Overturning the ACA's Medicaid Expansion Would Likely Decrease Low-Income, Reproductive-Age Women's Healthcare Spending and Utilization.
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ABSTRACT:
SUBMITTER: Chen L
PROVIDER: S-EPMC7734563 | biostudies-literature | 2020 Jan-Dec
REPOSITORIES: biostudies-literature
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Overturning the ACA's Medicaid Expansion Would Likely Decrease Low-Income, Reproductive-Age Women's Healthcare Spending and Utilization.
Chen Lucy L Frank Richard G RG Huskamp Haiden A HA
Inquiry : a journal of medical care organization, provision and financing 20200101
In late 2020, the Supreme Court began hearing a case challenging the Affordable Care Act (ACA), which led to coverage gains for many low-income, reproductive-age women. To explore potential implications of a full ACA repeal for this population, we examined gains experienced after Medicaid expansion, assuming that such gains may be reversed. Using restricted 2013 to 2014 data from the Medical Expenditure Panel Survey for 1190 women ages 18 to 44 with household incomes below 138% of the federal po ...[more]
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Project description:ObjectiveThis study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the postpartum period.MethodsWe linked Oregon birth certificates, Medicaid enrollment files, and claims to identify postpartum individuals (N = 73,669) who gave birth between 2011 and 2015. We created one pre-Medicaid expansion (2011-2012) and two post-expansion (2014-2015) cohorts (i.e., previously covered and newly covered by Medicaid). We used ordinary least squares and negative binomial regression models to examine changes in postpartum coverage duration and number of outpatient visits within a year of delivery for the post-expansion cohorts compared to the pre-expansion cohort. We examined monthly and overall changes in outpatient utilization during 0-2 months, 3-6 months, and 7-12 months after delivery.ResultsPostpartum coverage duration increased by 3.14 months and 2.78 months for the post-Medicaid expansion previously enrolled and newly enrolled cohorts (p < 0.001), respectively. Overall outpatient care utilization increased by 0.06, 0.19, and 0.34 visits per person for the previously covered cohort and 0.12, 0.13, and 0.26 visits per person for newly covered cohort during 0-2 months, 3-6 months, and 7-12 months, respectively. Monthly change in utilization increased by 0.006 (0-2 months) and 0.004 (3-6 months) visits per person for post-Medicaid previously enrolled cohort and decreased by 0.003 (0-2 months) and 0.02 (7-12 months) visits per person among newly enrolled cohort.ConclusionMedicaid expansion increased insurance coverage duration and outpatient care utilization during postpartum period in Oregon, potentially contributing to reductions in pregnancy-related mortality and morbidities among birthing individuals.
| S-EPMC10352675 | biostudies-literature
Project description:Importance:Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. Objective:To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. Design, Setting, and Participants:This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. Exposures:State Medicaid expansion between 2011 and 2017. Main Outcomes and Measures:Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Results:Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P?<?.001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P?=?.04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P?=?.049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P?=.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P?=?.14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P?=?.70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P?=?.06). Conclusions and Relevance:In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.
| S-EPMC7260619 | biostudies-literature
Project description:BACKGROUND:Medicaid expansion was associated with an increase in hospitalizations funded by Medicaid. Whether this increase reflects an isolated payer shift or broader changes in case-mix among hospitalized adults remains uncertain. RESEEARCH DESIGN:Difference-in-differences analysis of discharge data from 4 states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and 3 comparison states that did not (North Carolina, Nebraska, and Wisconsin). SUBJECTS:All nonobstetric hospitalizations among patients aged 19-64 years of age admitted between January 2012 and December 2015. MEASURES:Outcomes included state-level per-capita rates of insurance coverage, several markers of admission severity, and admission diagnosis. RESULTS:We identified 6,516,576 patients admitted during the study period. Per-capita admissions remained consistent in expansion and nonexpansion states, though Medicaid-covered admissions increased in expansion states (274.6-403.8 per 100,000 people vs. 268.9-262.8 per 100,000; P<0.001). There were no significant differences after Medicaid expansion in hospital utilization, based on per-capita rates of patients-designated emergent, admitted via the emergency department, admitted via clinic, discharged within 1 day, or with lengths of stay ?7 days. Similarly, there were no differences in diagnosis category at admission, admission severity, comorbidity burden, or mortality associated with Medicaid expansion (P>0.05 for all comparisons). CONCLUSIONS:Medicaid expansion was associated with a shift in payers among nonelderly hospitalized adults without significant changes in case-mix or in several markers of acuity. These findings suggest that Medicaid expansion may reduce uncompensated care without shifting admissions practices or acuity among hospitalized adults.
| S-EPMC6417939 | biostudies-literature
Project description:BackgroundThe expansion of state Medicaid programs under the U.S. Affordable Care Act has led to a dramatic increase in the number of Americans with health insurance coverage. Prior analyses of a limited number of states have suggested that greater utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) should be expected after Medicaid expansion. The purpose of our study was to examine whether increased utilization of THA and TKA occurred across a broader range of states after Medicaid expansion.MethodsWe analyzed administrative data from the Healthcare Cost and Utilization Project from 9 states (Arkansas, Arizona, Colorado, Iowa, Massachusetts, Maryland, Nevada, New York, and Vermont) that expanded Medicaid in 2014 and 2 states that did not expand Medicaid (Florida and Missouri). We included patients who were 18 to 64 years of age and had a primary THA or TKA from 2012 to 2015 with Medicaid as the primary payer. Other payers (including dual-eligible Medicaid and Medicare beneficiaries) were excluded. We performed multivariable regression modeling with the number of Medicaid-insured THAs or TKAs as the dependent variable and the interaction between the state Medicaid expansion status and year as the main policy independent variable, with adjustment for community characteristics.ResultsAmong all 11 states, there were 39,452 total joint arthroplasties (42% THA and 58% TKA) funded by Medicaid from 2012 to 2015. After adjusting for community characteristics, within expansion states, compared with 2013, THA and TKA increased 15% in 2014 (p < 0.0001) and 23% in 2015 (p < 0.0001) within expansion states. Within non-expansion states, compared with 2013, there were significant utilization decreases of 18% in 2014 (p < 0.0001) and 11% in 2015 (p = 0.0002).ConclusionsMedicaid expansion was associated with significant increases in Medicaid-funded THA and TKA utilization in 9 states. As additional states consider expanding Medicaid programs and as alternative health reforms that increase insurance eligibility are debated, surgeons, administrators, and policymakers should prepare for a surge in the utilization of THA and TKA.
| S-EPMC8186843 | biostudies-literature
Project description:ObjectiveTo examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.MethodsThis retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.ResultsChildren with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.ConclusionsAmong children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.
| S-EPMC7340572 | biostudies-literature
Project description:ImportanceAdministrative records indicate that more than half of the 80 million Medicaid enrollees identify as belonging to a racial and ethnic minority group. Despite this, disparities within the Medicaid program remain understudied. For example, we know of no studies examining racial differences in Medicaid spending, a potential measure of how equitably state resources are allocated.ObjectivesTo examine whether and to what extent there are differences in health care spending and utilization between Black and White enrollees in Medicaid.Design setting and participantsThis cross-sectional study used calendar year 2016 administrative data from 3 state Medicaid programs and included 1 966 689 Black and White Medicaid enrollees. Analyses were performed between January 28, 2021, and October 18, 2021.ExposuresSelf-reported race.Main outcomes and measuresRates and racial differences in health care spending and utilization (including Healthcare Effectiveness Data and Information Set [HEDIS] access measures).ResultsOf 1 966 689 Medicaid adults and children (mean [SD] age, 20.3 [17.1] years; 1 119 136 [56.9%] female), 867 183 (44.1%) self-identified as non-Hispanic Black and 1 099 506 (55.9%) self-identified as non-Hispanic White. Results were adjusted for age, sex, Medicaid eligibility category, zip code, health status, and usual source of care. On average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 (95% CI, $259-$375) lower than White enrollees, a 6% difference. Among children (18 years or younger), annual spending on Black enrollees was $256 (14%) lower (95% CI, $222-$290). Adult Black enrollees also had 19.3 (95% CI, 16.78-21.84), or 4%, fewer primary care encounters per 100 enrollees per year compared with White enrollees. Among children, the differences in primary care utilization were larger: Black enrollees had 90.1 (95% CI, 88.2-91.8) fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23% difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings.Conclusions and relevanceIn this cross-sectional study of US Medicaid enrollees in 3 states, Black enrollees generated lower spending and used fewer services, including primary care and recommended care for acute and chronic conditions, but had substantially higher emergency department use. While Black enrollees had higher rates of HEDIS preventive screenings, ensuring equitable access to all services in Medicaid must remain a national priority.
| S-EPMC9187949 | biostudies-literature
Project description:IntroductionThe Affordable Care Act (ACA) expanded the coverage of Medicaid to include entire population with income below 138% of federal poverty line. It remains unclear whether this policy change has improved access to and utilization of health care, particularly use of mammography and Pap tests among poor women.MethodsWe used a difference-in-difference (DID) design to estimate the impact of Medicaid expansion on mammography and Pap tests utilization among low-income women. Expansion states are the treatment group and non-expansion states are the control group. The years 2012-13 are the pre-expansion period and 2015-16 are the post-expansion period for the purpose of estimating the DID parameters.ResultsThe difference-in-difference estimate show that likelihood of utilizing mammograms did not change significantly among low-income women after the implementation of Medicaid expansion (DID coefficient -0.0476 with t-statistics at -1.26), Pap test decreased (coefficient -0.0615, t-statistics -2.76), and Medicaid enrollment has increased significantly among low-income women living in expansion states (coefficient 0.0889 with t-value of 3.68).ConclusionExpansion of Medicaid was associated with increased Medicaid enrollment but did not yield near-term improvement in use of mammography and Pap tests among low-income women. Factors beyond health insurance coverage may be important in determining the likelihood of obtaining these screenings. Policy makers should try to identify other barriers to cancer screenings among low-income women in the USA.
| S-EPMC6447234 | biostudies-literature
Project description:Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.
| S-EPMC7926836 | biostudies-literature
Project description:BackgroundAlthough Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).MethodsUsing administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014).ResultsThe percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012).ConclusionOur study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.
| S-EPMC6430692 | biostudies-literature
Project description:IntroductionPreconception and interconception health care are critical means of identifying, managing, and treating risk factors originating before pregnancy that can harm fetal development and maternal health. However, many women in the U.S. lack health insurance, limiting their ability to access such care. State-level variation in Medicaid eligibility, particularly before and after the 2014 Medicaid expansions, offers a unique opportunity to test the hypothesis that increasing healthcare coverage for low-income women can improve preconception and interconception healthcare access and utilization, chronic disease management, overall health, and health behaviors.MethodsIn 2018-2019, data on 58,365 low-income women aged 18-44 years from the 2011-2016 Behavioral Risk Factor Surveillance System were analyzed, and a difference-in-difference analysis was used to examine the impact of Medicaid expansions on preconception health.ResultsExpanded Medicaid eligibility was associated with increased healthcare coverage and utilization, better self-rated health, and decreases in avoidance of care because of cost, heavy drinking, and binge drinking. Medicaid eligibility did not impact diagnoses of chronic conditions, smoking cessation, or BMI. Medicaid eligibility was associated with greater gains in health insurance, utilization, and health among married (vs unmarried) women. Conversely, women with any (vs no) dependent children experienced smaller gains in insurance following the Medicaid expansion, but greater take-up of insurance when eligibility increased and larger behavioral responses to gaining insurance.ConclusionsExpanded Medicaid coverage may improve access to and utilization of health care among women of reproductive age, which could ultimately improve preconception health.
| S-EPMC6925642 | biostudies-literature