The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries

Objective

To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries.

Data Sources

2010–2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files.

Study Design

We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states.

Data Collection/Extraction Methods

The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community.

Principal Findings

ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020–0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005–0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: −0.003 to 0.050, p = 0.079).

Conclusions

ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.     

Medicaid expansions,preconception insurance,and unintended pregnancy among new parents

ObjectiveTo assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first‐time parents.Data SourceThis study used individual‐level data from the national Pregnancy Risk Assessment Monitoring System (2006‐2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.Study DesignOutcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female‐identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.Data Collection/Extraction MethodsThe sample included all individuals aged 20‐44 with a first live birth in 2009‐2017.Principal FindingsAmong all first‐time parents, a 10‐percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high‐school degree or less.ConclusionsIncreasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first‐time parents.     

The Impact of Private Insurance Coverage on Veterans' Use of VA Care: Insurance and Selection Effects

Objective. To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage.
Data Sources. The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File.
Study Design. We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care).
Principal Findings. VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect.
Conclusions. Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.