAH programs, along with, as Ania Wajnberg, MD, president of Mount Sinai at Home, puts it in the article, "people-heavy" aspect of the business. New York requires that HaH patients receive two in-person visits per day, and that these visits be made by nurses, the latter of whom seem to be in relatively short supply in relation to the demands of the program.

Dr. Wajnberg and her team have mitigated this challenge by opening the program up to a wider array of patients, including "patients who need dialysis, post-surgical care, or monitoring for complex cardiac conditions." The fact that they've managed to double their HaH staff speaks to the confidence Mt. Sinai leadership has in the program.

Reminiscent of the UK study I quoted earlier, the previously-mentioned CMS report on the AHCAH provides evidence for the efficiency of this care approach: "A variety of studies and systematic evidence reviews have demonstrated that HaH is similar to or better than in-hospital stays across a variety of measures, including costs, mortality, length of treatment, health care usage, readmissions, long-term care admissions, anxiety and depression, and patient and caregiver satisfaction."

This success can, at least in part, be attributed to the fact that, to ensure that the initiative carries out its intended purpose, AHCAH sites have to be selective when choosing which patients to enroll. As a fact sheet on the previously-quoted report attests, although hospitals were given some latitude to decide on inclusion criteria for participating patients, "Participating hospitals indicated that these criteria were developed and utilized with the intent to ensure that eligible patients were willing and able to participate in a HaH program, that such patients were clinically and psychosocially appropriate to safely receive care in the home, and that patients’ home and community environments were conducive to the safe and effective provision of acute inpatient care at home."

It's temping to think about home care purely in terms of a CMS-funded initiative, since it was the AHCAH waiver that triggered outfits like Atrium Health to go all in on home care. But in the intervening years the program has grown, and, like Atrium, participant sites have begun accepting a diverse mix of payers for their program.

As the AMA case study attests, Atrium (through Advocate Health) accepts patients who are enrolled in Traditional Medicare, select Medicare Advantage plans, North Carolina Medicaid, and "select commercial payers." As the same case study makes clear, however, "Coverage by commercial payers is inconsistent."

Similarly, Mt. Sinai has incorporated a dynamic payer mix into its program. According to the Becker's article, "Mount Sinai has been at this so long it has contracts with payers outside of Medicare." This seems to be a key way to hedge against the uncertainty of whether or not, at some point, Medicare patients may be dis-enrolled from the initiative.

Keeping in mind that patients other than those strictly on Medicare or Medicaid participate in acute care at home programs, it's instructive to look at the skew of Medicare versus Medicaid enrollee participation. In the previously-mentioned report, CMS found that, when compared to patients receiving comparable services in brick-and-mortar hospitals, the demographics of those enrolled in the AHCAH initiative were, on average, skewed toward Medicare beneficiaries. As the report states, "In general, AHCAH patients were more likely to be white and live in an urban location and less likely to receive Medicaid or low-income subsidies."

This care delivery approach lasted for the duration of the pandemic and has only gained traction in the intervening years. As a sign of its enduring value, at the end of the public health emergency, the Consolidated Appropriations Act, 2023 extended the waivers and flexibilities associated with the AHCAH initiative until December 31, 2024. And, as mentioned earlier, it was recently extended again through March of 2025.

In addition to expanding its insurance payer mix, teams like Advocate Health have found innovative ways to improve the program and help more people. For instance, in 2023, Atrium partnered with Best Buy Health to diversify its technological toolkit. Best Buy Health offers its own care at home platform called Current Health, which debuted in 2021 and "brings together remote patient monitoring, telehealth and patient engagement into a single solution for healthcare providers."

Through this partnership, Atrium is able to enhance its patient education along with enabling in-home technology offerings with the assistance of Geek Squad Agents, Best Buy's 24/7 support agents who are available to provide logistics and technical help.

For part two of an ongoing series, we're once again looking at the numbers of U.S. children enrolled in the federal government's Children's Health Insurance Program (CHIP). As I discussed in my last blog post, several U.S. states have either widened eligibility for CHIP, or are considering doing so now that the federal Covid emergency has ended.

As a recap, in the spring of 2023, a process called "Medicaid unwinding" took place where people were once again eligible to lose their Medicaid coverage based on changes in their life circumstances. To soften the blow of that unwinding, several states agreed to expand Medicaid eligibility to include more children.

Despite this, however, the unwinding has led to millions of people losing Medicaid coverage. This issue has drawn national headlines, such as this recent NBC News story that focused on large numbers of people losing their Medicaid coverage in Colorado. What the story leaves out is that Colorado has taken steps to correct this, which we'll get to in a minute.

According to Medicaid data, the numbers of children enrolled in Medicaid through Colorado's CHIP program have been on a steady decline ever since they hit a high of 652,517 enrollees in February of 2023. This is the month before the Consolidated Appropriations Act of 2023 decoupled the Medicaid continuous enrollment provision from the Covid-19 public health emergency (PHE) on March 31, 2023 and resumed Medicaid disenrollments.

Currently, CHIP enrollments in Colorado are at 520,641. Here is a graph that shows the overall decline in the state up until August of 2024, the last month for which data is available:

Data courtesy of Data.Medicaid.gov

To combat these declining numbers, Colorado's Department of Health Care Policy & Financing (HCPF) recently announced that it will be extending its CHP+ coverage eligibility for children. According to the department's press release detailing the particulars of the expansion, "The policy will support continuous coverage for children from birth to age three who are eligible for Health First Colorado (Colorado’s Medicaid program) or Children’s Health Insurance program (CHP+). This expands continuous coverage for young children to 36 months, rather than the current continuous coverage of 12 months."

The change was made possible by an amendment to a Medicaid section 1115 demonstration waiver. "Through this amendment," the press release states, "HCPF expects to prevent coverage gaps for an average of 31,000 children over a 5-year demonstration period." The program goes into operation on January 1, 2026, so it will likely be a while before we see CHIP enrollment numbers start improving in the state.

Colorado is one of 41 states and the District of Columbia that have expanded Medicaid. While 10 states have elected not to increase access to this safety net program, some (like Kansas) are still debating expansion. In our last blog post, we highlighted enrollment numbers in the expansion states of Maine and Arizona, a blue and swing state, respectively; for the remainder of this post, we'll zoom in on expanded enrollment in two reliably conservative states, namely North Dakota and Kansas.

Updated numbers from CMS for August 2024 CHIP enrollment were released at the end of November, so those are the numbers we'll use. As a quick reminder, there is a lag of several months in the data, so we won't be able to get up-to-the-minute numbers. That being said, let's dive in and look at the circumstances surrounding North Dakota's Medicaid expansion, how it stacks up against those of Maine and Arizona, and how the state's enrollment numbers performed through August of 2024.

As stated in our previous blog post, we chose to include North Dakota and Kansas in the mix because North Dakota is a solidly conservative state while Kansas, which is overall a conservative state, is still home to an interesting combination of conservative and liberal tendencies. Together with Maine (liberal) and Arizona (swing state), these four states constitute a spectrum of political leanings.

According to the North Dakota Health & Human Services website, "CHIP is intended to meet the needs of working families, who cannot afford health care coverage for their children, yet earn too much to qualify for Medicaid."

"To qualify," the website continues, "a family's Modified Adjusted Gross income (MAGI) must be greater than the Medicaid level, but cannot exceed 205% of the federal poverty level." This seems to be a stable benchmark that hasn't changed much in recent years.

Medicaid expansion was first enacted in North Dakota in 2014 as a result of the Affordable Care Act. While Medicaid expanded again in North Dakota as of April 1, 2024 for "individuals between 19-64 with household incomes up to 138% of the federal poverty level (FPL)," the CHIP component of the state's Medicaid program doesn't seem to have been affected.

So although North Dakota qualifies as a Medicaid expansion state, not much work seems to have been done in opening up healthcare access to more children in the state. But it's still worth asking: now that more adults are eligible for Medicaid there, might that also mean that increased awareness around enhanced Medicaid availability will prompt those adults who earn too much to qualify for Medicaid but who also still need help insuring their children to seek out insurance under the state's CHIP program?

I'm not sure how many residents fall into this category, so the premise of the question might be a long shot. But we're all about long shots here at Dragon Tree, so let's dig into the numbers and find out. First, here is a graph that looks at CHIP enrollment numbers between early 2023 and August of 2024.

Data courtesy of Data.Medicaid.gov

As you can see, CHIP enrollment is down year-over-year in the state, having declined 17.2% since the unwinding began in April of 2023. An interesting data point reported by the Kaiser Family Foundation that undercuts my premise stated above is that​, "During the unwinding of the Medicaid continuous enrollment provision, over 25 million people were disenrolled and over 56 million had their coverage renewed. Overall, 31% of people whose coverage was redetermined during the unwinding were disenrolled, but that share ranged widely across states."

Given that 45% of people were disenrolled from the state-run Medicaid program during the unwinding, that puts North Dakota in the upper fourth of states. So, although Medicaid eligibility criteria have become marginally more generous in North Dakota since the spring of 2023, not only have overall Medicaid enrollment numbers gone down, but there's also been a similar – although less drastic – downward trend of children enrolling in the CHIP program in the state.

Expansion of Medicaid is still only an aspiration of some lawmakers in Kansas. Still, it's worth establishing a baseline understanding of where CHIP enrollments stand so that, in the event the state does expand Medicaid eligibility in the near future, we can track its progress more effectively.

Let's start by looking at current qualifications for CHIP enrollment in Kansas. The Division of Health Care Finance (DHCF) is responsible for purchasing health services for children through CHIP. According to the DHCF website, "Kansas provides low-cost health insurance coverage to children who are under the age of 19, do not qualify for Medicaid, have family incomes under 232% of the federal poverty level, and are not covered by private health insurance."

That means that CHIP enrollment eligibility in Kansas is more generous than in North Dakota and is on par with Arizona, where annual family income limits will soon be 225% of the federal poverty level (FPL). It isn't, however, as generous as Maine, which sets limits on household income at 300% of the FPL.

Next, let's look at CHIP enrollment numbers over the past couple of years in Kansas. Like the other states on our list, there was a drop in enrollment in March of 2023 from which the state hasn't yet bounced back:

Data courtesy of Data.Medicaid.gov