In recent months, health policy watchers have focused mostly on the implementation of the Affordable Care Act. The ACA’s technical problems deserve to rank high in the pantheon of public administration debacles, but most analysts agree that in the end, the ACA’s 2014 coverage expansions have met or even exceeded expectations.
The numbers are starting to come in. According to the Health Reform Monitoring Survey, a quarterly tracking survey by the Urban Institute, the number of non-elderly uninsured adults nationally fell by nearly three percentage point by early March, with about a month to go in open enrollment. The best news in the HRMS is that the uninsured gap closed the most for young adults, the poor, and racial minorities — all groups with high uninsured rates before reform.
With the ACA coverage provisions dominating the news, it has been easy to lose track of some other long-standing challenges in New Jersey health care. A new report from the Commonwealth Fund provides a great opportunity to take a step back from current events and check in on the bigger picture.
This report is the third in a series of detailed scorecards of state health system performance, drawing on 34 performance metrics. The scorecard compares how the states were doing in the middle of the past decade to the most recent available data (2010 or 2012 for most measures).
The authors of the report conclude that overall the “story is mostly one of stagnation or decline” across the states. Sadly, this does not come as a big surprise: During this period the nation was struggling to dig out of the Great Recession and health policy elites were arguing over the ACA more than implementing necessary policy changes.
Still, in the few areas were policy changes were in play, improvements are evident. Childhood vaccination rates, for example, are a bright spot in the report with every state improving. Hospital quality metrics also generally improved, mainly due to Medicare monitoring and public reporting initiatives. But costs per capita rose sharply across nearly all of the states and a broad range of other scorecard measures showed no improvement, with some others worsening.
New Jersey largely tracks the national trends on most scorecard metrics. We inched up in the overall performance ranking – rising from 23rd to 17th. A bright spot for New Jersey in the scorecard is in the “healthy lives” dimension, where five measures improved, five stayed about the same, and only one got worse.
As a comparatively wealthy state, it should come as no surprise that New Jersey does well on these measures. Health status is driven by much more than healthcare delivery, and factors such as New Jersey’s high incomes and education levels drive good health. There are signs of progress on measures such as childhood obesity rates, on which New Jersey got better over this period and ranks third best in the nation. (Before celebrating too much, there is definitely much room for improvement on this measure, since 25 percent of New Jersey children ages 10 to 17 were overweight or obese in 2011-2012.) New Jersey also improved on two health measures where we rank in the bottom half of states — colorectal and breast cancer death rates.
The scorecard dimension where New Jersey does worst measures “avoidable hospital use and cost.” On one measure of cost — Medicare Parts A and B reimbursements per enrollee — New Jersey ranked 45th (out of 51 jurisdictions), and these costs rose 9 percent between 2008 and 2012.
Like the majority of states, New Jersey improved on measures of avoidable hospital use, including pediatric asthma admissions and potentially avoidable Medicare admissions. But New Jersey ranks low on these measures suggesting that there is considerable room for further improvement. The scorecard ranks New Jersey the 44th worst for Medicare 30-day hospital readmission rate. In fact, last year 92 percent of New Jersey hospitals were penalized for having “excess” unplanned hospital readmissions.
There are many drivers of New Jersey’s out-of-line health care costs, but excessive preventable hospital use is clearly one of them. The growth of Medicare Accountable Care Organizations in New Jersey (and around the nation) holds promise for improving community-based care in ways that bring down preventable admissions, and the Medicare hospital penalties are focusing hospital officials on doing better. Also, other ACA, state, and private-sector initiatives, such as primary-care practice improvement strategies, have the potential to improve care and slow cost growth.
Reducing the number of uninsured in New Jersey can also contribute to reducing excessive use of hospital resources. Historically, the hospitals serving large low-income and uninsured populations have done worse on a variety of quality metrics compared to their more well-to-do peers. This is in part because financially distressed hospitals lack resources to invest in quality improvement. Since most of those gaining coverage in the state have low to moderate incomes, the hospitals serving them stand to gain. Administrators of these hospitals would be wise to invest in care coordination and other quality-improvement initiatives. If they do, New Jersey will do better on the next Commonwealth Fund scorecard.