Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion.

Importance: The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective: To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants: Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure: Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures: Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results: The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (ß coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance: Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

BACKGROUND: Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. OBJECTIVE: We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. DESIGN: Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. PARTICIPANTS: 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. MAIN MEASURES: Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. KEY RESULTS: Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. CONCLUSIONS: Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.

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.

Association of the Affordable Care Act with access to highest-volume centers for patients with thyroid cancer.

BACKGROUND: Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear. METHODS: The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile. RESULTS: In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001). CONCLUSIONS: Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.

Federal Incentives to Reform Long-Term Care Under the Affordable Care Act: State Adoption of the Balancing Incentive Program, 2011-2014.

OBJECTIVES: The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states' participation in this program. METHODS: Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors was considered representing states' economic, political, and programmatic conditions. RESULTS: The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP. DISCUSSION: The findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.

Five-year impact of Medicare Part D coverage gap reform on drug expenditures and utilization.

OBJECTIVE: To estimate the impact of the Medicare Part D coverage gap reform under the Affordable Care Act (ACA) on the utilization of and expenditures for prescription drugs within the first five years of the policy's implementation. DATA SOURCES: 2008-2015 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN: We used a difference-in-differences approach to estimate the year-by-year changes in prescription drug use and expenditures before (2006-2010) and after (2011-2015) the ACA's Part D coverage gap reform between Part D beneficiaries not receiving the Low-Income Subsidy (LIS) and those receiving the LIS. DATA COLLECTION: The study sample included Part D beneficiaries (a) aged 65 years or older; (b) not disabled or having end-stage renal disease; (c) continuously enrolled in a Part D plan (d) having at least one prescription fill in a given year. Survey-reported and administrative Part D events data in the MCBS were used for the analyses. PRINCIPAL FINDINGS: After the ACA reform, annual out-of-pocket drug spending significantly decreased by $88 (P < .01) among non-LIS beneficiaries compared to LIS beneficiaries, with growing decreases over time (average decreases of $41 in 2011, $49 in 2012, $105 in 2013, and $135 in 2015, P < .01 or <.05). Changes in out-of-pocket costs were largely driven by significant decreases among brand-name drugs (overall decrease of $106, P < .01). Despite significantly reduced out-of-pocket spending, there were no significant changes in the overall number of 30-day drug fills and total drug spending; however, changes in the use of brand-name and generic drugs were seen after the ACA (increase of 1.9 fills for brand-name drugs and decrease of 2.3 fills for generic drug in 2015, P < .05). CONCLUSIONS: The ACA coverage gap reform has helped to reduce the out-of-pocket drug cost burden for beneficiaries, although it had no noticeable impact on drug use or total drug spending.

The Effect of the Affordable Care Act on Women's Postpartum Insurance and Depression in 5 States That Did Not Expand Medicaid, 2012-2015.

BACKGROUND: Before the Affordable Care Act (ACA), most women who gained pregnancy-related Medicaid were not eligible for Medicaid as parents postpartum. The ACA aimed to expand health insurance coverage, in part, by expanding Medicaid; introducing mandates; reforming regulations; and establishing exchanges with federal subsidies. Federal subsidies offer a means to coverage for individuals with income at 100%-400% of the federal poverty level who do not qualify for Medicaid. OBJECTIVE: The objective of this study was to identify the effects of the ACA's non-Medicaid provisions on women's postpartum insurance coverage and depressive symptoms in nonexpansion states with low parental Medicaid thresholds. PARTICIPANTS: Women with incomes at 100%-400% of the federal poverty level who had prenatal insurance and completed the Pregnancy Risk Assessment Monitoring System (2012-2015). SETTING: Five non-Medicaid expansion states with Medicaid parental eligibility thresholds below the federal poverty level. DESIGN: Interrupted time-series analyses were conducted to examine changes between pre-ACA (January 2012-November 2013) and post-ACA (December 2013-December 2015) trends for self-reported loss of postpartum insurance and symptoms of postpartum depression. RESULTS: The sample included 9,472 women. Results showed significant post-ACA improvements where the: (1) trend for loss of postpartum insurance reversed (change of -0.26 percentage points per month, P=0.047) and (2) level of postpartum depressive symptoms decreased (change of -3.5 percentage points, P=0.042). CONCLUSIONS: In these 5 states, the ACA's non-Medicaid provisions were associated with large increases in retention of postpartum insurance and reductions in postpartum depressive symptoms, although depressive symptoms findings are sensitive to model specification.

Carving Out Financial Success: The Power of Insurance Carve-Outs in a Private Plastic Surgery Practice.

BACKGROUND: Since the Patient Protection and Affordable Care Act was signed into law, there has been a push away from fee-for-service payment models. The rise of bundled payments has drastically impacted plastic surgeons' incomes, especially nonsalaried surgeons in private practice. As a result, physicians must now attempt to optimize contractual reimbursement agreements (carve-outs) with insurance providers. The aim of this article is to explain the economics behind negotiating carve-outs and to offer a how-to guide for plastic surgeons to use in such negotiations. METHODS: Based on work relative value units, Medicare reimbursement, overhead expenses, physician workload, and desired income, the authors present an approach that allows surgeons to evaluate the reimbursement they receive for various procedures. The authors then review factors that influence whether a carve-out can be pursued. Finally, the authors consider relevant nuances of negotiating with insurance companies. RESULTS: Using tissue expander insertion (CPT 19357) as an example, the authors review the mathematics, thought process required, and necessary steps in determining whether a carve-out should be pursued. Strategies for negotiation with insurance companies were identified. The presented approach can be used to potentially negotiate a carve-out for any reconstructive procedure that meets appropriate financial criteria. CONCLUSIONS: Understanding practice costs will allow plastic surgeons to evaluate the true value of insurance reimbursements and determine whether a carve-out is worth pursuing. Plastic surgeons must be prepared to negotiate adequate reimbursement carve-outs whenever possible. Ultimately, by aligning the best quality patient care with insurance companies' financial motivations, plastic surgeons have the opportunity to improve reimbursement for some reconstructive procedures.

Cost-sharing With Medicaid Expansion in Michigan: Obligations and Propensity to Pay.

BACKGROUND: Six states expanding Medicaid under the Affordable Care Act have obtained waivers to incorporate cost-sharing. OBJECTIVE: We describe the magnitude and distribution of cost-sharing imposed by the Healthy Michigan Plan and enrollees' propensity to pay. RESEARCH DESIGN: Enrollees are followed for at least 18 months (6-mo baseline period for utilization and spending before receipt of first cost-sharing statement; ≥12 mo follow-up thereafter to ascertain obligations and payments). Analyses stratified by income, comparing enrollees with income less than Federal Poverty Level (FPL) who faced only utilization-based copayments and those greater than or equal to FPL who also faced premium contributions. SUBJECTS: A total of 158,322 enrollees aged 22-62 who initially enrolled during the first year of the program and remained continuously enrolled ≥18 months. RESULTS: Among those enrolled ≥18 months, 51.0% faced cost-sharing. Average quarterly invoices were $4.85 ($11.11 for those with positive invoices) for income less than FPL and $26.71 ($30.93 for those with positive invoices) for incomes greater than or equal to FPL. About half of enrollees with obligations made at least partial payments, with payments being more likely among those >100% FPL. Payment of the full obligation was highest in the initial 6 months. CONCLUSIONS: Many payment obligations go uncollected, suggesting that in a system without the threat of disenrollment, the impacts of cost-sharing may be muted. Similarly, the ability of cost-sharing to defray the program's budgetary impact may also be less than anticipated.

Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms.

Importance: Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. Objective: To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer. Design, Setting, and Participants: This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021. Exposures: State Medicaid expansion status. Main Outcomes and Measures: Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses. Results: Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas. Conclusions and Relevance: These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.

Effects of inadequate coverage on healthcare utilization: A regression discontinuity analysis.

ABSTRACT: To examine the impact of inadequate health insurance coverage on physician utilization among older adults using a novel quasi-experimental design in the time period following the elimination of cost sharing for most preventative services under the US Affordable Care Act of 2010.The Medical Expenditure Panel Survey full year consolidated data files for the period 2010 to 2017 were used to construct a pooled cross-sectional dataset of adults aged 60 to 70. Regression discontinuity design was used to estimate the impact of transitioning between non-Medicare and Medicare plans on use of routine office-based physician visits and emergency room visits.For the overall population, gaining access to Medicare at age 65 is associated with a higher propensity to make routine office-based visits (2.94 percentage points [pp]; P < .01) and lower out-of-pocket costs (-23.86 pp; P < .01) Similarly, disenrollment from non-Medicare insurance plans at age 66 was associated with more routine office-based visits (3.01 pp; P < .01) and less out-of-pocket costs (-8.09 pp; P < .10). However, some minority groups reported no changes in visits and out-of-pocket costs or reported an increased propensity to make emergency department visits.Enrollment into Medicare from non-Medicare insurance plans was associated with increased use of routine office-based services and lower out-of-pocket costs. However, some subgroups reported no changes in routine visits or costs or an increased propensity to make emergency department visits. These findings suggest other nonfinancial, structural barriers may exist that limit patient's ability to access routine services.

The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.

Association of the Affordable Care Act's Medicaid expansion with the diagnosis and treatment of clinically localized melanoma: A National Cancer Database study.

BACKGROUND: The Affordable Care Act's Medicaid expansion is associated with earlier diagnosis and improved care among lower socioeconomic status populations with cancer, but its impact on melanoma is undefined. OBJECTIVE: To determine the association of Medicaid expansion with stage of diagnosis and use of sentinel lymph node biopsy in nonelderly adult patients with newly diagnosed clinically localized melanoma. METHODS: Quasi-experimental, difference-in-differences retrospective cohort analysis using data from the National Cancer Database from 2010 to 2017. Patients from expansion versus nonexpansion states and diagnosed before (2010-2013) versus after (2014-2017) expansion were identified. RESULTS: Of 83,322 patients, 46.6% were female, and the median age was 55 years (interquartile range, 49-60). After risk adjustment, Medicaid expansion was associated with a decrease in the diagnosis of T1b stage or higher melanoma (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.88-0.98; P = .011) and decrease in uninsured status (OR, 0.61; 95% CI, 0.52-0.72; P < .001) but was not associated with a difference in sentinel lymph node biopsy performance when indicated (OR, 1.06; 95% CI, 0.95-1.20; P = .29). LIMITATIONS: Retrospective study using a national database. CONCLUSION: In this study of patients with clinically localized melanoma, Medicaid expansion was associated with a decrease in the diagnosis of later T-stage tumors.

Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?

The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic-induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints-for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7-10 percent and hospital use by 0-3 percent. Modest administrative savings could offset the costs of such increases.