State trends in the cost of employer health insurance coverage, 2003-2013.

From 2010 to 2013--the years following the implementation of the Affordable Care Act--there has been a marked slowdown in premium growth in 31 states and the District of Columbia. Yet, the costs employees and their families pay out-of-pocket for deductibles and their share of premiums continued to rise, consuming a greater share of incomes across the country. In all but a handful of states, average deductibles more than doubled over the past decade for employees working in large and small firms. Workers are paying more but getting less protective benefits. Costs are particularly high, compared with median income, in Southern and South Central states, where incomes are below the national average. Based on recent forecasts that predict an uptick in private insurance growth rates starting in 2015, securing slow cost growth for workers, families, and employers will likely require action to address rising costs of medical care services.

How states are expanding Medicaid to low-income adults through Section 1115 waiver demonstrations.

In the wake of the Supreme Court's 2012 decision making state expansion of Medicaid to more adults optional under the Affordable Care Act, several states have received approval to combine such expansion with broader Medicaid reforms. They are doing so under Section 1115 of the Social Security Act, which authorizes Medicaid demonstrations that further program objectives. State demonstrations approved so far combine expanded adult coverage with changes in that coverage and in how the states deliver and pay for health care. These states have focused especially on expanding the use of private health insurance, requiring beneficiaries to pay premiums, and incentivizing them to choose cost-effective care. By enabling states to link wider program reforms to the adult expansion, Section 1115 has allowed them to better align Medicaid with local political conditions while extending insurance to more than 1 million adults who would otherwise lack a pathway to coverage.

Implementing the Affordable Care Act: state approaches to premium rate reforms in the individual health insurance market.

The Affordable Care Act protects people from being charged more for insurance based on factors like medical history or gender and establishes new limits on how insurers can adjust premiums for age, tobacco use, and geography. This brief examines how states have implemented these federal reforms in their individual health insurance markets. We identify state rating standards for the first year of full implementation of reform and explore critical considerations weighed by policymakers as they determined how to adopt the law's requirements. Most states took the opportunity to customize at least some aspect of their rating standards. Interviews with state regulators reveal that many states pursued implementation strategies intended primarily to minimize market disruption and premium shock and therefore established standards as consistent as possible with existing rules or market practice. Meanwhile, some states used the transition period to strengthen consumer protections, particularly with respect to tobacco rating.

Intergenerational enrollment and expenditure changes in Medicaid: trends from 1991 to 2005.

BACKGROUND: From its inception, Medicaid was aimed at providing insurance coverage for low income children, elderly, and disabled. Since this time, children have become a smaller proportion of the US population and Medicaid has expanded to additional eligibility groups. We sought to evaluate relative growth in spending in the Medicaid program between children and adults from 1991-2005. We hypothesize that this shifting demographic will result in fewer resources being allocated to children in the Medicaid program. METHODS: We utilized retrospective enrollment and expenditure data for children, adults and the elderly from 1991 to 2005 for both Medicaid and Children's Health Insurance Program Medicaid expansion programs. Data were obtained from the Centers for Medicare and Medicaid Services using their Medicaid Statistical Information System. RESULTS: From 1991 to 2005, the number of enrollees increased by 83% to 58.7 million. This includes increases of 33% for children, 100% for adults and 50% for the elderly. Concurrently, total expenditures nationwide rose 150% to $273 billion. Expenditures for children increased from $23.4 to $65.7 billion, adults from $46.2 to $123.6 billion, and elderly from $39.2 to $71.3 billion. From 1999 to 2005, Medicaid spending on long-term care increased by 31% to $84.3 billion. Expenditures on the disabled grew by 61% to $119 billion. In total, the disabled account for 43% and long-term care 31%, of the total Medicaid budget. CONCLUSION: Our study did not find an absolute decrease in the overall resources being directed toward children. However, increased spending on adults on a per-capita and absolute basis, particularly disabled adults, is responsible for much of the growth in spending over the past 15 years. Medicaid expenditures have grown faster than inflation and overall national health expenditures. A national strategy is needed to ensure adequate coverage for Medicaid recipients while dealing with the ongoing constraints of state and federal budgets.

Characteristics of hospitalizations for patients who use a structured clinical care program for children with medical complexity.

OBJECTIVE: To describe the characteristics of hospitalizations for patients who use clinical programs that provide care coordination for children with multiple, chronic medical conditions. STUDY DESIGN: Retrospective analysis of 1083 patients hospitalized between June 2006 and July 2008 who used a structured, pediatric complex-care clinical program within 4 children's hospitals. Chronic diagnosis prevalence (ie, technology assistance, neurologic impairment, and other complex chronic conditions), inpatient resource utilization (ie, length of stay, 30-day readmission), and reasons for hospitalization were assessed across the programs. RESULTS: Over the 2-year study period, complex-care program patients experienced a mean of 3.1 ± 2.8 admissions, a mean length of hospital stay per admission of 12.2 ± 25.5 days, and a 30-day hospital readmission rate of 25.4%. Neurologic impairment (57%) and presence of a gastrostomy tube (56%) were the most common clinical characteristics of program patients. Notable reasons for admission included major surgery (47.1%), medical technology malfunction (9.0%), seizure (6.4%), aspiration pneumonia (3.9%), vomiting/feeding difficulties (3.4%), and asthma (1.8%). CONCLUSIONS: Hospitalized patients who used a structured clinical program for children with medical complexity experienced lengthy hospitalizations with high early readmission rates. Reducing hospital readmission may be one potential strategy for decreasing inpatient expenditures in this group of children with high resource utilization.

Crisis and federalism: trends and regional patterns of health revenues and expenditures in the brazilian states. / Crise e federalismo: tendências e padrões regionais das receitas e despesas em saúde dos estados brasileiros.

This study aims to analyze regional trends and patterns of health revenues and expenditure in the Brazilian states from 2006 to 2016. This is an exploratory and descriptive study based on secondary national data and selected indicators. Higher per capita net current revenues for all states and regions, with decreasing levels in specific years associated with the crises of 2008-2009 and 2015-2016 were observed. Per capita health expenditure showed an increasing trend, even in times of economic crisis and declining collection. Diversity of sources and heterogeneity of health revenues and expenditures, as well as different impacts of the crisis on the regional budgets, were observed. The results suggest the protective effect of constitutional health linkage, spending commitments and priorities, and compensation mechanisms of fiscal federalism revenue sources in state health expenditures. However, challenges remain for the implementation of a transfer system that reduces inequalities and establishes greater cooperation among entities, in a context of austerity and strong public health financing constraints in Brazil.

O estudo tem como objetivo analisar as tendências e os padrões regionais das receitas e despesas em saúde dos estados brasileiros no período de 2006 a 2016. Trata-se de estudo exploratório e descritivo com base em dados secundários de abrangência nacional e indicadores selecionados. Verificou-se crescimento da receita corrente líquida per capita para o conjunto dos estados e regiões, com quedas em anos específicos associadas às crises de 2008-2009 e de 2015-2016. A despesa em saúde per capita apresentou tendência de crescimento, mesmo em momentos de crise econômica e queda da arrecadação. Observou-se diversidade de fontes e heterogeneidade de receitas e despesas em saúde, e impactos diferenciados da crise sobre os orçamentos estaduais das regiões. Os resultados sugerem o efeito protetor relacionado à vinculação constitucional da saúde, aos compromissos e prioridades de gastos, e aos mecanismos de compensação de fontes de receitas do federalismo fiscal nas despesas em saúde dos estados. Contudo, permanecem desafios para a implantação de um sistema de transferências que diminua as desigualdades e estabeleça maior cooperação entre os entes, em um contexto de austeridade e fortes restrições ao financiamento público da saúde no Brasil.

Comparing Neighborhoods of Children With Autism Spectrum Disorder in a Medicaid Waiver Program and a State Population, 2007-2015.

OBJECTIVE: This study investigated equity in enrollment in a Medicaid waiver program for early intensive behavioral intervention for children with autism spectrum disorder (ASD). METHODS: State administrative, Medicaid, and U.S. Census data for children enrolled in the waiver program between 2007 and 2015 (N=2,111) were integrated. Multivariate and bivariate analyses were used to compare enrollees' neighborhood demographic characteristics with those of the state's general population, with controls for enrollees' age, sex, and race-ethnicity. RESULTS: Findings indicate that in general, enrollment was equitable. During the years in which there were inequities, children who lived in neighborhoods of privilege were favored. These neighborhoods had higher median incomes, lower poverty levels, and fewer female-headed households and were located in urban areas. CONCLUSIONS: As states work to provide equitable treatment to children with ASD and their families, it is important to track potential inequities between children who do and do not enroll in services and to use this information to inform outreach efforts. States may turn to South Carolina for insight on how to ensure equity.

State health reform flatlines.

Massachusetts' recent health reform has generated laudatory headlines and a flurry of interest in state-based initiatives to achieve universal health insurance coverage. In 1988, a similar Massachusetts effort was also acclaimed and was imitated by several other states. Unfortunately, none of those efforts can be judged a success. The authors briefly review this earlier experience and caution against premature declaration of victory.

Implementation of a Proactive Pilot Health Plan-Driven Opioid Tapering Program to Decrease Chronic Opioid Use for Conditions of the Back and Spine in a Medicaid Population.

BACKGROUND: In 2016, the Oregon Health Authority and the Health Evidence Review Commission implemented guidance for Oregon Medicaid members who were taking opioids for chronic pain related to conditions of the back and spine. This guidance required that an individualized taper plan be developed and initiated by January 1, 2017, and a discontinuation date for all chronic opioid therapy of January 1, 2018. PROGRAM DESCRIPTION: This program evaluated the effect of a proactive and voluntary health plan-driven opioid tapering program on morphine equivalent daily dose (MEDD) before the implementation of governmental guidance. Two mailings were sent to the providers of the targeted members with a variety of resources to facilitate an opioid taper. Pharmacy claims were analyzed to measure member opioid use, in the form of MEDD, after the provider outreach to be compared with their MEDDs before the outreach. OBSERVATIONS: A total of 113 members met the study inclusion criteria for the second provider outreach. Of the 19 members' providers who submitted responses via fax to the health plan in response to this outreach, 6 indicated they would initiate taper plans. Of the 6 members with taper plans, 5 had decreases in MEDD (3.6%, 4.5%, 42.9%, 45.5%, and 46.1%) after the 3-month data collection period, while the sixth member had no change in MEDD. Of the 113 members, 16 members (14.2%) had a decrease in MEDD; 23 members (20.4%) had no change in MEDD; and 72 members (63.7%) had an increase in MEDD. IMPLICATIONS: This study demonstrated that when a physician agrees to enroll patients in a health-plan driven clinical program it may result in decreased opioid use as referenced by MEDD. However, the results also showed the progressive nature of opioid use in this population. While these initial taper results were promising, a larger sample size and longer follow-up duration are needed to validate long-term adherence to an opioid tapering program and confirm that these results are attributable to the program and not other factors. DISCLOSURES: This study was sponsored by Moda Health. Patel is employed by Moda Health; Page and Saliba were employed by Moda Health during this project; and Traver was employed by Moda Health during part of this project. Page is now employed by Oregon State University (during the writing of this manuscript) to support the College of Pharmacy's contract with the Oregon Health Authority to provide professional pharmacist support for the Oregon Medicaid program. All other authors have nothing to disclose. Study concept and design were contributed by Page and Traver, who also collected the data. Data interpretation was performed by Page and Patel. The manuscript was written by Page and revised by Page, Patel, and Saliba.

Developing personal care programs: national trends and interstate variation, 1992-2002.

This paper examines the development of programs delivering personal care to the elderly and disabled. First, we report the latest national participant and expenditure trend data for the three main personal care programs: the Medicaid Personal Care Services (PCS) benefit, Medicaid 1915(c) waivers, and the Older Americans Act Title III. Second, to examine interstate variation revealed in the trend analysis, we present three time-series regression models of personal care development (expenditures, participants, and existence of PCS benefit) that control for state socioeconomic, political, policy, and provider characteristics. Positive predictors of personal care development include: percentages of population aged 85 and older, and nonwhite; per capita income; and liberal state politics. Negative predictors of personal care development include rates of Medicare home health users and hospital beds.