Effects of Integrating Care for Medicare-Medicaid Dually Eligible Seniors in Minnesota.

Individuals dually eligible for Medicare and Medicaid often receive fragmented and inefficient care. Using Minnesota fee-for-service claims, managed care encounters, and enrollment data for 2010-2012, we estimated the likely impact of Minnesota Senior Health Option (MSHO)-seen as the first statewide fully integrated Medicare-Medicaid model-on health care and long-term services and supports use, relative to Minnesota Senior Care Plus (MSC+), a Medicaid-only managed care plan with Medicare fee for service. Estimates suggest that MSHO enrollees had significantly higher use of primary care and, potentially, of community-based services, combined with lower use of hospital-based care than similar MSC+ enrollees. Adopting fully integrated care models like MSHO may have merit in other states.

Using Data From the Healthcare Cost and Utilization Project for State Health Policy Research.

BACKGROUND: The Healthcare Cost and Utilization Project (HCUP), the nation's most complete source of all-payer hospital care data, supports analyses at the national, regional, state and community levels. However, national HCUP data are often used in inappropriate ways in studies of state-specific issues. OBJECTIVE: To describe the opportunities and challenges of using HCUP data to conduct state health policy research and to provide empirical examples of what can go wrong when using the national HCUP data inappropriately. RESEARCH DESIGN: Comparison of results from state-level analyses using national HCUP data and the state-specific HCUP data recommended by the Agency for Healthcare Research and Quality (AHRQ). Analyses included trends in state-specific rates of cesarean delivery and a difference-in-differences analysis of Connecticut's Medicaid expansion. SUBJECTS: Hospital discharges from the 2004 to 2011 HCUP Nationwide Inpatient Samples (NIS) and State Inpatient Databases (SID). MEASURES: Cesarean delivery rates, discharges per capita, and discharges by the payer. RESULTS: State-level estimates derived from the NIS are volatile and often provide misleading policy conclusions relative to estimates from the SID. CONCLUSIONS: The NIS should not be used for state-level research. AHRQ provides resources to assist analysts with state-specific studies using SID files.

Changes in mortality after Massachusetts health care reform: a quasi-experimental study.

BACKGROUND: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear. OBJECTIVE: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care. DESIGN: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions. SETTING: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score-defined control group of counties in other states. PARTICIPANTS: Adults aged 20 to 64 years in Massachusetts and control group counties. MEASUREMENTS: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146,825) from the Centers for Disease Control and Prevention's Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health. RESULTS: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (-2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100,000 adults). Deaths from causes amenable to health care also significantly decreased (-4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year. LIMITATIONS: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states. CONCLUSION: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care. PRIMARY FUNDING SOURCE: None.

The expansion of Medicaid coverage under the ACA: implications for health care access, use, and spending for vulnerable low-income adults.

The expansion of Medicaid coverage under the Affordable Care Act offers the potential for significant increases in health care access, use, and spending for vulnerable nonelderly adults who are uninsured. Using pooled data from the Medical Expenditure Panel Survey, this study estimates the potential effects of Medicaid, controlling for individual and local community characteristics. Our findings project significant gains in health care access and use for uninsured adults who enroll in Medicaid coverage and have chronic health conditions and mental health conditions. With that increased use, annual per capita health care spending for those newly insured individuals (excluding out-of-pocket spending) is projected to grow from $2,677 to $6,370 in 2013 dollars, while their out-of-pocket spending would drop by $921. It is expected that these increases in spending would be offset at least in part by reductions in uncompensated care and charity care.

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.

Is patients' trust in clinicians related to patient-clinician racial/ethnic or gender concordance?

OBJECTIVE: To examine the relationship between patient-clinician concordance (racial/ethnic and gender) and patients' trust in their regular clinician. METHODS: This mixed methods study used the 2019 U.S. Health Reform Monitoring Survey to examine concordance and patient trust in clinicians, and semi-structured interviews with 24 participants to explore patients' perceptions of how concordance relates to trust in their clinician. RESULTS: Almost six in ten adults (59.8%) who had a regular clinician reported having trust in their clinician. White, Black, and Latino participants were similarly likely to report trust. Those with racial/ethnic concordant clinicians were 7.5 percentage points more likely to report trust than were those with non-concordant clinicians (62.4% vs 54.9%). This finding was consistent for men and women, and did not differ significantly across racial and ethnic groups. In interviews, while almost all participants described having trusted non-racial/ethnic concordant clinicians, several described immediately trusting concordant clinicians. In contrast, we did not observe a consistent relationship between patient-clinician gender concordance and trust. CONCLUSION: The findings underscore the importance of increasing the number of Black and Latino clinicians, and also highlight that all clinicians need to work hard to build trust with patients from different racial/ethnic backgrounds.

Health care reform and young adults' access to sexual health care: an exploration of potential confidentiality implications of the affordable care act.

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent's private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences. Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues. Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.

Coverage, access, and affordability under health reform: learning from the Massachusetts model.

While the impacts of the Affordable Care Act will vary across the states given their different circumstances, Massachusetts' 2006 reform initiative, the template for national reform, provides a preview of the potential gains in insurance coverage, access to and use of care, and health care affordability for the rest of the nation. Under reform, uninsurance in Massachusetts dropped by more than 50%, due, in part, to an increase in employer-sponsored coverage. Gains in health care access and affordability were widespread, including a 28% decline in unmet need for doctor care and a 38% decline in high out-of-pocket costs.

Another Look at the Impacts of Health Reform in Massachusetts: Evidence Using New Data and a Stronger Model.

In April 2006, Massachusetts enacted a comprehensive health care reform bill that seeks to move the state to near universal insurance coverage. The bill included expanded eligibility for public coverage, subsidized insurance, market reforms, requirements for employers, and, most controversial, an individual mandate. A study of the early impacts of the state's initiative found evidence of a substantial drop in uninsurance--from 13 to 7 percent for nonelderly adults (Long 2008). Because that study relied on a simple pre-post comparison, it is possible that the estimates of the impact of health reform reflect both the changes under health reform and factors beyond health reform that changed over the same period, leading to biased estimates of the impacts of reform (Lawrence B. Mohr 1995). This paper expands on the earlier work to estimate the impacts of health reform in Massachusetts using new data and a stronger research design. Specifically, we rely on data over time for Massachusetts and other states from the Current Population Survey (CPS) to estimate difference-in-differences (DD) models (Jeffrey M. Wooldridge 2002).

Does high caregiver stress predict nursing home entry?

This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.

Health care spending and service use among high-cost Medicaid beneficiaries, 2002-2004.

Using program administrative data, this paper examines spending and service use patterns for the national Medicaid population between 2002 and 2004, with a focus on high-cost beneficiaries. We observed a high degree of spending persistence. 57.9% of those who were among the top 10% of Medicaid spenders in 2002 remained in the top 10% of spenders in the two subsequent years. We identified two distinct subgroups of high spenders--those with persistently high costs and those with episodically high costs-each with different services driving their costs.

Do for-profit health plans restrict access to care under Medicaid managed care?

Managed care is now the norm for many on Medicaid, with approximately 19 million people on Medicaid enrolled in health maintenance organizations. In 2005, nearly 300 plans nationwide participated in state Medicaid managed care programs, with many of those plans operating under for-profit ownership. Concerns about the impact of plan ownership on access to care arise because of differences in the incentives in place in for-profit and nonprofit organizations that may lead for-profit plans to restrict access to care. Using data from the 2002 National Survey of America's Families on plan enrollment for a national sample of Medicaid enrollees, this study examines the link between for-profit plan ownership and enrollees' access to health care. The results suggest that access to care for Medicaid enrollees may be better under nonprofit plans than for-profit plans.

Does managed care improve access to care for Medicaid beneficiaries with disabilities? A national study.

States increasingly are shifting Medicaid beneficiaries with disabilities from the fee-for-service (FFS) delivery system to managed care in an effort to control program costs and address long-standing problems with access to care under the program. Using a county-based measure of managed care enrollment and pooled data from the 1997 to 2004 National Health Interview Surveys, we investigate whether Medicaid managed care (MMC), relative to FFS Medicaid, improves access to care. We find some evidence of improved access to care under MMC; however, the gains appear to be largely limited to beneficiaries in urban areas with fully capitated managed care. There is little evidence of improved access under primary care case management or, regardless of MMC type, in rural areas.

The Affordable Care Act's Marketplaces Expanded Insurance Coverage For Adults With Chronic Health Conditions.

The Affordable Care Act (ACA) made private nongroup health insurance more accessible to nonelderly adults with chronic conditions, with enrollment growth occurring through the federal and state-based Marketplaces. During the July through December reference period in 2014-15, 45 percent of Marketplace enrollees ages 18-64 were treated for chronic conditions, compared with 35 percent of non-Marketplace nongroup enrollees and 38 percent of adults with employer-sponsored insurance. Marketplace enrollees also had higher service use than other privately insured adults did, which likely contributed to rising premiums in the nongroup market. As repeal of the ACA individual mandate takes effect in 2019, protecting coverage gains for adults with chronic conditions while stabilizing nongroup premiums may depend on state-level efforts to spread the risk of Marketplace enrollees' health care costs across a balanced insurance pool.

Evidence of Pent-Up Demand for Care After Medicaid Expansion.

We compared new Medicaid enrollees with similar ongoing enrollees for evidence of pent-up demand using claims data following Minnesota's 2014 Medicaid expansion. We hypothesized that if new enrollees had pent-up demand, utilization would decline over time as testing and disease management plans are put in place. Consistent with pent-up demand among new enrollees, the probability of an office visit, a new patient office visit, and an emergency department visit declines over time for new enrollees relative to ongoing Medicaid enrollees. The pattern of utilization suggests that the newly insured are connecting with primary care after the 2014 Medicaid expansion and, unlike ongoing Medicaid enrollees; the newly insured have a declining reliance on the emergency department over time.

Assessing the value of the NHIS for studying changes in state coverage policies: the case of New York.

RESEARCH OBJECTIVE: (1) To assess the effects of New York's Health Care Reform Act of 2000 on the insurance coverage of eligible adults and (2) to explore the feasibility of using the National Health Interview Survey (NHIS) as opposed to the Current Population Survey (CPS) to conduct evaluations of state health reform initiatives. STUDY DESIGN: We take advantage of the natural experiment that occurred in New York to compare health insurance coverage for adults before and after the state implemented its coverage initiative using a difference-in-differences framework. We estimate the effects of New York's initiative on insurance coverage using the NHIS, comparing the results to estimates based on the CPS, the most widely used data source for studies of state coverage policy changes. Although the sample sizes are smaller in the NHIS, the NHIS addresses a key limitation of the CPS for such evaluations by providing a better measure of health insurance status. Given the complexity of the timing of the expansion efforts in New York (which encompassed the September 11, 2001 terrorist attacks), we allow for difference in the effects of the state's policy changes over time. In particular, we allow for differences between the period of Disaster Relief Medicaid (DRM), which was a temporary program implemented immediately after September 11th, and the original components of the state's reform efforts-Family Health Plus (FHP), an expansion of direct Medicaid coverage, and Healthy New York (HNY), an effort to make private coverage more affordable. DATA SOURCES: 2000-2004 CPS; 1999-2004 NHIS. PRINCIPAL FINDINGS: We find evidence of a significant reduction in uninsurance for parents in New York, particularly in the period following DRM. For childless adults, for whom the coverage expansion was more circumscribed, the program effects are less promising, as we find no evidence of a significant decline in uninsurance. CONCLUSIONS: The success of New York at reducing uninsurance for parents through expansions of both public and private coverage offers hope for new strategies to expand coverage. The NHIS is a strong data source for evaluations of many state health reform initiatives, providing a better measure of insurance status and supporting a more comprehensive study of state innovations than is possible with the CPS.

Sustained Gains In Coverage, Access, And Affordability Under The ACA: A 2017 Update.

The significant gains in health insurance coverage and improvements in health care access and affordability that followed the implementation of the key coverage provisions of the Affordable Care Act in 2014 have persisted into 2017. Adults in all parts of the country, of all ages, and across all income groups have benefited from a large and sustained increase in the percentage of the US population that has health insurance. The gains have been particularly striking among low- and moderate-income Americans living in states that expanded Medicaid. Our latest survey data from the Urban Institute's 2017 Health Reform Monitoring Survey shows that only 10.2 percent of nonelderly adults are now uninsured-a decline of almost 41 percent from the period before implementation of the ACA. Nonetheless, repealing and replacing the ACA remained under consideration during the summer of 2017, along with more systematic changes to the financing of the Medicaid program. Many people will be at substantial risk if key components of the law are repealed or otherwise changed without carefully considering the health and financial consequences for those projected to lose coverage. Though the politics of health reform are challenging, opportunities exist to create a more equitable and efficient health care system.