Unwinding And The Medicaid Undercount: Millions Enrolled In Medicaid During The Pandemic Thought They Were Uninsured

Policy responses to the March 31, 2023, expiration of the Medicaid continuous coverage provision need to consider the difference between self-reported Medicaid participation on government surveys and administrative records of Medicaid enrollment. The difference between the two is known as the "Medicaid undercount." The size of the undercount increased substantially after the continuous coverage provision took effect in March 2020. Using longitudinal data from the Current Population Survey, we examined this change. We found that assuming that all beneficiaries who ever reported enrolling in Medicaid during the COVID-19 pandemic public health emergency remained enrolled through 2022 (as required by the continuous coverage provision) eliminated the worsening of the undercount. We estimated that nearly half of the 5.9 million people who we projected were likely to become uninsured after the provision expired, or "unwound," already reported that they were uninsured in the 2022 Current Population Survey. This finding suggests that the impact of ending the continuous coverage provision on the estimated uninsurance rate, based on self-reported survey data, may have been smaller than anticipated. It also means that efforts to address Medicaid unwinding should include people who likely remain eligible for Medicaid but believe that they are already uninsured.

Survey-Reported Coverage in 2019-2022 and Implications for Unwinding Medicaid Continuous Eligibility

Importance

Policy changes and the COVID-19 pandemic affected health coverage rates, and the "unwinding" of Medicaid's continuous coverage provision in 2023 and 2024 may cause widespread coverage loss. Recent coverage patterns in national survey and administrative data can inform these issues.

Objective

To assess national and state changes in survey-based Medicaid, private insurance, and uninsured rates between 2019 and 2022, as well as how these changes compare with administrative Medicaid enrollment totals.

Design, Setting, and Participants

This cross-sectional study analyzes nationally representative survey data for all US residents in the American Community Survey (ACS) from 2019 to 2022 compared with administrative data on Medicaid and the Children's Health Insurance Program from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted between June 2023 and January 2024.

Exposures

The COVID-19 pandemic, the Medicaid continuous coverage provision, and policy efforts to increase Marketplace coverage.

Main Outcomes and Measures

Medicaid coverage (self-reported [ACS] and administratively recorded [CMS]), survey-reported uninsured, Medicare, and private insurance status.

Results

A nationally representative sample consisted of 12 506 584 US residents of all ages (survey-weighted 59.7% aged 19-64 years and 50.6% female). CMS statistics showed an increase in Medicaid coverage of 5.2 percentage points as a share of the population from 2019 to 2022. However, changes in the uninsured rate and survey-reported Medicaid were smaller: -1.2 (95% CI, -1.3 to -1.2) percentage points and 1.3 (95% CI, 1.2-1.4) percentage points, respectively. There was a 3.9 percentage point increase in the ACS's "undercount" of Medicaid enrollment, compared with CMS data, from 2019 to 2022. This undercount was larger among children than adults but smaller in states that recently expanded Medicaid. Rates of additional forms of coverage (such as private insurance) among those in Medicaid also grew during this time.

Conclusion and Relevance

In this cross-sectional study, the uninsured rate declined considerably from 2019 to 2022 but was just one-fourth as large as the growth in administrative Medicaid enrollment under the pandemic continuous coverage provision. Survey-based Medicaid growth was far smaller than administrative growth. This suggests that many people who remained enrolled in Medicaid during the pandemic did not realize that their coverage had continued. These findings have implications for projecting uninsured changes during unwinding, as well as the effect of continuous coverage policies on continuity of care.

Reconsidering and Measuring Patient Access in Medicaid

This JAMA Forum discusses the ways that policymakers can use different metrics that are more meaningful to patients when measuring patient access to treatment in the Medicaid program.

Why Cost Sharing on Its Own Will Not Fix Health Care Costs

This Viewpoint describes issues with cost sharing for health care costs and suggests improvements to current cost sharing systems.

COVID-19 Medicaid Continuous Enrollment Provision Yielded Gains In Postpartum Continuity Of Coverage

The Medicaid continuous enrollment provision mandated by the Families First Coronavirus Response Act of 2020 effectively prohibited the termination of enrollees from Medicaid during the COVID-19 public health emergency, including people enrolled in Medicaid during pregnancy. Using data from the Transformed Medicaid Statistical Information System, we found that the rate of continuous Medicaid enrollment during the twelve months postpartum increased from 59.3 percent for births during March-December 2018 to 90.7 percent for births during March-December 2020, when the public health emergency was in effect. This corresponds to approximately 430,000 fewer people losing Medicaid coverage after pregnancy and an average of more than 2.5 months of additional postpartum enrollment. These findings indicate that states that have extended or that plan to extend pregnancy-related Medicaid eligibility in the postpartum year are likely to experience significant gains in continuity of coverage.

Clinical Risk and Outpatient Therapy Utilization for COVID-19 in the Medicare Population

Importance

Multiple therapies are available for outpatient treatment of COVID-19 that are highly effective at preventing hospitalization and mortality. Although racial and socioeconomic disparities in use of these therapies have been documented, limited evidence exists on what factors explain differences in use and the potential public health relevance of these differences.

Objective

To assess COVID-19 outpatient treatment utilization in the Medicare population and simulate the potential outcome of allocating treatment according to patient risk for severe COVID-19.

Design, Setting, and Participants

This cross-sectional study included patients enrolled in Medicare in 2022 across the US, identified with 100% Medicare fee-for-service claims.

Main Outcomes and Measures

The primary outcome was any COVID-19 outpatient therapy utilization. Secondary outcomes included COVID-19 testing, ambulatory visits, and hospitalization. Differences in outcomes were estimated based on patient demographics, treatment contraindications, and a composite risk score for mortality after COVID-19 based on demographics and comorbidities. A simulation of reallocating COVID-19 treatment, particularly with nirmatrelvir, to those at high risk of severe disease was performed, and the potential COVID-19 hospitalizations and mortality outcomes were assessed.

Results

In 2022, 6.0% of 20 026 910 beneficiaries received outpatient COVID-19 treatment, 40.5% of which had no associated COVID-19 diagnosis within 10 days. Patients with higher risk for severe disease received less outpatient treatment, such as 6.4% of those aged 65 to 69 years compared with 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]) and 6.4% of White patients compared with 3.0% of Black patients (aOR, 0.56 [95% CI, 0.54-0.58]). In the highest COVID-19 severity risk quintile, 2.6% were hospitalized for COVID-19 and 4.9% received outpatient treatment, compared with 0.2% and 7.5% in the lowest quintile. These patterns were similar among patients with a documented COVID-19 diagnosis, those with no claims for vaccination, and patients who are insured with Medicare Advantage. Differences were not explained by variable COVID-19 testing, ambulatory visits, or treatment contraindications. Reallocation of 2022 outpatient COVID-19 treatment, particularly with nirmatrelvir, based on risk for severe COVID-19 would have averted 16 503 COVID-19 deaths (16.3%) in the sample.

Conclusion

In this cross-sectional study, outpatient COVID-19 treatment was disproportionately accessed by beneficiaries at lower risk for severe infection, undermining its potential public health benefit. Undertreatment was not driven by lack of clinical access or treatment contraindications.

Climate-Informed Patient Care as a Social Determinant of Health

This JAMA Forum discusses the implications for patient care by recognizing climate change as a social determinant of health.

Worse Access, Quality, and Leadership-Redressing the Affirmative Action Ruling's Litany of Harms

This JAMA Forum discusses the US Supreme Court’s ruling on affirmative action in the context of the potential harms to access to care, quality of care, and leadership for the health care system.

Medicare Switching: Patterns Of Enrollment Growth In Medicare Advantage, 2006-22

Medicare Advantage (MA) has grown rapidly over the course of the past two decades and is projected to continue to grow. We examined sources of new enrollment in MA and analyzed the switching patterns between MA and traditional fee-for-service Medicare, using more recent and more detailed data than in previous analyses. We found that switching from fee-for-service Medicare to MA more than tripled between 2006 and 2022, whereas switching from MA to fee-for-service Medicare decreased, with the change rates accelerating since 2019. The share of switchers among all new MA enrollees rose from 61 percent in 2011 to 80 percent in 2022. Black, dual-eligible, and disabled beneficiaries had higher odds of switching in both directions, whereas younger and healthier beneficiaries had higher odds of switching from fee-for-service Medicare to MA but lower odds of switching from MA to fee-for-service Medicare. Two-thirds of annual switching between MA and fee-for-service Medicare in 2022 occurred in January, likely reflecting the open enrollment period.

Monoclonal Antibody and Oral Antiviral Treatment of SARS-CoV-2 Infection in US Nursing Homes

This study examines the use of COVID-19 antiviral treatments in US nursing homes and the facility characteristics associated with use of oral antivirals and monoclonal antibodies.

New Federal Efforts to Address Food and Nutrition Insecurity

This JAMA Forum discusses the expansion and improvement of federal food and nutrition programs, such as the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children, to combat food insecurity.

Trends in Missing Race and Ethnicity Information After Imputation in HealthCare.gov Marketplace Enrollment Data, 2015-2021

This cross-sectional study examines patterns of missing information on race and ethnicity after an imputation of HealthCare.gov enrollment data between 2015 and 2021.

Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015

Importance

Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage.

Objective

To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015.

Design, Setting, and Participants

This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021.

Exposures

Health insurance through Colorado Medicaid or Colorado's state-based Marketplace.

Main Outcomes and Measures

Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders.

Results

Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04).

Conclusions and Relevance

In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Dental Outcomes After Medicaid Insurance Coverage Expansion Under the Affordable Care Act

IMPORTANCE

Dental coverage for adults is a state option in Medicaid, and despite significant gains in coverage after the Medicaid expansion under the Affordable Care Act (ACA), dental outcomes among adults in expansion states remain unexplored.

OBJECTIVE

To explore the association of state coverage of dental benefits through Medicaid expansion with clinical dental outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2018. Included participants were low-income adults aged 19 to 64 years with income up to 138% of the federal poverty level. The study used a difference-in-differences analysis to compare changes from before to after ACA expansion in expansion states vs in control states. Changes were examined in the full sample and separately in states that did and did not provide Medicaid adult dental benefits. We defined a state as providing Medicaid adult dental benefits if it covered services beyond emergency dental benefits in 2014. Data were analyzed from November 2020 to March 2021.

EXPOSURES

Medicaid expansion under the ACA.

MAIN OUTCOMES AND MEASURES

Rates of health coverage, having a dental visit, affordability of dental care in the past year, poor oral health, and teeth flossing were obtained from self-reported data. Mean number of missing teeth and prevalence of untreated decayed teeth, filled teeth, and functional dentition were obtained from clinical examination data.

RESULTS

Among 7637 low-income adults, the mean (SD) age was 37.8 (13.4) years and 4153 (weighted percentage, 54.5 %) were women. At baseline, 1732 low-income adults in nonexpansion states compared with 2520 low-income adults in expansion states were more likely, as shown by weighted percentage, to be Black (473 individuals [21.0%] vs 508 individuals [15.1%]) and US born (1281 individuals [76.7%] vs 1613 individuals [69.6%]). In the full sample, Medicaid expansion, compared with nonexpansion, was associated with an increased rate of seeing a dentist in the prior year (12.4 percentage points; 95% CI 4.6 to 20.2 percentage points; P = .003). In expansion states that provided dental benefits, compared with nonexpansion states that provided dental benefits, the expansion was associated with increases in rates of Medicaid coverage (8.2 percentage points; 95%CI 0.5 to 15.8 percentage points; P = .04) and having seen a dentist in the previous year (11.4 percentage points, 95% CI, 3.7 to 19.1 percentage points; P = .006) and decreases in the uninsured rate (-12.6 percentage points, 95% CI -18.9 to -6.4 percentage points; P < .001) and prevalence of untreated decayed teeth (-16.8 percentage points; 95% CI, -25.5 to -8.0 percentage points; P = .001). In states without Medicaid dental benefits, the expansion was associated with an increase in the mean number of missing teeth (1.3 teeth; 95% CI 0.1 to 2.5 percentage points; P = .04) and a decrease in the prevalence of functional dentition (-8.7 percentage points; 95% CI, -14.1 to -3.3 percentage points; P = .003) compared with nonexpansion states.

CONCLUSIONS AND RELEVANCE

This study found that the combination of Medicaid expansion and coverage of Medicaid dental benefits was associated with improved oral health among low-income adults.

COVID-19-Related Insurance Coverage Changes and Disparities in Access to Care Among Low-Income US Adults in 4 Southern States

Importance

It is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid.

Objective

To determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status.

Design Setting and Participants

This random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020. Using a difference-in-differences design, we estimated changes in outcomes by Medicaid expansion status overall and by race and ethnicity in 2020 (n = 1804) compared with 2018 to 2019 (n = 5710). We also explored barriers to health care and use of telehealth by race and ethnicity. Data analysis was conducted from January 2021 to March 2021.

Exposures

COVID-19 pandemic and prior Medicaid expansion status.

Main Outcomes and Measures

Primary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access.

Results

Of 7514 respondents (11% response rate; 3889 White non-Latinx [51.8%], 1881 Black non-Latinx [25.0%], and 1156 Latinx individuals [15.4%]; 4161 women [55.4%]), 5815 (77.4%) were in the states with previous expansion and 1699 (22.6%) were in Texas (nonexpansion state). Respondents in the expansion states were older, more likely White, and less likely to have attended college compared with respondents in Texas. Uninsurance rate in 2020 rose by 7.4 percentage points in Texas (95% CI, 2.2-12.6; P = .01) and 2.5 percentage points in expansion states (95% CI, -1.9 to 7.0; P = .27), with a difference-in-differences estimate for Medicaid expansion of -4.9% (95% CI, -11.3 to 1.6; P = .14). Among Black and Latinx individuals, Medicaid expansion was associated with protection against a rise in the uninsured rate (difference-in-differences, -9.5%; 95% CI, -19.0 to -0.1; P = .048). Measures of access, including having a personal physician and regular care for chronic conditions, worsened significantly in 2020 in all 4 states, with no significant difference by Medicaid expansion status.

Conclusions and Relevance

In this survey of US adults, uninsured rates increased among low-income adults in 4 Southern states during the COVID-19 pandemic, but Medicaid expansion states, that association was diminished among Black and Latinx individuals. Nonfinancial barriers to care because of the pandemic were common in all states.

Medicaid expansions, preconception insurance, and unintended pregnancy among new parents

OBJECTIVE

To assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first-time parents.

DATA SOURCE

This study used individual-level data from the national Pregnancy Risk Assessment Monitoring System (2006-2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.

STUDY DESIGN

Outcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female-identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.

DATA COLLECTION/EXTRACTION METHODS

The sample included all individuals aged 20-44 with a first live birth in 2009-2017.

PRINCIPAL FINDINGS

Among all first-time parents, a 10-percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high-school degree or less.

CONCLUSIONS

Increasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first-time parents.

Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities

Question

Are policies that cap monthly prescriptions in Medicaid associated with access to medication and health care use among young adults with disabilities in Arkansas and Texas?

Findings

In this cohort study using difference-in-differences analysis of 28 046 young adults with disabilities, including 8214 in states with a 3-drug limit at age 21 years, the 3-drug limit was associated with lower monthly prescriptions for medications used to treat mental health conditions and higher inpatient admissions among all individuals with disabilities in states with the drug cap policy compared with those in states without this policy.

Meaning

In this study, state drug cap policies in Medicaid were associated with lower access to medications and higher use of inpatient care.

Importance

Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications.

Objective

To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid.

Design, Setting, and Participants

In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point.

Exposures

Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states.

Main Outcomes and Measures

Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years.

Results

Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, −21.3% to −17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, −21.9% to −10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions.

Conclusions and Relevance

In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults

BACKGROUND

Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care.

METHODS

Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion).

RESULTS

The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period.

CONCLUSIONS

The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Comparison of Income Eligibility for Medicaid vs Marketplace Coverage for Insurance Enrollment Among Low-Income US Adults

Importance

The Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.

Objective

To assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.

Design Setting and Participants

Using 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.

Main Outcome and Measures

The main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.

Results

The primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.

Conclusions and Relevance

In this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Medicaid healthy behavior incentives and use of dental services

OBJECTIVE

To examine changes in access to dental care in states using Section 1115 waivers to implement healthy behavior incentive (HBI) programs in their Medicaid expansion under the ACA, compared to traditional expansion states and nonexpansion states.

DATA SOURCES

Behavioral Risk Factor Surveillance System from 2008 to 2018.

STUDY DESIGN

We used difference-in-differences analysis to compare changes in three Medicaid expansion states with HBI (Iowa, Indiana, Michigan) to traditional expansion (Minnesota, North Dakota, Ohio) and nonexpansion states (Nebraska, South Dakota, Wyoming) in the same mid-Western region of the country. The sample included 32 556 low-income adults.

DATA COLLECTION/EXTRACTION METHODS

NA.

PRINCIPAL FINDINGS

We found no significant changes in dental visits associated with HBI or traditional expansion relative to nonexpansion states. HBI expansion was associated with an increase of 2.2 percentage points in reporting a dental visit in the past year for adults in urban areas (P < 0.05) while the traditional expansion was associated with a reduction of 8.5 percentage points (P < 0.01) in utilization in rural areas relative to nonexpansion states. However, after adjustment for preexisting trends, the coefficients were no longer significant, suggesting that these differences are likely due to preexisting trends.

CONCLUSIONS

We did not find evidence of increased utilization of routine dental care associated with HBI programs.

Health Insurance Coverage: What Comes After The ACA?

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All.

Changes In Coverage And Access To Dental Care Five Years After ACA Medicaid Expansion

With the implementation of the Affordable Care Act (ACA), millions of low-income adults gained health coverage. We examined how the ACA's expansion of Medicaid eligibility affected dental coverage and the use of oral health services among low-income adults, using data from the National Health Interview Survey from the period 2010-18. We found that the ACA increased rates of dental coverage by 18.9 percentage points in states that provide dental benefits through Medicaid. In terms of utilization, expansion states that provide dental benefits saw the greatest increase in people having a dental visit in the past year (7.2 percentage points). However, there was no significant change in the overall share of people who had a dental visit in the past year, although the expansion was associated with a significant increase in this metric among White adults. The expansion was also associated with a 1.4-percentage-point increase in complete teeth loss, which may be a marker of both poor oral health and the potential gaining of access to dental services (with subsequent tooth extractions). Our findings suggest that in addition to expanded coverage, policies need to tackle other barriers to accessing dental care to improve population oral health.

Changes in US Medicaid Enrollment During the COVID-19 Pandemic

This cross-sectional study analyzes changes in Medicaid enrollment for all 50 US states and Washington, DC, during the first 9 months of 2020, at the beginning of the COVID-19 pandemic.

Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults

IMPORTANCE

There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical.

OBJECTIVE

To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a propensity score-matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL.

EXPOSURES

Health insurance through Colorado Medicaid or Colorado's state-based Marketplace.

MAIN OUTCOMES AND MEASURES

The primary analytical approach was a multivariate regression analysis of the propensity score-matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care-sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score-matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020.

RESULTS

The propensity score-matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P < .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P < .001). No differences in ambulatory care-sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P < .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P < .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid.

CONCLUSIONS AND RELEVANCE

In this cross-sectional propensity score-matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.

Among Low-Income Adults Enrolled In Medicaid, Churning Decreased After The Affordable Care Act

Coverage disruptions and coverage loss occur frequently among Medicaid enrollees and are associated with delayed health care access and reduced medication adherence. Little is known about the effect on churning of the expansion of eligibility for Medicaid under the Affordable Care Act (ACA), which had the potential to reduce coverage disruptions as a result of increased outreach and more generous income eligibility criteria. We used a difference-in-differences framework to compare rates of coverage disruption in expansion versus nonexpansion states, and in subgroups of states that used alternative expansion strategies. We found that among low-income Medicaid beneficiaries ages 19-64, disruption in coverage decreased 4.3 percentage points in the post-ACA period in expansion states compared to nonexpansion states, and there was a similar decrease in the share of people who experienced a period without any insurance. Men, people of color, and those without chronic illnesses experienced the largest improvements in coverage continuity. Coverage disruptions declined in both traditional expansion states and those that used Section 1115 waivers for expansion. Our quasi-experimental study provides the first nationwide evidence that Medicaid expansion led to decreased rates of coverage disruption. We estimate that half a million fewer adults experienced an episode of churning annually.

Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization

Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Levels of Employment and Community Engagement among Low-Income Adults: Implications for Medicaid Work Requirements

CONTEXT

Twenty states are pursuing community engagement requirements ("work requirements") in Medicaid, though legal challenges are ongoing. While most nondisabled low-income individuals work, it is less clear how many engage in the required number of hours of qualifying community engagement activities and what heterogeneity may exist by race/ethnicity, age, and gender. The authors' objective was to estimate current levels of employment and other community engagement activities among potential Medicaid beneficiaries.

METHODS

The authors analyzed the US Census Bureau's national time-use survey data for the years 2015 through 2018. Their main sample consisted of nondisabled adults between 19 and 64 years with family incomes less than 138% of the federal poverty level (N = 2,551).

FINDINGS

Nationally, low-income adults who might become subject to Medicaid work requirements already spent an average of 30 hours per week on community engagement activities. However, 22% of the low-income population-particularly women, older adults, and those with less education-would not currently satisfy a 20-hour-per-week requirement.

CONCLUSIONS

Although the majority of potential Medicaid beneficiaries already meet community engagement requirements or are exempt, 22% would not currently satisfy a 20-hour-per-week requirement and therefore could be at risk for losing coverage.

Blue-Collar Workers Had Greatest Insurance Gains After ACA Implementation

Analyzing national survey data, we found that workers in traditionally blue-collar industries (service jobs, farming, construction, and transportation) experienced the largest gains in health insurance after implementation of the Affordable Care Act (ACA) in 2014. Compared to other occupations, these had lower employer-based coverage rates before the ACA. Most of the post-ACA coverage gains came from Medicaid and directly purchased nongroup insurance.

Medicaid Work Requirements In Arkansas: Two-Year Impacts On Coverage, Employment, And Affordability Of Care

In June 2018 Arkansas became the first US state to implement work requirements in Medicaid, requiring adults ages 30-49 to work twenty hours a week, participate in "community engagement" activities, or qualify for an exemption to maintain coverage. By April 2019, when a federal judge put the policy on hold, 18,000 adults had already lost coverage. We analyze the policy's effects before and after these events, using a telephone survey performed in late 2019 of 2,706 low-income adults in Arkansas and three control states compared with data from 2016 and 2018. We have four main findings. First, most of the Medicaid coverage losses in 2018 were reversed in 2019 after the court order. Second, work requirements did not increase employment over eighteen months of follow-up. Third, people in Arkansas ages 30-49 who had lost Medicaid in the prior year experienced adverse consequences: 50 percent reported serious problems paying off medical debt, 56 percent delayed care because of cost, and 64 percent delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year. Finally, awareness of the work requirements remained poor, with more than 70 percent of Arkansans unsure whether the policy was in effect.

Changes in Coverage, Access, and Health Following Implementation of Healthy Behavior Incentive Medicaid Expansions vs. Traditional Medicaid Expansions

BACKGROUND

Several states expanded Medicaid under the Affordable Care Act using Section 1115 waivers to implement healthy behavior incentive (HBI) programs, but the impact of this type of expansion relative to traditional expansion is not well understood.

OBJECTIVE

To examine whether Medicaid expansion with healthy behavior incentive programs and traditional Medicaid expansion were associated with differential changes in coverage, access, and self-rated health outcomes among low-income adults.

DESIGN

Difference-in-differences analysis of American Community Survey and Behavioral Risk Factor Surveillance System data from 2011 to 2017.

PARTICIPANTS

Low-income adults ages 19-64 in the Midwest Census region (American Community Survey, n = 665,653; Behavioral Risk Factor Surveillance System, n = 71,959).

INTERVENTIONS

Exposure to either HBI waiver or traditional Medicaid expansion in the state of residence.

MAIN MEASURES

Coverage: Medicaid, private, or any health insurance coverage; access: routine checkup, personal doctor, delaying care due to cost; health: cancer screening, preventive care, healthy behaviors, self-reported health.

KEY RESULTS

Healthy behavior incentive (HBI) and traditional expansion (TE) states experienced reductions in uninsurance (- 5.6 [- 7.5, - 3.7] and - 6.2 [- 8.1, - 4.4] percentage points, respectively) and gains in Medicaid (HBI, + 7.6 [2.4, 12.8]; TE, + 9.7 [5.9, 13.4] percentage points) relative to non-expansion states. Both expansion types were associated with increases in rates of having a personal doctor (HBI, + 3.8 [2.0, 5.6]; TE, + 5.9 [2.2, 9.6] percentage points) and mammography (HBI, + 5.6 [0.6, 10.6]; TE, + 7.3 [0.7, 13.9] percentage points). Meanwhile, checkups increased more in HBI than in TE states (p < 0.01), but no other changes in health care services differed between expansion types.

CONCLUSIONS

Medicaid expansion was associated with improvements in coverage and access to care with few differences between expansion types.

Community-Level Factors Associated With Racial And Ethnic Disparities In COVID-19 Rates In Massachusetts

Massachusetts has one of the highest cumulative incidence rates of coronavirus disease 2019 (COVID-19) cases in the US. Understanding which specific demographic, economic, and occupational factors have contributed to disparities in COVID-19 incidence rates across the state is critical to informing public health strategies. We performed a cross-sectional study of 351 Massachusetts cities and towns from January 1 to May 6, 2020, and found that a 10-percentage-point increase in the Black non-Latino population was associated with an increase of 312.3 COVID-19 cases per 100,000 population, whereas a 10-percentage-point increase in the Latino population was associated with an increase of 258.2 cases per 100,000. Independent predictors of higher COVID-19 rates included the proportion of foreign-born noncitizens living in a community, mean household size, and share of food service workers. After adjustment for these variables, the association between the Latino population and COVID-19 rates was attenuated. In contrast, the association between the Black population and COVID-19 rates persisted but may be explained by other systemic inequities. Public health and policy efforts that improve care for foreign-born noncitizens, address crowded housing, and protect food service workers may help mitigate the spread of COVID-19 among minority communities.

Assessment of Perceptions of the Public Charge Rule Among Low-Income Adults in Texas

This survey study investigates perceptions of the Trump administration’s new public charge rule among low-income Texan adults.

Work Requirements and Medicaid Disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018

Objectives. To identify risk factors for Medicaid disenrollment after the implementation of Arkansas's work requirements.Methods. Using a 2018 telephone survey of 1208 low-income adults aged 30 to 49 years in Arkansas (expansion state with work requirements implemented in June 2018), Kentucky (expansion state with proposed work requirements blocked by courts), Louisiana (expansion state without work requirements), and Texas (nonexpansion state), we assessed Medicaid disenrollment rates among the age group targeted by Arkansas's policy.Results. The Medicaid disenrollment rate was highest in Texas (12.8%), followed by Arkansas (10.5%), Kentucky (5.8%), and Louisiana (2.8%). Over half of those who disenrolled in Texas and Arkansas became uninsured, compared with less than a quarter in Kentucky and Louisiana. In multivariate models, Arkansas had significantly higher disenrollment compared with the 3 comparison states; men and non-Hispanic Whites experienced higher disenrollment than women and racial minorities. In Arkansas, having a chronic condition was associated with higher disenrollment.Conclusions. As states debate work requirements and Medicaid reforms, our findings provide insights for policymakers about which populations may be most vulnerable to losing Medicaid coverage.