COVID-19 Provider Relief Fund Payments Were Appropriately Targeted And Did Not Boost Selected Hospitals' Profits.

To help mitigate the COVID-19 pandemic's financial effects on health care providers, Congress allocated $178 billion to the Provider Relief Fund (PRF) beginning in 2020. Using monthly data from January 2018 through June 2022 from a nationally representative sample of US hospitals, we used a difference-in-differences approach to examine whether hospitals receiving medium and high PRF support intensity had higher average monthly operating margins (measured separately with and without accounting for PRF payments) than those that received low PRF support intensity. We also assessed the impact of PRF payments by hospitals' prepandemic financial vulnerability status, measured by whether their average operating margins in 2018 and 2019 were above or below the national median. Our findings indicate that PRF distributions to hospitals were appropriately targeted and did not make some hospitals significantly more profitable than others; rather, PRF payments helped offset financial losses associated with the pandemic. The effects of PRF support intensity were concentrated among hospitals that were financially vulnerable before the pandemic and thus in need of support to remain financially viable during the crisis.

An estimated $84.9 billion in uncompensated care was provided in 2013; ACA payment cuts could challenge providers.

Millions of uninsured people use health care services every year. We estimated providers' uncompensated care costs in 2013 to be between $74.9 billion and $84.9 billion. We calculated that in the aggregate, at least 65 percent of providers' uncompensated care costs were offset by government payments designed to cover the costs. Medicaid and Medicare were the largest sources of such government payments, providing $13.5 billion and $8.0 billion, respectively. Anticipating fewer uninsured people and lower levels of uncompensated care, the Affordable Care Act reduces certain Medicare and Medicaid payments. Such cuts in government funding of uncompensated care could pose challenges to some providers, particularly in states that have not adopted the Medicaid expansion or where implementation of health care reform is proceeding slowly.

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.

How five leading safety-net hospitals are preparing for the challenges and opportunities of health care reform.

Safety-net hospitals will continue to play a critical role in the US health care system, as they will need to care for the more than twenty-three million people who are estimated to remain uninsured after the Affordable Care Act is implemented. Yet such hospitals will probably have less federal and state support for uncompensated care. At the same time, safety-net hospitals will need to reposition themselves in the marketplace to compete effectively for newly insured people who will have a choice of providers. We examine how five leading safety-net hospitals have begun preparing for reform. Building upon strong organizational attributes such as health information technology and system integration, the study hospitals' preparations include improving the efficiency and quality of care delivery, retaining current and attracting new patients, and expanding the medical home model.

Among dual eligibles, identifying the highest-cost individuals could help in crafting more targeted and effective responses.

The nearly nine million people who receive Medicare and Medicaid benefits, known as dual eligibles, constitute one of the nation's most vulnerable and costly populations. Several initiatives authorized by the Affordable Care Act are intended to improve the health care delivered to dual eligibles and, at the same time, to achieve greater control of spending growth for the two government programs. We examined the 2007 costs and service use associated with dual eligibles. Although the population is indeed costly, we found nearly 40 percent of dual eligibles had lower average per capita spending than non-dual-eligible Medicare beneficiaries. In addition, we found that about 20 percent of dual eligibles accounted for more than 60 percent of combined Medicaid and Medicare spending on the dual-eligible population. But even among these high-cost dual eligibles, we found subgroups. For example, fewer than 1 percent of dual eligibles were in high-cost categories for both Medicare and Medicaid. These findings suggest that decision makers should tailor reform initiatives to account for subpopulations of dual eligibles, their costs, and their service use.

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.

Florida's medicaid reform: informed consumer choice?

Florida is among the first states to implement Medicaid reform using a competitive consumer choice model. Using data from a 2006-07 Kaiser Family Foundation survey of Medicaid recipients newly enrolled in Florida's reform program, we examine how well they understood the changes taking place and their experiences in selecting a health plan. We find important gaps in people's understanding of major components of the reform: About 30 percent were not aware that they were enrolled in reform, and more than half had trouble understanding plan information. These problems were not particular to any group but instead were experienced broadly across the full Medicaid population.

State responses to new flexibility in medicaid.

CONTEXT: States have long lobbied to be given more flexibility in designing their Medicaid programs, the nation's health insurance program for the low-income, the elderly, and individuals with disabilities. The Bush administration and the Deficit Reduction Act of 2005 have put in place policies to make it easier to grant states this flexibility. METHODS: This article explores trends in states' Medicaid flexibility and discusses some of the implications for the program and its beneficiaries. The article uses government databases to identify the policy changes that have been implemented through waivers and state plan amendments. FINDINGS: Since 2001, more than half the states have changed their Medicaid programs, through either Medicaid waivers or provisions in the Deficit Reduction Act of 2005. These changes are in benefit flexibility, cost sharing, enrollment expansions and caps, privatization, and program financing. CONCLUSIONS: With a few important exceptions, these changes have been fairly circumscribed, but despite their expressed interest, states have not yet fully used this flexibility for their Medicaid programs. However, states may exercise this newly available flexibility if, for example, the nation's health care system is not reformed or an economic downturn creates fiscal pressures on states that must be addressed. If this happens, the policies implemented during the Bush administration could lead to profound changes in Medicaid and could be carried out relatively easily.

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.

Restoring fiscal integrity to medicaid financing?

Using survey data, we examined Medicaid supplemental payments (SPs), including disproportionate-share hospital (DSH) and upper payment limit (UPL) payments in 2005 and changes in these payments between 2001 and 2005. We found that states increased their use of general funds in financing of DSH payments while expanding the size and scope of other SPs considerably. Although the federal government has made some headway in reforming state Medicaid financing, our findings suggest that more work remains.

The health care experiences of rural Medicaid beneficiaries.

Medicaid plays a vital role in rural America, yet, because of data limitations, little research exists on the health care experiences of low-income rural adults. We use data from the National Survey of America's Families, with its oversample of low-income populations, to examine differences in access to and use of care between urban and rural Medicaid beneficiaries, and between Medicaid beneficiaries and low-income privately insured adults in urban and rural areas. We find evidence that access to care under Medicaid is worse than under private insurance in both urban and rural areas; however, Medicaid beneficiaries have a more consistent level of access across urban and rural areas than do low-income privately insured people.

An early look at ten state HIFA Medicaid waivers.

In an examination of ten Health Insurance Flexibility and Accountability (HIFA) demonstrations, a major Medicaid initiative of the Bush administration, we found that states have adopted varied program designs, reflecting their particular goals and circumstances. Nationally, we estimate that 300,000 people were covered under HIFA demonstrations as of December 2005. Although this is a sizable number, coverage has fallen far short of the 820,000 expected.

Three years of state fiscal struggles: how did Medicaid and SCHIP fare?

During 2003-05, states faced some of the largest budget shortfalls since World War II. With a focus on Medicaid and SCHIP, we examine budget decisions in eight states during this period. Increasing Medicaid enrollment because of the economic down-turn and rising health care costs compounded state budget shortfalls as state revenues dropped; problems peaked in 2004. States, however, were reluctant to confront their budget deficits as long-term problems and implemented a variety of one-time revenue strategies and spending reductions that push fiscal problems into the future. The arrival of federal fiscal relief in late 2003 helped states avoid deeper cuts but did not eliminate cutbacks.

Assessing access to care under Medicaid: evidence for the nation and thirteen states.

States have broad latitude in designing their Medicaid programs; this has important implications for access to care. To understand the consequences of state variation, we evaluate, for the nation and for thirteen study states, how well the program is providing access for beneficiaries, using the level of access available to low-income privately insured people in the local health care market as our benchmark. Overall, we find that Medicaid beneficiaries' access matches that of the low-income privately insured for most of the ambulatory outcomes examined but is worse for dental services and prescription drugs. State-level analyses revealed some variation in the access gap.

Capitated Medicaid managed care in a rural area: the impact of Minnesota's PMAP program.

CONTEXT: Although states have had difficulty extending Medicaid managed care (MMC) to rural areas, rural models of capitated MMC are expected to grow in response to new federal regulations and the serious budget problems facing nearly all states. As such, understanding the effects of capitated MMC in rural settings is important for policy considerations. PURPOSE: To evaluate the effects of capitated MMC on beneficiary access and use in rural Minnesota. METHODS: We took advantage of delays in the timing of the introduction of MMC across rural counties in Minnesota to estimate the effects of managed care on adults and children under Medicaid using a difference-in-differences framework. FINDINGS: We found that Minnesota's shift from fee-for-service Medicaid to MMC in its rural counties had little effect on access to health care for either adults or children. CONCLUSIONS: Because Minnesota reports that Medicaid costs under MMC are below expected costs under FFS Medicaid, it appears that the primary accomplishment of Minnesota's rural MMC initiative is one of cost savings: MMC provides the same access to care as FFS Medicaid, but at lower cost. With steep budget deficits in nearly all states, other states may want to consider Minnesota's rural MMC model as a mechanism for reducing their Medicaid costs.

The implications of unmet need for future health care use: findings for a sample of disabled Medicaid beneficiaries in New York.

Using survey data linked with Medicaid claims data, this study examines the consequences of unmet need for future health care use for a sample of disabled Medicaid beneficiaries in Westchester County, New York. Among other things, we find that individuals reporting unmet need in 1999 were more likely to use emergency room and hospital care in 2000 than those not reporting unmet need. Addressing the barriers to care that underlie unmet need could generate cost savings to Medicaid and provide better health outcomes for program beneficiaries.

States' use of Medicaid UPL and DSH financing mechanisms.

Using data from a 2002 survey, we look at the design and operation of disproportionate-share hospital (DSH) and upper payment limit (UPL) programs in thirty-four states. We find that more of the available DSH gains are paid to safety-net hospitals than occurred in the late 1990s. By contrast, survey data suggest that the bulk of available UPL gains are being kept by states and not by providers. Using simulation analyses, we estimate that because of DSH and UPL practices among the survey states, the effective 2001 federal Medicaid match rate was about three percentage points higher on average in these states than it would have been otherwise.

Access to Care for Disabled Children Under Medicaid.

This article examines differences in access and use of care among children on Medicaid with physical disabilities, mental illness, and mental retardation/development disabilities (MR/DD) in New York City (NYC). We use 1999 and 2000 survey data obtained from the parents of a random sample of disabled children on Medicaid to conduct both descriptive and multivariate analyses. We find that the Medicaid Program has been successful at linking disabled children to health care providers. However, there is evidence of greater access problems for some subgroups of disabled children. Improving access for disabled children under the Medicaid Program will require targeted help to specific groups of children.

Adult health care access and use under Medicaid: does it vary by state?

States are given considerable discretion in designing their Medicaid programs and, as a result, Medicaid is made up of 51 different programs. Using data from the 1997 National Survey of America's Families, the authors examine variation in health care access and use by adults in 13 states and then compare those differences with national estimates of access and use. The authors find significant differences in access and use among the 13 study states. This variation persisted after differences in state Medicaid caseload characteristics, including demographic, socioeconomic, and health status, were controlled for. State variation in beneficiaries' access and use also persisted after differences in health care market characteristics, such as supply of health care providers, level of employer-sponsored coverage, and level of HMO penetration, and characteristics of the state Medicaid programs were controlled for.