Probing the “Insurance Coverage” Numbers

Insurance coverage broken down by state.
Insurance coverage broken down by state. Chart source: StatChat

With Governor Terry McAuliffe making another bid to expand Medicaid via a budget amendment, the publication by the StatChat blog ten days ago of data on the extent of insurance coverage in Virginia couldn’t be more timely.

The blog post is content to present the data with little commentary or explanation of what’s happening, however, so I’ll try to fill in the gaps.

The good news is that in Virginia, more than 90% of the population has some form of insurance (including Medicare and Medicaid). The bad news is that 9.1% of the population still has no insurance coverage. And, despite a lower unemployment rate and a higher median household income than the national average, the percentage of the insured population hovers just at the national average.

By eyeballing the chart above, we can see that Virginia’s uninsured population bounced around the 12% mark for several years, then jumped ahead one or two percentage points after the implementation of the Obamacare health exchanges. One also can surmise that some states leaped ahead of Virginia in the rankings by extending Medicaid to the working poor while the General Assembly rejected the option.

These data would seem to back the McAuliffe narrative on the desirability of expanding the Medicaid program, 90% of the cost of which would be paid for by the federal government. If Virginia added just 5% of the population to the Medicaid rolls, the state would have a higher rate of insurance coverage than all but five states.

But dig a little deeper, and the picture gets more complicated. The chart above breaks down those with and without health insurance by age. Roughly two-thirds of the uninsured population is below 45 years old. This younger demographic segment tends to be considerably healthier than the older age cohorts, and its medical needs correspondingly less. Indeed, thousands likely opted out of the Obamacare exchanges because they did not need or want the coverage at the price it was available. Although we can’t tell from this data how many opted out, it is worth noting that some portion of Virginia’s 10% uninsured population is voluntarily uninsured.

Finally, it’s worth studying the map above, which shows the variation in the uninsured population around the state. (I would refer you to the interactive map at StatChat for details.) The uninsured rate in the working-age 18-to-64-year-old age cohort varies from 32.3% in the city of Manassas Park to 4.6% in the nearby city of Falls Church. Clearly there is a link between income, unemployment and insurance coverage. One could argue that the best antidote to uninsurance is a strong economy and high employment; if we want more people covered by insurance, perhaps we should be investing state funds in making people more employable.

But other factors are at play, although I’m not sure what they are. Why, for example, do the Interstate 81 corridor localities of Roanoke, Botetourt and Montgomery counties — not exactly known for a booming economy — have such low percentages of working-age uninsured? Are there unique institutional forces at work? It’s worth looking into.

Bacon’s bottom line: The debate over health care has gotten hung up on the number of uninsured. But that number is almost meaningless without considering the quality of the insurance programs.

For example, thousands of Virginians are “insured” through Medicaid. But what quality of care people do people receive when low reimbursement rates discourage 22% of Virginia physicians from participating, according to a 2016 Physicians Foundation survey? What percentage of Medicaid patients, unable to find a personal physician, routinely get their health care in hospital emergency rooms? And how does the quality of care compare to that provided uninsured people who go to emergency rooms and have their expenses written off as “charity” care or “uncompensated care”?

Another example: Thousands of Virginians have coverage through Obamacare health care exchanges. But what kind of access do they enjoy? Are they restricted to certain hospitals and physicians? How high are their deductibles and co-pays? To what degree, as a practical matter, has the quality of their health care improved? Likewise, how many Virginians forced into Obamacare lost their old insurance policies, how many lost access to their physicians, and how many perceive that they have worse insurance coverage than they had before? Nobody is generating that data.

One more point: How extensive is the safety net for the uninsured in Virginia compared to that in other states? Virginia has a fairly robust system of clinics that provide primary care to the uninsured and under-insured. How many people are getting at least some of their medical needs met through these clinics? How many are  slipping between the cracks? And what happens to clinic patients when they require treatment unavailable at the clinics?

Counting the percentage of the “insured” population provides a rough measure of access to the health care system. But there’s a lot it doesn’t tell us. Before undertaking a massive expansion of Medicaid at considerable fiscal risk to the commonwealth, we need a keener understanding of how Virginia’s health care system functions. We should not blindly accept the proposition that an expanded Medicaid program will improve real-world access to the uninsured. While the StatChat data is valuable for starting a discussion, it does not purport to tell us all we need to know.

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14 responses to “Probing the “Insurance Coverage” Numbers”

  1. djrippert Avatar

    Manassas Park vs Falls Church? Oh dear Jim – you’ve fallen into the Virginia city trap again. You’re not comparing two cities, you’re comparing two neighborhoods. Manassas Park has about 16,000 people. Falls Church has about 13,000 people. Add them both together and they’re about half the size of Reston.

    Your point may be accurate but the implication is that you are comparing two real cities.

    Falls Church has a median household income of approximately $74k, Manassas Park $60k. That’s a notable difference but way shore of explaining the insurance percentage gap. Unemployment in Manassas Park is at 3.7% (1/2017) while unemployment in Falls Church is 2.8% (1/2017). Again, a difference but not a big one.

    My suspicion is that your two “samples” are so small that you can’t really draw statistically relevant conclusions. But, that’s just a guess.

  2. TooManyTaxes Avatar

    One thing needed is to strip the federal government from most of its authority over health insurance and return it to the states where it had been traditionally. The old 51 laboratories concept still makes sense. The carry the kids till they’re 26 and a modified guaranteed coverage for preexisting conditions could be kept as a federal mandate because of their popularity. I say “modified” because there should be a catch that, for preexisting conditions to be covered, a person should be required to carry and continue to carry insurance, say with no more than a 6-month (?) break in coverage.

    Then states should develop standards allow younger people to buy less coverage than is mandated today by the ACA. Have the morons at the DoHHS ever heard of marketing? Get younger people used to purchasing insurance and they will continue to do so over their lives and will likely add coverage as they age.

    Uncle Sam should also begin a measured phase-out of EMTALA to encourage people to buy insurance.

  3. “Roughly two-thirds of the uninsured population is below 45 years old. This younger demographic segment tends to be considerably healthier than the older age cohorts, and its medical needs correspondingly less. Indeed, thousands likely opted out of the Obamacare exchanges because they did not need or want the coverage at the price it was available. Although we can’t tell from this data how many opted out, it is worth noting that some portion of Virginia’s 10% uninsured population is voluntarily uninsured.” Very important point. Could it be, the ACA penalties simply weren’t high enough to induce enough young people to participate? Or, the coverage was too comprehensive and the cross-subsidization of the elderly too great and therefore too expensive? Or all of these? Medicaid won’t help many of these folks. But if they help themselves by signing up, they would help the exchanges work as they were intended to.

    1. LarrytheG Avatar

      re: ” it is worth noting that some portion of Virginia’s 10% uninsured population is voluntarily uninsured.” Very important point. Could it be, the ACA penalties simply weren’t high enough to induce enough young people to participate?”

      yup. the same crowd that would not buy auto insurance if it was not required with substantial financial penalties.

      I just see that issue as more distractions….

      People who don’t have insurance and go to emergency rooms shift those costs to others.. it’s as simple as that.. and it’s basic irresponsible behavior and the opponents are making out like these folks have a legitimate beef.

      they don’t . they’re just your average scofflaws.. who will game the system unless they are called to account.

      How many of these same people would actually pay FICA tax towards Medicare Part A and Social Security if it were “optional”?

    2. TooManyTaxes Avatar

      I’ve read several articles that suggest the ACA simply attempted to get too much subsidy from younger users to the point where, given their general lack of health problems and present belief in their immortality, they simply aren’t willing to pay the perceived high premiums necessary for the ACA to work as planned. Another reason why we need to kick most of the regulation of health care back to the states. They are more likely to come up with workable ideas that can be copied elsewhere.

      Another big problem, IMO, was the failure of the Obama administration to concentrate its initial focus on driving costs out of health care before expanding it. More proof to me that his goal was trolling for votes more than making health care more affordable. Had cost-cutting, such as by adopting Virginia’s no-fault reimbursement plan for birth injuries, been adopted as well as some of the mechanization requirements that were, we’d probably see lower prices for insurance today.

      Taking a shot at the GOP, we should also have put pressure on Big Pharma by requiring a company to sell its products at the lowest price offered in any OECD nation. Why should U.S. consumers pay for all the R&D and subsidize other First World Nations?

      And federal Medicaid spending increases should have been capped at a conservative measurement of inflation, rather than tied to how much the states spend.

  4. LarrytheG Avatar

    so here’s an easy question. If DOD offered Virginia about 1.6 billion and 25,000 jobs would we turn it down?

    If they said the money and jobs might go away in 5-10 years would we say “no thanks… if you can’t guarantee the money, we shouldn’t take it to begin with”?

    All this foolish talk about whether people can see a doctor or not is just a diversion. People on Medicaid should be handled by managed-care clinics and ER’s should directly refer non-emergency cases to those clinics.

    Is this not something Virginia can figure out to do on it’s own without “interference” from the Feds other than taking the money?

    Or if you don’t want the Feds – then what is keeping us from setting up managed care clinics on our own .. ??

    but we don’t want 25,000 jobs? really?

  5. TMT, I agree in general with the “51 laboratories” idea; but health care also needs a pan-US framework in which to operate — bother because consumers travel and relocate families, and because we need stronger interstate competition among providers. Balancing the federal “framework” with giving the States latitude for the details seems like one of the biggest challenges here. I’ve wanted for years now to get to work on drafting that Republican version of a federal framework — the real ACA alternative — and been frustrated of course by the more fundamental conservative political divide over whether there should even be a federal role in health care. IMHO that’s unavoidable, a given, but HOW the feds and States should divide their responsibilities is very much still open for discussion. I agree, the ACA was too aggressive with the cost redistributive component. Indeed any hidden cross subsidization seems like a bad idea. Can the States do better? Well, the idea for the ACA came from Massachusetts after all. Why the hell not try variations. My concern is, will any but the deep blue States tackle the problem comprehensively without a big federal push to do SOMETHING about health care? How create that federal incentive without stifling the 51 laboratories?

    1. TooManyTaxes Avatar

      Acbar – the people who put the ACA together are idiots and incompetent failures. Conceding for the moment some good faith on the part of Obama, what they turned out was nothing like what the President said it would be. They failed big time. These are Washington bureaucrats, lobbyists and policy wonk want-to-bes. Why would we want any of these people to touch health care again? If there were any justice in the world, their names and business affiliations would be published so that their incompetence cannot be hidden from future employers.

      I agree that any changes should attempt to pick from both sides of the aisle. With the current climate that would be hard to do, but I sit the boards of several organizations where the members are divergently split politically and we manage to find compromises and solutions because we put away our partisan beliefs for a few hours each month.

      A good rule of thumb that could be used to measure what should be included or excluded is the opposite of what Washington “insiders” think.

      I understand your concern about some states not reforming and, by implication, over-reforming. Those actions can be tempered by allowing people to purchase insurance across state lines – a legitimate federal role. If a Red State comes up with virtually nothing, consumers can purchase policies from states where more services are covered. And, at the same time, if California wants to cover every illegal immigrant and provide subsidies such that rates skyrocket, Golden State consumers can select more modest coverage at lower rates a state where legislators still have fiscal sense.

      And maybe Congress should pass a law requiring all the work to be done in Kansas City where evil vapors of Washington cannot invade the conference room.

      1. I like interstate shopping as a competitive cure. Never did understand why it was prohibited under the ACA — some misguided sense of protecting a State’s pools, as though they’d be contaminated by out-of-Staters? Or the cross subsidy overpricing problem again? Whatever, I’m happy to get on with a replacement for the ACA — only, let’s reform it and keep anything worth retaining, not force it to collapse first solely to “prove” it is hopelessly unsalvageable.

        Re wanting any Obama wonks to touch health care again — no, no, but there were folks in the middle of that debate whose protests were ignored in 2009 too.

      2. LarrytheG Avatar

        @TMT – who do you think set the rules for Employer-Proved Insurance? HINT – it’s a law called HIPPA.

        How about EMTALA?

        How about Medicare?

        The VA?


        How about your Medicare Part A which comes from your FICA taxes and is more than 60 years old?

        Do you seriously want the Feds out of ALL HEALTH CARE entirely and to turn it all over to the private sector?

        Where do you think the rule about pre-existing conditions came from?

        How abou Community-rating which says that everyone, including those with employer-provided would pay the same premiums for their class regardless of their health status?

        How about annual and lifetime caps? where do you think that came from?

        The problem is that too many people or basically ignorant and take for granted their existing health insurance that IS a product of those same govt “bureaucrats”.

        Medicare has been changed over the years to deal with it’s early flaws – which is to be expected with ANY initial program.

        Finally – I’d be FINE with doing the things that need to be done with the ACA – but we actually need to identify those things – cogently – with actual facts and not beliefs that are fed by misinformation .

        The GOP has no plan. If Obama lied about “keeping your own doctor” (which really makes no sense at all.. to begin with) .. but let’s grant that and then ask where the GOP plan is since they have been talking about it for 8 years.

        THey have no plan because the GOP itself is split asunder on whether or not the Govt should be involved in health care to start with but the folks who say they don’t believe that – would they also get rid of Employer-provided, Medicare, etc?

        If that is their plan they need to say so -and get on with it – and stand for election on it… instead of hiding their real motives…

        If you believe the govt should get out of health care -you too should say that – and support the folks who want to get out of it – totally.

        what we have right now is people who are more than happy with their govt-enabled and protected health insurance who oppose the same benefit for others… that’s just rank hypocrisy… and it won’t fly.. the country won’t buy it and they should not.

        but if you do believe everyone should get the same treatment from the govt – no matter what that is – as long as everyone gets treated the same then I’m with you.

        I just see hypocrisy on this.

        If employer-provided insurance and Medicare COULD get rid of sick and older people or charge them way more – then that would be consistent with what some folks are saying they support for the ACA or it’s replacement. that sounds pretty hypocritical to me.

        why should one set of folks get special treatment on their health insurance and another set – none? why not have a system where everyone get the same deal?

        That’s essentially what the ACA was designed to do. If was to be the group-health insurance for people who worked but did not have employer-provided.

        If you or the GOP has a better plan to do that – I’d totally support it but if your “plan” is to take us back to where you get your employer-provided and those who work but don’t have it are just screwed.. then I’m not with you at all.

        have a system that is fair – to all. do that and I’m with you

  6. TMT, To continue that last point: The ACA created so many impediments to moving forward constructively that it makes some political sense to scrap and replace it, cold turkey. But if anything came out of Ryan’s recent effort, it was the public concern about a smooth transition that doesn’t rock the boat. If we could just agree on an end point and then prescribe a (very long) transition, maybe there’s a way forward. We’re still hung up on what the end point is, whether it’s entitlement rollback or tax reduction or a quality focused health care system or universal health coverage. The Republicans alone aren’t capable of resolving that threshold question.

    1. LarrytheG Avatar

      re: ” But if anything came out of Ryan’s recent effort, it was the public concern about a smooth transition that doesn’t rock the boat. If we could just agree on an end point and then prescribe a (very long) transition, maybe there’s a way forward. We’re still hung up on what the end point is, whether it’s entitlement rollback or tax reduction or a quality focused health care system or universal health coverage. The Republicans alone aren’t capable of resolving that threshold question.”

      we totally agree. I am FINE with first identifying what is actually wrong with the ACA – THEN coming up with a realistic approach to change – and a transition period that does not cause serious problems and disruptions.

      having said that – the devil is in the details and I do not mean disagreement about what kinds of things to do … but disagreement of WHAT we should be doing from the get go.

      an example: high deductibles – if you are going to have a rule that says insurance cannot deny pre-existing conditions – then it’s going to cost money and it’s just simple denial of fiscal reality to think you can get pre-existing conditions as well as no annual or lifetime caps without that being costly.

      is getting that kind of coverage “better” than lower premiums and deductibles?

      should people be able to choose between pre-existing and not when they buy it so that those with no pre-existing get lower premiums and deductibles and those who do have pay much higher rates?

      these kinds of things are not the kind where we just make the “obvious” choice for what the ACA (or replacement) should do or not do.. these kinds of issues are at the core of the philosophical differences.

  7. LarrytheG Avatar

    The ACA does not prohibit insurance across state lines… you guys needs to get facts and not myths and selling across State lines is something the Feds have to force on the States as the States each have their own regulatory regime of which they want to regulation ANYONE who sells ANYTHING in THEIR state and what selling across state lines means is that you cannot have a system where the insurance companies are subjected to more than one state’s regulations in each state.. that won’t work so what it basically means is the Feds would drive the regulations not the states.

    1. TooManyTaxes Avatar

      Larry, as you know, the Constitution vests Congress with the authority to regulate interstate commerce. A person in Virginia who wants to buy insurance in Tennessee seeks to engage in interstate commerce. Congress would have the authority to preempt state regulations that prohibit interstate sales as well as regulate the application of state law to such sales. For example, federal law could provide that the law of the state selling the insurance policy governs. This is not rocket science. A first year law student could outline a bill to handle this.

      I’m not arguing that this should be the only reform, but, if enacted, it would be a strong protection for consumers who don’t like the coverage requirements, too strong or too weak, in their home state. And we could downsize both the IRS and HHS by returning most regulatory controls to the states.

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