The report is only produced every four years and examines markets in the entire U.S.

By Rose Hoban

The performance of some health systems in North Carolina has improved during the past four years, but according to a new report, they could serve people better if the state expanded Medicaid.

In a report that’s issued every four years, the Commonwealth Fund found that some North Carolina “hospital referral regions” improved on measures such as access to care and avoidable hospitalizations. But, in general, areas in states that have expanded Medicaid, as allowed under the Affordable Care Act, have seen more improvement in efficiency, access to preventive care and better outcomes.

Image courtesy: Parker Knight, flickr creative commons
Image courtesy: Parker Knight, flickr creative commons

“We do find there’s a strong relationship between access to care and quality of care,” said Douglas McCarthy, a senior researcher at the Commonwealth Fund. “Although it’s still too early to judge the long-term effects of the Affordable Care act, improvement in these domains could contribute to better outcomes in the long term.”

The New York City-based Commonwealth Fund, is a foundation that focuses on research about improving the health care system. This is the second time the organization has examined the performance of 309 hospital referral regions across the country, areas that delineate health care markets. In the Commonwealth Fund methodology, there are nine of these referral regions in North Carolina.

Medicaid expansion was not the only factor that drove improvement in health-care outcomes, said Sarah Collins, who studies health care coverage and access for the organization.

“If you look at the top 16 states that had the biggest improvement in coverage and access, about half were in Medicaid expansion states and the others were not,” Collins said.

She noted that other factors, such as a four-year-old Medicare program that penalizes hospitals with too many patient readmissions, as well as better reporting about injuries in nursing homes, have moved the needle on improving the way health systems deliver care.

‘Poverty is not destiny’

While the study found a strong relationship between low income and poor outcomes, Commonwealth Fund president David Blumenthal noted that some low-income communities performed well. He said some have even improved “dramatically,” largely due to collaboration within communities.

Blumenthal pointed to Stockton, Calif., a city that declared bankruptcy in 2013 after the city’s housing market and tax base collapsed during the depths of the Great Recession.

North Carolina's hospital referral regions, as defined by the Commonwealth Fund.
North Carolina’s hospital referral regions, as defined by the Commonwealth Fund.

In recent years, that city has embraced a nurse-led program to support pregnant African-American women for a year after the birth of their infants. Meanwhile, local hospitals encouraged more breastfeeding. That helped the infant mortality rate to drop in Stockton. The city also allowed a nonprofit organization to run health clinics in four local high schools. The clinics provided check-ups, gave flu shots and helped address students’ behavioral health issues.

Closer to home, Collins said, in Wilmington, where 39 percent of households have incomes less than 200 percent of the federal poverty level ($48,600 for a family of four), rankings on health outcomes improved and exceeded those in most other parts of North Carolina.

See box below for how each hospital region’s ranking changed over time.

“The share of adults 18 and older who went without care because of costs went from 20 percent in 2011 to 13 percent in 2013-14,” she said. Collins added that many of the people who got insurance in a ACA marketplace plan were some of the highest-risk people who had the greatest health care needs.

“I think people shifted from probably skimpier, poorer coverage in individual markets and small group markets to much more comprehensive coverage in the [ACA] marketplaces,” Collins said. “So even in the non-expansion states you see the effects of the Affordable Care Act’s expansion of insurance.”

Adam Zolotor, head of the North Carolina Institute of Medicine, said that areas of North Carolina with more improvement have been doing some innovative things.

“It was interesting to me to see Asheville and Wilmington near the top of the list; those are both health systems that are doing a good job with care management around avoidable readmissions,” Zolotor said. “Mission Health in Asheville is one of the better hospital systems in the state in terms of patient and family engagement.”

However, he said, in some instances an area’s poverty might overwhelm the positives of a local hospital system.

Zolotor said that’s probably the case in Durham, where Duke University Medical System has entered into collaborations with local clinics to address community needs. Nonetheless, Durham’s ranking dropped in this survey.

“And Vidant [in Greenville] is great for their work in patient and family engagement, but the health system is covering the poorest third of the state,” Zolotor said. “It’s hard to improve their health outcomes without improved access to care and improved insurance rates.”

Frayed safety net

Many markets that saw improvement during the past four years shared one feature — they have robust networks of community health centers. Even though the Commonwealth researchers did not look specifically at those clinics, they said there’s other data showing the positive effect of the clinics on a community.

Ben Money, head of the NC Association of Community Health Centers.
Ben Money, head of the NC Community Health Center Association. Photo courtesy NCACHC

“From our case studies, we do hear anecdotally how important community health centers are,” McCarthy said. “In Stockton, about half of the Medicaid beneficiaries that are enrolled in the county health plan are served by community health centers. The collaboration between the plan and those clinics is really critical.”

Collins said in the 19 states that haven’t expanded Medicaid, community health centers have kept the safety net intact.

“There are many lower-income people who remain uninsured,” she said.

But Ben Money, the head of the North Carolina Community Health Center Association, bemoaned state leaders’ resistance to expanding Medicaid.

“We’re doing well with the resources that we have, but we could do far better with the resources we could get through Medicaid expansion,” he said.

Money noted that the federal Bureau of Primary Health Care, which provides funding and support for community health centers, has not been giving any extra help to centers in non-expansion states.

“I can’t blame a federal agency that says why should we give you money to do what you could be doing if your state expanded Medicaid,” he said.

“Why treat you differently if your state hasn’t taken advantage of a resource?” he asked. “It’s like if your kid says ‘I’m hungry, but I won’t eat my peas. Give me ice cream.’ Well, you gotta eat your peas first.”


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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...