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How Are Hospitals Faring Under the Affordable Care Act? Early Experiences from Ascension Health

Peter Cunningham, Rachel Garfield, and Robin Rudowitz
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Table 1: Change in Ascension Health Inpatient Discharge Volume, by Payer, 2013-2014
  Q2-4,
2013		 Q1-3,
2014		 Δ,
2013-2014		 % Δ,
2013-2014
Total discharges for Ascension system
Total 578,029 564,193 -13,836 -2.4
   Medicaid 88,524 91,775 3,251 3.7
   Medicare 269,982 262,839 -7.143 -2.6
   Commercial 158,965 156,964 -2,001 -1.3
   Uninsured/self-pay 33,383 29,798 -3,585 -10.7
Expansion States Discharges
Total 195,869 189,462 -6,407 -3.3
   Medicaid 33,611 36,112 2,501 7.4
   Medicare 95,409 91,770 -3,639 -3.8
   Commercial 53,205 51,372 -1,833 -3.4
   Uninsured 7,597 5,144 -2,453 -32.3
Non-Expansion States Discharges
Total 382,160 374,731 -7,429 -1.9
   Medicaid          54,913 55,663 750 1.4
   Medicare 174,573 171,069 -3,504 -2.0
   Commercial 105,760 105,592 -168 -0.2
   Uninsured 25,786 24,654 -1,132 -4.4
Note: Expansion states include CT, DC, IL, MD, MI, NY, WA.
Hospitals in Arizona were excluded from the estimates for expansion states due to incomplete revenue data.
Non-expansion states include AL, FL, ID, IN, KS, OK, TN, TX, WI.
Source: Ascension Health
Table 2: Distribution of Ascension Health Inpatient Discharges, by Payer, 2013-2014
  2013 2014
  Quarter
ending
June 30		 Quarter
ending
Sept. 30		 Quarter
ending
Dec. 31		 Quarter
ending
March 31		 Quarter
ending
June 30		 Quarter
ending
Sept. 30
Total discharges for Ascension system 194,736 193,582 189,711 185,575 189,160 189,458
Percent distribution of discharges by payer
 Medicaid 15.1 15.2 15.6 15.6 16.2 17.0
 Medicare 47.5 46.3 46.3 47.4 46.8 45.6
 Commercial 27.5 27.2 27.8 27.2 27.9 28.3
 Uninsured/self-pay 5.6 6.2 5.6 6.1 5.1 4.7
 Other 4.3 5.0 4.8 3.6 4.0 4.5
Total discharges in expansion states 65,805 65,245 64,819 62,227 63,535 63,700
Percent distribution of discharges by payer
 Medicaid 16.8 17.4 17.4 17.4 18.6 21.2
 Medicare 49.5 48.3 48.3 49.1 49.6 46.7
 Commercial 27.1 27.0 27,4 26.8 27.1 27.4
 Uninsured/self-pay 3.7 4.0 3.9 3.8 2.3 2.1
 Other 3.0 3.3 3.0 2.9 2.4 2.7
Total discharges non-expansion states 128,931 128,337 124,892 123,348 125,625 125,758
Percent distribution of discharges by payer
 Medicaid 14.3 14.2 14.7 14.7 15.0 14.9
 Medicare 46.5 45.3 45.3 46.6 45.3 45.0
 Commercial 27.7 27.4 28.0 27.4 28.3 28.8
 Uninsured/self-pay 6.6 7.2 6.4 7.3 6.5 6.0
 Other 4.9 5.9 5.7 4.0 4.9 5.3
Note: Expansion states include CT, DC, IL, MD, MI, NY, WA.
Hospitals in Arizona were excluded from the estimates for expansion states due to incomplete revenue data.
Non-expansion states include AL, FL, ID, IN, KS, OK, TN, TX, WI.
Source: Ascension Health
Table 3: Changes in Ascension Health Total Patient Revenue, by Payer, 2013-2014
  Q2-4,
2013
($ millions)		 Q1-3,
2014
($ millions)
Δ,
2013-2014

($ millions)
% Δ,
2013-2014
Total for Ascension system $13,278 $13,542 $264 2.0%
   Medicaid $1,500 $1,458 -$42 -2.8%
   Commercial $4,144 $4,251 $107 2.6%
   Medicare $4,763 $4,931 $168 3.5%
   Self-pay $1,611 $1,465 -$146 -9.1%
   Other $1,261 $1,438 177 14.0%
Total in expansion states $4,209 $4,264 $55 1.3%
   Medicaid $560 $606 $46 8.2%
   Commercial $1,101 $1,103 $2 0.2%
   Medicare $1,732 $1,788 $56 3.2%
   Self-pay $287 $106 -$181 -63.2%
   Other $530 $661 $132 24.8%
Total in non-expansion states $9,069 $9,278 $209 2.3%
   Medicaid $940 $852 -$88 -9.4%
   Commercial $3,043 $3,148 $105 3.5%
   Medicare $3,031 $3,143 $112 3.7%
   Self-pay $1,324 $1,359 $35 2.6%
   Other $731 $777 $46 6.3%
Note: Expansion states include CT, DC, IL, MD, MI, NY, WA.
Hospitals in Arizona wereexcluded from the estimates for expansion states due to incomplete revenue data.
Non-expansion states include AL, FL, ID, IN, KS, OK, TN, TX, WI.
Source: Ascension Health
Table 4: Distribution of Ascension Health Hospital Revenue by Payer
 
Q2-4,
2013
Q1-3,
2014
Total for Ascension system $13,278 $13,542
   Medicaid 11.3% 10.8%
   Commercial 31.2% 31.4%
   Medicare 35.9% 36.4%
   Self-pay 12.1% 10.8%
   Other 9.5% 10.6%
Total in expansion states $4,209 $4,264
   Medicaid 13.3% 14.2%
   Commercial 26.2% 25.9%
   Medicare 41.1% 41.9%
   Self-pay 6.8% 2.5%
   Other 12.6% 15.5%
Total in non-expansion states $9,069 $9,278
   Medicaid 10.4% 9.2%
   Commercial 33.6% 33.9%
   Medicare 33.4% 33.9%
   Self-pay 14.6% 14.6%
   Other 8.1% 8.4%
Note: Expansion states include CT, DC, IL, MD, MI, NY, WA.
Hospitals in Arizona wereexcluded from the estimates for expansion states due to incomplete revenue data.
Non-expansion states include AL, FL, ID, IN, KS, OK, TN, TX, WI.
Source: Ascension Health
Table 5: Change in Ascension Health’s Cost of Care to the Poor, 2013-2014
 
Q2-4,
2013
($ millions)
Q1-3,
2014
($ millions)
Δ,
2013-2014
($ millions)
% Δ,
2013-2014
Charity care costs $453 $395 -$58 -12.8%
   Expansion states $85 $50 -$35 -40.1%
   Non-expansion states $368 $345 -$23 -6.2%
Medicaid shortfalls $383 $505 $122 31.9%
   Expansion states $106 $129 $23 21.7%
   Non-expansion states $277 $376 $99 35.5%
Net cost of direct care provision to the poor1 $836 $900 $64 7.7%
   Expansion states $191 $179 -$12 -6.3%
   Non-expansion states $645 $721 $76 11.8%
1Includes the sum of charity care costs and Medicaid shortfalls
Note: Expansion states include CT, DC, IL, MD, MI, NY, WA. Hospitals in Arizona wereexcluded from the estimates for expansion states due to incomplete revenue data.
Non-expansion states include AL, FL, ID, IN, KS, OK, TN, TX, WI.
Source: Ascension Health
Supplementary Table 1:   Distribution of Ascension Health Inpatient Discharges by State, 2014
  Share of Discharges
States with Ascension Health hospitals that expanded Medicaid
Total 211,092
   Arizona 10.2
   Connecticut 6.3
   D.C. 3.9
   Illinois 14.3
   Maryland 6.0
   Michigan 52.4
   New York 6.1
   Washington 0.8
States with Ascension Health hospitals that did not expand Medicaid
Total 374,731
   Alabama 10.9
   Florida 14.4
   Idaho 1.0
   Indiana 15.8
   Kansas 8.9
   Oklahoma 7.8
   Tennessee 11.3
   Texas 16.9
   Wisconsin 13.1
Source: Ascension Health
Supplementary Table 2:   Pre-ACA uninsured rates and 2013 and 2014 adult Medicaid income eligibility limits for states with Ascension Health hospitals
  Uninsured rate in 2013(as a share of total state population) Medicaid income eligibility limits for working parents(as a share of poverty) Medicaid income eligibility limits for childless adults(as a share of poverty)
  2013 2014 2013 2014
States with Ascension Health hospitals that expanded Medicaid
Total
   Arizona 19% 106% 138% 100% (closed) 138%
   Connecticuta 9% 191% 201% 70% 138%
   D.C. a 8% 206% 221% 211% 215%
   Illinois 11% 139% 138% 0 138%
   Maryland 10% 122% 138% 0 138%
   Michigan 11% 64% 138% 0 138%
   New York 9% 150% 138% 100% 138%
   Washington 11% 71% 138% 0 138%
States with Ascension Health hospitals that did not expand Medicaid
Total
   Alabama 16% 23% 16% 0 0
   Florida 19% 56% 35% 0 0
   Idaho 14% 37% 27% 0 0
   Indianab 12% 24% 24% 0 0
   Kansas 10% 31% 38% 0 0
   Oklahomab 14% 51% 48% 0 0
   Tennessee 13% 122% 111% 0 0
   Texas 20% 25% 19% 0 0
   Wisconsinc 9% 200% 100% 0 100%
Notes:  Income eligibility for parents based on a family of three; income eligibility for childless adults based on an individual.
a. Connecticut and the District of Columbia had previously expanded Medicaid to parents with incomes above 138% FPL and are maintaining these higher limits.
b. These states currently have additional coverage for parents or other adults above state plan limits through a section 1115 demonstration. The demonstrations include limits on eligibility and/or benefits, do not offer coverage to all residents of the state, and/or include an enrollment cap.  Indiana received approval to implement the Medicaid expansion through a waiver with coverage beginning in February 2015, so for purposes of this analysis and the dates under review, Indiana is considered a non-expansion state.
c. Wisconsin has a waiver to provide full Medicaid coverage to parents and childless adults up to 100% FPL as of January 1, 2014.
Sources: Uninsured rate from:  2014 Current Population Survey, Annual Social Economic Supplement, as reported on Kaiser State Health Facts website.  https://www.kff.org/other/state-indicator/total-population/
Medicaid eligibility from: Kaiser Commission on Medicaid and the Uninsured. Medicaid Eligibility for Adults as of January 1, 2014. October 1, 2013. Available at: https://www.kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/
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