Real-World Impacts of Medicaid Expansion: Focus on Washington State

December 2022 Vol 13, No 12 —December 20, 2022



Research has consistently found positive effects associated with Medicaid expansion in the United States, according to J. Richard Goss, MD, MPH, FACP, medical director at Harborview Medical Center (HMC) and director of the University of Washington (UW) Medicine Quality Metrics.

According to Dr Goss, multiple studies have demonstrated the benefits of the Affordable Care Act (ACA) Medicaid expansion across a range of categories. An analysis performed by the Kaiser Family Foundation of almost 200 studies showed that the expansion has positively impacted people with cancer, chronic disease, and disabilities, as well as their providers. It has also benefited state economies and improved disparities, sexual and reproductive health, behavioral health, social determinants of health, and importantly, mortality.

“This really shows the tremendous benefits that are starting to accumulate,” he noted.

At the 2022 Summit on Cancer Health Disparities in Seattle, Dr Goss provided a broad overview on the ACA and Medicaid expansion in the state of Washington, and honed in on how it has impacted a major public safety net hospital located in Seattle—HMC.

ACA/Medicaid Expansion in Washington

The state of Washington was among the first 25 states to adopt Medicaid expansion, in January 2014. Because of its early adoption, Washington’s Medicaid program and Children’s Health Insurance Program have now provided coverage to over 2 million of its residents: double the number of residents who were covered prior to the expansion.

“When I look at these county-by-county numbers, it really brings it home that these are real people who probably have not had health insurance for a long time,” he said. “And now they have it.”

What Is a Safety Net Hospital?
The History of Harborview

In the 1960s, King County Hospital was attempting to manage the expenses and quality-of-care issues associated with an increasingly modern hospital system. Not being able to do it alone, the hospital worked out a contractual relationship with UW, agreeing that the university would essentially manage the facility owned by King County, leading to the modern HMC footprint.

This collaboration led to an influx of national leaders in education and research to the institution. “Harborview really became a pioneer in prehospital care, trauma, burn care, ICU care, education in many different disciplines, and a host of other programs,” noted Dr Goss.

Harborview is owned by the citizens of King County, managed by UW and governed by a Board of Trustees appointed by King County, but receives no operating budget support from King County. The hospital supports itself through clinical programs, as well as some supplemental funding from the state. But county voters recently passed a bond for $1.74 billion to build a new Harborview facility.

Dr Goss noted this as one of the benefits of being a county hospital: “When the county builds the buildings, you don’t have a mortgage payment. When you don’t have a mortgage, you can actually distribute those resources to people without insurance, and that’s been the arrangement for many years,” he said.

Importantly, the thread that has held true throughout the decades is the mission statement of HMC, he added. The Harborview mission statement clearly calls out the most vulnerable groups as the priority, including but not limited to people who are non–English-speaking, in poverty, uninsured or underinsured, people who experience domestic violence or sexual assault, people with substance abuse issues, and incarcerated people.

“I don’t see many mission statements that call out specific subgroups in need like this,” he said. “Harborview can’t take care of everyone in these categories, but we will always be there for those in the greatest need, and will never say no to these individuals.”

How Does ACA Expansion Impact a Modern Safety Net Organization?

According to Dr Goss, the impact of Medicaid expansion on patients at HMC became incredibly evident to him when reviewing the hospital’s monthly financial summaries. In October 2013, just prior to the expansion rollout, 11.4% of Harborview’s patients were uninsured, and by July 2014, only 3.5% were uninsured.

“This happened in only 6 months, and that number got as low as 2.7%,” he said. “We’d never seen numbers like that.”

However, he noted that these numbers are starting to drift back up because of increasing copays and more demand on insurance programs.

Pioneer Square Clinic and Charity Care

At Pioneer Square Clinic, where Harborview’s highest proportion of vulnerable patients are seen (largely homeless), Medicaid expansion led to a drop in uninsured patients from 51% to 17%.

“This is staggering,” he said.

Harborview is also one of the largest providers of charity care in the state of Washington, but between 2014 and 2015, amounts billed for charity care plummeted because patients actually had some form of insurance.

In addition, the rollout granted patients access to Hopelink; pharmacy benefits, such as blister packs, prosthetics, CPAP, and wheelchairs; expanded mental health services; and easier access to skilled nursing placement. Dr Goss noted that while the direct cost of medical care was already typically waived for these patients, Harborview was not previously able to provide these types of benefits.

“This is a tremendous expansion of services,” he said.

Ongoing Equity Initiatives at Harborview

“While I do think that having insurance is the single most important factor in creating equity in our healthcare system, insurance alone doesn’t reduce all disparities,” he added.

These disparities are measurable in screening mammography rates across racial and ethnic groups. According to Dr Goss, in the state of Washington, screening rates are higher among White women when compared with Black women. However, screening rates at Harborview are nearly equivalent between Black and White women, although the overall rates are still lower than the national benchmarks.

In addition to using the Seattle Cancer Care Alliance Mammogram Van to reach those in need, the team at Harborview plans to expand their on-site mammography screening services in an effort to further address these disparities and bring screening rates up to the level of national benchmarks, he said.

Last modified: August 10, 2023

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