Assessment of Health Status and Barriers to Employment Among Medicaid Beneficiaries Not Meeting Work Requirements After Accounting for State Medical Frailty Exemptions.
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ABSTRACT:
SUBMITTER: Silvestri DM
PROVIDER: S-EPMC7199172 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:In June 2018 Arkansas became the first US state to implement work requirements in Medicaid, requiring adults ages 30-49 to work twenty hours a week, participate in "community engagement" activities, or qualify for an exemption to maintain coverage. By April 2019, when a federal judge put the policy on hold, 18,000 adults had already lost coverage. We analyze the policy's effects before and after these events, using a telephone survey performed in late 2019 of 2,706 low-income adults in Arkansas and three control states compared with data from 2016 and 2018. We have four main findings. First, most of the Medicaid coverage losses in 2018 were reversed in 2019 after the court order. Second, work requirements did not increase employment over eighteen months of follow-up. Third, people in Arkansas ages 30-49 who had lost Medicaid in the prior year experienced adverse consequences: 50 percent reported serious problems paying off medical debt, 56 percent delayed care because of cost, and 64 percent delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year. Finally, awareness of the work requirements remained poor, with more than 70 percent of Arkansans unsure whether the policy was in effect.
| S-EPMC7497731 | biostudies-literature
Project description: Not available
| S-EPMC6248197 | biostudies-literature
Project description:ImportanceStates are pursuing Section 1115 Medicaid demonstration waiver authority to apply community engagement (CE) requirements (eg, participation in work, volunteer activities, or training) to beneficiaries deemed able-bodied as a condition of coverage. Understanding the size and characteristics of the populations included in these requirements can help inform policy initiatives and anticipate effects.ObjectiveTo estimate the number and characteristics of Kentucky Medicaid beneficiaries who would have to meet CE requirements.Design, setting, and participantsCross-sectional study in which administrative records for the entire population of Medicaid beneficiaries in Kentucky as of February 2018 and original survey data, based on responses from 9396 Medicaid beneficiaries included in the waiver program, were analyzed.ExposuresEligibility for Kentucky's Medicaid demonstration waiver as of the originally planned implementation date (July 2018).Main outcomes and measuresNumber of beneficiaries included in CE requirements, including those already meeting vs not meeting hour quotas and those who may qualify for medical frailty exemptions.ResultsAmong the 9396 individuals included in the Section 1115 waiver program who participated in the survey, the mean weighted (SD) age was 36.1 (11.9) years; a weighted 47.2% of respondents were female, and most beneficiaries (weighted percentage, 78.2%) were non-Hispanic white participants. We estimated that 132 790 (95% CI, 129 132-136 449) beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver. Of this group, 25 422 (95% CI, 23 135-27 710) beneficiaries may have qualified for a medical frailty exemption either by self-attestation (after confirmation by their Medicaid insurer) or by being identified as eligible by physicians or their insurer. Another 58 943 (95% CI, 55 687-62 196) beneficiaries likely would have met CE hour requirements and been required to report compliance. Ultimately, 48 427 (95% CI, 45 281-51 574) individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver. Beneficiaries in the potentially medically frail group reported worse socioeconomic status, poorer health outcomes, and higher rates of hospital admission and emergency department use than those meeting CE requirements. Similarly, the group currently not meeting and not exempt from CE hour requirements reported worse socioeconomic status than those meeting the CE requirements, although magnitudes of the differences were smaller.Conclusions and relevanceFindings suggest that most beneficiaries who would be included in CE programs either already meet activity requirements, which they will be required to proactively report, or may qualify for a medical frailty exemption. Consequently, the outcomes of CE programs will depend on states' processes for addressing health-related, socioeconomic, and administrative barriers to participating in and reporting CE activities and identifying medical frailty.
| S-EPMC6647552 | biostudies-literature
Project description:ImportanceFederal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements.ObjectiveTo identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums.Design, setting, and participantA cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023.Main outcomes and measuresAgreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an internet panel to recruit residents aged 18 years or older. Findings were weighted to reflect state demographics. Of 39 110 landlines called, 209 reached an eligible person (of whom 150 participated), 8654 were of unknown eligibility, and 30 247 were ineligible. Of 55 305 cell phone lines called, 617 reached an eligible person (of whom 451 participated), 29 951 were of unknown eligibility, and 24 737 were ineligible. Internet recruitment (602 participants) used a panel of adult Kentucky residents maintained by an external data collector.ResultsPercentages were weighted to resemble the adult population of Kentucky residents. Of the participants in the study, 52% (95% CI, 48%-55%) were women, 80% (95% CI, 77%-82%) were younger than 65 years, 41% (95% CI, 38%-45%) were enrolled in Medicaid, 36% (95% CI, 32%-39%) were Republican voters, 32% (95% CI, 29%-36%) were Democratic voters, 14% (95% CI, 11%-16%) were members of racial and ethnic minority groups (including but not limited to American Indian or Alaska Native, Asian, Black, Hispanic or Latinx, and Native Hawaiian or Pacific Islander), and 48% (95% CI, 44%-52%) were employed. Most participants supported work requirements generally (69% [95% CI, 66%-72%]) but did not support terminating benefits due to noncompliance (43% [95% CI, 39%-46%]) or requiring quotas of 20 or more hours per week (34% [95% CI, 31%-38%]). Support for monthly premiums (34% [95% CI, 31%-38%]) and exclusion penalties for premium nonpayment (22% [95% CI, 19%-25%]) was limited. Medicaid enrollees were significantly less supportive of these policies than nonenrollees. For instance, regarding work requirements, agreement was lower (64% [95% CI, 59%-69%] vs 72% [95% CI, 68%-77%]) and disagreement higher (26% [95% CI, 21%-31%] vs 20% [95% CI, 16%-24%]) among current Medicaid enrollees compared with nonenrollees (P = .04). Among Medicaid enrollees, some beliefs about work requirements varied significantly by employment status but not by political affiliation. Among nonenrollees, beliefs about work requirements, premiums, and Medicaid varied significantly by political affiliation but not by employment.Conclusions and relevanceThis study suggests that even when public constituencies express general support for Medicaid work requirements or premiums, they may oppose central design features, such as quotas and termination of benefits. Program participants may also hold significantly different beliefs than nonparticipants, which should be understood before policies are changed.
| S-EPMC10589806 | biostudies-literature
Project description:Alternative approaches in Medicaid are proliferating under the Trump administration. Using a novel telephone survey, we assessed views on health savings accounts, work requirements, and Medicaid expansion. Our sample consisted of 2,739 low-income nonelderly adults in three Midwestern states: Ohio, which expanded eligibility for traditional Medicaid; Indiana, which expanded Medicaid using health savings accounts called POWER accounts; and Kansas, which has not expanded Medicaid. We found that coverage rates in 2017 were significantly higher in the two expansion states than in Kansas. However, cost-related barriers were more common in Indiana than in Ohio. Among Medicaid beneficiaries eligible for Indiana's waiver program, 39 percent had not heard of POWER accounts, and only 36 percent were making required payments, which means that nearly two-thirds were potentially subject to loss of benefits or coverage. In Kansas, 77 percent of respondents supported expanding Medicaid. With regard to work requirements, 49 percent of potential Medicaid enrollees in Kansas were already employed, 34 percent were disabled, and only 11 percent were not working but would be more likely to look for a job if required by Medicaid. These findings suggest that current Medicaid innovations may lead to unintended consequences for coverage and access.
| S-EPMC6076424 | biostudies-literature
Project description:ImportanceA growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM).ObjectiveTo determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees.Design, setting, and participantsThis retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older.ExposureEnrollment in MA vs TM.Main outcomes and measuresFrailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed.ResultsThe final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, -0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, -0.009 [95% CI, -0.067 to 0.049]), SPPB score (mean [SD], -0.144 [2.064] vs -0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, -0.076 to 0.212]), and gait speed (mean [SD], -0.0160 [0.148] m/s vs -0.007 [0.148] m/s; adjusted mean difference, -0.010 m/s [95% CI, -0.067 to 0.049 m/s]).Conclusions and relevanceIn this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.
| S-EPMC11365002 | biostudies-literature
Project description:Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity.
| S-EPMC5682123 | biostudies-other
Project description:OBJECTIVE: To examine the effect of capitated transportation brokerage services on Medicaid beneficiaries' access to care and expenditures. DATA SOURCES/STUDY SETTING: The study period from 1996 to 1999 corresponds to the period of a natural experiment during which Georgia and Kentucky implemented transportation brokerage services. Effects were estimated for asthmatic children and diabetic adults. STUDY DESIGN: We used difference-in-differences models to assess the effects of transportation brokerage services on access to care, measured by Medicaid expenditures and health services use. The study design is strengthened by the staggered implementation dates between states and within each state. PRINCIPAL FINDINGS: For asthmatic children, transportation brokerage services increased nonemergency transportation expenditures and the likelihood of using any services; reductions in monthly expenditures more than offsetting the increased transportation costs. For diabetic adults, nonemergency transportation costs decreased despite increased monthly use of health services; average monthly medical expenditures and the likelihood of hospital admission for an ambulatory care-sensitive condition (ACSC) also decreased. CONCLUSIONS: The shift to transportation brokerage services improved access to care among Medicaid beneficiaries and decreased the expenditures. The increase in access combined with reduced hospitalizations for asthmatic children and ACSC admissions for diabetic adults are suggestive of improvements in health outcomes.
| S-EPMC2669622 | biostudies-literature
Project description:ObjectiveLive interactive telemedicine is increasingly covered by state Medicaid programs, but whether telemedicine is improving equity in utilization of subspecialty care is not known. We examined patterns of telemedicine use for outpatient pediatric subspecialty care within the state Medicaid programs.MethodsWe identified children ≤17 years old in 2014 Medicaid Analysis eXtract data for 12 states. We identified telemedicine-using and telemedicine-nonusing medical and surgical subspecialists. Among children cared for by telemedicine-using subspecialists, we assessed child and subspecialist characteristics associated with any telemedicine visit using logistic regression with subspecialist-level random effects. Among children cared for by telemedicine-using and nonusing subspecialists, we compared visit rates across child characteristics by assessing negative binomial regression interaction terms.ResultsOf 12,237,770 pediatric Medicaid beneficiaries, 2,051,690 (16.8%) had ≥1 subspecialist visit. Of 42,695 subspecialists identified, 146 (0.3%) had ≥1 telemedicine claim. Among children receiving care from telemedicine-using subspecialists, likelihood of any telemedicine use was increased for rural children (odds ratio [OR] 10.4, 95% confidence interval [CI] 6.3-17.1 compared to large metropolitan referent group) and those >90 miles from the subspecialist (OR 13.4, 95% CI 10.2-17.7 compared to 0-30 mile referent group). Compared to children receiving care from telemedicine-nonusing subspecialists, matched children receiving care from telemedicine-using subspecialists had larger differences in visit rates by distance to care, county rurality, ZIP code median income, and child race/ethnicity (P < .001 for interaction terms).ConclusionsChildren in rural communities and at distance to subspecialists had increased likelihood of telemedicine use. Use overall was low, and results indicated that early telemedicine policies and implementation did not close disparities in subspecialty visit rates by child geographic and sociodemographic characteristics.
| S-EPMC7194998 | biostudies-literature
Project description:BackgroundThere is a well-established need for population-based screening strategies to identify people at risk of suicide. Because only about half of suicide decedents are ever diagnosed with a behavioral health condition, it may be necessary for providers to consider life circumstances that may also put individuals at risk. This study described the alignment of medical diagnoses with life circumstances by identifying suicide typologies among decedents. Demographics, stressful life events, suicidal behavior, perceived and diagnosed health problems, and suicide method contributed to the typologies.MethodsThis study linked North Carolina Medicaid and North Carolina Violent Death Reporting System (NC-VDRS) data for analysis in 2020. For suicide decedents from 2014 to 2017 aged 25-54 years, we analyzed 12 indicators of life circumstances from NC-VDRS and 6 indicators from Medicaid claims, using a latent class model. Separate models were developed for men and women.ResultsMost decedents were White (88.3%), with a median age of 41, and over 70% had a health care visit in the 90 days prior to suicide. Two typologies were identified in both males (n = 175) and females (n = 153). Both typologies had similar profiles of life circumstances, but one had high probabilities of diagnosed behavioral health conditions (45% of men, 71% of women), compared to low probabilities in the other (55% of men, 29% of women). Black beneficiaries and men who died by firearm were over-represented in the less-diagnosed class, though estimates were imprecise (odds ratio for Black men: 3.1, 95% confidence interval: 0.8, 12.4; odds ratio for Black women: 5.0, 95% confidence interval: 0.9, 31.2; odds ratio for male firearm decedents: 1.6, 95% confidence interval: 0.7, 3.4).ConclusionsNearly half of suicide decedents have a typology characterized by low probability of diagnosis of behavioral health conditions. Suicide screening could likely be enhanced using improved indicators of lived experience and behavioral health.
| S-EPMC8832648 | biostudies-literature