The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity.

Importance: Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. Objective: To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. Evidence Review: Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. Findings: Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. Conclusions and Relevance: Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Health Care Access and Management of Cardiovascular Risk Factors Among Working-Age Adults With Low Income by State Medicaid Expansion Status.

Importance: Medicaid expansion led to gains in insurance coverage among working-age adults with low income. To date, the extent to which disparities in access and cardiovascular care persist for this population in Medicaid nonexpansion and expansion states is unknown. Objective: To compare insurance coverage, health care access, and cardiovascular risk factor management between working-age adults (age 18-64 years) with low income in Medicaid nonexpansion and expansion states and between uninsured and insured adults in these states. Design, Setting, and Participants: This cross-sectional study analyzed data on adults aged 18 to 64 years with low income from the Behavioral Risk Factor Surveillance System from January 1 to December 31, 2019. Exposures: State Medicaid expansion and insurance status. Main Outcomes and Measures: The main outcomes were health care access and monitoring and treatment of cardiovascular risk factors. The estimated adjusted risk difference (RD) in outcomes was estimated to compare adults in Medicaid nonexpansion and expansion states and uninsured and insured individuals in nonexpansion and expansion states. Results: The weighted study population consisted of 28 028 451 working-age adults with low income, including 10 094 994 (36.0%) in Medicaid nonexpansion states (63.4% female) and 17 933 457 (64.0%) in expansion states (59.2% female). Adults in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2%-44.7%] vs 23.8% [95% CI, 22.8%-24.8%]), were less likely to have a usual source of care (55.4% [95% CI, 53.1%-57.6%] vs 65.4% [95% CI, 64.3%-66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]) or a recent examination (78.9% [95% CI, 77.0%-80.9%] vs 84.4% [95% CI, 83.5%-85.2%]; RD, -6.2% [95% CI, -8.4% to -4.0%]), and were more likely to have deferred care owing to cost (36.1% [95% CI, 34.0%-38.2%] vs 21.8% [95% CI, 20.9%-22.8%]; RD, 14.2% [95% CI, 11.9%-16.6%]) than were those in expansion states. There were no significant differences in cardiovascular risk factor management between these groups. In nonexpansion states, uninsured adults had significantly worse access to care across these measures and were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7%-77.4%] vs 93.7%; [95% CI, 92.4%-95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1c (55.2% [95% CI, 40.0%-72.5%] vs 88.5% [95% CI, 79.2%-97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]) levels or to receive treatment for hypertension (49.4% [95% CI, 43.3%-55.6%] vs 74.7% [95% CI, 71.5%-78.0%]; RD, -16.3% [95% CI, -23.2% to -9.4%]) and hyperlipidemia (30.2% [95% CI, 23.5%-36.8%] vs 58.7% [95% CI, 53.9%-63.5%]; RD, -19.3% [95% CI, -27.9% to -10.7%]) compared with insured adults. These patterns were similar for uninsured and insured adults in expansion states. Conclusions and Relevance: In this study, working-age adults with low income in Medicaid nonexpansion states experienced higher uninsurance rates and worse access to care than did those in expansion states; however, cardiovascular risk factor management was similar and treatment rates were low. In nonexpansion states, uninsured adults were less likely to receive appropriate cardiovascular risk factor management compared with insured adults.

Health insurance expansion and family violence prevention: A conceptual framework.

Family violence, including child maltreatment (CM) and intimate partner violence (IPV), plagues far too many American families, particularly those in low-income communities. CM and IPV are intertwined and impose a significant emotional, health and financial burden on children and families and an economic burden on our country. Although these and other forms of violence are influenced by shared risk factors across the socioecological spectrum, prevention efforts typically intervene on a single type of violence at a microsystem level via individual or family intervention. Research is needed to identify policies operating at macrosystem levels that reduce, at scale, multiple forms of violence affecting children. In this paper, we propose a three-step theory of change through which health insurance expansions might reduce rates of CM and IPV, using Medicaid expansion as an exemplar. The proposed framework can inform research examining the link between health insurance and the primary prevention of CM and IPV.

Changing Pediatric Hospice and Palliative Care Through Medicaid Partnerships.

Since its inception in 2010, the Concurrent Care for Children Provision of the Affordable Care Act has enabled seriously ill pediatric patients and their families to access comprehensive, supportive hospice services while simultaneously receiving ongoing treatment-directed therapies. Although this groundbreaking federal legislation has resulted in improvements in care for vulnerable pediatric patients, the implementation of the law has varied from state to state through Medicaid programming. The pediatric professional community is called to consider how Medicaid services can more effectively be delivered by leveraging legislative mandates and collaborative relationships between clinicians, Medicaid administrators, and policy makers. In this article, we examine ways concurrent care has been executed in 3 different states and how key stakeholders in care for children with serious illness advocated to ensure effective implementation of the legislation. The lessons learned in working with state Medicaid programs are applicable to any advocacy issue impacting children and families .

Nursing home care under Medicaid managed long-term services and supports.

OBJECTIVE: To measure the impact of Medicaid managed long-term services and supports (MLTSS) on nursing home (NH) quality and rebalancing. DATA SOURCES/STUDY SETTING: This study analyzes secondary data from annual NH recertification surveys and the minimum dataset (MDS) in three states that implemented MLTSS: Massachusetts (2001-2007), Kansas and Ohio (2011-2017). STUDY DESIGN: We utilized a difference-in-difference approach comparing NHs in border counties of states that implemented MLTSS with a control group of NHs in neighboring border counties in states that did not implement MLTSS. Sensitivity analyses included a triple-difference model (stratified by Medicaid payer mix) and a within-state comparison. We examined changes in six NH-level outcomes (percentage of low-care NH residents, facility occupancy, and four NH quality measures) after MLTSS implementation. DATA COLLECTION/EXTRACTION METHODS: For each state, all freestanding NHs in border counties were included, as were NHs in neighboring counties located in other states. Information on low-care residents was aggregated to the NH level from MDS data, then combined with Online Survey Certification and Reporting (OSCAR) and Certification and Survey Provider Enhanced Reporting (CASPER) data. PRINCIPAL FINDINGS: MLTSS had no statistically significant effects on NH quality outcomes in Massachusetts or Kansas. In Ohio, MLTSS led to an increase of 0.21 nursing hours per resident day [95% CI: 0.03, 0.40], and a decrease of 1.47 deficiencies [95% CI: -2.52, -0.42] and 9.38 deficiency points [95% CI: -18.53, -0.24] per certification survey. After MLTSS, occupancy decreased by 1.52 percentage points [95% CI: -2.92, -0.12] in Massachusetts, but increased by 3.17 percentage points [95% CI: 0.36, 5.99] in Ohio. We found no effect on low-care residents in any state. Findings were moderately sensitive to the choice of comparator group. CONCLUSION: The study provides little evidence that MLTSS reduces quality of care, occupancy, or the percentage of low-care residents in NHs.

Effects of medicaid expansion on poverty disparities in health insurance coverage.

BACKGROUND: More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level. METHOD: American Community Survey (2012-2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) < 138 %, (2) 138-400 % and (3) > 400 % federal poverty level (FPL). RESULTS: Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for < 138 %, 138-400 %, and > 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and < 138 % FPL group had the highest uninsured rate. Compared with ≥ 138 % FPL groups, there was a 2.54 % reduction in uninsured risk after Medicaid expansion among < 138 % FPL group in Medicaid expansion states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18 % decrease was estimated. CONCLUSION: Poverty disparity in uninsured rates improved with Medicaid expansion. However, < 138 % FPL population are still at a higher risk for being uninsured.

Use of behavioral health care in Medicaid managed care carve-out versus carve-in arrangements.

OBJECTIVE: To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group"). DATA SOURCES/STUDY SETTING: Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016. STUDY DESIGN: In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits. DATA COLLECTION: We used Medicaid claims, including adults with at least 9 months of enrollment. PRINCIPAL FINDINGS: The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees). CONCLUSIONS: Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.

Does Medicaid coverage of Medicare cost sharing affect physician care for dual-eligible Medicare beneficiaries?

OBJECTIVE: To assess changes in physicians' provision of care to duals (low-income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare's cost sharing for office visits with these patients. This policy-a provision of the Affordable Care Act-effectively increased payments for office visits with duals by 0%-20%, depending on the state, in 2013 and 2014. DATA SOURCES: Fee-for-service claims for a 5% random sample of Medicare beneficiaries in 2010-2016. STUDY DESIGN: We conducted a difference-in-differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)-the largest subpopulation of duals for whom payment rates were affected by this policy-to changes among other low-income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple-differences analysis that compared changes between QMBs and other low-income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases. DATA COLLECTION: The study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low-income Medicare beneficiaries (1 914 073 beneficiary-years from 2010 to 2016). PRINCIPAL FINDINGS: Nationally, we did not find a differential increase in office visits among QMBs versus other low-income beneficiaries that coincided with this payment change. In the triple-differences analysis, we did not observe a greater increase in visits among QMBs vs other low-income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple-differences estimate: -0.12 annual visits, 95% CI: -0.28, 0.04; P = 0.15). CONCLUSIONS: Physicians' provision of care to low-income Medicare beneficiaries may not be responsive to short-run payment changes.

Protecting and Expanding Medicaid to Improve Women's Health: ACOG Committee Opinion, Number 826.

ABSTRACT: Medicaid, the state-federal health insurance program for individuals with low incomes, serves as a safety net for women throughout the life span. Historically, expansions of Medicaid have been associated with improved access to health care, less delay in obtaining health care, better self-reported health, and reductions in mortality. Compared with nonexpansion states, states that have participated in the Affordable Care Act's Medicaid expansion have experienced improvements in maternal and infant mortality and decreases in uninsured rates and have decreased racial inequities for these measures. In addition to supporting policies that expand access to Medicaid, the American College of Obstetricians and Gynecologists strongly supports education for its members, other obstetrician-gynecologists, and other health care practitioners regarding the complex system for regulation of Medicaid and encourages advocacy for policies that increase access to care for all women. This Committee Opinion has been revised to emphasize the importance of Medicaid to improving women's health, the history and growth of Medicaid, including the ACA's Medicaid expansion, and the mechanisms by which changes to the Medicaid program can occur, and it includes relevant examples for each.

The Future of the Indispensable Insurer: The Biden Administration and Medicaid.

Medicaid presents both legislative and regulatory challenges and opportunities. As it moves a legislative agenda forward, the Biden administration also will confront a series of immediate regulatory matters, some of which have been made urgent because of pending judicial action. Chief among these pressing matters are ending Medicaid work requirements and block grant experiments, rescinding the public charge rule, ensuring optimal use of Medicaid's enrollment and renewal simplification tools, rescinding the Title X family planning rule (which has enormous implications for Medicaid beneficiaries), and, when the time comes, preparing states to wind down the "Families First" Medicaid maintenance of effort protection while avoiding erroneous beneficiary disenrollment. The administration could consider encouraging remaining nonexpansion states to pursue §1115 Medicaid expansion experiments; additionally, the administration could pursue Medicaid pandemic recovery demonstrations to support health system recovery during the long period that lies ahead. Thus, while certain advances must await legislation, the administration can move Medicaid forward through executive action.

Economic assessment of changes to an existing medication therapy management program of a large regional health plan.

BACKGROUND: Although medication therapy management (MTM) has specific eligibility criteria and is mandated for specific Medicare Part D enrollees, some health plans have expanded MTM eligibility beyond the minimum criteria to include other Medicare Part D enrollees, Medicaid, and commercial health plan patients. Differences exist in the mode of delivery, location of services, type of personnel involved in managing the service, and the subsequent outcomes. The type and intensity of MTM services delivered have evolved with time to more streamlined and robust interventions, necessitating ongoing evaluation of the effect on clinical and economic outcomes. OBJECTIVE: To assess the effect of changes to an existing MTM program on cost of care, utilization, and medication adherence. METHODS: UPMC Health Plan made changes to an existing MTM program by expanding eligibility (customized by the type of health plan), intervention types, pharmacist involvement, and patient followup contacts. After matching our intervention cohort (identified January 2017-June 2018) with the pre-2016 MTM historical controls (patients identified January 2014-June 2015 who would have been eligible if we used the intervention cohort eligibility criteria), we estimated that the effect of the program changes with a difference-in-difference model (preintervention [2014-2016] and postintervention [2017-2019]). Outcomes of interest included cost (total cost of care including medical, pharmacy, and unplanned care [i.e., unscheduled health care use such as emergency department visits] in 2017 U.S. dollars); utilization; medication adherence (proportion of days covered); and return on investment (ROI). Target population included continuously enrolled patients aged ≥ 21 years in the commercial, Medicare, and Medicaid health plans. RESULTS: Total propensity score-matched members was 10,747, 55% of which were in the historic control group. The average (SD) ages after matching the groups were similar (historical control group: 57.08 years [14.23], intervention group: 56.79 years [14.21]) and the majority was female (57%). Comorbidities identified most for patients included hypertension (77%), dyslipidemia (70%), and diabetes (52%). Forty-one percent were in the commercial, 37% in the Medicaid, and 23% in the Medicare health plans. Proportion of care activities undertaken in the intervention period compared with the control period were significantly different: "sent letter to physician" (67% vs. 87%), "sent letter to member" (15% vs. 0%), "pharmacist phone call to physician" (15% vs. 0.1%), and "pharmacist phone call to member" (13% vs. 7%). There were statistically significant reductions in unplanned care across all health plans especially in the Medicare population, in total cost of care, and increases in medication adherence in 4 therapeutic classes: anticoagulants (OR = 1.25, P = 0.005), cardiac medications (OR = 1.20, P < 0.001), statins (OR = 1.21, P < 0.001), and antidepressants (OR = 1.15, P < 0.001). There was a positive ROI of $18.50 per dollar spent, which equated to a cumulative net savings of $11 million over 24 months. CONCLUSIONS: In a large health plan, expanding MTM eligibility, intensifying patient follow-up contact and pharmacist involvement, and improving provider awareness had favorable clinical and economic benefits. DISCLOSURES: There was no funding for this project except employees' time. All authors are employees of UPMC and have no conflicts of interest to report.