Access to care and health insurance coverage for workers with disabilities: Outcomes by state-level responses to the ACA

BackgroundStates had flexibility in their implementation of the Patient Protection and Affordable Care Act (ACA) Medicaid expansions, which may have led to variation in coverage and changes in access to care for workers with disabilities.Objective/hypothesisTo examine differential trends in health insurance coverage and access to care among workers with disabilities by states’ decisions about expanding Medicaid under the ACA.MethodsWe aggregated data from the National Health Interview Survey into groups by time period relative to ACA implementation: pre-ACA (2006–2009), early ACA (2010–2013), and later ACA (2014–2017). We produced health insurance and access statistics for each time period, by state-level Medicaid expansion status.ResultsUninsurance rates decreased after 2014 in all states, regardless of the state’s decision whether to expand Medicaid. There was a substantial increase after 2014 in the share of workers with disabilities covered by Medicaid in states that expanded in that year; in other states, workers with disabilities experienced larger increases in privately purchased coverage. At the same time, the share of workers with disabilities reporting cost-related barriers to care declined markedly in 2014 Medicaid expansion states, but it increased slightly in the non-expansion states. Structural barriers to accessing care increased in all states, with the smallest increase in 2014 expansion states.ConclusionsMedicaid coverage and cost-related access to care improved significantly among workers with disabilities in 2014 Medicaid expansion states, both overall and relative to workers with disabilities in non-expansion states.     

Effects of the Medicaid expansion under the Affordable Care Act on health insurance coverage,health care access,and use for people with disabilities

BackgroundPeople with disabilities have higher health care needs, service utilization, and expenditures. They are also more likely to lack insurance and experience unmet need for medical care. There has been limited research on the effects of the Affordable Care Act Medicaid expansion on people with disabilities.ObjectiveTo examine the effects of the Medicaid expansion on health insurance coverage, access, and service use for working-age adults with disabilities.MethodsA retrospective study using 11 years (2007–2017) of data from the Medical Expenditure Panel Survey - Household Components, linked to Area Health Resource Files and Local Area Unemployment Statistics (N = 40,995). Difference-in-differences multinomial logistic and linear probability models with state and year fixed-effects were used to estimate the effects.ResultsWe found strong evidence of increased Medicaid coverage in expansion states (3.2 to 5.0 percentage points), reasonably strong evidence of reduced private insurance coverage (?2.2 to ?2.5 percentage points), and some evidence of reduced uninsured rate (from no effect to ?3.7 percentage points). Results suggest that the increase in Medicaid coverage was due at least in part to the “crowd-out” of private insurance in expansion states. No statistically significant effects were detected for access and use outcomes.ConclusionsFindings suggest that state Medicaid expansions led to an increase in Medicaid coverage and a decrease in private insurance coverage as well as the uninsured. However, no evidence was found for health care access and use outcomes. Further research into access and use is needed when more data become available for the post-expansion period.     

Insurance coverage and access to care for workers with disabilities, 2001–2017

BackgroundWorkers with disabilities have different options than their peers for obtaining health insurance, and face unique barriers in accessing care. The Patient Protection and Affordable Care Act (ACA) led to sweeping changes in the availability and affordability of health insurance in the United States beginning in 2010, and may have had important effects for workers with disabilities.Objective/HypothesisDocument how the ACA changed insurance coverage and access to care for workers with disabilities, and compare those changes to changes among other groups.MethodsWe document health insurance coverage and access to care among workers with disabilities using the 2001–2017 National Health Interview Survey.ResultsThe share of insured workers with disabilities increased from 79.9% in 2009 to 87.8% in 2017. This gain resulted from an 11 percentage point (pp) increase in the share with Medicaid coverage in 2014–2017 compared with 2001–2009 and a 5 pp increase in privately purchased coverage over those periods. These were accompanied by an 11 pp decline in the share with employer-sponsored coverage. Despite coverage gains, cost-related barriers to accessing medical care did not change much after the ACA, for any group. Workers with disabilities experienced an increase in structural access barriers, from 18.4% before the ACA to 24.8% after.ConclusionsThe gain in insurance coverage for workers with disabilities is an important benefit of the ACA, but more investigation and monitoring should be considered to understand whether such coverage will translate into improvements in access to needed health care.     

Changes in health insurance coverage,access to care,and health services utilization by sexual minority status in the United States, 2013‐2018

ObjectiveTo examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013‐2014 and 2017‐2018.Data SourcesData on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18‐64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys.Study DesignUnadjusted and regression‐adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression‐adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics.Principal FindingsUninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013‐2014 and 2017‐2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017‐2018 compared with 2013‐2014. Low‐income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults.ConclusionsSexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.     

Young Adult Preventive Healthcare: Changes in Receipt of Care Pre- to Post-Affordable Care Act

PurposeYoung adults have unique health and health care needs. Although morbidity and mortality stem largely from preventable factors, they lack a structured set of preventive care guidelines. The Affordable Care Act (ACA), enacted in 2010, increased young adult insurance coverage, prohibited copayments for preventive visits among privately insured and for many preventive services. The objectives were to evaluate pre- to post-ACA changes in young adults' past-year well visits and, among those using a past-year health care visit, the receipt of preventive services.MethodsWe used pooled Medical Expenditure Panel Survey data, comparing pre-ACA (2007–2009, N = 10,294) to post-ACA (2014–2016, N = 10,567) young adults aged 18–25 years. Bivariable and multivariable stratified logistic regression, adjusting for sociodemographic covariates, were conducted to determine differences in well visits and in preventive services among past-year health care utilizers: blood pressure and cholesterol checks, influenza immunization, and all three received.ResultsPast-year well visits increased from pre-ACA (28%) to post-ACA (32%), p < .001. Increases were noted for most demographic subgroups with greatest increases among males, Asian, and highest income subgroups. Larger pre- to post-ACA increases were found for most of the preventive services, p < .05, including the receipt of all three services (7% vs. 16%), p < .001, among past-year health care utilizers.ConclusionFollowing ACA implementation, young adults experienced modest increases in well visit rates and larger increases in most preventive services received. Overall rates of both remain low. Building on these improvements requires concerted efforts that account for young adults' unique combination of health care issues and challenges in navigating an adult health care system.     

Health Care Reform and Young Adults' Access to Sexual Health Care: An Exploration of Potential Confidentiality Implications of the Affordable Care Act

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent’s private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences.Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues.Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.ON MARCH 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, effecting the most significant change to the US health care system since the creation of the Medicare and Medicaid programs in 1965.1 All components of the health sector are affected: the legislation includes expansions of public coverage, new subsidies for private coverage, health insurance exchanges, insurance coverage requirements and mandates, and strategies to increase the efficiency of health care delivery and rein in health care costs. Such sweeping reforms bring a host of intended changes and potential unforeseen ramifications. One provision of the ACA expands access to dependent coverage for young adults on their parent’s health insurance up to age 26 years, regardless of marital, employment, or educational status, effective September 2010. Previously, the maximum age varied by state, with eligibility for dependent coverage often linked to factors such as educational enrollment status. The government Web site describes the intended benefits of this provision: “By allowing children to stay on their parent''s plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.”2Young adults aged 19 to 26 years have the highest uninsured rate of any age group in the country; 30% were without coverage in 2009.3 The high rate reflects many contributing factors. Young adults are more likely than other working-aged adults to be unemployed; if working, they are more likely to be newly employed, employed in entry-level jobs, and working in part-time positions without access to employer coverage. Furthermore, most young adults do not meet the traditional categorical eligibility requirements for the Medicaid program—the parent of a child younger than 19 years or an aged or disabled individual—and so young adults, even those with very low incomes, seldom qualify for public coverage. The subsequent low levels of insurance result in limited access to care and high levels of unmet need for care.4By expanding access to health insurance coverage, the ACA addresses two Healthy People 2020 goals5: attaining a higher proportion of individuals with insurance and reducing the proportion of individuals who are unable to obtain or who delay obtaining necessary medical care. This provision of the ACA has already shown significant success in expanding health insurance coverage for young adults. The percentage of young people with health insurance increased by 3.8 points from the first quarter of 2010 to the first quarter of 2011, far outstripping gains in other age groups.6 However, the reliance on expanding dependent coverage to address the high levels of uninsured young adults contains the potential for unintended consequences, because concerns about confidentiality could disrupt access to care.     

Effects of health insurance coverage on risky behaviors

Prior to implementation of the Patient Protection and Affordable Care Act, dependent health insurance coverage was typically available only for young adults under the age of 19. As of September 2010, the Affordable Care Act extended dependent health insurance coverage to include young adults up to the age of 26. I use the National Health Interview Survey for the sample period from 2011 to 2013 to analyze the causal relationship between the expansion of dependent coverage and risky behaviors including smoking and drinking as well as preventive care. I employ a regression discontinuity design to estimate the causal effect of health insurance coverage and overcome the endogeneity problem between insurance status and risky behaviors. When young adults become 26 years old, they are 7 to 10 percentage points more likely to lose health insurance than young adults under the age of 26. Although young adults over the age of 26 are generally aged out of insurance coverage, presence or absence of health insurance does not affect their smoking and drinking behaviors and their access to preventive care.     

National trends in health insurance coverage of pregnant and reproductive-age women, 2000 to 2009

PurposeHealth insurance facilitates financial access to health services, including prenatal and preconception care. This study characterized changes in health insurance coverage among reproductive-age women in the United States from 2000 to 2009.MethodsData from female respondents (ages 18–49) to the National Health Interview Surveys, 2000 to 2009 (n = 207,968), including those pregnant when surveyed (n = 3,204), were used in a repeated cross-sectional design. Changes over time were estimated using longitudinal regression models.Main FindingsOf the reproductive-age women in this study, 25% were uninsured at some point in the prior year. Ten percent of pregnant women reported currently being uninsured, and 27% and 58% reported Medicaid coverage or private health insurance, respectively. Among women who were not pregnant, 19% were currently uninsured, 8% had Medicaid, and 68% had private coverage. From 2000 to 2009, an increasing percentage of reproductive-age women reported having gone without health insurance in the past year. Controlling for sociodemographic and health variables, the chances that a reproductive-age woman had been uninsured increased by approximately 1.5% annually (p < .001), and did not differ between pregnant women and those who were not pregnant. The odds that an insured pregnant woman had Medicaid coverage increased 7% per year over the study period (p < .001), whereas the odds of private coverage decreased.ConclusionReproductive-age women are increasingly at risk of being uninsured, which raises concerns about access to prenatal and preconception care. Among pregnant women, access to private health insurance has decreased, and state Medicaid programs have covered a growing percentage of women. Health reform will likely impact future trends.     

Have working-age people with disabilities shared in the gains of Massachusetts health reform?

The Massachusetts health reform, implemented in 2006 and 2007, reduced the uninsurance rate for working-age people with disabilities by nearly half Enrollment in Medicaid and subsidized insurance accounted for most of the gain in insurance coverage. The reduction in uninsurance was greatest among younger adults. The reform also reduced cost-related problems obtaining care; however, cost remains an obstacle, particularly among young adults with disabilities. The Massachusetts outcomes demonstrate that insurance subsidies, Medicaid expansions for low-income adults, individual insurance mandates, and enrollment initiatives can lead to substantial reductions in uninsurance and cost-related problems obtaining care among working-age people with disabilities.     

Health Services Utilization by Low-Income Limited English Proficient Adults

Objectives We evaluated the health care utilization of limited English proficiency (LEP) compared to English proficient (EP) adults with the same health insurance (Medicaid managed care) and full access to professional medical interpreters. Methods Health care utilization over two years was compared for 567 LEP and 1162 EP adults. Multivariate analysis controlled for age, gender, months enrolled in Medicaid and morbidity. Results LEP compared to EP subjects were enrolled longer and more continuously in Medicaid, were 94% more likely to use primary care and 78% less likely to use the emergency department. Specialty visits and hospitalization did not differ. Conclusions When language barriers are reduced and health insurance coverage is the same, LEP patients show ambulatory health care utilization associated with lower cost and more access to preventive care through establishing a primary care home.     

Young Adults' Health Care Utilization and Expenditures Prior to the Affordable Care Act

PurposeTo examine young adults' health care utilization and expenditures prior to the Affordable Care Act.MethodsWe used 2009 Medical Expenditure Panel Survey to (1) compare young adults' health care utilization and expenditures of a full-spectrum of health services to children and adolescents and (2) identify disparities in young adults' utilization and expenditures, based on access (insurance and usual source of care) and other sociodemographic factors, including race/ethnicity and income.ResultsYoung adults had (1) significantly lower rates of overall utilization (72%) than other age groups (83%–88%, p < .001), (2) the lowest rate of office-based utilization (55% vs. 67%–77%, p < .001) and (3) higher rate of emergency room visits compared with adolescents (15% vs. 12%, p < .01). Uninsured young adults had high out-of-pocket expenses. Compared with the young adults with private insurance, the uninsured spent less than half on health care ($1,040 vs. $2,150/person, p < .001) but essentially the same out-of-pocket expenses ($403 vs. $380/person, p = .57). Among young adults, we identified significant disparities in utilization and expenditures based on the presence/absence of a usual source of care, race/ethnicity, home language, and sex.ConclusionsYoung adults may not be utilizing the health care system optimally by having low rates of office-based visits and high rates of emergency room visits. The Affordable Care Act provision of insurance for those previously uninsured or under-insured will likely increase their utilization and expenditures and lower their out-of-pocket expenses. Further effort is needed to address noninsurance barriers and ensure equal access to health services.     

Spillover Effects of the Affordable Care Act? Exploring the Impact on Young Adult Dental Insurance Coverage

ObjectivesTo assess whether the Affordable Care Act’s (ACA) dependent coverage health insurance mandate had a spillover impact on young adult dental insurance coverage and whether any observed effects varied by household income.DataMedical Expenditure Panel Surveys from 2006 through 2011.ResultsPrivate dental insurance increased by 6.7 percentage points among young adults compared to a control group of 27–30-year olds. Increases were concentrated at middle-income levels (125–400 percent FPL).ConclusionsThe dependent coverage mandate provision of the Affordable Care Act has not only increased health insurance rates among young adults but also dental insurance coverage rates.     

The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon

BackgroundThe Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion.ObjectiveTo examine the association of the ACA expansion on health care access and utilization for adults ages 18–64 years who have qualified for Supplemental Security Income (SSI) in Oregon.MethodsWe used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits.ResultsThe Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon’s counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association.ConclusionsWe did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.     

A decade of health care access declines for adults holds implications for changes in the Affordable Care Act

The pending Supreme Court decision on the Affordable Care Act and the fall presidential election raise concerns about what would happen if the insurance expansion promised by the landmark health reform law were to be curtailed. This paper's analysis of national survey estimates found that access to health care and use of health services for adults ages 19-64--the primary targets of the Affordable Care Act--deteriorated between 2000 and 2010, particularly among those who were uninsured. More than half of uninsured US adults did not see a doctor in 2010, and only slightly more than a quarter of these adults were seen by a dentist. We also found that children--many of whom qualify for public coverage through Medicaid and the Children's Health Insurance Program--generally maintained or improved their access to care during the same period. This provides a reason for optimism about the ability of the coverage expansion in the Affordable Care Act to improve access for adults, but it suggests that eliminating the law or curtailing the coverage expansion could result in continued erosion of adults' access to care.     

Has Massachusetts health care reform worked for the working poor? Results from an analysis of opportunity

PurposeHealth care reform was introduced in Massachusetts (MA) in 2006 and serves as a model for what was subsequently introduced nationally as the Patient Protection and Affordable Care Act. The Boston Area Community Health survey collected data before (2002–2005) and after (2006–2010) introduction of the MA health insurance mandate, providing a unique opportunity to assess its effects in a large, epidemiologic cohort.MethodsWe report on the apparent effects of the mandate on the same participants over time, focusing specifically on the vulnerable working poor (WP). We evaluated differences in subpopulations of interest at pre- and post-reform periods to explore whether MA health care reform resulted in an overall gain in insurance coverage.ResultsMA health care reform was associated with net gains in health insurance coverage overall and among the subgroups studied. Our findings suggest that despite being targeted by health care reform legislation, the WP in MA continue to report lower rates of insurance coverage compared with both the nonworking poor and the not poor.ConclusionsMA health care reform legislation, including the expansion of Medicaid, resulted in substantial overall gains in coverage. Disparities in insurance coverage persist among some subgroups following health care reform implementation in MA. These results have important implications for health services researchers and policy makers, particularly in light of the ongoing implementation of the Patient Protection and Affordable Care Act.     

Emergency unemployment benefits and health care spending during Covid

ObjectiveTo estimate the impact of the $600 per week Federal Pandemic Unemployment Compensation (FPUC) payments on health care services spending during the Covid pandemic and to investigate if this impact varied by state Medicaid expansion status.Data SourcesThis study leverages novel, publicly available data from Opportunity Insights capturing consumer credit and debit card spending on health care services for January 18–August 15, 2020 as well as information on unemployment insurance claims, Covid cases, and state policy changes.Study DesignUsing triple‐differences estimation, we leverage two sources of variation—within‐state change in the unemployment insurance claims rate and the introduction of FPUC payments—to estimate the moderating effect of FPUC on health care spending losses as unemployment rises. Results are stratified by state Medicaid expansion status.Extraction MethodsNot applicable.Principal FindingsFor each percentage point increase in the unemployment insurance claims rate, health care spending declined by 1.0% (<0.05) in Medicaid expansion states and by 2.0% (<0.01) in nonexpansion states. However, FPUC partially mitigated this association, boosting spending by 0.8% (<0.001) and 1.3% (<0.05) in Medicaid expansion and nonexpansion states, respectively, for every percentage point increase in the unemployment insurance claims rate.ConclusionsWe find that FPUC bolstered health care spending during the Covid pandemic, but that both the negative consequences of unemployment and moderating effects of federal income supports were greatest in states that did not adopt Medicaid expansion. These results indicate that emergency federal spending helped to sustain health care spending during a period of rising unemployment. Yet, the effectiveness of this program also suggests possible unmet demand for health care services, particularly in states that did not adopt Medicaid expansion.     

Food security and health in transition to adulthood for individuals with disabilities

BackgroundDue to a more stringent disability definition used for eligibility redetermination at age 18, individuals with disabilities may lose eligibility for the Supplement and Nutrition Assistance Program (SNAP).ObjectiveThis study examines how the transition to adulthood may affect the association between food security and self-rated health and healthcare needs for individuals with disabilities.MethodsThe study uses five years of data (2011–2015) from the National Health Interview Survey (NHIS). One health indicator, self-rated health status, and two indicators of unmet healthcare needs, delayed medical care and not receiving medical care due to cost, are analyzed as dependent variables. The effects of food security status on health and health-related outcomes are closely examined for the four groups: youth without disabilities, youth with disabilities, young adults without disabilities and young adults with disabilities.ResultsResults indicate a statistically significant association between food security status and self-rated health and unmet healthcare needs in late childhood and young adulthood. Such association is stronger for young adults than for youth. The association between low food security and self-rated health and health-related outcomes does not significantly differ between the two youth groups or the two young adult groups by disability status.ConclusionsSuggestions for improving accessibility of public food and nutrition programs are discussed. The study also suggests the importance of creating a healthcare system that benefits every member of the society.     

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.     

National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care

BackgroundTo reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans.ObjectiveThis study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries.MethodsWe used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21–64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year.ResultsNationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%–46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state.ConclusionsFrom 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.