Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults.

BACKGROUND: Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care. METHODS: Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion). RESULTS: The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period. CONCLUSIONS: The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care.

BACKGROUND: Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs. OBJECTIVES: Examine the changes in reasons for ED use associated with Medicaid expansion. RESEARCH DESIGN: Difference-in-difference analysis. SUBJECTS: We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259). MEASURES: We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and nonexpansion states. RESULTS: Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022]. CONCLUSIONS: Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

Changes in Coverage, Access, and Health Following Implementation of Healthy Behavior Incentive Medicaid Expansions vs. Traditional Medicaid Expansions.

BACKGROUND: Several states expanded Medicaid under the Affordable Care Act using Section 1115 waivers to implement healthy behavior incentive (HBI) programs, but the impact of this type of expansion relative to traditional expansion is not well understood. OBJECTIVE: To examine whether Medicaid expansion with healthy behavior incentive programs and traditional Medicaid expansion were associated with differential changes in coverage, access, and self-rated health outcomes among low-income adults. DESIGN: Difference-in-differences analysis of American Community Survey and Behavioral Risk Factor Surveillance System data from 2011 to 2017. PARTICIPANTS: Low-income adults ages 19-64 in the Midwest Census region (American Community Survey, n = 665,653; Behavioral Risk Factor Surveillance System, n = 71,959). INTERVENTIONS: Exposure to either HBI waiver or traditional Medicaid expansion in the state of residence. MAIN MEASURES: Coverage: Medicaid, private, or any health insurance coverage; access: routine checkup, personal doctor, delaying care due to cost; health: cancer screening, preventive care, healthy behaviors, self-reported health. KEY RESULTS: Healthy behavior incentive (HBI) and traditional expansion (TE) states experienced reductions in uninsurance (- 5.6 [- 7.5, - 3.7] and - 6.2 [- 8.1, - 4.4] percentage points, respectively) and gains in Medicaid (HBI, + 7.6 [2.4, 12.8]; TE, + 9.7 [5.9, 13.4] percentage points) relative to non-expansion states. Both expansion types were associated with increases in rates of having a personal doctor (HBI, + 3.8 [2.0, 5.6]; TE, + 5.9 [2.2, 9.6] percentage points) and mammography (HBI, + 5.6 [0.6, 10.6]; TE, + 7.3 [0.7, 13.9] percentage points). Meanwhile, checkups increased more in HBI than in TE states (p < 0.01), but no other changes in health care services differed between expansion types. CONCLUSIONS: Medicaid expansion was associated with improvements in coverage and access to care with few differences between expansion types.

Work Requirements and Medicaid Disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018.

Objectives. To identify risk factors for Medicaid disenrollment after the implementation of Arkansas's work requirements.Methods. Using a 2018 telephone survey of 1208 low-income adults aged 30 to 49 years in Arkansas (expansion state with work requirements implemented in June 2018), Kentucky (expansion state with proposed work requirements blocked by courts), Louisiana (expansion state without work requirements), and Texas (nonexpansion state), we assessed Medicaid disenrollment rates among the age group targeted by Arkansas's policy.Results. The Medicaid disenrollment rate was highest in Texas (12.8%), followed by Arkansas (10.5%), Kentucky (5.8%), and Louisiana (2.8%). Over half of those who disenrolled in Texas and Arkansas became uninsured, compared with less than a quarter in Kentucky and Louisiana. In multivariate models, Arkansas had significantly higher disenrollment compared with the 3 comparison states; men and non-Hispanic Whites experienced higher disenrollment than women and racial minorities. In Arkansas, having a chronic condition was associated with higher disenrollment.Conclusions. As states debate work requirements and Medicaid reforms, our findings provide insights for policymakers about which populations may be most vulnerable to losing Medicaid coverage.

Levels of Employment and Community Engagement among Low-Income Adults: Implications for Medicaid Work Requirements.

CONTEXT: Twenty states are pursuing community engagement requirements ("work requirements") in Medicaid, though legal challenges are ongoing. While most nondisabled low-income individuals work, it is less clear how many engage in the required number of hours of qualifying community engagement activities and what heterogeneity may exist by race/ethnicity, age, and gender. The authors' objective was to estimate current levels of employment and other community engagement activities among potential Medicaid beneficiaries. METHODS: The authors analyzed the US Census Bureau's national time-use survey data for the years 2015 through 2018. Their main sample consisted of nondisabled adults between 19 and 64 years with family incomes less than 138% of the federal poverty level (N = 2,551). FINDINGS: Nationally, low-income adults who might become subject to Medicaid work requirements already spent an average of 30 hours per week on community engagement activities. However, 22% of the low-income population-particularly women, older adults, and those with less education-would not currently satisfy a 20-hour-per-week requirement. CONCLUSIONS: Although the majority of potential Medicaid beneficiaries already meet community engagement requirements or are exempt, 22% would not currently satisfy a 20-hour-per-week requirement and therefore could be at risk for losing coverage.

Risk Factors for Early Disenrollment From Colorado's Affordable Care Act Marketplace.

BACKGROUND: Midyear disenrollment from Marketplace coverage may have detrimental effects on continuity of care and risk pool stability of individual health insurance markets. OBJECTIVE: The main objective of this study was to assess associations between insurance plan characteristics, individual and area-level demographics, and disenrollment from Marketplace coverage. DATA: All payer claims data from individual market enrollees, 2014-2016. STUDY DESIGN: We estimated Cox proportional hazards models to assess the relationship between plan actuarial value and Marketplace enrollment. The primary outcome was disenrollment from Marketplace coverage before the end of the year. We also calculated the proportion of enrollees who transitioned to other coverage after leaving the Marketplace, and identified demographic and area-level factors associated with early disenrollment. Finally, we compared monthly utilization rates between those who disenrolled early and those who maintained coverage. RESULTS: Nearly 1 in 4 Marketplace beneficiaries disenrolled midyear. The hazard rate of disenrollment was 30% lower for individuals in plans receiving cost-sharing reductions and 21% lower for those enrolled in gold plans, compared with silver plans without cost-sharing subsidies. Young adults had a 70% increased hazard of disenrollment compared with older adults. Those who disenrolled midyear had greater hospital and emergency department utilization before disenrollment compared with those who maintained continuous coverage. CONCLUSIONS: Plan generosity is significantly associated with lower disenrollment rates from Marketplace coverage. Reducing churning in Affordable Care Act Marketplaces may improve continuity of care and insurers' ability to accurately forecast the health care costs of their enrollees.

The Impact of Medicaid Expansion on Continuous Enrollment: a Two-State Analysis.

BACKGROUND: Discontinuous Medicaid insurance erodes access to care, increases administrative costs, and exposes enrollees to substantial out-of-pocket spending. OBJECTIVE: To assess the impact of Medicaid expansion under the Affordable Care Act on continuity of Medicaid coverage among those enrolled prior to expansion. DESIGN: Using a difference-in-differences framework, we compared Colorado, a state that expanded Medicaid, to Utah, a nonexpansion state, before and after Medicaid expansion implementation. PARTICIPANTS: Adults ages 18-62 who were enrolled in Medicaid coverage in Colorado and Utah prior to expansion, from the Utah and Colorado All Payer Claims Databases, 2013-2015. MAIN MEASURES: The primary outcomes were the duration of Medicaid enrollment and rates of disrupted coverage. KEY RESULTS: Following Medicaid expansion, enrollees in Colorado gained an additional 2 months of coverage over two years of follow-up and were 16 percentage points less likely to experience a coverage disruption in a given year relative to enrollees in Utah. CONCLUSIONS: Increasing Medicaid eligibility levels under the Affordable Care Act appears to be an effective strategy to reduce churning in the Medicaid program, with important implications for other states that are considering Medicaid expansion.

The Affordable Care Act and Access to Care for Reproductive-Aged and Pregnant Women in the United States, 2010-2016.

OBJECTIVES: To estimate the association between the Affordable Care Act (ACA), health insurance coverage, and access to care among reproductive-aged and pregnant women. METHODS: We performed an observational study comparing current insurance type, cost-related barriers to medical care, and no usual source of care among reproductive-aged (n = 128 352) and pregnant (n = 2179) female respondents to the National Health Interview Survey in the United States, before (2010-2013) and after (2015-2016) the ACA coverage expansions. RESULTS: Among reproductive-aged women, the ACA was associated with a 7.4 percentage-point decrease in the probability of uninsurance (95% confidence interval [CI] = -8.6, -6.2), a 3.6 percentage-point increase in Medicaid (95% CI = 2.5, 4.7), and a 3.1 percentage-point increase in nongroup private coverage (95% CI = 2.1, 4.1). The ACA was also associated with a 1.5 percentage-point decline in cost-related barriers to medical care (95% CI = -2.6, -0.5) and a 2.4 percentage-point reduction in lacking a usual source of care (95% CI = -4.5, -0.3). We did not find significant changes in insurance or cost-related barriers to care for pregnant women. CONCLUSIONS: The ACA was associated with expanded insurance coverage and improvements in access to care for women of reproductive age, particularly for those with lower incomes.

Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes.

Importance: The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown. Objective: To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes. Design, Setting, and Participants: Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status. Main Exposures: The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years. Main Outcomes and Measures: Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission. Results: The study population included 1 379 005 births among women aged 24-25 years (exposure group; 299 024 in 2009; 1 079 981 in 2011-2013), and 1 551 192 births among women aged 27-28 years (control group; 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women. Conclusions and Relevance: In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.

Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease.

Importance: The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. Objective: To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. Design, Setting, and Participants: Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. Exposure: Living in a Medicaid expansion state. Main Outcomes and Measures: The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. Results: A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. Conclusions and Relevance: Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.

Monoclonal Antibody and Oral Antiviral Treatment of SARS-CoV-2 Infection in US Nursing Homes.

This study examines the use of COVID-19 antiviral treatments in US nursing homes and the facility characteristics associated with use of oral antivirals and monoclonal antibodies.

Kansas and Medicaid: New Evidence on Potential Expansion and Work Requirements.

Issue: Kansas remains one of 17 states that have not expanded Medicaid. In 2017, the Kansas legislature voted to expand Medicaid, but former Governor Sam Brownback vetoed the measure. Goal: To examine evidence on health care coverage and access among low-income Kansans and to review the potential impact of expanding Medicaid with the possible addition of a work requirement as a condition of eligibility. Methods: Findings from a telephone survey of 1,000 low-income nonelderly adults in Kansas were compared with data on low-income adults in Ohio and Indiana, both of which expanded Medicaid. Findings and Conclusions: The uninsured rate among low-income Kansans ages 19 to 64 is 20 percent, significantly higher than rates in Ohio and Indiana. Low-income Kansans also reported comparatively more frequent delays in care because of cost, greater difficulty affording medical bills, and worse health care quality. Survey data show Medicaid expansion is favored by 77 percent of low-income Kansans, and state policymakers have expressed interest in using a Section 1115 waiver for expansion, which would include a work requirement. Our data suggest such a provision would likely have little impact on employment in Kansas, where most potential Medicaid enrollees are disabled or already employed.

Evidence from the Private Option: The Arkansas Experience.

Issue: Arkansas was the first state to receive approval to expand Medicaid under the Affordable Care Act through a Section 1115 waiver. This approach, known as the "private option," uses Medicaid funds to purchase private health plans on the state's marketplace. It is intended to promote market competition, continuity of coverage, and greater access to care. Goal: To describe the key features of the private option and evaluate its impact on health care for low-income adults in the state after two years. Methods: Survey data from 2013­2015 that assessed health insurance coverage, access to care, utilization, and self-reported health among low-income adults in Arkansas compared to adults in two other states. Key findings and conclusions: Arkansas's private option improved access to primary care and prescription medications, reduced reliance on the emergency department, increased use of preventive care, and improved perceptions of quality and health among low-income adults in the state, compared to Texas, which did not expand Medicaid. Arkansas's benefits were similar to those observed in Kentucky's traditional Medicaid expansion. Churning in coverage remained a challenge for nearly a quarter of low-income adults each year.