Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children

OBJECTIVE

To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously.

DATA SOURCES

We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation.

STUDY DESIGN

We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state.

DATA EXTRACTION METHODS

We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions.

PRINCIPAL FINDINGS

Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations.

CONCLUSIONS

Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

How did the Affordable Care Act Medicaid Expansion Affect Coverage and Access to Care for Low-Income Parents Who Were Eligible for Medicaid Before the Law Was Passed?

We use the National Health Interview Survey from 2010 to 2017 and a difference-in-differences approach to assess the impact of the Affordable Care Cct (ACA) Medicaid expansion on coverage and access to care for a subset of low-income parents who were already eligible for Medicaid when the ACA was passed. Any gains in coverage would typically be expected to improve access to and affordability of care, but there were concerns that by increasing the total population with coverage and thereby straining provider capacity, that the ACA would reduce access to care for individuals who were already eligible for Medicaid prior to the passage of the law. We found that the expansion reduced uninsurance among previously eligible parents by 12.6 percentage points, or a 40 percent decline from their 2012–2013 uninsurance rate. Moreover, these effects grew stronger over time with a 55 percent decline in uninsurance 2 to 3 years following expansion. Though we identified very few statistically significant impacts of the expansion on affordability of care, descriptive estimates show substantial declines in unmet needs due to cost and problems paying family medical bills. Descriptively, we find no significant increases in provider access problems for previously eligible parents, and very limited evidence that the Medicaid expansion was associated with more constrained provider capacity. Though sample size constraints were likely a factor in our ability to identify impacts on access and affordability measures, our overall findings suggest that the ACA Medicaid expansion positively affected our sample of low-income parents who met pre-ACA Medicaid eligibility criteria.

Children's Health Insurance Coverage: Progress, Problems, And Priorities For 2021 And Beyond

Expansion of Medicaid and establishment of the Children's Health Insurance Program (CHIP) represent a significant success story in the national effort to guarantee health insurance for children. That success is reflected in the high rates of coverage and health care access achieved for children, including those in low-income families. But significant coverage gaps remain-gaps that have been increasing since 2016 and are likely to accelerate with the coronavirus disease 2019 (COVID-19) pandemic and the associated recession. Using National Health Interview Survey data, we found that the proportion of uninsured children was 5.5 percent in 2018. Children continue to face coverage interruptions, and Latino, adolescent, and noncitizen children continue to face elevated risks of being uninsured. Although we note the benefits of a universal, federally financed, single-payer approach to coverage, we also offer two possible reform pathways that can take place within the current multipayer system, aimed at ensuring coverage, access, continuity, and comprehensiveness to move the nation closer to the goal of providing the health care that children need to reach their full potential and to reduce racial and economic inequalities.

ACA Medicaid Expansion and Insurance Coverage Among New Mothers Living in Poverty

BACKGROUND

Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act's (ACA's) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty.

METHODS

We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010-2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers.

RESULTS

A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers.

CONCLUSIONS

ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.

Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey

OBJECTIVE

Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices.

STUDY DESIGN

We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California.

RESULTS

Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in.

CONCLUSIONS

We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.

Medicaid/CHIP Participation Reached 93.7 Percent Among Eligible Children In 2016

Children's participation in Medicaid and the Children's Health Insurance Program (CHIP) rose by 5 percentage points between 2013 and 2016. As a result, 1.7 million fewer Medicaid/CHIP-eligible children were uninsured in 2016. Participation was lower among adults than among children, and nearly 6 million Medicaid-eligible adults were uninsured in 2016.

Opioid and Substance Use Disorder and Receipt of Treatment Among Parents Living With Children in the United States, 2015-2017

PURPOSE

Little is known about the prevalence of opioid use disorder (OUD) among parents who are living with children and their receipt of treatment, which could reduce the harmful effects of OUD on families.

METHODS

We used 2015-2017 cross-sectional national survey data to estimate prevalence and treatment of opioid use disorder and other substance use disorders (SUD) among parents living with children.

RESULTS

An estimated 623,000 parents with opioid use disorder are living with children, and less than one-third of these parents received treatment for illicit drug or alcohol use at a specialty facility or doctor's office. Treatment rates were even lower among the more than 4,000,000 parents estimated to have other SUDs.

CONCLUSION

Many parents in both groups have concurrent mental health issues, including suicidal thoughts and behavior. Primary care practices can play a critical role in screening and facilitating treatment initiation.

Most Primary Care Physicians Provide Appointments, But Affordability Remains A Barrier For The Uninsured

The US uninsurance rate has nearly been cut in half under the Affordable Care Act, and access to care has improved for the newly insured, but less is known about how the remaining uninsured have fared. In 2012-13 and again in 2016 we conducted an experiment in which trained auditors called primary care offices, including federally qualified health centers, in ten states. The auditors portrayed uninsured patients seeking appointments and information on the cost of care and payment arrangements. In both time periods, about 80 percent of uninsured callers received appointments, provided they could pay the full cash amount. However, fewer than one in seven callers in both time periods received appointments for which they could make a payment arrangement to bring less than the full amount to the visit. Visit prices in both time periods averaged about $160. Trends were largely similar across states, despite their varying changes in the uninsurance rate. Federally qualified health centers provided the highest rates of primary care appointment availability and discounts for uninsured low-income patients.

Changes in primary care access at community health centers between 2012/2013 and 2016

OBJECTIVE

To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act.

DATA SOURCE

Ten state primary care audit conducted in 2012/2013 and 2016.

STUDY DESIGN

CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type.

PRINCIPAL FINDINGS

In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance.

CONCLUSION

Appointment availability at CHCs improved after ACA implementation, without increased wait times.

Previous Medicaid Expansion May Have Had Lasting Positive Effects On Oral Health Of Non-Hispanic Black Children

Healthy tooth development starts early in life, beginning even before birth. We present new evidence suggesting that a historic public health insurance expansion for pregnant women and children in the United States in the 1980s and 1990s may have had long-lasting effects on the oral health of the children gaining eligibility. We estimated the relationship between adult oral health and the extent of state public health insurance eligibility for pregnant women, infants, and children throughout childhood separately for non-Hispanic whites, non-Hispanic blacks, and Hispanics. We found that expanded Medicaid coverage geared toward pregnant women and children during their first year of life was linked to better oral health in adulthood among non-Hispanic blacks. Our results also suggested that there might be a benefit to expanded public health insurance eligibility for children at ages 1-6 among non-Hispanic blacks and Hispanics. Medicaid expansions appear to have had long-lasting effects for certain low-income children and helped narrow racial/ethnic disparities in adult oral health.

Medicaid Versus Marketplace Coverage For Near-Poor Adults: Effects On Out-Of-Pocket Spending And Coverage

In states that expanded Medicaid eligibility under the Affordable Care Act, nonelderly near-poor adults-those with family incomes of 100-138 percent of the federal poverty level-are generally eligible for Medicaid, with no premiums and minimal cost sharing. In states that did not expand eligibility, these adults may qualify for premium tax credits to purchase Marketplace plans that have out-of-pocket premiums and cost-sharing requirements. We used data for 2010-15 to estimate the effects of Medicaid expansion on coverage and out-of-pocket expenses, compared to the effects of Marketplace coverage. For adults with family incomes of 100-138 percent of poverty, living in a Medicaid expansion state was associated with a 4.5-percentage-point reduction in the probability of being uninsured, a $344 decline in average total out-of-pocket spending, a 4.1-percentage-point decline in high out-of-pocket spending burden (that is, spending more than 10 percent of income), and a 7.7-percentage-point decline in the probability of having any out-of-pocket spending relative to living in a nonexpansion state. These findings suggest that policies that substitute Marketplace for Medicaid eligibility could lower coverage rates and increase out-of-pocket expenses for enrollees.

Declining Medicaid Fees and Primary Care Appointment Availability for New Medicaid Patients

This study examines the association of reduced Medicaid reimbursement with a decrease in office-visit appointment availability for new Medicaid patients.

Newly Eligible Enrollees In Medicaid Spend Less And Use Less Care Than Those Previously Eligible

Understanding the health care spending and utilization of various types of Medicaid enrollees is important for assessing the budgetary implications of both expansion and contraction in Medicaid enrollment. Despite the intense debate surrounding the Affordable Care Act (ACA), however, little information is available on the spending and utilization patterns of the nonelderly adult enrollees who became newly eligible for Medicaid under the ACA. Using data for 2012-14 from the Medical Expenditure Panel Survey, we compared health care spending and utilization of newly eligible Medicaid enrollees with those of nondisabled adults who were previously eligible and enrolled. We found that average monthly expenditures for newly eligible enrollees were $180-21 percent less than the $228 average for previously eligible enrollees. Utilization differences between these groups likely contributed to this differential.

Primary Care Appointment Availability and the ACA Insurance Expansions

In the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, both Medicaid patients and the privately insured experienced a one-day increase in median wait times. Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new Medicaid enrollees. In this Issue Brief, we summarize our study’s findings, expand on possible explanations, and extend the analysis by examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these results suggest coverage provisions in the ACA have not overwhelmed primary care capacity.

Access to Primary Care Appointments Following 2014 Insurance Expansions

PURPOSE

The Patient Protection and Affordable Care Act (ACA) expanded coverage to roughly 12 million individuals by mid-2014 and 20 million by 2016, raising concern about the capacity of the primary care system to absorb these individuals. We set out to determine how justified the concern was.

METHODS

We used an audit design in which simulated patients called primary care practices seeking new-patient appointments in 10 diverse states (Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas) from November 2012 through March 2013 and from May 2014 through July 2014, before and after the major ACA insurance expansions. Callers were randomly assigned to scripts specifying either private or Medicaid insurance and called only offices identified as "in network" for each plan.

RESULTS

We completed 5,385 private insurance and 4,352 Medicaid calls in 2012-2013 and 2,424 private insurance and 2,474 Medicaid calls in 2014. Overall appointment rates for private insurance remained stable from 2012 (84.7%) to 2014 (85.8%) with Massachusetts and Pennsylvania experiencing significant increases. Overall, Medicaid appointment rates increased 9.7 percentage points (57.9% to 67.6%) with substantial variation by state. Across all callers, median wait times for those obtaining an appointment were 7 days in 2012 and 5 days in 2014, but the difference was not statistically significant.

CONCLUSIONS

Contrary to widespread concern, we find no evidence that the millions of individuals newly insured through the ACA decreased new-patient appointment availability across 10 states as shown by stable wait times and appointment rates for private insurance as of mid-2014.

The search for a national child health coverage policy

Thirty-eight percent of US children depend on publicly financed health insurance, reflecting both its expansion and the steady erosion of employment-based coverage. Continued funding for the Children's Health Insurance Program (CHIP) is an immediate priority. But broader reforms aimed at improving the quality of coverage for all insured children, with a special emphasis on children living in low-income families, are also essential. This means addressing the "family glitch," which bars premium subsidies for children whose parents have access to affordable self-only employer-sponsored benefits. It also means addressing the quality of health plans sold in the individual and small-group markets-whether or not purchased through the state and federal exchanges-that are governed by the "essential health benefit" standard of the Affordable Care Act (ACA). In this article we examine trends in coverage and the role of Medicaid and CHIP. We also consider how the ACA has shaped child health financing, and we discuss critical issues in the broader insurance market and the need to ensure plan quality, including the scope of coverage, use of a pediatric medical necessity standard that emphasizes growth and development, the structure of pediatric provider networks, and attention to the quality of pediatric health care.

California's Early Coverage Expansion under the Affordable Care Act: A County-Level Analysis

OBJECTIVE

To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an "early expansion" under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes.

DATA SOURCES/STUDY SETTING

2008-2012 American Community Survey (ACS). The sample contained California adults ages 19-64 years (n = 237,876) and children 0-18 years (n = 113,159) with incomes below 200 percent of the federal poverty level.

STUDY DESIGN

Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children.

PRINCIPAL FINDINGS

Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment.

CONCLUSIONS

California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA.

The Role of Public Health Insurance in Reducing Child Poverty

Over the past 30 years, there have been major expansions in public health insurance for low-income children in the United States through Medicaid, the Children's Health Insurance Program (CHIP), and other state-based efforts. In addition, many low-income parents have gained Medicaid coverage since 2014 under the Affordable Care Act. Most of the research to date on health insurance coverage among low-income populations has focused on its effect on health care utilization and health outcomes, with much less attention to the financial protection it offers families. We review a growing body of evidence that public health insurance provides important financial benefits to low-income families. Expansions in public health insurance for low-income children and adults are associated with reduced out of pocket medical spending, increased financial stability, and improved material well-being for families. We also review the potential poverty-reducing effects of public health insurance coverage. When out of pocket medical expenses are taken into account in defining the poverty rate, Medicaid plays a significant role in decreasing poverty for many children and families. In addition, public health insurance programs connect families to other social supports such as food assistance programs that also help reduce poverty. We conclude by reviewing emerging evidence that access to public health insurance in childhood has long-term effects for health and economic outcomes in adulthood. Exposure to Medicaid and CHIP during childhood has been linked to decreased mortality and fewer chronic health conditions, better educational attainment, and less reliance on government support later in life. In sum, the nation's public health insurance programs have many important short- and long-term poverty-reducing benefits for low-income families with children.

Medicaid Expansions from 1997 to 2009 Increased Coverage and Improved Access and Mental Health Outcomes for Low-Income Parents

OBJECTIVE

To assess the effects of past Medicaid eligibility expansions to parents on coverage, access to care, out-of-pocket (OOP) spending, and mental health outcomes, and consider implications for the Affordable Care Act (ACA) Medicaid expansion.

DATA SOURCES

Person-level data from the National Health Interview Survey (1998-2010) is used to measure insurance coverage and related outcomes for low-income parents. Using state identifiers available at the National Center for Health Statistics Research Data Center, we attach state Medicaid eligibility thresholds for parents collected from a variety of sources to NHIS observations.

STUDY DESIGN

We use changes in the Medicaid eligibility threshold for parents within states over time to identify the effects of changes in eligibility on low-income parents.

PRINCIPAL FINDINGS

We find that expanding Medicaid eligibility increases insurance coverage, reduces unmet needs due to cost and OOP spending, and improves mental health status among low-income parents. Moreover, our findings suggest that uninsured populations in states not currently participating in the ACA Medicaid expansion would experience even larger improvements in coverage and related outcomes than those in participating states if they chose to expand eligibility.

CONCLUSIONS

The ACA Medicaid expansion has the potential to improve a wide variety of coverage, access, financial, and health outcomes for uninsured parents in states that choose to expand coverage.

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign

OBJECTIVE

To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits.

DATA SOURCES

West Virginia Medicaid enrollment and claims data from 2005 to 2010.

STUDY DESIGN

We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps.

DATA COLLECTION

Data were obtained from the West Virginia Bureau for Medical Services.

PRINCIPAL FINDINGS

We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan.

Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided states with the option of expanding eligibility for federally funded public insurance to low-income immigrant children within their first five years of legal residence in the United States. By 2011 twenty states and the District of Columbia had adopted that option. Using cross-sectional data from the 2003, 2007, and 2011-12 National Survey of Children's Health, we compared trends in coverage and access to care among immigrant children in states that did expand eligibility to children in states that did not. Compared to immigrant children in states that did not expand eligibility, children in states expanding eligibility experienced a 24.5 percent increase in insurance coverage, largely due to greater enrollment in public insurance. Immigrant children in states that expanded eligibility also experienced significant reductions in unmet health care needs, compared to their counterparts in nonexpansion states. Disparities relative to children in nonimmigrant families were substantially reduced in states that expanded eligibility, compared to states that did not. Expanding eligibility for federally funded public insurance to immigrant children within their first five years of legal residence in other states could improve coverage for immigrant children and might also increase access to care.

Availability of New Medicaid Patient Appointments and the Role of Rural Health Clinics

OBJECTIVE

To examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers.

DATA SOURCES

Experimental (audit) data from a 10-state study of primary care practices, county-level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services.

STUDY DESIGN

We generate appointment rates for rural and nonrural areas by patient-payer type (private, Medicaid, self-pay) to then motivate our focus on within-rural variation by clinic type (RHC vs. non-RHC). Multivariate linear models test for statistical differences and assess the estimates' sensitivity to the inclusion of control variables.

DATA COLLECTION

The primary data are from a large field study.

PRINCIPAL FINDINGS

Approximately 80 percent of Medicaid callers receive an appointment in rural areas-a rate more than 20 percentage points greater than nonrural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non-RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment.

CONCLUSIONS

Our study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees.

Medicaid family planning waivers in 3 States: did they reduce unwanted births?

Effects of Medicaid family planning waivers on unintended births and contraceptive use postpartum were examined in Illinois, New York, and Oregon using the Pregnancy Risk Assessment Monitoring System. Estimates for women who would be Medicaid eligible "if" pregnant in the waiver states and states without expansions were derived using a difference-in-differences approach. Waivers in New York and Illinois were associated with almost a 5.0 percentage point reduction in unwanted births among adults and with a 7 to 8.0 percentage point reduction, among youth less than 21 years of age. Oregon's waiver was associated with an almost 13 percentage point reduction in unintended, mostly mistimed, births. No statistically significant effects were found on contraceptive use.

New evidence on the Affordable Care Act: coverage impacts of early medicaid expansions

The Affordable Care Act expands Medicaid in 2014 to millions of low-income adults in states that choose to participate in the expansion. Since 2010 California, Connecticut, Minnesota, and Washington, D.C., have taken advantage of the law's option to expand coverage earlier to a portion of low-income childless adults. We present new data on these expansions. Using administrative records, we documented that the ramp-up of enrollment was gradual and linear over time in California, Connecticut, and D.C. Enrollment continued to increase steadily for nearly three years in the two states with the earliest expansions. Using survey data on the two earliest expansions, we found strong evidence of increased Medicaid coverage in Connecticut (4.9 percentage points; $$p ) and positive but weaker evidence of increased coverage in D.C. (3.7 percentage points; $$p=\mathbf{\boldsymbol{0.08}}$$). Medicaid enrollment rates were highest among people with health-related limitations. We found evidence of some crowd-out of private coverage in Connecticut (30-40 percent of the increase in Medicaid coverage), particularly for healthier and younger adults, and a positive spillover effect on Medicaid enrollment among previously eligible parents.

Appointment availability after increases in Medicaid payments for primary care

BACKGROUND

Providing increases in Medicaid reimbursements for primary care, a key provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers. The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states before policymakers had much empirical evidence about its effects.

METHODS

We measured the availability of and waiting times for appointments in 10 states during two periods: from November 2012 through March 2013 and from May 2014 through July 2014. Trained field staff posed as either Medicaid enrollees or privately insured enrollees seeking new-patient primary care appointments. We estimated state-level changes over time in a stable cohort of primary care practices that participated in Medicaid to assess whether willingness to provide appointments for new Medicaid enrollees was related to the size of increases in Medicaid reimbursements in each state.

RESULTS

The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups.

CONCLUSIONS

Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.).

The impact of recent CHIP eligibility expansions on children's insurance coverage, 2008-12

Following the reauthorization of the Children's Health Insurance Program (CHIP) in 2009, fifteen states raised their CHIP income eligibility thresholds to further reduce uninsurance among children. We examined the impact of these expansions on uninsurance, public insurance, and private insurance among children who became newly eligible for CHIP after the expansions. Using a difference-in-differences approach, we estimated that the expansions reduced uninsurance by 1.1 percentage points among the newly eligible, cutting their uninsurance rate by nearly 15 percent. Public coverage increased by 2.9 percentage points, with variations in take-up among the states. A better understanding of these state-level differences in take-up could inform efforts to enroll children who remain uninsured but are eligible for CHIP. CHIP is up for reauthorization in 2015, and further funding will be needed to maintain the program, which provides insurance to children who might not have access to affordable private coverage.

Primary care access for new patients on the eve of health care reform

IMPORTANCE

Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients.

OBJECTIVE

To assess primary care appointment availability by state and insurance status.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state.

MAIN OUTCOMES AND MEASURES

The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured.

RESULTS

Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to $75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern.

CONCLUSIONS AND RELEVANCE

Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plan's network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

The effects of express lane eligibility on Medicaid and CHIP enrollment among children

OBJECTIVE

To estimate the impact of Express Lane Eligible (ELE) implementation on Medicaid/CHIP enrollment in eight states.

DATA SOURCES/STUDY SETTING

2007 to 2011 data from the Statistical Enrollment Data System (SEDS) on Medicaid/CHIP enrollment.

STUDY DESIGN

We estimate difference-in-difference equations, with quarter and state fixed effects. The key independent variable is an indicator for whether the state had ELE in place in the given quarter, allowing the experience of statistically matched non-ELE states to serve as a formal counterfactual against which to assess the changes in the eight ELE states. The model also controls for time-varying economic and policy factors within each state.

DATA COLLECTION/EXTRACTION METHODS

We obtained SEDS enrollment data from CMS.

PRINCIPAL FINDINGS

Across model specifications, the ELE effects on Medicaid enrollment among children were consistently positive, ranging between 4.0 and 7.3 percent, with most estimates statistically significant at the 5 percent level. We also find that ELE increased combined Medicaid/CHIP enrollment.

CONCLUSIONS

Our results imply that ELE has been an effective way for states to increase enrollment and retention among children eligible for Medicaid/CHIP. These results also imply that ELE-like policies could improve take-up of subsidized coverage under the ACA.

Determinants of receipt of recommended preventive services: implications for the Affordable Care Act

OBJECTIVES

We examined preventive care use by nonelderly adults (aged 18-64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.

METHODS

We used data from the 2005-2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.

RESULTS

There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.

CONCLUSIONS

Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.

The health reform monitoring survey: addressing data gaps to provide timely insights into the affordable care act

The Health Reform Monitoring Survey (HRMS) was launched in 2013 as a mechanism to obtain timely information on the Affordable Care Act (ACA) during the period before federal government survey data for 2013 and 2014 will be available. Based on a nationally representative, probability-based Internet panel, the HRMS provides quarterly data for approximately 7,400 nonelderly adults and 2,400 children on insurance coverage, access to health care, and health care affordability, along with special topics of relevance to current policy and program issues in each quarter. For example, HRMS data from summer 2013 show that more than 60 percent of those targeted by the health insurance exchanges struggle with understanding key health insurance concepts. This raises concerns about some people's ability to evaluate trade-offs when choosing health insurance plans. Assisting people as they attempt to enroll in health coverage will require targeted education efforts and staff to support those with low health insurance literacy.

Preventive and reproductive health services for women: the role of California's family planning waiver

PURPOSE

Examine effects of a Medicaid family planning waiver on the receipt of reproductive health care and pregnancy.

DESIGN

The present study uses a quasi-experimental design using data from the California Women's Health Survey and the Behavioral Risk Factor Surveillance System (BRFSS) for exposure and comparison groups, before and after California's Planning Access Care and Treatment waiver.

SETTING

The setting was California and comparison states.

SUBJECTS

The study included women who were ages 18 to 44 years and below 200% of the federal poverty level (FPL), who are eligible for services under the waiver.

MEASURES

The study measured self-reported pregnancy and receipt of routine checkup, clinical breast exam, Pap test, Chlamydia screening, and discussion of birth control with provider in the past year.

ANALYSIS

The study analyzes outcomes for exposure and comparison groups using probit regression models based on data both within California and in states without waivers.

RESULTS

Estimates from the California Women's Health Survey analysis indicate that among parents 100% to 200% of the FPL, the waiver led to an 8-percentage point increase in the receipt of a routine checkup and a 12-percentage point increase (p = .03) in discussion of birth control. There was an estimated 3-percentage point decline (p = .05) in current pregnancies among nulliparous women. Multistate analysis using the BRFSS confirmed positive effects on routine checkups (p < .01).

CONCLUSIONS

The waiver appears to have led to a reduction in pregnancy rates and increased receipt of reproductive health care, particularly routine checkups.

Lessons from early Medicaid expansions under health reform: interviews with Medicaid officials

BACKGROUND

The Affordable Care Act (ACA) dramatically expands Medicaid in 2014 in participating states. Meanwhile, six states have already expanded Medicaid since 2010 to some or all of the low-income adults targeted under health reform. We undertook an in-depth exploration of these six "early-expander" states-California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington-through interviews with high-ranking Medicaid officials.

METHODS

We conducted semi-structured interviews with 11 high-ranking Medicaid officials in six states and analyzed the interviews using qualitative methods. Interviews explored enrollment outreach, stakeholder involvement, impact on beneficiaries, utilization and costs, implementation challenges, and potential lessons for 2014. Two investigators independently analyzed interview transcripts and iteratively refined the codebook until reaching consensus.

RESULTS

We identified several themes. First, these expansions built upon pre-existing state-funded insurance programs for the poor. Second, predictions about costs and enrollment were challenging, indicating the uncertainty in projections for 2014. Other themes included greater than anticipated need for behavioral health services in the expansion population, administrative challenges of expansions, and persistent barriers to enrollment and access after expanding eligibility-though officials overall felt the expansions increased access for beneficiaries. Finally, political context-support or opposition from stakeholders and voters-plays a critical role in shaping the success of Medicaid expansions.

CONCLUSIONS

Early Medicaid expansions under the ACA offer important lessons to federal and state policymakers as the 2014 expansions approach. While the context of each state's expansion is unique, key shared experiences were significant implementation challenges and opportunities for expanding access to needed services.

Health status, risk factors, and medical conditions among persons enrolled in Medicaid vs uninsured low-income adults potentially eligible for Medicaid under the Affordable Care Act

IMPORTANCE

Under the Affordable Care Act (ACA), states can extend Medicaid eligibility to nearly all adults with income no more than 138% of the federal poverty level. Uncertainty exists regarding the scope of medical services required for new enrollees.

OBJECTIVE

To document the health care needs and health risks of uninsured adults who could gain Medicaid coverage under the ACA. These data will help physicians, other clinicians, and state Medicaid programs prepare for the possible expansions.

DESIGN, SETTING, AND PATIENTS

Data from the National Health and Nutrition Examination Survey 2007-2010 were used to analyze health conditions among a nationally representative sample of 1042 uninsured adults aged 19 through 64 years with income no more than 138% of the federal poverty level, compared with 471 low-income adults currently enrolled in Medicaid.

MAIN OUTCOMES AND MEASURES

Prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests, measures of self-reported health status including medical conditions, and risk factors such as measured obesity status.

RESULTS

Compared with those already enrolled in Medicaid, uninsured adults were less likely to be obese and sedentary and less likely to report a physical, mental, or emotional limitation. They also were less likely to have several chronic conditions. For example, 30.1% (95% CI, 26.8%-33.4%) of uninsured adults had hypertension, hypercholesterolemia, or diabetes compared with 38.6% (95% CI, 32.0%-45.3%) of those enrolled in Medicaid (P = .02). However, if they had these conditions, uninsured adults were less likely to be aware of them and less likely to have them controlled. For example, 80.1% (95% CI, 75.2%-85.1%) of the uninsured adults with at least 1 of these 3 conditions had at least 1 uncontrolled condition, compared with 63.4% (95% CI, 53.7%-73.1%) of adults enrolled in Medicaid.

CONCLUSION AND RELEVANCE

Compared with adults currently enrolled in Medicaid, uninsured low-income adults potentially eligible to enroll in Medicaid under the ACA had a lower prevalence of many chronic conditions. A substantial proportion of currently uninsured adults with chronic conditions did not have good disease control; projections based on sample weighting suggest this may represent 3.5 million persons (95% CI, 2.9 million-4.2 million). These adults may need initial intensive medical care following Medicaid enrollment.

The effects of Medicaid policy changes on adults' service use patterns in Kentucky and Idaho

BACKGROUND

In 2006, Idaho and Kentucky became two of the first states to implement changes to their Medicaid programs under authority granted by the 2005 Deficit Reduction Act (DRA). The DRA granted new flexibility in the design of state Medicaid programs, including a state plan amendment (SPA) option for changes that previously would have required a waiver. This paper uses state Medicaid administrative data to analyze the impact of Medicaid policy changes implemented in these states through a series of SPAs in 2006 and 2007.

METHODS

Changes in utilization are examined for multiple services, including physician, dental, and ER visits, inpatient stays, and prescriptions, among non-elderly adult Medicaid recipients following changes in cost sharing, reimbursement, service delivery, and covered services. Where possible, enrollees not affected by the changes served as a comparison group.

RESULTS

While relatively few adults in Idaho received a wellness exam after such coverage was added, the adoption of managed care for dental services was associated with increased receipt of dental care, including preventive care. The new limits on brand name prescriptions in Kentucky were associated with a reduction in the proportion of enrollees with two or more monthly name brand prescriptions while the small copayments introduced did not appear to have a dramatic impact.

CONCLUSIONS

We find that changes in financial incentives on both the supply-side (such as reimbursement increases) and the demand-side (i.e., benefit changes) alone may not be enough to generate the desired levels of preventive care, especially among those with chronic health conditions.

Variation in Medicaid eligibility and participation among adults: implications for the Affordable Care Act

Steep declines in the uninsured population under the Affordable Care Act (ACA) will depend on high enrollment among newly Medicaid-eligible adults. We use the 2009 American Community Survey to model pre-ACA eligibility for comprehensive Medicaid coverage among nonelderly adults. We identify 4.5 million eligible but uninsured adults. We find a Medicaid participation rate of 67% for adults; the rate is 17 percentage points lower than the national Medicaid participation rate for children, and it varies substantially across socioeconomic and demographic subgroups and across states. Achieving substantial increases in coverage under the ACA will require sharp increases in Medicaid participation among adults in some states.