Impact of Enroll America on the Number of Individuals Covered through the Federally Facilitated Marketplace.

OBJECTIVE: To assess the impact of Enroll America's field outreach activities on the number of individuals enrolled in Marketplace coverage during the first open enrollment period. DATA SOURCES/STUDY SETTING: Marketplace enrollment for the initial open enrollment period linked with data on Enroll America's field activities and baseline local-area demographic, economic, and health services characteristics. STUDY DESIGN: We used a quasi-experimental design, comparing Marketplace enrollment during the first open enrollment period in local areas drawn from Enroll America field states to a comparison group of local areas drawn from states that were not served by Enroll America's field effort, but that otherwise match up well with Enroll America states. PRINCIPAL FINDINGS: We find evidence of a large, positive effect of Enroll America's field outreach on Marketplace enrollment in non-Medicaid expansion states. Across model specifications, the Enroll America effects on Marketplace enrollment ranged between 10 and 15 percent, with most estimates statistically significant at the 5 percent level. CONCLUSIONS: Enroll America played an important role in the success of individual states' efforts to boost Marketplace enrollment. Enroll American's evidence-driven, grassroots approach could serve as a model for others interested in conducting similar outreach campaigns for Affordable Care Act-related coverage.

Association Between Extending CareFirst's Medical Home Program to Medicare Patients and Quality of Care, Utilization, and Spending.

Importance: CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients. From 2013 to 2015, CareFirst extended the program to Medicare fee-for-service (FFS) beneficiaries in participating practices. If the model extension improved quality while reducing spending, the Centers for Medicare and Medicaid Services could expand the program to Medicare beneficiaries broadly. Objective: To test whether extending CareFirst's program to Medicare FFS patients improves care processes and reduces hospitalizations, emergency department visits, and spending. Design, Setting, and Participants: This difference-in-differences analysis compared outcomes for roughly 35 000 Medicare FFS patients attributed to 52 intervention practices (grouped by CareFirst into 14 "medical panels") to outcomes for 69 000 Medicare patients attributed to 42 matched comparison panels during a 1-year baseline period and 2.5-year intervention at Maryland primary care practices. Main Outcomes and Measures: Hospitalizations (all-cause and ambulatory-care sensitive), emergency department visits, Medicare Part A and B spending, and 3 quality-of-care process measures: ambulatory care within 14 days of a hospital stay, cholesterol testing for those with ischemic vascular disease, and a composite measure for those with diabetes. Interventions: CareFirst hired nurses who worked with patients' usual primary care practitioners to coordinate care for 3656 high-risk Medicare patients. CareFirst paid panels rewards for meeting cost and quality targets for their Medicare patients and advised panels on how to meet these targets based on analyses of claims data. Results: On average, each of the 14 intervention panels had 9.3 primary care practitioners and was attributed 2202 Medicare FFS patients in the baseline period. The panels' attributed Medicare patients were, on average, 73.8 years old, 59.2% female, and 85.1% white. The extension of CareFirst's program to Medicare patients was not statistically associated with improvements in any outcomes, either for the full Medicare population or for a high-risk subgroup in which impacts were expected to be largest. For the full population, the difference-in-differences estimates were 1.4 hospitalizations per 1000 patients per quarter (P = .54; 90% CI, -2.1 to 5.0), -2.5 outpatient ED visits per 1000 patients per quarter (P = .26; 90% CI, -6.2 to 1.1), and -$1 per patient per month in Medicare Part A and B spending (P = .98; 90% CI, -$40 to $39). For hospitalizations and Medicare spending, the 90% CIs did not span CareFirst's expected impacts. Hospitalizations for the intervention group declined by 10% from baseline year to the final 18 months of the intervention, but this was matched by similar declines in the comparison group. Conclusion and Relevance: The extension of CareFirst's program to Medicare did not measurably improve quality-of-care processes or reduce service use or spending for Medicare patients. Further program refinement and testing would be needed to support scaling the program more broadly to Medicare patients.

The Affordable Care Act and Access to Care for People Changing Coverage Sources.

OBJECTIVES: We investigated how access to and continuity of care might be affected by transitions between health insurance coverage sources, including the Marketplace (also called the Exchange), Medicaid, and the Children's Health Insurance Program (CHIP). METHODS: From January to February 2014 and from August to September 2014, we searched provider directories for networks of primary care physicians and selected pediatric specialists participating in Marketplace, Medicaid, and CHIP in 6 market areas of the United States and calculated the degree to which networks overlapped. RESULTS: Networks of physicians in Medicaid and CHIP were nearly identical, meaning transitions between those programs may not result in much physician disruption. This was not the case for Marketplace and Medicaid and CHIP networks. CONCLUSIONS: Transitions from the Marketplace to Medicaid or CHIP may result in different degrees of physician disruption for consumers depending on where they live and what type of Marketplace product they purchase.

Program Churning and Transfers Between Medicaid and CHIP.

OBJECTIVE: In the 10 states that are the focus of the Children's Health Insurance Program Reauthorization Act of 2009 evaluation, we analyze in detail the states' recent progress in retaining children in public coverage and public coverage churning. METHODS: We used administrative data spanning a five-and-a-half-year period collected from 10 study states-Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia-to analyze the extent to which children return to the same program a short time after disenrollment and the extent to which transfers between Medicaid and Children's Health Insurance Program (CHIP) lead to public coverage gaps. RESULTS: Our analysis yielded 3 key findings. First, many children moved between Medicaid and CHIP; while most transitioned seamlessly, coverage gaps occurred for as many as 40%, depending on the type of transition. Second, churning continued to be a concern for public coverage programs, with approximately 21% of Medicaid disenrollees and 10% of separate CHIP disenrollees returning to the same program within 7 months. Third, we found sizable differences in rates of program churning and nonseamless program transfers across the 10 study states. CONCLUSIONS: Notable variation existed across programs and states, which persisted over the period in public program churning. These results suggest the need for continued efforts to simplify renewal processes, particularly in state Medicaid programs, along with the adoption of processes that improve coordination across programs and policies that simplify these transfers.