CRANSTON – The facts are definitive and undeniable: Rhode Island has reduced its number of uninsured in the last three years, from 112,774 in 2012 to 45,591 in 2015, dropping the total of uninsured residents to single digits at 5 percent, lower than the state’s current unemployment rate.

Translated, some 95 percent of Rhode Islanders now have health insurance, according the Rhode Island Health Information Survey data released on Sept. 10.

The reasons for the big drop in uninsured in Rhode Island are unequivocal: the Affordable Care Act worked; the state’s decision to expand Medicaid proved an important policy choice  in increasing health insurance coverage; and the state’s health benefits exchange, HealthSourceRI, served as an effective tool in achieving this task.

“The Affordable Care Act is working, and [it is] working best in states like Rhode Island that have fully implemented Medicaid expansion and embraced a state-run exchange,” said Anya Rader Wallack, director of HealthSourceRI, in a news release, and repeated in response to a question by ConvergenceRI at a news briefing.

While HealthSourceRI had previously reported that it had helped to enroll more than 37,000 Rhode Islanders to obtain health insurance coverage, and, in addition, some 82,000 Rhode Islanders had been enrolled in Medicaid under expanded eligibility, the lingering, unanswered question had been: how many of the newly enrolled had been uninsured before.

The new research data released on Sept. 10 moves beyond anecdotal stories to evidence-based facts. The 2015 Health Information Survey was robust: it surveyed 5,000 households and 12,000 individuals; it was conducted in the spring of 2015 by Market Decisions of Portland, Maine, by phone, including both land lines and cell phones; and it was tailored to Rhode Island, with specific terminology. Its margin of error was +/- 1 percent.

[As the new release noted, the declining rate of Rhode Island’s uninsured was consistent with the recent Gallup survey that placed the state’s rate at 2.7 percent, with a margin of error of +/- 4 percent. It was based on a much, much smaller sample size of 269.]

The 2015 Health Information Survey cost $369,126; it was paid for entirely by federal funds and no state funds were used, according to HealthSourceRI officials.

The context
The facts contained in the 2015 Health Information Survey provide documented evidence that the number of uninsured was reduced by more than 60,000 in Rhode Island during the last three years.

For all the noise raised by opponents of the Affordable Care Act, questioning whether the number of uninsured in Rhode Island would actually be reduced, whether young people would actually sign up for health insurance, and whether firms would resist health insurance mandates, the reality is clear, unclouded by political posturing: implementation of the law in Rhode Island has proven to be very effective in reducing the number of uninsured.

All the brouhaha turned out to be just that – brouhaha, an uproar marked by controversy and fuss that, afterward, seems to have been pointless or irrational.

For sure, reducing the number of uninsured in Rhode Island is a very positive step forward, something that had never been accomplished by the private marketplace.

That said, it serves as a way to make more visible and transparent the bigger conundrum: how to curb the ever-escalating costs of the health care delivery system, which, at best, spends about 20 percent [some say that it’s as low as 5 percent] of its resources to further health, wellness and prevention.

The numbers across the board in terms of insurance also reflect ongoing changes for the commercial health insurance market that bear watching:

•   Between 2012-2015, the number of uninsured in Rhode Island dropped 63,000, the number of Medicaid members increased by 82,000, the number of Medicare members increased by 5,000, those insured by the military dropped by 2,000, but the number of those insured by commercial health insurers dropped by 21,000 [emphasis added].

Equally important is the question: how can Rhode Island create a collaborative, community-driven approach to address the economic and social determinants of health and promote health equity? Access to a health insurance card does not, in and of itself, guarantee access to timely, affordable, quality health care; it is but a first step.

As Ray Lavoie, executive director of Blackstone Valley Community Health Care community health center, told ConvergenceRI in January of 2015, “Lots of folks now have health insurance cards as a result of the Affordable Care Act. But that’s half the solution. The other half of the solution is having a place to get care and [be able] use that insurance card.”

To achieve that, the overarching question becomes: how and where will future resources be invested? In transforming the health care delivery system? By addressing the social determinants of health? In expanding the community health center network? In building out the concept of neighborhood health stations? And, who gets to share in any of the shared savings achieved?

Facts and nuance
The facts, however, are nothing without their nuance, as Norman Mailer [in the role of a journalist] once wrote.

The nuance here involves the setting: the news briefing on the 2015 Health Information Survey took place on Sept. 10 in a makeshift room at HealthSourceRI’s new office digs, at Building 043, a very small, recently renovated cottage on the John Pastore Center campus in Cranston.

The modest two-story brick building, without any signage, save for a big “O43” located on the outside, is behind the sprawling Division of Motor Vehicles headquarters. The official address is 43 Cherrydale Court, but there was no street sign, making it difficult for reporters from WPRO and AP to find the location of the news briefing.

The new space reflects how the agency has come full circle: née as an executive order, it grew up amidst ideological turmoil over what was termed Obamacare; the agency was subject of relentless attacks about its alleged profligate spending; it became the object of a concerted effort to defund the agency and return its function to the federal exchange. [It was also plagued by glitches caused by efforts to implement UHIP, the new state health IT system; those glitches cost the agency some $9.7 million in 2014 in additional costs, according to a briefing book issued in early 2015. See link to ConvergenceRI story below.]

That full circle was very much reflected in its oft-changing locale: HealthSourceRI’s initial headquarters in 2013 was squeezed into the rooms on the second floor of the State House next to former Gov. Lincoln Chafee’s offices, where press briefings were held in a makeshift conference room, with reporters literally having to crowd around a table, shoulder-to-shoulder.

The headquarters then shifted in 2014 to the expansive second floor at One Weybosset Hill, at 33 Broad St. in Providence, in a building owned by Joseph Paolino [where then Gov.-elect Gina Raimondo located her transition offices], where news conferences were held in spacious conference rooms.

As of July 1, 2015, the agency headquarters are squeezed into a tiny cottage where the recent news briefing took place, once again, in a makeshift setting.

The budget hawks in the R.I. General Assembly may have triumphed in producing an austerity budget for the agency, as evidenced from the location of the headquarters. But the latest data report speaks for itself in terms of the effectiveness of the agency's results: reducing the number of uninsured in Rhode Island by more than 60,000 in two years is quite an accomplishment.

It is worth recalling the spurious joke by former Rep. Spencer E. Dickinson. At a legislative and advocacy breakfast in April of 2014 sponsored by the R.I. Business Group on Health, Dickinson complained that he couldn’t ever seem to locate the offices of HealthSourceRI, and if anyone in the audience did, could they please take him on a tour – to the heh heh hehs and guffaws of many who were attending. [All Dickinson had to do was walk to the second floor of the State House.]

That joke, it seems, has now become the reality. “What we need to do is [to find a way] to make [HealthSourceRI]much smaller,” Dickinson said at the time. He had sponsored legislation to deny any state revenue for funding the exchange. [See link to ConvergenceRI story below.]

Dickinson is no longer in the R.I. General Assembly, having been defeated in a primary election in 2014.

But, the new data from HealthSourceRI, issued from its “cozy” new location, certainly trumps its critics, offering an evidence-based riposte.

That said, the state’s willingness to invest its “own” money, so to speak, in building out and supporting the expansion of the state’s health exchange to the small business community, remains very much a political football.

On one hand, there are those who believe that the state should reduce its investment in health care expenditures so as not to crowd out other potential investments in efforts to reboot the state’s economy. “Stabilizing health insurance coverage is about more than expanding Medicaid and maximizing federal tax credits,” said Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services, in the news release accompanying the data drop. “To sustain a high-quality health care system and build strong, healthier communities across Rhode Island, we also have to address the fundamental drivers of health care cost growth that continue to burden our employers, taxpayers and state government.”

On the other hand, there is the statement offered by Neil Steinberg, president and CEO of The Rhode Island Foundation, at a gathering of the primary care practices involved with the Care Transformation Collaborative in October of 2014, who said: “If we can say we have the best primary care and the best public education in the U.S., we will not have to do anything else for economic development, because folks from all over the country will flock here to Rhode Island.”

In between there is a middle ground: more than just measuring the number of uninsured as benchmark of success, there needs to be new metrics developed about the cost-effectiveness of health care delivery as compared to health outcomes across Rhode Island’s entire population and its communities.

How the news gets covered
The release of the good news that the rolls of the uninsured in Rhode Island had been reduced by more than 60,000, a 50 percent reduction, in the last three years, according to the data of Rhode Island Health Information Survey, had to pass through the convoluted process that is now communications news management under the Raimondo administration.

The news release and background slide deck were provided to reporters on an embargoed basis, the embargo to be lifted at 12 noon following the 11 a.m. news briefing.

Only three reporters – ConvergenceRI, Jennifer McDermott from AP, and Steve Klamkin – showed up for the briefing at HealthSourceRI headquarters in Cranston. Richard Salit from The Providence Journal chose not to come to the briefing; there was no TV coverage.

The briefing proceeded in a relaxed atmosphere with Anya Rader Wallack, director of HealthSourceRI, and Amy Black, the data specialist, walking the reporters through the data outcomes.

McDermott announced that she would be live-tweeting during the news briefing, saying that AP did not agree to the embargo. In turn, Salit, who was not in attendance, apparently broke the embargo, tweeting it as an early breaking news story, which Klamkin pointed out during the news briefing.

Embargoing stories with a new briefing in advance is no longer a format that works in today’s news world, driven by social media, and the ever-present desire to be first, not to be scooped, and to put the information out ahead of the crowd on Twitter.

A deeper dive
The uninsured population differs from the general population in being younger, more male-dominated and disproportionately childless adults, according to the survey results. It also found that the bulk of the remaining uninsured, some 70 percent, lives in Providence County, which HealthSourceRI officials said was not surprising, given that 60 percent of Rhode Island’s population lives in Providence County.

About half of the current uninsured in Rhode Island – 26,000 out of the total 45, 591 that are uninsured – are income eligible for coverage through HealthSourceRI, according to the survey.

Further, the data showed that 30 percent of the uninsured had not been born in the U.S., and one-third of those had been in the U.S. less than five years. The conclusion drawn by the agency was that in terms of characteristics, the uninsured are more likely to be low-income and not born in the U.S.

What the data did not capture was the critical role played by community health centers in provision of health care for the uninsured – and in serving as the point of contact in signing up the uninsured. Wallack and Black said that it had not been part of the data analysis and that they didn’t readily have the information when asked by ConvergenceRI.

But the information was readily available from the Health Center fact sheet distributed recently by the Rhode Island Health Center Association: in 2014, the network of community health centers provided health services to 22,143 uninsured patients – some 50 percent of all the uninsured in Rhode Island. In turn, the health centers also provide services to about one-third of all Medicaid beneficiaries in Rhode Island – 81,636 patients. In total, in 2014, the community health centers served a total of 151,160 patients – 15 percent of Rhode Island’s population.

The other key players in providing health care to the uninsured in Rhode Island are two free clinics: Clinica Esperanza, which provides primary care to about 1,500 patients, serving an uninsured, multicultural and multilingual population; and the Rhode Island Free Clinic, which provides care to more than 2,000 uninsured patients statewide.

Translated, the community health centers and the free clinics are caring for some 25,643 uninsured Rhode Islanders, some 57 percent.

Cost a key factor in delaying care
Perhaps a more prescient question to ask is this: how is the risk being distributed across the health delivery system, as a factor of cost, as a factor of delaying care, as a factor of non-adherence to medication for the underinsured as well as the uninsured.

The recent study in Massachusetts related to health care costs, as reported in last week’s issue of ConvergenceRI, raised some issues around cost escalation:

•   The report said that total medical expenses, per member per month, among commercial payers grew by 2.9 percent in 2014, compared to a 1.2 percent increase in 2013 – more than doubling.


•   It also said that spending for MassHealth, the state’s Medicaid program, increased by $2.4 billion, a jump of 19 percent, while enrollment increased by 23 percent.



•   The costs shared by members of insurance plans rose by 4.9 percent in 2014, with individual purchasers and small group members continuing to pay the most out of pocket, according to the report. 



•   And the report identified two trends: increased enrollment in high deductible health plans, now 19 percent of the commercial market; and tiered network plans, now 16 percent of the market, appear to show that employers are shifting health care costs to employees.

•

  The report also highlighted a 13 percent rise in drug costs.