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The Milbank Quarterly Mar 2020Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and...
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Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and reduce avoidable hospital costs for homeless populations. Compared with nonhomeless adult Medicaid beneficiaries, homeless adult beneficiaries have higher levels of health care needs, due in part to mental health issues and substance use disorders. Homeless adults are also more likely to visit the emergency department or require inpatient admissions. Emergency care and inpatient admissions may sometimes be avoided when individuals have high-quality community-based care and healthful living conditions. Offering tenancy support services that help homeless adults achieve stable housing may therefore be a cost-effective strategy for improving the health of this vulnerable population while reducing spending on avoidable health care interventions. Medicaid beneficiaries with disabling health conditions and more extensive histories of homelessness experience the most potentially avoidable health care interventions and spending, with the greatest opportunity to offset the cost of offering tenancy support benefits.
CONTEXT
Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending.
METHODS
Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries.
FINDINGS
More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups.
CONCLUSIONS
A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.
Topics: Adult; Female; Health Policy; Health Services Needs and Demand; Ill-Housed Persons; Humans; Male; Medicaid; Middle Aged; New Jersey; Patient Protection and Affordable Care Act; United States
PubMed: 31967354
DOI: 10.1111/1468-0009.12446 -
The Milbank Quarterly Mar 2021Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to...
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Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies. Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers' experiences and perspectives into their program design and governance.
CONTEXT
Consumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient-centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done.
METHODS
We conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio-recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses.
FINDINGS
First, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer-term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers' participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement.
CONCLUSIONS
Sharing best practices across states could help strengthen programs' engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.
Topics: Centers for Medicare and Medicaid Services, U.S.; Community Participation; Health Planning; Health Policy; Humans; Interviews as Topic; Medicaid; Patient Protection and Affordable Care Act; State Government; State Health Planning and Development Agencies; State Health Plans; United States
PubMed: 33320389
DOI: 10.1111/1468-0009.12492 -
Health Services Research Jun 2020To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.
OBJECTIVE
To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.
DATA SOURCES
State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.
STUDY DESIGN
The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.
PRINCIPAL FINDINGS
Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).
CONCLUSIONS
Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.
Topics: Humans; Infant; Infant Mortality; Medicaid; Patient Protection and Affordable Care Act; Sex Distribution; United States
PubMed: 32196658
DOI: 10.1111/1475-6773.13286 -
Public Health Reports (Washington, D.C.... 2022Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) pediatric benefit is designed to meet children's medically necessary needs for care. A 2018...
OBJECTIVES
Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) pediatric benefit is designed to meet children's medically necessary needs for care. A 2018 Centers for Medicare & Medicaid Services (CMS) Bulletin advised Medicaid programs to ensure that their dental payment policies and periodicity schedules include language that highlights that medically necessary care should be provided even if that care exceeds typical service frequency or intensity. We assessed the extent to which Medicaid agencies' administrative documents reflect EPSDT's flexibility requirement.
METHODS
From August 2018 through July 2019, we retrieved dental provider manuals, periodicity schedules, and fee schedules in all 50 states and the District of Columbia; analyzed these administrative documents for consistency with the CMS advisory; and determined whether instructions were provided on how to bill for services that exceed customary frequencies or intensities.
RESULTS
Dental-specific periodicity schedules were not evident in 11 states. Eighteen states did not include flexibility language, for example, as advocated by the American Academy of Pediatric Dentistry. Flexibility language was not evident in 24 dental provider manuals or in 47 fee schedules. Only 8 states provided billing instructions within fee schedules for more frequent or intensive services.
CONCLUSION
Updating Medicaid agency administrative documents-including dental provider manuals and periodicity and fee schedules-holds promise to promote individualized dental care as ensured by EPSDT.
Topics: Aged; Child; Child Health Services; Dental Care; Humans; Medicaid; Medicare; Policy; United States
PubMed: 33874788
DOI: 10.1177/00333549211008452 -
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012-2018.Population Health Management Aug 2022This study assesses cost savings associated with specific contraceptive methods provided to beneficiaries enrolled in South Carolina Medicaid between 2012 and 2018....
This study assesses cost savings associated with specific contraceptive methods provided to beneficiaries enrolled in South Carolina Medicaid between 2012 and 2018. Incremental cost-effectiveness ratios, defined as the additional cost of contraception provision per live birth averted, were estimated for 4 contraceptive methods (intrauterine devices [IUDs], implants, injectable contraceptives, and pills), relative to no prescription method provision, and savings per dollar spent on method provision were calculated. Costs associated with publicly funded live births were derived from published sources. The analysis was conducted for the entire Medicaid sample and separately for individuals enrolled under low-income families (LIFs), family planning, and partners for healthy children (PHC) eligibility programs. Sensitivity analysis was performed on contraceptive method costs. IUDs and implants were the most cost-effective with cost savings of up to $14.4 and $7.2 for every dollar spent in method provision, respectively. Injectable contraceptives and pills each yielded up to $4.8 per dollar spent. However, IUDs and implants were less cost-effective than injectable contraceptives and pills if the average length of use was less than 2 years. Medicaid's savings varied across Medicaid eligibility programs, with the highest and lowest savings from contraceptive provision to women in the LIFs and PHC eligibility programs, respectively. The results suggest the need to account for unique needs and preferences of beneficiaries in different Medicaid eligibility categories during contraception provision. The findings also inform program administration and provide evidence to justify legislative appropriations for Medicaid reproductive health care services.
Topics: Child; Contraception; Contraceptive Agents; Cost Savings; Female; Humans; Medicaid; South Carolina; United States
PubMed: 35527673
DOI: 10.1089/pop.2021.0392 -
JAMA Health Forum Jun 2024States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic...
IMPORTANCE
States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care.
OBJECTIVE
To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states.
DESIGN, SETTING, AND PARTICIPANTS
This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level.
EXPOSURE
Medicaid enrollment at any point since March 2020, when continuous coverage began.
MAIN OUTCOMES AND MEASURES
Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment.
RESULTS
The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care.
CONCLUSIONS AND RELEVANCE
The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.
Topics: Humans; Medicaid; United States; Health Services Accessibility; Adult; Female; Male; Insurance Coverage; Middle Aged; COVID-19; Poverty; Young Adult; Arkansas
PubMed: 38943683
DOI: 10.1001/jamahealthforum.2024.2193 -
American Journal of Epidemiology Sep 2021In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nonelderly adults (persons aged 18-64 years) with incomes up to 138% of the...
In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nonelderly adults (persons aged 18-64 years) with incomes up to 138% of the federal poverty level. To our knowledge, the association of Medicaid expansion with suicide, a leading cause of death in the United States, has not been examined. We used 2005-2017 data from the National Violent Death Reporting System to analyze suicide mortality in 8 Medicaid expansion states and 7 nonexpansion states. Using a difference-in-differences approach, we examined the association between Medicaid expansion and the rate of suicide death (number of deaths per 100,000 population) among nonelderly adults. After adjustment for state-level confounders, Medicaid expansion states had 1.2 fewer suicide deaths (β = -1.2, 95% confidence interval: -2.5, 0.1) per 100,000 population per year during the postexpansion period than would have been expected if they had followed the same trend in suicide rates as nonexpansion states. Medicaid expansion was associated with reductions in suicide rates among women, men, persons aged 30-44 years, non-Hispanic White individuals, and persons without a college degree. Medicaid expansion was not associated with a change in suicide rates among persons aged 18-29 or 45-64 years or among non-White or Hispanic individuals. Overall, Medicaid expansion was associated with reductions in rates of suicide death among nonelderly adults. Further research on inequities in Medicaid expansion benefits is needed.
Topics: Adolescent; Adult; Female; Hispanic or Latino; Humans; Male; Medicaid; Medically Uninsured; Middle Aged; Patient Protection and Affordable Care Act; Poverty; Suicide; United States; White People; Young Adult
PubMed: 34467410
DOI: 10.1093/aje/kwab130 -
Journal of Managed Care & Specialty... Dec 2021Chronic obstructive pulmonary disease (COPD) and asthma are common respiratory diseases that impose a significant economic burden on Medicaid. Inhalers are the mainstay...
Chronic obstructive pulmonary disease (COPD) and asthma are common respiratory diseases that impose a significant economic burden on Medicaid. Inhalers are the mainstay treatment for relieving symptoms and improving outcomes for COPD and asthma patients. To describe the total spending and trends of Medicaid expenditures on inhalers between 2012 and 2018 in the United States. We analyzed the deidentified data from the Medicaid Drug Spending Dashboard and utilization datasets from 2012 to 2018. We identified 9 classes of inhalers and described the Medicaid total spending on and relative annual changes for those inhalers. We also described the spending on available generic inhalers and compared the Medicaid spending by manufacturers during this time frame. Medicaid spent $26.2 billion on inhalers from 2012 to 2018. This spending increased by $2.5 billion (120%) over this time frame. During this specified period, the highest Medicaid spending was on the group of inhaled corticosteroid (ICS)-containing inhalers ($14.9 billion). Within this group, the inhaler class of ICS/long-acting beta-2 adrenoceptor agonists contributed to the highest Medicaid spending (53%), with a growth of 607% between 2012 and 2018. Of the $26.2 billion that Medicaid spent on inhalers, $35.5 million (less than 0.01%) was spent on 2 generic inhalers: fluticasone propionate with salmeterol and levalbuterol tartrate hydrofluoroalkane. Between 2012 and 2018, on average, $3.5 billion per year was spent by Medicaid on inhalers. Decreasing the price of inhalers by introducing more generic inhalers in the market can potentially reduce the cost burden on Medicaid. : This study was funded by the American Foundation for Pharmaceutical Education (AFPE). The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript. The authors declare no conflicts of interest.
Topics: Databases, Factual; Health Expenditures; Humans; Medicaid; Nebulizers and Vaporizers; United States
PubMed: 34818085
DOI: 10.18553/jmcp.2021.27.12.1744 -
Social Work in Public Health Jul 2020Medicaid expansion has been shown to improve access to care, health, and finances in general populations. Until now no studies have considered how Medicaid expansion may...
Medicaid expansion has been shown to improve access to care, health, and finances in general populations. Until now no studies have considered how Medicaid expansion may affect informal family caregivers who are the backbone of the long term supports and services infrastructure. Family caregivers provide substantial cost savings to Medicare and Medicaid. Yet, they sustain financial, physical, and mental health strain from their caregiving role which Medicaid expansion may offset. This study evaluated the impact of Medicaid expansion on caregivers' mental health using 2015-2018 data from the Behavioral Risk Factor Surveillance System. After adjusting for demographics, socioeconomic status, and health behaviors, caregivers in Medicaid expansion states had a significantly fewer number of poor mental health days in the previous month than caregivers in non-expansion states (ß = -0.528, CI -1.019, -0.036, < .01). Study findings indicate that Medicaid expansion state status was protective for caregiver's mental health.
Topics: Caregivers; Humans; Medicaid; Quality of Life; United States
PubMed: 32840459
DOI: 10.1080/19371918.2020.1798836 -
Journal of Burn Care & Research :... Sep 2021Frostbite is a high morbidity, high-cost injury that can lead to digit or limb necrosis requiring amputation. Our primary aim is to describe the rate of readmission...
Frostbite is a high morbidity, high-cost injury that can lead to digit or limb necrosis requiring amputation. Our primary aim is to describe the rate of readmission following frostbite injury. Our secondary aims are to describe the overall burden of care, cost, and characteristics of repeat hospitalizations of frostbite-injured people. Hospitalizations following frostbite injury (index and readmissions) were identified in the 2016 and 2017 Nationwide Readmission Database. Multivariable logistic regression was clustered by hospital and additionally adjusted for severe frostbite injury, gender, year, payor group, severity, and comorbidity index. Population estimates were calculated and adjusted for by using survey weight, sampling clusters, and stratum. In the 2-year cohort, 1065 index hospitalizations resulted in 1907 total hospitalizations following frostbite injury. Most patients were male (80.3%), lived in metropolitan/urban areas (82.3%), and nearly half were insured with Medicaid (46.4%). Of the 842 readmissions, 53.7% were associated with complications typically associated with frostbite injury. Overall, 29% of frostbite injuries resulted in at least one amputation. The average total cost and total length of stay of readmissions were $236,872 and 34.7 days. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge against medical advice (AMA) were independent predictors of unplanned readmission. Factors associated with multiple readmissions include discharge AMA and Medicare insurance, but not drug or alcohol abuse or homelessness. The population-based estimated unplanned readmission rate following frostbite injury was 35.4% (95% confidence interval 32.2%-38.6%). This is the first study examining readmissions following frostbite injury on a national level. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge AMA were independent predictors of unplanned readmission, while only AMA discharge and Medicare insurance were associated with multiple readmissions. Supportive resources (community and hospital-based) may reduce unplanned readmissions of frostbite-injured patients with those additional risk factors.
Topics: Adult; Aged; Databases, Factual; Female; Frostbite; Hospital Costs; Humans; Length of Stay; Male; Medicaid; Medicare; Middle Aged; Patient Discharge; Patient Readmission; Retrospective Studies; United States
PubMed: 33993288
DOI: 10.1093/jbcr/irab076