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Advocate staff photo by TRAVIS SPRADLING – Gov. John Bel Edwards signs the first executive order of his new administration at the State Capitol, No. JBE 16-01, which provides for Medicaid expansion in the state of Louisiana.

The gains in health insurance coverage Louisiana experienced after expanding Medicaid three years ago — leading to about half a million people getting coverage — made the state an exception to a national trend of stalling or even eroding insurance coverage.

A new report from the Commonwealth Fund, a New York health care think tank, shows Louisiana’s drop in uninsured from 2016 to 2017 came as 16 other states experienced upticks of at least one percentage point in their uninsured rates. Low-income people made the largest gains in health coverage in Louisiana, as Medicaid expansion drove down the state's uninsured rate.

The findings, outlined in the Commonwealth Fund’s 2019 Scorecard on State Health System Performance, track with what LSU researchers found in an annual survey released last year: Medicaid expansion drove down the uninsured rate dramatically in the year after Gov. John Bel Edwards expanded the program.

The LSU survey found the uninsured rate fell by half – from 22.7% to 11.4% – from 2015 to 2017, almost entirely because of the expansion of Medicaid. The expansion began offering Medicaid coverage to adults whose incomes were under 138% of the federal poverty line, or about $34,638 for a family of four as of 2018. 

The new report shows Louisiana's expansion came at a time when more than half of states simply held onto earlier gains in insurance coverage. Louisiana was "one notable exception" from the trend, the authors wrote, experiencing a 3 percentage-point drop in its adult uninsured rate — from 15% to 12% from the end of 2016 to the end of 2017. 

But Louisiana still has glaring problems with health insurance and outcomes. While the state posted gains in some areas tracked by Commonwealth, it ranked 45 out of 50 states and the District of Columbia in the scorecard, which evaluates states on 47 health indicators, like insurance rates, health spending and premature deaths. The data is for 2017.

Workers in Louisiana paid more for employer-sponsored health insurance than any other state in the country, when compared to median income. Far more adults in Louisiana went without the appropriate flu and pneumonia vaccines than in other states. And Louisiana ranked last for the number of adults who went without an annual dental visit.

“There are a mix of things Louisiana needs to address but Medicaid expansion was a very important first step for the state,” Sara Collins, a co-author of the report, said in a conference call with reporters.

Among people who get their health insurance through an employer, Louisiana workers paid premiums that amounted to about 10% of median income, the highest rate of any state. Other southern states also performed poorly in that metric.

Louisiana’s overall ranking of 45 is slightly better than the previous two years, when the state ranked 49 in the scorecard.

Rebekah Gee, secretary of the Louisiana Department of Health, said ranking 45 may not sound great, but it is a "big step" in a state with a large number of low-income people that has ranked last on many health outcome lists. 

The report found the state performed well on the number of uninsured children, something Gee said has long been a priority in Louisiana. She also pointed to improvements in outcomes for nursing home residents with antipsychotic medication. 

Bob Johannessen, an LDH spokesman, said the agency is aiming to tackle vaccines – something that has worsened in Louisiana, according to the Commonwealth Fund scorecard – as part of a new set of contracts with the companies that manage care for Medicaid enrollees. 

"The bottom line is Louisiana is a poor state," Gee said. "We’re going to be poor for at least the foreseeable future. While we’re poor, it’s a lifesaver to have the Medicaid expansion.”

The federal government pays most of the costs associated with Louisiana's Medicaid expansion, with the state paying a relatively small share with money from a tax on providers. The insurance is the second-most common type of insurance coverage in Louisiana, according to the LSU research, covering about 21% of adults. More than half of adults get coverage from their employers. 

Republicans in the Louisiana Legislature have taken aim at the Medicaid program amid critical reports from Legislative Auditor Daryl Purpera. Meanwhile, Gov. Edwards has touted Medicaid expansion as a life-saver for the working poor as he runs for re-election this fall. 

LDH rolled out a new Medicaid eligibility system last fall, a project that was in the works before audits found certain enrollees did not qualify for the program. Critics have said the audits suggest a larger problem with the program covering people who don't actually qualify. 

The agency kicked about 30,000 people off the Medicaid rolls at the end of March after the vast majority did not respond to letters seeking verification they qualify, part of the new system. Last month, the agency sent out another 17,000 letters to patients asking them to verify they are eligible or be kicked off at the end of June. 

After topping 500,000 enrollees in April, LDH data show the number of people enrolled in the Medicaid expansion dropped to 465,871 in May, largely because of the new eligibility system. 

Gee said the state has always expected about 470,000 people would benefit from the Medicaid expansion. 

Follow Sam Karlin on Twitter, @samkarlin.