Exploring the Effect of Anti-immigration Rhetoric on Emergency Department Use by Undocumented Adults.

An unwelcoming policy climate can create barriers to health care access and produce a 'Chilling Effect' among immigrant communities. For undocumented immigrants, barriers may be unique and have a greater impact. We used administrative emergency department (ED) data from 2015 to 2019 for a Midwestern state provided under a data use agreement with the state hospital association. General linear modelling was used to estimate the impact of anti-immigrant rhetoric on ED visit intensity among non-elderly adults who were likely Hispanic/Latino with undocumented status. Compared to 2015, the average ED visit intensity among adults who were likely Hispanic/Latino with undocumented status was significantly higher during 2016-2019 when anti-immigrant rhetoric was heightened. The magnitude of this change increased over time (0.013, 0.014, 0.021, and 0.020, respectively). Additionally, this change over time was not observed in the comparison groups. Our findings suggest that anti-immigrant rhetoric may alter health care utilization for adults who are likely Hispanic/Latino with undocumented status. Limitations to our findings include the use of only those likely to be Hispanic/Latino, data from only one Midwestern state and the loss of data due to non-classification using the NYU ED algorithm. Further research should focus on validating these findings and investigating these identification methods and anti-immigrant rhetoric effects among other undocumented groups including children and adults of different race or ethnicity such as black, both those that identify as Hispanic/Latino and those that do not. Developing strategies to improve health care access for undocumented Hispanic/Latino adults also warrants future research.

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits.

BACKGROUND: The goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance's adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults. METHODS: Medicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity. RESULTS: Adult Medicaid enrollees' ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%. CONCLUSIONS: Testing revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit. PRACTICAL IMPLICATIONS: Adoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.

Food Insecurity Is Prevalent in Iowa's Medicaid Expansion Population.

BACKGROUND: Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations. OBJECTIVE: Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa's Medicaid expansion population. DESIGN: We conducted a cross-sectional telephone survey between March and May of 2019. PARTICIPANTS: Our sample was drawn from Medicaid members enrolled in Iowa's expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample. MAIN OUTCOME MEASURE: Our main outcome was whether a respondent's household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool. STATISTICAL ANALYSES PERFORMED: We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors. RESULTS: The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity. CONCLUSIONS: Our findings show that food insecurity is prevalent in Iowa's Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access. ABBREVIATIONS: Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP).

Time trends in emergency department use among adults with intellectual and developmental disabilities.

BACKGROUND: Emergency Department (ED) visits are common among adults with intellectual and developmental disabilities (IDD). However, little is known about how ED use has varied over time in this population, or how it has been affected by recent Medicaid policy changes. OBJECTIVE: To examine temporal trends in ED use among adult Medicaid members with IDD in eight states that ranged in the extent to which they had implemented state-level Medicaid policy changes that might affect ED use. METHODS: We conducted repeated cross-sectional analyses of 2010-2016 Medicaid claims data. Quarterly analyses included adults ages 18-64 years with IDD (identified by diagnosis codes) who were continuously enrolled in Medicaid for the past 12 months. We assessed change in number of ED visits per 1000 member months from 2010 to 2016 overall and interacted with state level policy changes such as Medicaid expansion. RESULTS: States with no Medicaid expansion experienced an increase in ED visits (linear trend coefficient: 1.13, p < 0.01), while states operating expansion via waiver had a much smaller (non-significant) increase, and states with ACA-governed expansion had a decrease in ED visits (linear trend coefficient: 1.17, p < 0.01). Other policy changes had limited or no association with ED visits. CONCLUSIONS: Medicaid expansion was associated with modest reduction or limited increase in ED visits compared to no expansion. We found no consistent decrease in ED visits in association with other Medicaid policy changes.

Applying "Stages of Readiness to Change" Model to Dentists' Decisions to Participate in Medicaid: An Exploratory Study.

BACKGROUND: The Stages of Readiness to Change (SOC) behavioral model describes behavior change as a process and distinguishes individuals based on their current behavior and readiness to change that behavior. SOC can be used to improve dentists' participation in a state public dental benefit program (Medicaid) by targeting them at different SOC with interventions, strategies, and tools tailored to those stages. Therefore, this study assessed the usefulness of using SOC to describe dentists' attitudes towards and participation in Medicaid. Dentists' participation in Medicaid is of interest to policymakers, and this study demonstrates a method to identify potential opportunities for intervention. METHODS: A modified SOC algorithm used data from a periodic survey of Iowa Dentists to categorize dentists (N=514) into: 1) pre-contemplation, 2) considering participation (SOC contemplation and preparation), 3) acting (SOC action and maintenance), and 4) risk of relapse (at risk for discontinuing participation). The four SOC stages were compared using ANOVA and post hoc Tukey's test among: practice characteristics, Dentists Altruism scale, Attitude about Program Administration scale, Attitude about Medicaid patients scale and Perception of Importance of Medicaid Problems scale. RESULTS: Among survey respondents, 36% were categorized as pre-contemplation, 6% were considering Medicaid participation, 12% were acting as Medicaid providers with minimal risk of relapse, and 46% were participating and at risk of discontinuing. Dentists' attitudes towards program administration, Medicaid patients, and access to care varied across the SOC cycle. CONCLUSION: Nearly, 46% dentists in this analysis were identified as at risk of discontinuing participation - a much larger proportion than dentists considering Medicaid participation. Categorizing dentists using this approach has important implications for programmatic interventions. For example, policymakers targeting our study population could focus their efforts on reducing the likelihood of dentists dropping out of the program, with less emphasis targeting dentists in the precontemplation stage.

Dental Care in Programs of All-Inclusive Care for the Elderly: Organizational Structures and Protocols.

OBJECTIVES: This study uses a national model of community-based long-term services and supports, the Program of All-inclusive Care for the Elderly (PACE), to identify organizational structures and protocols that can facilitate the delivery of dental examinations. DESIGN: We developed an online survey instrument and conceptual model for this study representing 10 domains believed to characterize a quality PACE dental program. SETTING AND PARTICIPANTS: The Qualtrics survey was distributed nationally to all 124 PACE programs in the 31 states PACE was available. Respondents in this study represented 35 programs (program response rate = 28.2%) in 23 states (state response rate = 74.2%). METHODS: Selected independent variables from each of the 10 domains were tested against the reported delivery of dental examinations variable using the Kendall τ and χ2. Twenty-nine programs were included in the final analysis. RESULTS: Most programs mandated a dental examination within 31-60 days of enrollment (63.6%). Few programs had a dental manual (15.6%) or any quality assurance for dental care (32.3%). A majority of programs (58.8%) stated that they had a protocol for enrollees to receive a cleaning every 6-12 months. Having a system for quality assurance for dental care, protocol for a cleaning every 6-12 months, mandating a comprehensive dental examination and providing preventive dental services onsite with built-in equipment, were all statistically associated with a higher reported delivery of dental examinations. CONCLUSION AND IMPLICATIONS: Organizations providing long-term services and supports, including PACE, can use these identified domains to develop minimal standards to ensure dental care is part of innovative models of community-based long-term services and supports. Implementing these domains can facilitate effective delivery of dental examinations that have the potential to support positive oral health and general health outcomes.

Health Service Utilization Patterns Among Medicaid-Insured Adults With Intellectual and Developmental Disabilities: Implications for Access Needs in Outpatient Community-Based Medical Services.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care-sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5-24.7]), and psychiatric conditions (RRs = 5.8-15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care-sensitive conditions and to manage chronic medical and mental health conditions.

Disability, Hospital Care, and Cost: Utilization of Emergency and Inpatient Care by a Cohort of Children with Intellectual and Developmental Disabilities.

OBJECTIVE: To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs. STUDY DESIGN: Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012. RESULTS: Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively). CONCLUSIONS: Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

Communicating a Complicated Medicaid Waiver Program to Enrollees in Iowa: How Federally Qualified Health Centers Support Medicaid Members.

Iowa expanded Medicaid eligibility with a waiver including a personal responsibility component. Early program evaluation revealed low compliance and awareness among members. There is little research on leveraging existing contact points in the health care system to effectively communicate with Medicaid enrollees. We interviewed outreach and enrollment staff at Federally Qualified Health Centers (FQHCs) to explore their work. We show that FQHCs use several strategies to enroll individuals in appropriate programs and support them in understanding and navigating their health insurance coverage. With increasingly complex Medicaid programs, this support will be more widely needed to prevent hardship and loss of coverage.

Implementation Matters: Lessons From Iowa Medicaid's Healthy Behaviors Program.

Iowa's Medicaid expansion includes the Healthy Behaviors Program (HBP), which incentivizes enrollees to receive a wellness exam and complete a health risk assessment annually to waive a monthly premium. We conducted a telephone survey with enrollees to examine their awareness and understanding of the HBP, and we then merged the survey data with claims data to examine factors associated with the completion of program requirements. As found in previous research, awareness of the HBP remains low, with approximately half of respondents unaware of the program or the premium requirement. Our results suggest that four years after the program was implemented, requirements are not being effectively communicated to enrollees. When designing and implementing such programs, policy makers should note that they are unlikely to succeed without consideration of how the program is structured and promoted. Limited program awareness is likely to result in low participation and consequences related to paying premiums or being disenrolled.

Iowa's Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012-17.

Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.

Setting the PACE for frail older adults in the community: An underused opportunity for furthering medical-dental integration.

BACKGROUND: The integration of dentistry into comprehensive and long-term care has occurred infrequently and with limited success. The authors aim to describe how the Program of All-Inclusive Care for the Elderly (PACE) has the potential for such incorporation for the growing population of nursing home-appropriate older adults preferring to age in place. METHODS: The authors used a 56-item online survey to explore aspects of oral health care within PACE, including organizational structure, availability and provision of care, preventive protocols, and provider reimbursement. The survey was distributed to all 124 programs nationally. Data analyses included descriptive statistics for each of the variables of interest. RESULTS: Thirty-five programs completed the survey (28%) in 23 states (74%) where PACE is available. Most programs covered comprehensive dental services and predominantly provided care off-site. Most programs reimbursed dentists at Medicaid fee-for-service rates and some at commercial rates. Dentistry was most frequently ranked the second-highest specialty focus behind mental health. CONCLUSIONS: PACE is a comprehensive interdisciplinary model of care and an underused opportunity for furthering medical-dental integration. It uses local dental resources in order to accommodate the oral health care needs of the growing population of older adults preferring to age in place. PRACTICAL IMPLICATIONS: PACE is an opportunity for the dental profession to further medical-dental integration and ensure that newer models of long-term care include comprehensive and coordinated oral health care programs. It is also an opportunity to promote an integrated model of care with policy makers to support integrated oral health care for the nursing home-eligible population.

Disparities in diabetes management among medicaid recipients with intellectual and developmental disabilities (IDD): Evidence from five U.S. states.

BACKGROUND: Diabetes is one of the most common chronic conditions among adults. Little is known about the quality of diabetes care received by adults with intellectual and developmental disabilities (IDD). OBJECTIVE: To determine the extent to which the diabetes care needs are met for a population with both IDD and diabetes who are solely insured by Medicaid in five states (Iowa, Massachusetts, New York, Oregon and South Carolina). METHODS: Medicaid administrative data in 2012 were used to identify Medicaid members (excluding dual eligibles) with diabetes and IDD in five states. Four diabetes care measures were compared between members with and without IDD using bivariate analyses. For those with diabetes and IDD, a logistic regression model was fitted for each state with the following predictors: age, sex, IDD subgroup, and occurrence of a specialist visit in the current or past year. A meta-analysis was then conducted to synthesize cross-state results. RESULTS: Across the five states, 6229 (2%) of the 308,804 non-dual adult Medicaid members 18-64 years old with diabetes in 2012 also had IDD. Comparing those with IDD to their non-IDD peers on receipt of all four diabetes care measures showed differences by state, but state rates of overall adherence were very low, ranging from 16.6% to 28.5% of the population. CONCLUSIONS: Meta-analysis results identified specialist visits as a strong predictor of adults with diabetes and IDD receiving all four components of diabetes care. This important information should be considered in efforts to improve quality care for this population.

Purged from the Rolls: A Study of Medicaid Disenrollment in Iowa.

Purpose: To describe the impact of disenrollment from Medicaid because of failure to pay premiums as part of Iowa's Medicaid program's personal responsibility component. Methods: We conducted a mixed method study consisting of in-depth interviews with disenrolled members in 2016 and 2017 (n=72) and a survey of disenrolled members in 2017 (n=225). Results: Many disenrollees did not know why they were disenrolled, were unaware of the personal responsibility component or premium requirement, and were confused by the disenrollment process. Disenrollment had negative effects including stress, financial burden, and engaging in behaviors such as skipping medication and postponing medical or dental care. Furthermore, disenrollees were often unable to enroll in health insurance, and for those who did, many reported it was a difficult process. Conclusions: Disenrollment had numerous, negative impacts on members who failed to pay their premiums. There was confusion about program requirements, which might indicate challenges communicating about a complicated program. Policymakers need to consider how to design and implement personal responsibility programs to achieve their desired outcome and reduce confusion and negative consequences.

Dental caries experience and associated risk indicators among Palestinian pregnant women in the Jerusalem area: a cross-sectional study.

BACKGROUND: This study described the dental caries experience of Palestinian pregnant women and examined its relationships to their oral health knowledge, beliefs, behavior, and access to dental care. METHODS: Pregnant women receiving prenatal care at the Ministry of Health (MOH) centers in the Jerusalem Governorate were invited to participate in this study. Structured interviews were conducted to assess pregnant mothers' beliefs about oral health care and their oral hygiene practices. Screening for mothers' dental caries experience was carried out using the Decayed, Missing and Filled Teeth/Surfaces (DMFT/S) index. Univariate, bi-variate and multi-variable analysis were conducted to explain the high level of disease in this population. RESULTS: A total of 152 pregnant women participated in this study. Mean DMFT in this sample was 15.5 ± 4.5 and an average DMFS of 31.8 ± 21. According the World Health Organization (WHO) criteria, 89% of our sample were categorized in the "Extremely High" dental caries experience. Fifty-eight percent of the DMFT scores among this sample were due to untreated dental decay, while 22% of the same DMFT scores demonstrated restorative care received by this sample. Bivariate analysis showed that mothers who completed a degree after high school had lower DMFT scores than mothers who did not (F = 4, n = 152, p = .024). In addition, mothers who believed they could lose a tooth just because they are pregnant had higher DMFT scores (t = - 4, n = 152, p = .037). The final model found that age, level of education, providers' advice on utilizing dental care during pregnancy, and the belief that a woman can lose a tooth just because she is pregnant explained 22% of the variation in DMFT scores. CONCLUSIONS: Women in this study had a high prevalence of dental diseases and knew little about dental care during pregnancy. Faulty beliefs about dental care during pregnancy among women and health care providers were major factors in the high levels of disease.

Using Medicaid Data to Characterize Persons With Intellectual and Developmental Disabilities in Five U.S. States.

This project sought to identify Medicaid members with intellectual and developmental disabilities (IDD) in five states (Delaware, Iowa, Massachusetts, New York, and South Carolina) to develop a cohort for subsequent analyses of medical conditions and service utilization. We estimated that over 300,000 Medicaid members in these states had IDD. All members with diagnostic codes for IDD were identified and the three most frequent diagnoses were unspecified intellectual disability, autism or pervasive developmental disorder, and cerebral palsy. The percentage of Medicaid members with IDD ranged from 2.3% in New York to 4.2% in South Carolina. Identifying and characterizing people with IDD is a first step that could guide public health promotion efforts for this population.

Factors related to high dental caries experience in Palestinian pregnant women in the Jerusalem governorate: a cross-sectional study.

BACKGROUND: Beliefs about oral health during pregnancy demographic factors, such as level of education and socioeconomic status, are associated with an increased risk of oral diseases during pregnancy. The aim of this study was to assess the oral health status of pregnant women and the relation to the women's oral health knowledge, beliefs, behaviour, and access to dental care. METHODS: For this cross-sectional study, pregnant women visiting pre-natal care clinics at the Palestinian Ministry of Health centres in the Jerusalem governorate were invited to complete a structured interview with questions about beliefs about oral health care and their oral hygiene practices. Screening for oral health conditions was done using the Decayed, Missed and Filled Teeth (DMFT) index to assess the women's dental caries experience, and gingival health indices (plaque, gingival, and calculus) were measured to assess gingival health. Ethical approval was obtained from Al-Quds University Ethics Committee. FINDINGS: 152 pregnant women agreed to participate in this study. Participants had a mean DMFT score of 15·5 (SD 4·5). Bivariate analysis showed that women who had completed a degree after high school had a lower DMFT score than women who did not (F=4; p=0·024). Women who had visited a dentist in the past 6 months had a higher DMFT score than women who had never visited a dentist (F=2·4, p=0·05). Additionally, women who believed they could lose a tooth just because they are pregnant scored high DMFT scores (t=-4; p=0·037). Results of the multivariable analysis showed that age, level of education, recent dental visit, and the belief that it is unsafe to get routine dental care during pregnancy explained 25% of the variation in the DMFT score. INTERPRETATION: Women in this study had high prevalence of dental disease and knew little about dental care during pregnancy. Faulty beliefs about oral health care and barriers to dental care were major factors in the high prevalence of the disease. FUNDING: This project was partially funded by 2016 International Dental Federation FDI SMILE Award.

Preventive dental care among Medicaid-enrolled senior adults: from community to nursing facility residence.

OBJECTIVE: The primary objective of this study was to determine whether the utilization rate of preventive oral health care services while senior adults were community-dwelling differed from the rate after those same senior adults were admitted to nursing facilities. A secondary objective was to evaluate other significant predictors of receipt of preventive oral health procedures after nursing facility entry. METHODS: Iowa Medicaid claims from 2007-2014 were accessed for adults who were 68+ years upon entry to a nursing facility and continuously enrolled in Medicaid for at least three years before and at least two years after admission (n = 874). Univariate, bivariate and multivariable analyses were conducted. RESULTS: During the five years that subjects were followed, 52.8% never received a dental exam and 75.9% never received a dental hygiene procedure. More Medicaid-enrolled senior adults received ≥1 preventive dental procedure in the two years while residing in a nursing facility compared to the three years before entry. In multivariable analyses, the strongest predictor of preventive oral health care utilization after entry was the receipt of preventive oral health services before entry (p < 0.01). CONCLUSIONS: The strongest predictor of receipt of dental procedures in the two years after nursing facility entry was the receipt of dental procedures in the three years before entry while community-dwelling. This underscores the importance of the senior adult establishing a source of dental care while community-dwelling.

Completion of Requirements in Iowa's Medicaid Expansion Premium Disincentive Program, 2014-2015.

OBJECTIVES: To evaluate rates of member compliance with Iowa's Medicaid expansion premium disincentive program. METHODS: We used 2014 to 2015 Iowa Medicaid data to construct rolling 12-month cohorts of Wellness Plan and Marketplace Choice members (Iowa's 2 Medicaid expansion waiver programs for individuals ≤ 100% and 101%-138% of the federal poverty level, respectively), calculated completion rates for required activities (i.e., wellness examinations and health risk assessments), and identified factors associated with program compliance. RESULTS: Overall, 18.5% of Wellness Plan and 12.5% of Marketplace Choice members completed both activities (P < .001). From 2014 to 2015, completion rates for both activities decreased for Wellness Plan members but increased for Marketplace Choice members. Members who were younger, male, or non-White were less likely to complete required activities. CONCLUSIONS: Approximately 81% of Wellness Plan members and 87% of Marketplace Choice members failed to comply with program requirements and should have been subject to paying premiums the following year or face disenrollment. Disparities in completion rates may exacerbate disparities in insurance coverage and health outcomes. Public Health Implications. As states consider establishing Medicaid premium disincentive programs, they should anticipate challenges to successful implementation.

Iowa's Medicaid Expansion Promoted Healthy Behaviors But Was Challenging To Implement And Attracted Few Participants.

As part of Iowa's Medicaid expansion, the Healthy Behaviors Program was designed to provide members with incentives to complete specified healthy activities in return for waiving monthly premiums. We used claims data and interviews to document the first year (2014) of the program's implementation. Healthy activities completion rates did not exceed 17 percent. Interviews with members and clinic managers revealed low levels of awareness of the program's existence, deficits in knowledge about how the program works, and a variety of barriers to activity completion. Our findings suggest that the lack of knowledge hindered the state's ability to incentivize activities and that it subjected beneficiaries to premium expenses and potential disenrollment. These results should guide federal and state policy makers in devising more effective ways of educating Medicaid beneficiaries and providers about programs that incentivize responsibility for healthy behaviors. The results suggest that efforts by federal and state governments to reform Medicaid by shifting responsibility onto program members for healthy behaviors are unlikely to succeed, especially without careful thought and design of premiums, penalties, and incentives for participants.