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1.
Health Aff (Millwood) ; 40(11): 1740-1748, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34724415

RESUMO

With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.


Assuntos
Medicaid , Patient Protection and Affordable Care Act , Governo Federal , Gastos em Saúde , Humanos , Estados Unidos , Washington
2.
Health Aff (Millwood) ; 40(11): 1731-1739, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34724426

RESUMO

Although all state Medicaid programs cover children's dental care, Medicaid-eligible children are more likely to experience tooth decay than children in higher-income families. Using data from the 1999-2016 National Health and Nutrition Examination Survey and the 2003, 2007, and 2011-12 waves of the National Survey of Children's Health, we examined the association between Medicaid adult dental coverage (an optional benefit) and children's oral health. Adult dental coverage was associated with a statistically significant 5-percentage-point reduction in the prevalence of untreated caries among children after Medicaid-enrolled adults had access to coverage for at least one year. These policies were also associated with a reduction in parent-reported fair or poor child oral health with a two-year lag between the onset of the policy and the effect. Effects were concentrated among children younger than age twelve. We estimated declines in poor oral health among all racial and ethnic subgroups, although there was some evidence that non-Hispanic Black children experienced larger and more persistent effects than non-Hispanic White children. Future assessments of the costs and benefits of offering adult dental coverage may consider potential effects on the children of adult Medicaid enrollees.


Assuntos
Medicaid , Saúde Bucal , Adulto , Criança , Saúde da Criança , Acesso aos Serviços de Saúde , Humanos , Cobertura do Seguro , Inquéritos Nutricionais , Estados Unidos
3.
Health Aff (Millwood) ; 40(11): 1722-1730, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34724431

RESUMO

In 2020 the COVID-19 pandemic caused millions to lose their jobs and, consequently, their employer-sponsored health insurance. Enacted in 2010, the Affordable Care Act (ACA) created safeguards for such events by expanding Medicaid coverage and establishing Marketplaces through which people could purchase health insurance. Using a novel national data set with information on ACA-compliant individual insurance plans, we found large increases in Marketplace enrollment in 2020 compared with 2019 but with varying percentage increases and spending risk implications across states. States that did not expand Medicaid had enrollment and spending risk increases. States that expanded Medicaid but did not relax 2020 Marketplace enrollment criteria also had spending risk increases. In contrast, states that expanded Medicaid and relaxed 2020 enrollment criteria experienced enrollment increases without spending risk changes. The findings are reassuring with respect to the ability of Marketplaces to buffer employment shocks, but they also provide cautionary signals that risks and premiums could begin to rise either in the absence of Medicaid expansion or when Marketplace enrollment is constrained.


Assuntos
COVID-19 , Trocas de Seguro de Saúde , Humanos , Cobertura do Seguro , Seguro Saúde , Medicaid , Pandemias , Patient Protection and Affordable Care Act , SARS-CoV-2 , Estados Unidos
4.
Acad Pediatr ; 21(8S): S146-S153, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34740422

RESUMO

Over the past 20 years, the United States greatly expanded eligibility for public health insurance under the Medicaid and Child Health Insurance Program programs. This expansion improved children's access to health care and their health, ultimately lowering preventable hospitalizations, chronic conditions, and mortality rates in the most vulnerable children at a cost that is 4 times lower than the average per capita cost for the elderly. They also had broader antipoverty effects, increasing economic security, children's educational attainments, and their eventual employment and earnings opportunities. However, in recent years, this progress has been rolled back in many states. Remarkably, although income eligibility cutoffs have remained largely constant, states have reduced child coverage through a number of administrative measures ranging from increased paperwork, to reduced outreach, new parental work requirements, changes to public charge rules for immigrants, and waivers of federal requirements to provide retroactive coverage to new applicants. The number of uninsured children was rising for the first time in decades even prior to the pandemic. With rising numbers who have lost their jobs in the pandemic-induced recession, it is more important than ever to defend and restore and improve access to public health insurance for our children.


Assuntos
Serviços de Saúde da Criança , Medicaid , Idoso , Criança , Saúde da Criança , Acesso aos Serviços de Saúde , Humanos , Seguro Saúde , Pobreza , Estados Unidos
6.
Am J Occup Ther ; 75(5)2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34780629

RESUMO

IMPORTANCE: An analysis by the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015a) found that an additional 10,000 mental health care providers will be needed by 2025 to meet the expected growth in demand for treatment of people with mental illness, substance use disorder, or both. Despite being the largest payer of mental health services in the United States, the Medicaid program has extremely low numbers of mental health providers (Frank et al., 2003). OBJECTIVE: This Health Policy Perspectives column is a collaboration among academics, clinicians, and students in the fields of occupational therapy and law in an effort to advance state occupational therapy associations' efforts to gain formal recognition of occupational therapy practitioners as Qualified Mental Health Providers (QMHPs) and/or Qualified Behavioral Health Providers (QBHPs). CONCLUSION: Coordination among states to identify barriers and opportunities in this important advocacy effort are needed for continued successful inclusion of occupational therapy practitioners as QMHPs, QBHPs, or both. What This Article Adds: This column will assist other states in their efforts by providing legislation, strategic advocacy examples, and a course of action.


Assuntos
Serviços de Saúde Mental , Terapia Ocupacional , Transtornos Relacionados ao Uso de Substâncias , Humanos , Medicaid , Estados Unidos
7.
J Am Board Fam Med ; 34(6): 1189-1202, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34772774

RESUMO

BACKGROUND: Primary care is crucial to the health of individuals and communities, but it faces numerous structural and systemic challenges. Our study assessed the state of primary care in Virginia to prepare for Medicaid expansion. It also provides insight into the frontline of health care prior to an unprecedented global COVID-19 pandemic. METHODS: We surveyed 1622 primary care practices to understand organizational characteristics, scope of care, capacity, and organizational stress. RESULTS: Practices (484) varied in type, ownership, location, and care for medically underserved and diverse patient populations. Most practices accepted uninsured and Medicaid patients. Practices reported a broad scope of care, including offering behavioral health and medication-assisted therapy for opioid addiction. Over half addressed social needs like transportation and unstable housing. One in three practices experienced a significant stress in 2019, prepandemic, and only 18.8% of practices anticipated a stress in 2020. CONCLUSIONS: Primary care serves as the foundation of our health care system and is an essential service, but it is severely stressed, under-resourced, and overburdened in the best of times. Primary care needs strategic workforce planning, adequate access to resources, and financial investment to sustain its value and innovation.


Assuntos
COVID-19 , Pandemias , Acesso aos Serviços de Saúde , Humanos , Medicaid , Atenção Primária à Saúde , SARS-CoV-2 , Estados Unidos , Virginia
8.
BMC Health Serv Res ; 21(1): 1189, 2021 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-34727944

RESUMO

BACKGROUND: First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient's medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale. METHODS: The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid's (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators. RESULTS: The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (µ = 16.22, SD = 0.28), appropriate (µ = 15.33, SD = 0.03), and feasible (µ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout. CONCLUSION: The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid's MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.


Assuntos
Serviços Comunitários de Farmácia , Conduta do Tratamento Medicamentoso , Humanos , Medicaid , Farmacêuticos , Tennessee , Estados Unidos
10.
J Manag Care Spec Pharm ; 27(10): 1489-1493, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34595946

RESUMO

SUMMARY The 1-month drug-dispensing limit is a common drug utilization tool used by state Medicaid agencies to control spending. Since the beginning of the COVID-19 pandemic, many states relaxed the 1-month dispensing limit restriction in order to align with social distancing recommendations. Yet, some states have not relaxed this limit and have differed substantially regarding the policies that have been implemented. Among states that relaxed the 1-month supply limit, determining which chronic disease drugs qualified for this extension can be challenging for patients and clinicians. As more commercial and Medicare insurance beneficiaries are offered 90-day drug supplies, the 30-day drug supply limit with Medicaid has become a health equity issue, since many individuals insured by Medicaid have already experienced a disproportionate impact from and remain at high risk for severe COVID-19 disease. Thus, we propose policy solutions to ensure that Medicaid beneficiaries have safe and uninterrupted access to chronic disease medications during and beyond the COVID-19 pandemic. DISCLOSURES: No funding was received for this work. Alpern has received funding from Arnold Ventures for research related to the use and spending of off-patent drugs, unrelated to this work, and is a member of the Pharmacy and Therapeutics Committee at Regions Hospital, St. Paul, MN. DeSilva has received CDC support for work on Vaccine Safety Datalink, VISION network, and Center of Excellence for Newcomer Health, unrelated to this work. Chomilo is Medicaid Medical Director for the State of Minnesota's Department of Human Services.


Assuntos
COVID-19/epidemiologia , Medicaid/normas , Distanciamento Físico , Doença Crônica , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/normas , Medicaid/economia , Pandemias , Políticas , SARS-CoV-2 , Estados Unidos/epidemiologia
11.
Artigo em Inglês | MEDLINE | ID: mdl-34639761

RESUMO

Ensuring access to pre-kindergarten (Pre-K) education remains a pressing policy issue in the United States. Prior research has shown the positive effects that Pre-K has on children's cognitive development. However, studies on its effects on children's health outcomes are scarce. This study aimed to investigate the effects of the Pre-K program on pediatric asthma. Children's individual data from existing research conducted in North Carolina were linked with state Medicaid claims data from 2011-2017. There were 51,408 observations (person-month unit) of 279 children enrolled in Pre-K and 333 unenrolled children. Asthma was identified using the ICD 9/10 codes. A difference-in-differences model was adopted using a panel analysis with three time periods: before, during, and after Pre-K. The explanatory variables were interaction terms between Pre-K enrollment and (a) before vs. during period and (b) during vs. after period. The results indicated that children enrolled in Pre-K had a greater risk of asthma diagnosis during Pre-K (b = 0.0145, p = 0.058). Conversely, in the post-intervention period, the enrolled children had a lower of receiving an asthma diagnosis (b = -0.0216, p = 0.002). These findings indicate that Pre-K may increase the use of asthma-related health services in the short term and decrease the service use after participants leave the program.


Assuntos
Asma , Asma/epidemiologia , Criança , Escolaridade , Serviços de Saúde , Humanos , Medicaid , Instituições Acadêmicas , Estados Unidos/epidemiologia
12.
J Prim Care Community Health ; 12: 21501327211052401, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34686099

RESUMO

CONTEXT: Increasing rates of Opioid Use Disorder among pregnant women are a significant public health issue. Care for these women is fragmented, and multiple barriers to care have been identified. Program: The Tides, Inc. is attempting to address these needs by providing comprehensive, coordinated care, beginning in pregnancy and extending beyond the birth of their infant. IMPLEMENTATION: Using a collaborative model, care is coordinated between multiple existing agencies in an effort to reduce barriers and improve access to care. Funding for these services is provided through county funding and existing payor sources (eg, insurance, Medicaid). EVALUATION: Participant and program outcomes were evaluated at the end of each year of the program. In addition, participants who had completed the program at the end of year 1 were asked to complete a survey providing qualitative information about their experience in the program. Of these participants, 73% reported no opiate use and 100% had full custody of their infants. DISCUSSION: The Tides, Inc. program utilizes existing resources to provide coordinated and comprehensive care for pregnant women with Opioid Use Disorder. In addition to improving outcomes for women and their infants, this program can reduce cost and burden on community entities such as the justice system and foster care networks. This program can serve as a model for other communities to coordinate care for women and their infants.


Assuntos
Mães , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Lactente , Medicaid , Gravidez
13.
BMC Health Serv Res ; 21(1): 1152, 2021 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-34696801

RESUMO

BACKGROUND AND OBJECTIVE: To characterize health care use and costs among new Medicaid enrollees before and during the COVID pandemic. Results can help Medicaid non-expansion states understand health care use and costs of new enrollees in a period of enrollment growth. RESEARCH DESIGN: Retrospective cross-sectional analysis of North Carolina Medicaid claims data (January 1, 2018 - August 31, 2020). We used modified Poisson and ordinary least squares regression analysis to estimate health care use and costs as a function of personal characteristics and enrollment during COVID. Using data on existing enrollees before and during COVID, we projected the extent to which changes in outcomes among new enrollees during COVID were pandemic-related. SUBJECTS: 340,782 new enrollees pre-COVID (January 2018 - December 2019) and 56,428 new enrollees during COVID (March 2020 - June 2020). MEASURES: We observed new enrollees for 60-days after enrollment to identify emergency department (ED) visits, nonemergent ED visits, primary care visits, potentially-avoidable hospitalizations, dental visits, and health care costs. RESULTS: New Medicaid enrollees during COVID were less likely to have an ED visit (-46 % [95 % CI: -48 %, -43 %]), nonemergent ED visit (-52 % [95 % CI: -56 %, -48 %]), potentially-avoidable hospitalization (-52 % [95 % CI: -60 %, -43 %]), primary care visit (-34 % [95 % CI: -36 %, -33 %]), or dental visit (-36 % [95 % CI: -41 %, -30 %]). They were also less likely to incur any health care costs (-29 % [95 % CI: -30 %, -28 %]), and their total costs were 8 % lower [95 % CI: -12 %, -4 %]. Depending on the outcome, COVID explained between 34 % and 100 % of these reductions. CONCLUSIONS: New Medicaid enrollees during COVID used significantly less care than new enrollees pre-COVID. Most of the reduction stems from pandemic-related changes in supply and demand, but the profile of new enrollees before versus during COVID also differed.


Assuntos
COVID-19 , Pandemias , Estudos Transversais , Serviço Hospitalar de Emergência , Custos de Cuidados de Saúde , Humanos , Medicaid , Estudos Retrospectivos , SARS-CoV-2 , Estados Unidos/epidemiologia
14.
J Law Med Ethics ; 49(3): 394-400, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34665096

RESUMO

From 2018 through 2020, HHS approved state Medicaid demonstration waivers to impose new eligibility conditions such as work requirements, connecting current "personal responsibility" rhetoric and historical suspicion of malingering. The Biden administration reversed course but advocated to the Supreme Court for expansive administrative discretion. This approach supports health equity now but could enable reemergence of restrictive health policies down the road.


Assuntos
Simulação de Doença , Medicaid , Definição da Elegibilidade , Política de Saúde , Humanos , Estados Unidos
15.
BMC Oral Health ; 21(1): 540, 2021 10 20.
Artigo em Inglês | MEDLINE | ID: mdl-34670549

RESUMO

BACKGROUND: Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. METHODS: Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012-2017. The analytic sample included 2054 CHC-year observations. RESULTS: Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). CONCLUSIONS: Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.


Assuntos
Procedimentos Cirúrgicos Bucais , Patient Protection and Affordable Care Act , Adulto , Acesso aos Serviços de Saúde , Humanos , Cobertura do Seguro , Medicaid , Saúde Pública , Estados Unidos
17.
Health Aff (Millwood) ; 40(10): 1637-1643, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34606344

RESUMO

Addressing health inequities for racial and ethnic minority populations is challenging. After passage of the Affordable Care Act, Michigan launched its Healthy Michigan Plan, which expanded Medicaid eligibility in the state. Our evaluation of the expansion provided the opportunity to study its impact on racial and ethnic minority groups, including Arab American and Chaldean American enrollees, an understudied population. Using data from telephone surveys collected in 2016, 2017, and 2018, we conducted an analysis to study the plan's impact on access to a regular source of care and health status among racial and ethnic minority groups. More than 90 percent of respondents of all racial and ethnic groups reported having a regular source of care after plan enrollment compared with 74.4 percent before enrollment. Respondents who identified as non-Hispanic White, African American, and Hispanic reported improvements in health status after plan enrollment. Our study demonstrates the potential of health insurance access to narrow health inequities between racial and ethnic groups.


Assuntos
Grupos Étnicos , Medicaid , Acesso aos Serviços de Saúde , Nível de Saúde , Humanos , Michigan , Grupos Minoritários , Patient Protection and Affordable Care Act , Autorrelato , Estados Unidos
18.
Health Aff (Millwood) ; 40(10): 1605-1611, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34606358

RESUMO

Poor perinatal mental health is a common pregnancy-related morbidity with potentially serious impacts that extend beyond the individual to their family. A possible contributing factor to poor perinatal mental health is discontinuity in health insurance coverage, which is particularly important among low-income people. We examined impacts of Medicaid expansion on prepregnancy depression screening and self-reported depression and postpartum depressive symptoms and well-being among low-income people giving birth. Medicaid expansion was associated with a 16 percent decline in self-reported prepregnancy depression but was not associated with postpartum depressive symptoms or well-being. Associations between Medicaid expansion and prepregnancy mental health measures increased with time since expansion. Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.


Assuntos
Medicaid , Saúde Mental , Feminino , Acesso aos Serviços de Saúde , Humanos , Cobertura do Seguro , Patient Protection and Affordable Care Act , Gravidez , Estados Unidos
19.
J Midwifery Womens Health ; 66(5): 589-596, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34596945

RESUMO

INTRODUCTION: We calculate the financial margins for delivery of routine antenatal care as reimbursed by Medicaid. Prenatal care cost varies with overhead, health care provider type, and number of office visits. Antenatal care is only one component of the global maternity bundle, which also includes intrapartum and postpartum care. METHODS: Time for provision of low-risk antenatal care was determined prospectively from a study of 133 low-risk pregnant patients. Health care provider time cost was estimated using mean wages for obstetricians and midwives. Margins were estimated by subtracting cost of provider services and overhead for the antenatal component of maternity care from total Medicaid reimbursement for the pregnancy global package (CPT 59400) using 2015 dollars. The maternity bundle elements of routine prenatal laboratory tests, ultrasounds, intrapartum care, and postpartum care were not included in our analysis of cost components. RESULTS: Patients received an average of 215 minutes of direct provider time per pregnancy. At the 50th percentile for physician payment and assuming overhead is 53.4% of revenue, practice margins varied by state from -$1067 to +$675, with a median of -$357. Median margins for midwifery care were +$15, with a range of -$579 to +$885. Margins were negative if overhead costs exceeded 33% of revenue for physician care and 55% of revenue for midwifery care. DISCUSSION: In many states, Medicaid reimbursement for the global maternity package is less than the actual cost of antenatal care alone. Improving reimbursement or decreasing costs is necessary to make maternity care more cost-effective.


Assuntos
Serviços de Saúde Materna , Medicaid , Atenção à Saúde , Feminino , Custos de Cuidados de Saúde , Humanos , Gravidez , Cuidado Pré-Natal , Estados Unidos
20.
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