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Census: Insured population holds steady, with a slight shift from private to public coverage

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Census: Insured population holds steady, with a slight shift from private to public coverage - North Carolina Health News

Among all of the regions of the U.S., the South has the most uninsured, with 16.4 percent lacking coverage, compared to 11.3 percent who are uninsured in the West and 6.6 percent uninsured in the Northeast.

By Victoria Knight and Julie Appleby

Kaiser Health News

Despite a pandemic-fueled recession, the number of uninsured Americans has increased only slightly since 2018, according to Census Bureau health insurance data released Tuesday.

Twenty-eight million people, or 8.6 percent of Americans, were uninsured for all of 2020. In 2019, 8 percent of people were uninsured during the full year; in 2018, it was 85 percent.

During a press conference, Census officials said there was no statistically significant difference in the number of uninsured when comparing 2018 and 2020 data. (The Census Bureau has cautioned against comparing 2020 data to 2019 data because of a disruption in data collection and individual responses due to the covid-19 pandemic — which is why 2018 served as the primary comparison.)

“It’s remarkable that, during a pandemic with massive job losses, the share of Americans uninsured did not go up,” said Larry Levitt, executive vice president for health policy at KFF. “This is likely a testament to what is now a much more protective health insurance safety net.”

Still, the annual report shows a shift in where Americans get their insurance coverage. Private insurance coverage decreased by 0.8 percentage points from 2018. Public coverage rose by 0.4 percentage points from 2018. That shift was likely driven partly by older Americans becoming eligible for Medicare, at age 65, and showed a 0.5 percentage point increase from 2018 to 2020.

Coverage through employers also dropped significantly, said Joseph Antos, a senior fellow in health care policy at the American Enterprise Institute, and low-income people were hit especially hard as pandemic cutbacks led to job and health insurance losses. Employment-based coverage dropped by 0.7 percentage points compared with 2018.

The Census 2020 data did show a decline in the number of workers employed full time year-round, and an increase in the number of workers who worked less than full time, suggesting that many individuals shifted to part-time work.

This changing nature of work is “part of the overall story,” said Sharon Stern, assistant division chief of employment characteristics at the Census Bureau. For the group that didn’t work full time, the uninsured rate increased to 16.4 percent in 2020 from 14.6 percent in 2018. And that impact was concentrated at the bottom of the earnings index.

“Almost certainly, the people most prone to lose coverage because they lost their jobs were lower-paid workers to begin with,” Antos said.

Antos said the Census Bureau data, which showed there wasn’t a significant difference between 2018 and 2020 in the percentage of Americans covered by the Affordable Care Act, misses the larger role the ACA played in helping those who lost coverage get it through the program. Many of those who looked into ACA plans may have met income requirements for Medicaid and joined those rolls instead. Medicaid is a federal-state program for the poor and coverage is free or available at a very low cost. Even with a subsidy, many ACA enrollees may face premium or deductibles or both.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said one of the main points that jumped out for her was the sharp rise in children below the federal poverty level who were uninsured, rising from 7.8 percent in 2018 to 9.3 percent in 2020.

“The rich kids actually did a little bit better, and the poor kids did a whole lot worse,” said Alker.

Overall, the percentage of uninsured children ticked up only slightly and wasn’t considered statistically significant.

Further research is needed to determine the causes of rising uninsurance among the poorest children, Alker said.

Oddly, the Census report did not show an uptick in Medicaid enrollment, although other reports have shown a big increase.

Data from the Centers for Medicare & Medicaid Services, which comes from state insurance records, shows a 15.6 percent increase in the number of Medicaid and Children’s Health Insurance Program enrollees from February 2020 to March 2021.

A recent report from KFF, which analyzed the CMS data, found enrollment in Medicaid and CHIP increased by 10.5 million from February 2020 to March 2021. Enrollment increased steadily each consecutive month, with increases attributed to people losing their jobs and thus becoming eligible for public coverage and the Families First Coronavirus Response Act, which passed in 2020 and ensured continuous Medicaid coverage.

This disconnect may be a result of the nature of Census data, which is self-reported by individuals.

“That’s always subject to error, and probably especially so right now,” said Levitt. “It could also be a result of particularly high non-response rates among some groups.”

Census officials acknowledged during the Tuesday press conference that response rates to their surveys were lower than normal in 2020 and have only just started rebounding in 2021. Other data sources do seem to confirm that the uninsured rate has remained relatively constant over the past couple of years.

Another important takeaway from the data was illustrating the continuing gap in the number of uninsured people between states that chose to expand Medicaid under the ACA and states that didn’t. The Census data showed that in 2020, 38.1 percent of poor, non-elderly adults were uninsured in non-expansion states, compared with 16.7 percent in expansion states.

“That became a huge gap after the ACA, and it’s not surprising at all that it remains a huge gap,” said Gideon Lukens, director of research and data analysis for health policy at the Center on Budget and Policy Priorities. “That highlights the need to close the coverage gap.”

The Census Bureau report also offered insights into national income and poverty rates:

  • The official poverty rate in 2020 was 11.4 percent, up 1 percentage point from 2019, marking the first increase in poverty after five consecutive annual declines. In 2020, 37.2 million people lived in poverty, approximately 3.3 million more than in 2019.
  • Medical expenses boosted the number of impoverished people by 5 million in 2020.
  • The median household income in 2020 decreased 2.9 percent from 2019 to 2020. This is the first statistically significant decline in median household income since 2011.
shows the opening web page for the affordable care act marketplace site

Insurance Signups Surprisingly Strong, Yet Number of Uninsured Creeps Up

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Insurance Signups Surprisingly Strong, Yet Number of Uninsured Creeps Up - North Carolina Health News

Signups on the Affordable Care Act insurance marketplace surged in the last week of enrollment, but that strong showing masks some reductions in coverage.

By Rose Hoban

It seemed like this year’s Affordable Care Act open enrollment was going to be lackluster, after all, at the end of six weeks of the online marketplace being open, only 236,693 North Carolinians had signed up for health insurance coverage, less than 50 percent of last year’s total.

But the last week of open enrollment almost always packs a surprise punch.

“People are procrastinators,” said Mark Van Arnam, the head of the North Carolina Navigators Network, a group that promotes access to insurance through the online Obamacare marketplace. “We saw traffic picking up [at the end], as it normally does.”

Van Arnam had been criss-crossing the state, attending enrollment events and rallying the small army of volunteers to assist people through the sometimes complicated process of buying insurance online before the deadline at midnight last Saturday.

“I was at an enrollment event in Winston-Salem as the final hours wound down,” he said. “People were calling into the site that we were at, because… our call center had closed by that point.

NewsMatch announcement: We are the only newsroom in NC fully dedicated to covering health. Your donation TRIPLED thru Dec. 31 thanks to NewsMatch. Donate at https://www.northcarolinahealthnews.org/support-health-journalism-matters/“They were asking if they could get there by 7:30 or 8:00 and would we still be there?”

In the end, 502,464 North Carolinians signed up for health insurance, down only about 3 percent from last year’s tally, and in line with enrollment trends across the nation.

Van Arnam said his organization encountered tens of thousands of people over the past year at more than 1,600 informational events, and his people did a final push to send out emails and make phone calls. But he also admitted that much of the enrollment surge came from people who simply re-enrolled in the same plan they had this year.

While the number of enrollments is strong, it’s down 18 percent from a high enrollment mark of 613,487 in 2016.

Nonetheless, the final count was surprisingly robust, said Mark Holmes, a professor of health economics at the Gillings School of Global Public Health at UNC Chapel Hill. He said that’s despite considerable headwinds.

“We’ve seen relatively invisible changes… to the way that the marketplaces are run that have led to decreases in the number of people who sign up through them,” Holmes said. He noted court decisions, including one handed down late last week where a district court judge ruled the entire Affordable Care Act unconstitutional, had lead to confusion for many potential enrollees.

2017 saw a steady drumbeat of news about Congress attempting to repeal the Affordable Care Act, attempts which ultimately failed, but which may have lead to consumer confusion, Van Arnam said.

In addition, the Trump administration made changes to other parts of the insurance market, making allowances for short-term insurance plans that are cheaper, but that don’t provide all of the guarantees found in ACA-compliant plans. Then at the end of 2017, Congress eliminated the penalty for not buying insurance that was part of the individual mandate, eliminating one incentive to purchase coverage.

All of this was on top of cuts to the marketing budget for encouraging enrollment and fewer weeks to sign up.

“It’s hard to get people to buy something that seems to always be changing just a little bit and you’re not really sure what you’re getting,” Holmes said.

Fewer adults with coverage

The steady ratcheting down of Obamacare insurance enrollees has been paralleled by a slow uptick in the number of uninsured people in 2016 and 2017.

The number of uninsured Americans reached a low point of 9.8 percent in 2016, but a recent study in the journal Health Affairs finds an “erosion of the ACA’s coverage gains, especially in Medicaid nonexpansion states.”

The number of uninsured Americans had crept back up to 10.8 percent by the first quarter of 2018.

graphic shows rates of uninsured for adults in Medicaid expansion and non-expansion states, as well as the overall adult average
Trends in Uninsurance Among Adults Ages 18 to 64, by 2018 State ACA Medicaid Expansion Status, Quarter 3 2013 to Quarter 1 2018 Graphic courtesy: Health Affairs

A similar erosion of coverage occurred in North Carolina.

“The rate of uninsured went up a bit from 12.3 percent in 2016 to 12.7 percent in 2017, and this is among adults under the age of 64,” explained Michelle Ries, a project director at the North Carolina Institute of Medicine.

She said that while cost is a barrier for some, many of the people without insurance earn enough to qualify for subsidies on the ACA insurance marketplace that could bring their insurance costs to almost nothing.

“There’s a big awareness barrier also about the subsidies that people might be eligible for,” she said.

Uninsurance Rates Among Adults Ages 18 to 64, by 2018 State ACA Medicaid Expansion Status and Family Income, Quarter 1 2018 Graphic courtesy: Health Affairs

Holmes said it “defies logic” to see increases in the number of uninsured in such a strong economy and job market.

“We’ve really known how, in the past, that strong economies lead to decreases in the uninsured rate,” he said. “Here we have the opposite trend and we can really only look to policy changes as a major driver of those differences.”

Fewer kids too

Of concern to many advocates was the uptick in the number of kids under the age of 18 who lacked insurance this past year, said Ciara Zachary from NC Child.

A study from the Georgetown Center for Children and Families found an increase in the number of uninsured children nationwide for the first time since they’ve kept count.

Nationwide, “the rate for children age 18 and under went up from 4.7 percent in 2016 to 5 percent in 2017, according to our analysis of U.S. Census Bureau’s American Community Survey data,” wrote Joan Alker, who leads the center.

graphic shows steady decrease in uninsured rate since 2008, with an upturn in 2017
Graphic courtesy: Georgetown Center for Children and Families

Alker also noted a rising number of uninsured kids happening even as the economy strengthened.

In North Carolina, the uptick consisted of about 4,000 more kids who lacked coverage, increasing the overall number of uninsured children to about 119,000, the report showed.

Zachary said that leaving kids uninsured creates risks for their future.

“We know it from studies of public health coverage, like Medicaid, [coverage] is really key in making sure that children get the screenings and the immunizations and the well-checks that they need as a young child to really build that foundation,” for long-term health, she said.

Coverage of adults has been found to be correlated to coverage in children, the Institute of Medicine’s Ries said.

“As parents are seeking out services for their children, they find out about services or programs or plans that they might be eligible for just in that process of connecting with the system,” she said. “We also see that parents who have health insurance tend to have healthier children.”

So, the increased number of uncovered adults could be related to the number of kids without coverage, she said.

“When parents are insured, their kids are insured,” Zachary added. “So once parents start losing insurance and don’t access care, the more children are at risk.”

red barn on a hillside, next to a field of grass. It's an analogy for rural health or the rural-urban divide.

Drug Addiction Tops List Of Rural Concerns

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Drug Addiction Tops List Of Rural Concerns - North Carolina Health News

More rural people in the United States list opioids and other drugs as the biggest problem their communities face, according to a new randomized poll of nonmetropolitan residents. But within their families, financial worries are the biggest issue.

By Tim Marema

Daily Yonder

A quarter of rural Americans say that drug addiction is the biggest problem their communities face, according to a new poll of rural residents.

A lot of that assessment is based on first-hand information. About half of rural residents say they personally know someone, like a friend or family member, who has struggled with opioid addiction. Younger adults were even more likely to know someone struggling with addiction.

While drug addiction topped the list of community problems, a slightly smaller percentage of rural residents think that economic concerns are the biggest issue in their communities, according to the poll.

When it comes to family matters, however, rural people are more concerned about money and financial problems. Twenty-seven percent said economic issues were their biggest family problem (as opposed to community problem), while only 1 percent said drug addiction was their family’s biggest problem. Health concerns overall (including drug abuse) were the second biggest family problem on the open-ended list, at 16 percent of respondents. The third highest group said their families had no “biggest problem.”shows side by side bar graphs titled:

NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health, Life in Rural America, 6/6/18 – 8/4/18. N=1,300 rural adults ages 18+.The findings are part of a public opinion survey of people who live in nonmetropolitan counties. (See “How the poll defines rural” at the bottom of this article for more information.) The poll was commissioned by the Robert Wood Johnson Foundation, the nation’s largest philanthropy focused solely on health, along with NPR and the Harvard T.H. Chan School of Public Health.

Aside from being more likely to personally know someone struggling with addiction, younger people (ages 18-49) were also more likely than older respondents (aged 50 and up) to know someone who struggled with suicide.

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On economic matters, however, younger people were more optimistic than their older neighbors. They were more likely to think the number of good jobs had increased in the past five years (36 percent vs. 25 percent). Young people were nearly twice as likely to say their personal finances had improved in the past five years (61 percent vs. 33 percent for older rural residents). And they were a bit more likely to be involved in solving problems in their communities (59 percent for young people vs. 45 percent for older respondents).

Young people were also much more likely than older people to perceive that residents of their communities discriminate against groups like Latinos and Hispanics, recent immigrants, and gays and lesbians.

Politically, both conservatives and liberals were more likely than the general population to think that they were being discriminated against. More than a third of liberals said they were discriminated against in their rural communities, while only 21 percent of the total population said that was the case. A fifth of conservatives also felt they were discriminated against, while only 15 percent of the general population did.

Different opinions about the existence of discrimination were also observed among racial groups:

  • 36 percent of African Americans said they were discriminated against, versus 22 percent for the total population.
  • 44 percent of Latinos and Hispanics observed discrimination, vs. 21 percent of the general rural population.
  • 22 percent of disabled people said they were discriminated against while only 12 percent of the overall rural population shared that belief.

Rural Americans said they have a lot to love about their nonmetropolitan communities. The best thing about living in a rural area had to do with a feeling of closeness to other residents, the perception that people there were good and friendly, and that church and religious communities were important, they said. More than half said they are active in their communities.

Rural residents were also optimistic that rural areas could solve their community’s major problem in the next five years. But a majority also said they would need help from outside their community to make progress. Of the people who thought rural areas need outside help to solve problems, about two thirds say local, state, or federal government should be the source of that help.

Other findings in the poll:

  • Most rural Americans (54 percent) say they are better off today than their parents were at the same age.
  • A majority of rural parents (55 percent) think their children will be better off financially than they are.
  • Nearly half of respondents (48 percent) think the opioid epidemic has become worse in the past five years. Another 40 percent say the problem has remained about the same.
  • Half of rural Americans say their health-care costs have caused a serious problem for their overall finances.
  • Fifty-five percent of rural Americans rate their local economy as only fair or poor. But 45 percent say their personal financial situation has gotten better in the past five years.
  • Nearly nine out of 10 rural Americans believe the number of jobs in their community will remain about the same or increase in the next five years. Twelve percent believe the number of jobs will decrease.
  • About eight in 10 rural residents believe their community’s population has increased or remained stable in the past five years.
  • Of parents who have children age 18 an up who moved out of the area, about two-thirds said they moved because of employment issues.
  • Most rural Americans (59 percent) have lived in other places, while 41 percent say they have lived in and around their community all their lives.
  • The biggest reason rural people chose to live where they do is to be close to family (31 percent). Twelve percent said they were there because of job opportunities, and 10 percent said they lived there because that’s where they were born.
  • Rural residents of Appalachia were much more likely to say that the opioid epidemic is the biggest problem their community faces (41 percent vs. 25 percent nationally). People in the Midwest were slightly more likely to name economic concerns as the top problems (24 percent vs. 21 percent nationally).

How the poll defines rural. The poll defines rural as nonmetropolitan counties (i.e., respondents to the poll were located in counties that are not within a Metropolitan Statistical Area). There’s more on how to define rural over at the USDA Economic Research Service website.

The survey used a probability-based sample of 1,300 “rural” respondents age 18 or older. Telephone interviews (both land line and cell) were conducted in English and Spanish. The margin of error is plus or minus 3.6 percentage points for questions involving the entire sample. 

shows printouts from a sonogram, used to determine if a fetus has a disability

NC Pregnancy, Abortion Rates Continued to Tick Down in 2016

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NC Pregnancy, Abortion Rates Continued to Tick Down in 2016 - North Carolina Health News

As Senate confirmation hearings in Washington bring attention to abortion rights, we take a look at the state of abortion in North Carolina.

By Rose Hoban

With U.S. Senate confirmation hearings on Judge Brett Kavanaugh underway, advocates for abortion rights are expressing concern over what his confirmation might mean for access to the procedure in the future. Some have suggested that if the landmark 1972 decision Roe vs Wade were overturned, abortion policy would devolve to being determined more at the state level than at the national level.

In past six years since Republicans have had supermajorities in the North Carolina General Assembly, lawmakers have enacted more restrictions on access to abortion in North Carolina. In 2015, lawmakers imposed a 72-hour waiting period before a woman can obtain an abortion. Legislators also passed a law requiring physicians to report abortion procedures to the state Department of Health and Human Services and that increases inspections on clinics. Physicians are also required to tell a woman that she can see a sonogram of her fetus and provide women with counseling materials that encourage carrying a pregnancy to term.

Over the past decade, the number of abortions in North Carolina has ticked up only slightly, even as the population has increased quickly, meaning that, in general, abortion rates have decreased. Although the number of pregnancies has ticked upwards, the overall rate of pregnancies in the state has ticked downward.

Fewer teens are having abortions, in large part because fewer teens are getting pregnant, said Elizabeth Finley from SHIFT NC, a reproductive rights organization focused on North Carolina teens.

“We definitely know that the primary reason for the drop is the increased use of contraception in general and LARCs (long-acting reversible contraceptives),” she said. “Compared to 10, 15 years ago, young people are more likely to contracept and to use long-acting contraceptives.”


A note about this map: Numbers shown in county data reflect total pregnancies as reported to the N.C. State Center for Health Statistics. However, more women become pregnant, but those data may never have been reported because their pregnancies ended in early miscarriage.
Data sources: NC State Center for Health Statistics, US Census

Finley attributed some of this drop in the teen pregnancy rate to a growing use of clinic-based initiatives and comprehensive sex education, both developed using a growing body of evidence-based research on how to get through to kids.

Long-acting reversible contraceptives have gained popularity since 2008, with use almost doubling, even as permanent methods of contraception, such as sterilization, decreased, according to data compiled by the Guttmacher Institute, which tracks reproductive health statistics.

“Even small improvements in contraceptive use among women at highest risk for unintended pregnancy may have had a substantial impact on recent declines in unintended pregnancy,” said study author Megan Kavanaugh in a Guttmacher press release on the research.

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Another Guttmacher researcher, Laura Lindberg, recently analyzed surveys that found that fewer adolescents are getting pregnant, even as the rate of sexual activity remained about the same. In a study published in the Journal of Adolescent Health, Lindberg looked at the National Survey of Family Growth, which found that each of the survey years 2007, 2009, 2012 and 2014, about a third of females aged 15-19 reported being sexually active. But during that time, the number of young women using no birth control dropped from 22 percent down to 12 percent, and the number of young women using two or more methods to prevent pregnancy grew from 24 to 33 percent.

Lindberg noted that a different long-term study, the biennial Youth Behavior Risk Survey, finds a decrease in the number of teens having sex.

Finley said SHIFT NC’s analysis has found that teens are delaying the initiation of sexual activity somewhat.

“A lot has to do with how they’re spending their time,” she said. “They have far less unsupervised, unscheduled time than their peers did in the past. That’s a huge component, fewer kids alone after school, fewer going out alone on dates.”

She also said online culture could be contributing to a decrease in the number of kids having sex.

“If you wanted to hang out with friends on Friday, you were physically out with your friends on Friday night and that could go in a lot of directions,” Finley said. “Now you can hang out with your friends on Snapchat and you’re home in your own room.”

Kids are more risk averse, too, she noted.

“For lots of risk behaviors, you see a downward trend: drinking, smoking, sex. Researchers attribute it to the combination of the scary things you’re exposed to on the Internet, plus helicopter parenting and this constant exposure to things that could be harmful,” she said. “So they’re just generally a slightly more worried group of young people.”

Jared Weber contributed to data compilation.

Characteristics of NC Women Receiving Abortions

NC RESIDENT ABORTIONS: Characteristics of Women Receiving Abortions, NC Residents, 2016
NUMBER PERCENT
TOTALS 23,070 100.0
LOCATION OF PROCEDURE
North Carolina 22,452 97.3
Out of State 618 2.7
AGE
14 and under 61 0.3
15-19 2,019 8.8
20-24 6,943 30.1
25-29 6,481 28.1
30-34 3,985 17.3
35 and over 3,017 13.1
Unknown 564 2.4
RACE
White Non-Hispanic 7,810 33.9
Af. Am. Non-Hispanic 10,536 45.7
Other Non-Hispanic 795 3.4
Hispanic 2,573 11.2
Unknown 1,101 4.8
MARITAL STATUS
Married 3,148 13.6
Unmarried 18,261 79.2
Unknown 1,661 7.2
YEARS OF EDUCATION
Not completed high school 2,214 9.6
High school graduate 5,946 25.8
Some college 13,403 58.1
Unknown 1,507 6.5
NUMBER OF LIVING CHILDREN
None 7,137 37.1
1 5,307 26.2
2 or more 8,146 35.3
Unknown 791 1.5
NUMBER OF PREVIOUS ABORTIONS
None 12,725 55.2
1 4,950 21.5
2 2,012 8.7
3 or more 1,051 4.6
Unknown 2,332 10.1
WEEKS OF GESTATION
First trimester 0-12 weeks 20,087 87.1
13-20 2,233 9.7
Greater than 20 weeks* 36 0.2
Unknown 714 3.1
TYPE OF PROCEDURE
Any Surgical 12,610 54.7
Medical (nonsurgical) 9,748 42.3
Other/Unknown 712 3.1
*In-state occurrence = 1
Out-of-state occurrence = 35
Generic emergency room/ department entrance photo, with a carport and sign saying "Emergency" No hospital name is visible.

Health Policy Experts Give WalletHub Health Ranking Low Grade

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Health Policy Experts Give WalletHub Health Ranking Low Grade - North Carolina Health News

Although WalletHub’s report earns lots of headlines, researchers say other reports do a better job of assessing state health care systems.

By Rose Hoban

Last week, headlines across North Carolina (and the U.S.) touted a recent “study” from the personal finance website, WalletHub.

In Florida, the headline was “Florida Among The 10 Worst States for Health Care,” and in South Carolina, it was “SC Ranks One Of The Worst States For Health Care.”

In the one-page report, Vermont’s health care system ranked first, while Louisiana’s ranked last. North Carolina came out near the bottom of the list, ranking 47th in health care systems.

But what does that really mean?

For example, one of the metrics in the WalletHub report was the number of hospital beds per capita, where North Carolina was on the lower end.

“I just walked out of Duke Hospital, where you can get a vast investigation,” said health economist Don Taylor while walking across the Duke University campus where he works. He said that just looking at the number of beds in a state is inadequate and doesn’t take into account distribution. “Durham has got to have some of the highest numbers of hospital beds around, but Greene County where my people come from doesn’t even have a hospital.”

Some of the 40 metrics considered in the WalletHub study included average monthly insurance premium, the numbers of physicians, nurses, geriatric specialists and dentists per capita, urgent care centers per capita and the share of patients readmitted to the hospital before 30 days, along with the infant, maternal and child mortality rates.

North Carolina's ranking is high for the number of at risk adults who have seen the doctor in the past year.
In the WalletHub report, this metric boosts North Carolina’s overall ranking.

“It sounds like what they did was suck in existing data that was easy to get and spit something out,” Taylor said.

That’s basically WalletHub’s strategy: In the past year, the company produced reports on the happiest states, most patriotic states, the best cities for pets, best and worst places to be a teacher and more. Once at the company’s website, curious readers are urged to get a new credit card or check their credit score.

So, what’s a person to believe when they see headlines like the ones above? That’s a question we posed to a number of health economists and health policy experts around the state.

‘Some’ truth

The WalletHub survey broke down the data into three categories — cost, access and outcome — before bestowing a final score. The ranking for “patient outcomes” placed North Carolina at 30th in the nation.

The outcomes ranking is about right, said health policy researcher Mark Hall from Wake Forest University. He noted that as a state, North Carolina tends to do better than the rest of the South on patient outcomes, but worse than places such as Minnesota or Vermont, where the state makes significantly higher investments in local health care systems.

Hall also said that WalletHub’s assessment of North Carolina health care costs (50th in the nation) squared with the fact that the state has not expanded Medicaid.

“That hurts us and you can see that in a number of other states that haven’t expanded Medicaid are near the bottom of [WalletHub’s] rankings,” he said. “The out-of-pocket costs for the uninsured create higher costs via cost shifting for uncompensated care.

screenshot of ranking on insurance premiums, North Carolina is 45th highest in the nation
In the WalletHub report, this metric drags down North Carolina’s overall ranking.

He also said that not expanding Medicaid has resulted in higher premiums for everyone else in the state.

Hall pointed to what he considered to be a better report produced every spring by the Commonwealth Fund, an organization which focuses on health policy research. That report focused on how well states’ health systems perform. In that assessment, North Carolina ranked 35th.

Commonwealth examined data from the U.S. Census, such as how many households were below 200 percent of the federal poverty level (35 percent, higher than the national average) and median household income ($53,402, below the national average of $62,470). That study also looked at indicators from the federal Centers for Medicare and Medicaid Services about how well patients have their diabetes controlled or whether heart attack patients take aspirin.

The Commonwealth study allows readers to examine each metric in detail, creating comparisons to other states. And because the focus is narrow, it can tell a more nuanced story about what’s happening in a given state. Because Commonwealth has been performing the same study, year after year, for many years, the organization is able to note where states have  made changes and made progress.

In general, these organizations look at a narrow portion of health care and refrain from making sweeping judgments about the sector as a whole.

Ask a friend

Other health policy experts noted that most consumers don’t really care that a health care system is good or bad, they’re more interested in knowing whether their local doctor or hospital is good or bad. And that’s still a word of mouth thing, said Oscar Aylor, who teaches health policy at Campbell University as well as at UNC-Chapel Hill.

“Most health care choices are largely subjective,” Aylor said.

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He said that there are better ways of looking at information about health care systems, such as the annual United Health Foundation report, which rates a state’s health care systems by examining information such as rates of poverty, infectious disease outcomes, air and water pollution policy, smoking rates, physical activity and dozens of other metrics, in exhaustive detail.

United Health Foundation boils all this information down into state profiles that look mostly at outcomes for individuals. This year, the organization determined that North Carolina’s health system ranked 33rd in the nation, somewhat similar to the outcomes score for WalletHub and the Commonwealth Fund.

Aylor said he also likes to look at the data contained on the Kaiser Family Foundation website, which takes the approach of amassing lots of data but doesn’t create “scores” for individual states.

So, how to assess who’s doing well?

“I was afraid you’d ask that,” Aylor said. Instead, he made the argument that like politics, “all health care is local.”

“I think the average person doesn’t go looking at these sites,” he said. “They go and talk to someone they trust.”

Not there yet

If people really want data about their local systems, the place to go is the annual Robert Wood Johnson Foundation county health rankings.

Aylor noted that for two decades many have tried to crack the nut of helping consumers make decisions about health care quality. He mentioned the Leapfrog Group which uses many metrics to rate hospitals on safety, a pretty narrow target.

Leapfrog surveys hospitals and uses peer pressure in order to get those hospitals to cough up data about safety. The data are collected from around 2,000 hospitals, they crunch the numbers and give each hospital a letter grade.

“By making the Hospital Safety Grades public, we’ve galvanized major changes in these states and many communities,’’ Leapfrog Group president Leah Binder said in 2017.

NC Institute of Medicine head Adam Zolotor likes directing people to a federal website: HospitalCompare.gov, which uses the massive amounts of data collected by CMS to generate some safety and quality scores.

Related: North Carolina Hospitals Continue to Improve on Safety

He also said that publicly reported patient surveys are a “new, interesting source of data.”

But Zolotor, who also practices family medicine at UNC Health Care, said the problem with patient surveys is that people usually fill them out when they’re really happy, or really angry.

“It’s enough that you can make a judgment,” he said. “I’m not so sure it’s a sound way to make a judgment.”

Two decades into a national effort to measure health care quality, Zolotor said, “we’re still not there.”

“I actually believe we’re gonna get there,” he said. “The fact that we get quality information about almost every other transaction we have is going to push health care to catch up.”

But in the meantime, he and the others said there are better resources to learn about a state’s health system than  “studies” like the one produced by WalletHub.

red barn on a hillside, next to a field of grass. It's an analogy for rural health or the rural-urban divide.

CDC report details health disparities between rural minorities

by

CDC report details health disparities between rural minorities - North Carolina Health News

Health disparities exist between all types of demographic groups, with many contributing factors such as ethnicity, income, education and where you live.

By Taylor Knopf

For years, studies have pointed out the gaps between rural and urban communities when it comes to health outcomes. But there are also significant health divides between ethnicities within rural America, according to a recent Centers for Disease Control and Prevention report.

Though urban areas still have more diverse populations, the study authors found that in recent years, rural communities have displayed increasing racial diversity. They also found that different health issues were more prevalent among certain racial ethnicities.

The authors, who work mostly out of the CDC’s Office of Minority Health & Health Equity, found that rural white populations have better access to health providers than minorities. They also found that members of minority populations living in rural areas tended to be younger than the white residents, with lower incomes and less education.

Kim Schwartz, CEO of the Ahoskie-based Roanoke Chowan Community Health Center, said the area she serves in eastern North Carolina is particularly diverse, about 65 percent of her center’s patients are African American. She suspects this is common in many parts of the rural south.

Schwartz said her organization has an internal “health equity” team that works on identifying and addressing her organization’s own lingering racism that could affect patients’ care experience.

Poor, fair or good

There have been many studies examining disparities between rural and urban populations, but not much about the differences within rural communities themselves, the CDC study authors explain.

The goal of their study was to understand different health behaviors among rural residents. The authors used the National Center for Health Statistics’ 2013 Urban-Rural Classification Scheme for Counties to determine which areas qualified as rural and used self-reported data collected between 2012–2015 from rural residents in all 50 states.

They found that rural, non-white populations were more likely to report “fair” or “poor” health (as opposed to “good” health) and obesity. They were also less likely to see a doctor during the past year because of cost and were less likely than white folks to report have a regular doctor.

Meanwhile, whites were more likely to report binge drinking in the past month and more whites were current smokers.

The study is based on 263,054 rural residents:

231,221 white (87 percent)
12,751 black (4.9 percent)
10,947 American Indian/ Alaskan native (4 percent),
7,223 Hispanic (2.8 percent)
912 Asian (0.35 percent)

“Notice, for example, that rural black respondents are less likely than rural white adults to report binge drinking,” explained Janice Probst, who heads the South Carolina Rural Health Research Center and is a professor at the Department of Health Services Policy and Management at the University of South Carolina. “This stems from greater black membership in religious denominations that frown on alcohol. Similarly, black respondents are less likely ever to have smoked.”

Other research has shown that people tend to engage in health behaviors, such as smoking or quitting smoking, based on the behavior of their social networks.

“Folks tend to hang with folks like themselves,” Probst said.

Different struggles

The CDC study found that each rural ethnic population struggled with different health issues. For example, heart disease and stroke were higher among African Americans. Tuberculosis was more prevalent among Asians.

American Indians and Alaskans have higher rates of suicide compared to other rural populations. They also reported the highest rates of depression. And Hispanics struggled more than others with finding a regular source of health care.

The study pointed out that health outcomes have generally improved for all populations over time, but racial disparities still exist within rural populations.

“What we are seeing relates to generational poverty issues surrounding the social determinants of health and racial inequities,” Schwartz said.

“The challenges our populations face in order to try and implement any kind of healthy lifestyle are overwhelming: transportation across a wide rural area with no public options, food deserts, economic and educational barriers and cultural mistrust in a system that will take a few more generations to repair,” she added.

The study authors noted the importance of breaking down rural health data by race.

“Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data,” they wrote.

The study authors recommended that in the future the CDC should break down rural health data by different demographics to best understand any disparities and the unique needs of each community.

“Despite a few quibbles, those of us who do rural minority health are very excited about this report,” Probst said. “It puts the full weight of the major U.S. public health agency on the question of rural disparities, which has largely been ignored in the past.”

Small numbers, big differences

Probst noted there are several explanations behind the increasing diversity in rural areas. For example, if one person from an ethnic group moves into an area where there were few others from the same group, that could result in a large increase, percentage-wise.

“Because [Asians and Non-Hispanic Other Pacific Islanders] have generally been relatively small and concentrated in places like Hawaii and the West Coast, any influx seems large,” Probst said.

Additionally, Probst said there have been increases in rural Hispanic populations in certain rural states, such as Nebraska and North Carolina, because of new work opportunities.

During the early 2000s, North Carolina had the fastest growing Latino population in the country. In 1990, only 1.04 percent of the state was Latino, by 2016 that number had grown to 9.2 percent, according to the U.S. Census.

“Much of this is related to industries (e.g., chicken processing) that are relatively new to the areas and for which local residents cannot be found,” Probst said.

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