The third open enrollment period for health care coverage under the Affordable Care Act closed on January 31, 2016, bringing the number of Americans enrolled in a Marketplace health insurance plan to an estimated 14.1 million.
The third open enrollment period for health care coverage under the Affordable Care Act (ACA) closed on January 31, 2016, bringing the number of Americans enrolled in a Marketplace health insurance plan to an estimated 14.1 million.1
To understand the implications of this expanded health care coverage, a quick review is in order. Two main avenues exist for increasing the number of Americans insured under the ACA: implementation of the Health Insurance Marketplace and federal support for states expanding their Medicaid plans, both of which significantly increased the number of newly insured patients in the first 2 years the ACA was enacted.1
Since the beginning of open enrollment in October 2013 through September 12, 2015, a total of 15.3 million adults gained health insurance. An additional 2.3 million young adults aged 19 to 25 years also gained insurance during that time, bringing the total number of newly insured Americans to 17.6 million.2As of September 22, 2015, the number of uninsured had dropped to less than 13%,2 and October 2015 estimates report the number of individuals eligible for a qualified health plan at 10.5 million.3
The Newly Insured
What do we know about these newly insured patients? From a financial perspective, we know they are paying attention to cost. Of those with 2014 Marketplace plans, 23% switched to a new plan in 2015 compared with 2.8% of those with traditional employer- sponsored plans. This illustrates patients’ sensitivity to cost-sharing requirements, provider networks, and net plan premium costs. Furthermore, most Marketplace enrollees selected a silver plan and stayed at that level for the next enrollment period. The appeal of this plan is 2-fold: most patients who are eligible for cost-sharing reductions can only apply for them when enrolled in a silver plan, and the amount of premium tax credits is based on the second-lowest-cost silver plan in that patient’s geographic area.4Of the 10.5 million Americans who were eligible to enroll in a qualified health plan during the most recent enrollment period, nearly half were aged 18 to 34 years with family incomes between 100% and 250% of the federal poverty limit, and about 80% of them had less than $1000 in savings.3
From a clinical perspective, although newly insured patients are reported to have lower health status and more chronic conditions,5new patients visiting primary care offices in 2014 were not sicker or more complex than in 2013, as some had feared would be the case.6Those newly insured under Medicaid are asking for more primary care physician visits than the previously enrolled Medicaid population,5and many previously uninsured patients need help understanding their benefits, such as the implications of a drug formulary.7The insured are also more likely to use health care services than the uninsured: 69% of insured patients visit their provider for well visits or routine checkups compared with only 30% of uninsured patients who do the same.5As previously uninsured patients gain coverage, they will be unfamiliar with the health care services now available to them, particularly preventive care services.
Although the majority of primary care nurse practitioners and physician assistants have seen an increase in the number of Medicaid patients or newly insured patients since the ACA expansion took effect, 63% of them reported no change in their ability to provide high-quality care to all of their patients.8Given the attributes of the newly insured and the successful management of these patients in primary care practices, retail clinicians can further meet the needs of these patients by serving as a complement to primary care practice, especially with regard to population health approaches.5Two important aspects of care that must be prioritized for the newly insured are health literacy and preventive services.
In order to make appropriate health decisions, patients must have sufficient health literacy—including reading, writing, verbal, and numerical skills—to obtain, process, and understand basic health information. Individuals with limited health literacy have less understanding of their health problems, receive fewer preventive services, and make more errors when taking medications.9,10Patients with inadequate health literacy report less knowledge about their medical conditions (particularly hypertension, diabetes, asthma, and HIV) and management strategies, worse health status, and less understanding and use of preventive services.
Health literacy also appears to be inversely related to health care resource utilization, likely because individuals with limited health literacy are more apt to use health care services designed to treat complications of disease, as opposed to services designed to prevent complications. A lack of health insurance or lack of access to services may lead patients to postpone needed care, especially preventive care, screenings, medical tests, and treatments, including prescription medications.11
Astonishingly, 88% of US adults lack the health literacy skills needed to manage all of the demands of the current health care system.9,10Findings from the National Adult Assessment of Literacy survey further underscore the relationship between health literacy and insurance coverage: patients with employer-sponsored or private insurance had higher health literacy scores than those with Medicaid, Medicare, or no insurance.12
Limited health literacy is both common and difficult to recognize. Therefore, experts—including the Agency for Healthcare Research and Quality—recommend using “universal precautions.” Just as infection control universal precautions assume that all patients are potentially infectious, health literacy universal precautions assume that all patients and caregivers may have difficulty comprehending health information. The use of health literacy universal precautions serves to minimize the risk for miscommunication through the practice of simplifying communication with and confirming comprehension for all patients. Furthermore, these precautions aim to make navigation through the health system easier for patients and actively support patients’ efforts to improve their health.9
To improve spoken communication, retail clinicians should conduct “brown bag” medication reviews at visits, use a “teach-back” technique with patients, and actively follow up with patients after their visits. To improve written communication, easy-to-understand materials should be provided to patients and families.9,11To empower patients and improve self-management, retail clinicians should encourage questions, get patient feedback, and collaborate to create action plans.9 Retail clinics already mitigate some of the challenges faced by patients with lower health literacy, most notably cost of care, accessibility, and convenience.11By adopting health literacy universal precautions, retail clinicians can significantly improve the health care of newly insured patients.
As health literacy improves among the newly insured, the request for and utilization of preventive services will increase. The ACA provides improved access to recommended preventive services without imposing cost-sharing, such as deductibles, co-payments, or coinsurance. As of May 2015, an estimated 137 million Americans—including 28.5 million children, 55.6 million women, and 53.5 million men—had preventive services coverage with no cost sharing.13
Both public and private sectors have encouraged the newly insured to think of insurance as “wellness care” and to take advantage of services with no cost sharing, especially those for preventive care and chronic condition management.14As part of its “Coverage to Care Roadmap,” the Centers for Medicare & Medicaid Services (CMS) suggests that patients maintain a healthy lifestyle, get recommended screenings, manage chronic conditions, and keep their health information in one place. Furthermore, CMS stresses the importance of appropriate health care resource utilization, such as knowing when to seek care from a primary care provider rather than at an emergency department.15
The US Preventive Services Task Force has a number of recommendations for preventive services for adults, many of which can be implemented successfully in a retail health care environment (Table).16In addition, the American Academy of Pediatrics recently updated its recommendations to include testing for high blood cholesterol and screening for depression during visits with children and young adults aged 11 to 21 years.17Finally, the seasonal influenza vaccination is recommended for nearly everyone.18
Capturing Newly Insured Patients in a Retail Clinic Setting
Driven by the expansion of insurance coverage through the ACA, millions of newly insured patients are seeking health care in primary and community settings, including retail clinics. Lacking appropriate health literacy, the newly insured need help in understanding their benefits under the ACA, particularly regarding the use of preventive services. Retail clinicians are ideally positioned to positively impact the health of the newly insured by adopting universal health literacy precautions and by recommending and encouraging the use of preventive services that are covered under the ACA at no cost to patients.
TABLE: PREVENTIVE SERVICES RETAIL CLINICS CAN PROVIDE16
Tobacco use counseling and interventions
Healthy diet and physical activity counseling
Alcohol misuse screening and counseling
Blood pressure screening
Chlamydia, gonorrhea, and syphilis screening in young women
Intimate partner violence screening
Folic acid supplementation
Cholesterol abnormalities screening
Cervical and colorectal cancer screening
Vitamin D supplementation for fall prevention in older adults
Obesity screening and counseling
HIV and hepatitis B and C screening
Aspirin to prevent cardiovascular disease and preeclampsia
A family nurse practitioner for 20 years, Sue Brown has practiced in a variety of clinical and academic settings, including rural primary care, schools of nursing, urgent care, and—for the past 10 years—retail health. She is a transformational leader who empowers providers and patients to realize their full potential through education and development. She currently serves as the director of clinical informatics for MinuteClinic.