Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.
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ABSTRACT:
SUBMITTER: Tipirneni R
PROVIDER: S-EPMC6374260 | biostudies-literature | 2019 Feb
REPOSITORIES: biostudies-literature
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Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.
Tipirneni Renuka R Kullgren Jeffrey T JT Ayanian John Z JZ Kieffer Edith C EC Rosland Ann-Marie AM Chang Tammy T Haggins Adrianne N AN Clark Sarah J SJ Lee Sunghee S Solway Erica E Kirch Matthias A MA Mrukowicz Christina C Beathard Erin E Sears Erin E Goold Susan D SD
Journal of general internal medicine 20181205 2
<h4>Background</h4>Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy.<h4>Objective</h4>To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in healt ...[more]
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Project description:BACKGROUND:It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions. OBJECTIVE:Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being. DESIGN:Mixed-methods study including a telephone survey and semi-structured interviews. SETTING:Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP). PARTICIPANTS:4090 survey respondents (response rate 54%) with ??12 months HMP enrollment and 67 interviewees with ??6 months enrollment. MAIN MEASURES:Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status. KEY RESULTS:Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health. CONCLUSIONS:Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.
| S-EPMC6848397 | biostudies-literature
Project description:BackgroundMedicaid expansion substantially increased health insurance coverage, but its effect on the delivery of preventative health care is unclear.ObjectiveThe objective of this study was to assess the impact of Medicaid expansion on the receipt of 15 different measures of preventive care including cancer screening, cardiovascular risk reduction, diabetes care, and other primary care measures.Research designWe performed serial cross-sectional analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data from 2012 to 2017. We used a quasi-experimental design with difference-in-differences (DiD) analyses to examine changes in preventative health care delivery over 3 time periods in Medicaid expansion compared with nonexpansion states.SubjectsWe included low-income (<138% federal poverty level) nonelderly (age younger than 65 y) adults residing in 46 US states.MeasuresOur predictor was residing in a Medicaid expansion state (24 states) versus nonexpansion state (19 states). Our primary outcomes were preventative health care services, which we categorized as cancer screening (breast cancer, cervical cancer, and colorectal cancer); cardiovascular risk reduction (serum cholesterol screening in low-risk groups, serum cholesterol monitoring in high-risk groups, and aspirin use); diabetes care (serum cholesterol monitoring, hemoglobin A1c monitoring, foot examination, eye examination, and influenza vaccination, and pneumonia vaccination); and other primary care measures [influenza vaccination, alcohol use screening, and human immunodeficiency virus (HIV) screening].ResultsSurvey responses from 500,495 low-income nonelderly adults from 2012 to 2017 were included in the analysis, representing 68.2 million US adults per year. Of the 15 outcomes evaluated, we did not detect statistically significant differences in cancer screening (3 outcomes), cholesterol screening or monitoring (2 outcomes), diabetes care (6 outcomes), or alcohol use screening (1 outcome) in expansion compared with nonexpansion states. Aspirin use (DiD 8.8%, P<0.001), influenza vaccination (DiD 1.4%, P=0.016), and HIV screening (DiD 1.9%, P=0.004) increased in expansion states compared with nonexpansion states.ConclusionsMedicaid expansion was associated with an increase in aspirin use, influenza vaccination, and HIV screening in expansion states. Despite improvements in access to care, including health insurance, having a primary care doctor, and routine visits, Medicaid expansion was not associated with improvements in cancer screening, cholesterol monitoring, diabetes care, or alcohol use screening. Our findings highlight implementation challenges in delivering high-quality primary care to low-income populations.
| S-EPMC7230002 | biostudies-literature
Project description:BackgroundMichigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs).ObjectiveAssess PCPs' perspectives about the impact of HMP on their patients and practices.DesignIn 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs.SettingInterviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail.ParticipantsInterviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104).MeasurementsPCPs' experiences with HMP patients and recent changes in their practices.ResultsInterviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened.LimitationsPCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias.ConclusionsPCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.
| S-EPMC6082204 | biostudies-literature
Project description:BackgroundThe expansion of Medicaid as part of the Affordable Care Act opened new opportunities to provide health coverage to low-income adults who may be involved in other public sectors.ObjectiveThe main objective of this study was to describe cross-sector utilization patterns among urban Medicaid expansion enrollees.Research designWe merged data from 4 public sectors (health care, human services, housing, and criminal justice) for 98,282 Medicaid expansion enrollees in Hennepin County, MN. We fit a latent class model to indicators of cross-sector involvement.MeasuresIndicator variables described involvement levels within each sector from March 2011 through December 2014. Demographic and chronic condition indicators were included post hoc to characterize classes.ResultsWe found 6 archetypes of cross-sector involvement: The "Low Contact" class (33.9%) had little involvement in any public sector; "Primary Care" (26.3%) had moderate, stable health care utilization; "Health and Human Services" (15.3%) had high rates of health care and cash assistance utilization; "Minimal Criminal History" (11.0%) had less serious criminal justice involvement; "Cross-sector" (7.8%) had elevated emergency department use, involvement in all 4 sectors, and the highest prevalence of behavioral health conditions; "Extensive Criminal History" (5.7%) had serious criminal justice involvement. The 3 most expensive classes (Health and Human Services, Cross-sector, and Extensive Criminal History) had the highest rates of behavioral health conditions. Together, they comprised 29% of enrollees and 70% of total public costs.ConclusionsMedicaid expansion enrollees with behavioral health conditions deserve focus due to the high cost-reduction potential across public sectors. Cross-sector collaboration is a plausible path to reduce costs and improve outcomes.
| S-EPMC7045703 | biostudies-literature
Project description:ImportanceThe extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known.ObjectiveTo assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations.Design, setting, and participantsDifference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys.ExposureTime-varying state-level adoption of Medicaid expansion.Main outcomes and measuresPrimary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits.ResultsThe sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion.Conclusion and relevanceMedicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.
| S-EPMC10900969 | biostudies-literature
Project description:ObjectiveTo determine the extent to which the elimination of behavioral health benefits for selected beneficiaries of Oregon's Medicaid program affected general medical expenditures among enrollees using outpatient mental health and substance abuse treatment services.Data source/study settingTwelve months of claims before and 12 months following a 2003 policy change, which included the elimination of the behavioral health benefit for selected Oregon Medicaid enrollees.Study designWe use a difference-in-differences approach to estimate the change in general medical expenditures following the 2003 policy change. We compare two methodological approaches: regression with propensity score weighting; and one-to-one covariate matching.Principal findingsEnrollees who had accessed the substance abuse treatment benefit demonstrated substantial and statistically significant increases in expenditures. Individuals who accessed the outpatient mental health benefit demonstrated a decrease or no change in expenditures, depending on model specification.ConclusionsElimination of the substance abuse benefit led to increased medical expenditures, although this offset was still smaller than the total cost of the benefit. In contrast, individuals who accessed the outpatient mental health benefit did not exhibit a similar increase, although these individuals did not include a portion of the Medicaid population with severe mental illnesses.
| S-EPMC2517280 | biostudies-literature
Project description:ImportanceTo date, 32 states and the District of Columbia have expanded Medicaid programs under the Patient Protection and Affordable Care Act. It is vital to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward improving reproductive health outcomes.ObjectiveTo evaluate the association of Medicaid expansion coverage with access to birth control and family planning services among women of reproductive age enrolled in the Michigan expansion plan.Design, setting, and participantsIn a survey study, from January 13 through December 15, 2016, telephone surveys of a stratified sample of enrollees in Michigan's Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), were conducted. Interviewers completed surveys for 4090 sampled enrollees, of whom 1166 were women aged 19 to 44 years. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. The sample was weighted to 113 565 women. Dates of data analysis were from January 27 through September 18, 2017.Main outcomes and measuresSelf-reported change in access to birth control and family planning services through HMP (better, worse, about the same, or don't know/doesn't apply), compared with before enrollment.ResultsAmong the 1166 survey respondents aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) and the weighted sample of 113?565, 74.7% (95% CI, 72.2%-76.9%) lived in very-low-income households (<100% federal poverty level), 64.0% (95% CI, 60.5%-67.3%) reported at least 1 chronic medical condition, 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health, and 17.7% (95% CI, 15.7%-19.9%) lived in rural settings. Overall, 35.5% (95% CI, 32.2%-39.0%) reported increased access to family planning services. After adjusting, those most likely to report increased access were women without health insurance coverage in the year preceding HMP enrollment (adjusted odds ratio [aOR], 2.02; 95% CI, 1.41-2.89) compared with women with health insurance for the full 12 months preceding enrollment; younger women (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [95% CI, 1.60-3.45]) compared with women aged 35 to 44 years; and women with a recent visit to a primary care clinician (aOR 1.69; 95% CI, 1.03-2.76) compared with women without a primary care visit in the preceding 12 months.Conclusions and relevanceOne in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This finding suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.
| S-EPMC6324283 | biostudies-literature
Project description:BACKGROUND:There is interest in assessing health care utilization and expenditures among new Medicaid enrollees after the 2014 Medicaid expansion. Recent studies have not differentiated between newly enrolled individuals and those returning after coverage gaps. OBJECTIVES:To assess health care expenditures among Medicaid enrollees in the 24 months after Oregon's 2014 Medicaid expansions and examine whether expenditure patterns were different among the newly, returning, and continuously insured (CI). RESEARCH DESIGN:Retrospective cohort study using inverse-propensity weights to adjust for differences between groups. SUBJECTS:Oregon adult Medicaid beneficiaries insured continuously from 2014 to 2015 who were either newly, returning, or CI. MEASURES:Monthly expenditures for inpatient care, prescription drugs, total outpatient care, and subdivisions of outpatient care: emergency department, dental, mental and behavioral health, primary care, and specialist care. RESULTS:After initial increases, newly and returning insured (RI) outpatient expenditures dropped below CI. Expenditures for emergency department and dental services among the RI remained higher than among the newly insured. Newly insured mental and behavioral health, primary care, and specialist expenditures plateaued higher than RI. Prescription drug expenditures increased over time for all groups, with CI highest and RI lowest. All groups had similar inpatient expenditures over 24 months post-Medicaid expansion. CONCLUSIONS:Our findings reveal that outpatient expenditures for new nonpregnant, non-dual-eligible Oregon Medicaid recipients stabilized over time after meeting pent-up demand, and prior insurance history affected the mix of services that individuals received. Policy evaluations should consider expenditures over at least 24 months and should account for enrollees' prior insurance histories.
| S-EPMC5893375 | biostudies-literature
Project description:OBJECTIVE:To assess the effect of the 2014 Medicaid expansion on Medicaid managed care plan quality. DATA SOURCES:Three composite measures of plan-level quality constructed from the Health Care Effectiveness Data and Information Set. STUDY SETTING:One hundred and sixty-three plans in 27 Medicaid expansion states and 100 plans in 14 nonexpansion states. STUDY DESIGN:Quasi-experimental difference-in-differences (DID) analysis, comparing quality before (2011-13) and after (2014-15) Medicaid expansion in states that elected to expand Medicaid eligibility and those that did not. PRINCIPAL FINDINGS:Mean plan enrollment increased from 130,533 to 274,259 in expansion states and from 105,449 to 148,194 in nonexpansion states. The proportion of enrollees receiving recommended preventive care increased from 62.6 to 65.2 percent in expansion states and from 59.3 to 62.5 percent in nonexpansion states (adjusted DID: -0.7 percentage points [95% CI -2.2, 0.7]). The proportion of enrollees receiving recommended chronic disease care management increased from 65.4 to 66.0 percent in expansion states and from 62.5 to 63.1 percent in nonexpansion states (adjusted DID: 1.1 percentage points [95% CI -0.5, 2.6]). We observed similar patterns for the receipt of recommended maternity care. CONCLUSIONS:Medicaid expansion increased enrollment in managed care plans, but it did not result in erosion of quality.
| S-EPMC6056574 | biostudies-literature
Project description:Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status.(1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization.Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (?1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region.PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period.Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.
| S-EPMC5065382 | biostudies-other