Did Medicaid slow declines in access to health care during the great recession?

ObjectiveWe examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.Data Source2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).Study DesignFlexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.Data Collection/Extraction MethodsNonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state''s 2007 Medicaid guidelines using data from the 2007 Current Population Survey''s Annual Social and Economic Supplement.Principal FindingsA percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.ConclusionsIncreased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.     

COVID‐19‐related Medicaid enrollment in Medicaid expansion and non‐expansion states

Research ObjectiveTo explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID‐19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss.Data SourcePhase 1 of the Census Bureau''s Experimental Household Pulse Survey covering April 23, 2020–July 21, 2020.Study DesignWe compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID‐19 pandemic in states that expanded Medicaid against states that did not expand Medicaid.Data Collection/Extraction MethodsOur analytical dataset was limited to 733,181 non‐elderly adults aged 20–64.Principal FindingsTwenty‐six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey—16% experienced job losses (e.g., layoff, furlough) due to the COVID‐19 crisis, and 11% had other reasons they were not working. COVID‐linked job losses were associated with a 20 (p < 0.01) percentage‐point (PPT) lower likelihood of having employer‐sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID‐linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously.ConclusionsOur findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed.     

Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States

BackgroundThe Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers.MethodsUsing electronic health record data from 354 community health centers in 14 states (10 expansion, 4 nonexpansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid.ResultsExcept for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51–2.60; and 1.98; 95% confidence interval, 0.91–3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: ?4.21; 95% confidence interval, ?6.98 to ?1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states.ConclusionsAmong female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.     

Medicaid healthy behavior incentives and use of dental services

ObjectiveTo examine changes in access to dental care in states using Section 1115 waivers to implement healthy behavior incentive (HBI) programs in their Medicaid expansion under the ACA, compared to traditional expansion states and nonexpansion states.Data sourcesBehavioral Risk Factor Surveillance System from 2008 to 2018.Study designWe used difference‐in‐differences analysis to compare changes in three Medicaid expansion states with HBI (Iowa, Indiana, Michigan) to traditional expansion (Minnesota, North Dakota, Ohio) and nonexpansion states (Nebraska, South Dakota, Wyoming) in the same mid‐Western region of the country. The sample included 32 556 low‐income adults.Data collection/extraction methodsNA.Principal findingsWe found no significant changes in dental visits associated with HBI or traditional expansion relative to nonexpansion states. HBI expansion was associated with an increase of 2.2 percentage points in reporting a dental visit in the past year for adults in urban areas (P < 0.05) while the traditional expansion was associated with a reduction of 8.5 percentage points (P < 0.01) in utilization in rural areas relative to nonexpansion states. However, after adjustment for preexisting trends, the coefficients were no longer significant, suggesting that these differences are likely due to preexisting trends.ConclusionsWe did not find evidence of increased utilization of routine dental care associated with HBI programs.     

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.     

The impact of urgent care centers on nonemergent emergency department visits

ObjectiveTo estimate the impact of urgent care centers on emergency department (ED) use.Data SourcesSecondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.Study DesignWe used a difference‐in‐differences design to examine ZIP code‐level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.Data Collection/Extraction MethodsUrgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.Principal FindingsWe found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.ConclusionsDuring the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.     

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.     

Younger Individuals Increase Their Use of Nursing Homes Following ACA Medicaid Expansion

ObjectivesThis study examines the effect of Medicaid eligibility expansion under the Affordable Care Act (ACA) on the utilization of nursing home services by younger individuals and those covered by Medicaid.DesignCompared the age of nursing home residents, proportion of individuals covered by Medicaid, annual nursing home admissions in those younger than 65, and nursing home length of stay in states that expanded Medicaid eligibility through the ACA to states that did not. We used data from LTCFocus (nursing home level), the Minimum Data Set (individual level), and Medicaid expansion status from the Kaiser Family Foundation.Setting and ParticipantsThe study included 15,005,888 nursing home admissions, 2,446,950 of which were residents younger than 65, across 14,132 nursing homes between 2009 and 2016.MethodsA time-varying difference-in-difference model including state and year fixed effects with effect modification by pre-2014 nursing home occupancy.ResultsFacilities in expansion states with a pre-ACA occupancy rate of more than 70% increased the fraction of residents younger than 65 by 2.74% to 6.32%, compared with similar facilities in nonexpansion states. Medicaid admissions varied, with an increase in year 2 after expansion compared with nonexpansion states. Among residents entering from an acute care hospital, the proportion younger than 65 increased in facilities with pre-2014 occupancy rates of more than 70%, compared with similar facilities in nonexpansion states, an increase of up to 6.51%. Median nursing home length of stay for individuals younger than 65 decreased relative to nonexpansion states across all occupancy categories, ranging from 1.68 to 6.06 days after Medicaid expansion.Conclusions and ImplicationsMedicaid expansion increased access to nursing home post-acute care for individuals younger than 65. It remains unclear if the benefit of post-acute care is the same among this group, or if the needs of younger individuals can be adequately met in this setting.     

Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States

BackgroundAs employment, financial status, and residential location change, people can gain, lose, or switch health insurance coverage, which may affect care access and health. Among Women's Interagency HIV Study participants with HIV and participants at risk for HIV attending semiannual visits at 10 U.S. sites, we examined whether the prevalence of coverage types and rates of coverage changes differed by HIV status and Medicaid expansion in their states of residence.MethodsGeocoded addresses were merged with dates of Medicaid expansion to indicate, at each visit, whether women lived in Medicaid expansion states. Age-adjusted rate ratios (RRs) and rate differences of self-reported insurance changes were estimated by Poisson regression.ResultsFrom 2008 to 2018, 3,341 women (67% Black, 71% with HIV) contributed 43,329 visits at aged less than 65 years (27% under Medicaid expansion). Women with and women without HIV differed in their proportions of visits at which no coverage (14% vs. 19%; p < .001) and Medicaid enrollment (61% vs. 51%; p < .001) were reported. Women in Medicaid expansion states reported no coverage and Medicaid enrollment at 4% and 69% of visits, respectively, compared with 20% and 53% of visits for those in nonexpansion states. Women with HIV had a lower rate of losing coverage than those without HIV (RR, 0.81; 95% confidence interval [CI], 0.70 to 0.95). Compared with nonexpansion, Medicaid expansion was associated with lower coverage loss (RR, 0.62; 95% CI, 0.53 to 0.72) and greater coverage gain (RR, 2.32; 95% CI, 2.02 to 2.67), with no differences by HIV status.ConclusionsBoth women with HIV and women at high risk for HIV in Medicaid expansion states had lower coverage loss and greater coverage gain; therefore, Medicaid expansion throughout the United States should be expected to stabilize insurance for women and improve downstream health outcomes.     

Estimating health care delivery system value for each US state and testing key associations

ObjectiveTo estimate health care systems'' value in treating major illnesses for each US state and identify system characteristics associated with value.Data sourcesAnnual condition‐specific death and incidence estimates for each US state from the Global Burden Disease 2019 Study and annual health care spending per person for each state from the National Health Expenditure Accounts.Study designUsing non‐linear meta‐stochastic frontier analysis, mortality incidence ratios for 136 major treatable illnesses were regressed separately on per capita health care spending and key covariates such as age, obesity, smoking, and educational attainment. State‐ and year‐specific inefficiency estimates were extracted for each health condition and combined to create a single estimate of health care delivery system value for each US state for each year, 1991–2014. The association between changes in health care value and changes in 23 key health care system characteristics and state policies was measured.Data collection/extraction methodsNot applicable.Principal findingsUS state with relatively high spending per person or relatively poor health‐outcomes were shown to have low health care delivery system value. New Jersey, Maryland, Florida, Arizona, and New York attained the highest value scores in 2014 (81 [95% uncertainty interval 72‐88], 80 [72‐87], 80 [71‐86], 77 [69‐84], and 77 [66‐85], respectively), after controlling for health care spending, age, obesity, smoking, physical activity, race, and educational attainment. Greater market concentration of hospitals and of insurers were associated with worse health care value (p‐value ranging from <0.01 to 0.02). Higher hospital geographic density and use were also associated with worse health care value (p‐value ranging from 0.03 to 0.05). Enrollment in Medicare Advantage HMOs was associated with better value, as was more generous Medicaid income eligibility (p‐value 0.04 and 0.01).ConclusionsSubstantial variation in the value of health care exists across states. Key health system characteristics such as market concentration and provider density were associated with value.     

Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality

ObjectivesThis study explores the effect of Medicaid expansion under the Affordable Care Act on the maternal mortality ratio in the United States.MethodsA difference-in-differences research design was used to analyze the effect of Medicaid expansion on maternal mortality. Maternal mortality was defined with and without late maternal deaths, to substantiate the contribution of increased preconception and postpartum insurance coverage. To examine whether there was a racial difference in the effects of Medicaid expansion, models were stratified by the woman's race/ethnicity for non-Hispanic Black women, non-Hispanic White women, and Hispanic women.ResultsMedicaid expansion was significantly associated with lower maternal mortality by 7.01 maternal deaths per 100,000 live births (p = .002) relative to nonexpansion states. When maternal mortality definitions excluded late maternal deaths, Medicaid expansion was significantly associated with a decrease in maternal mortality per 100,000 live births by 6.65 (p = .004) relative to nonexpansion states. Medicaid expansion effects were concentrated among non-Hispanic Black mothers, suggesting that expansion could be contributing to decreasing racial disparities in maternal mortality.ConclusionsAlthough maternal mortality overall continues to increase in the United States, the maternal mortality ratio among Medicaid expansion states has increased much less compared with nonexpansion states. These results suggest that Medicaid expansion could be contributing to a relative decrease in the maternal mortality ratio in the United States. The decrease in the maternal mortality ratio is greater when maternal mortality estimates include late maternal deaths, suggesting that sustained insurance coverage after childbirth as well as improved preconception coverage could be contributing to decreasing maternal mortality.     

Increasing Medicaid enrollment among formerly incarcerated adults

ObjectiveTo estimate the incremental associations between the implementation of expanded Medicaid eligibility and prerelease Medicaid enrollment assistance on Medicaid enrollment for recently incarcerated adults.Data Sources/Study SettingData include person‐level merged, longitudinal data from the Wisconsin Department of Corrections and the Wisconsin Medicaid program from 2013 to 2015.Study DesignWe use an interrupted time series design to estimate the association between each of two natural experiments and Medicaid enrollment for recently incarcerated adults. First, in April 2014 the Wisconsin Medicaid program expanded eligibility to include all adults with income at or below 100% of the federal poverty level. Second, in January 2015, the Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance at all state correctional facilities.Data Collection/Extraction MethodsWe collected Medicaid enrollment, and state prison administrative and risk assessment data for all nonelderly adults incarcerated by the state who were released between January 2013 and December 2015. The full sample includes 24 235 individuals. Adults with a history of substance use comprise our secondary sample. This sample includes 12 877 individuals. The primary study outcome is Medicaid enrollment within the month of release.Principal FindingsMedicaid enrollment in the month of release from state prison grew from 8 percent of adults at baseline to 36 percent after the eligibility expansion (P‐value < .01) and to 61 percent (P‐value < .01) after the introduction of enrollment assistance. Results were similar for adults with a history of substance use. Black adults were 3.5 percentage points more likely to be enrolled in Medicaid in the month of release than White adults (P‐value < .01).ConclusionsMedicaid eligibility and prerelease enrollment assistance are associated with increased Medicaid enrollment upon release from prison. States should consider these two policies as potential tools for improving access to timely health care as individuals transition from prison to community.     

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness

ObjectiveTo evaluate the impact of Maryland''s behavioral health homes (BHHs) on receipt of follow‐up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI).Data SourcesMaryland Medicaid administrative claims for 12 232 individuals.Study DesignWeighted marginal structural models were estimated to account for time‐varying exposure to BHH enrollment and time‐varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow‐up care within 7 and 30 days following hospitalization.Data Collection/Extraction MethodsEligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21‐64 years; and use of psychiatric rehabilitation services.Principal FindingsOver three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow‐up service within 7 days of discharge from a mental illness–related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow‐up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission.ConclusionsBHHs may improve follow‐up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.     

Insurer Market Structure and Variation in Commercial Health Care Spending

ObjectiveTo examine the relationship between insurance market structure and health care prices, utilization, and spending.MethodsRegression models are used to estimate the association between insurance market concentration and health care spending, utilization, and price, adjusting for differences in patient characteristics and other market-level traits.ResultsInsurance market concentration is inversely related to prices and spending, but positively related to utilization. Our results imply that, after adjusting for input price differences, a market with two equal size insurers is associated with 3.9 percent lower medical care spending per capita (p = .002) and 5.0 percent lower prices for health care services relative to one with three equal size insurers (p < .001).ConclusionGreater fragmentation in the insurance market might lead to higher prices and higher spending for care, suggesting some of the gains from insurer competition may be absorbed by higher prices for health care. Greater attention to prices and utilization in the provider market may need to accompany procompetitive insurance market strategies.     

Connecting policy to licensed assisted living communities,introducing health services regulatory analysis

ObjectiveTo document dementia‐relevant state assisted living regulations and their changes over time as they pertain to licensed care settings.Data SourcesFor all states, current directories of licensed assisted living communities and state regulations for each year, 2007‐2018, were obtained from state agency websites and Nexis Uni, respectively.Study DesignWe identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally.Data Collection/Extraction MethodsWe used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question‐based coding to record the presence or absence of specific policies for each classification and study year.Principal FindingsOur team empirically documented provisions requiring dementia‐specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two.ConclusionsWe identified significant, previously undocumented, within‐state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia‐designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.     

The Effects of Medicaid Eligibility on Mental Health Services and Out‐of‐Pocket Spending for Mental Health Services

Objective

Millions of low‐income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out‐of‐pocket spending.

Data Sources

Secondary data from the 1998–2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.

Study Design

Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out‐of‐pocket spending for mental health services.

Data Extraction Methods

Person‐year files were constructed including adults ages 21–64 under 300 percent of the Federal Poverty Level.

Principal Findings

Medicaid expansions significantly increased health insurance coverage and reduced out‐of‐pocket spending on mental health services for low‐income adults. Effects of expanded Medicaid eligibility on out‐of‐pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.

Conclusions

Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out‐of‐pocket mental health care spending.     

Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles

ObjectiveTo provide the first plausibly causal national estimates of health outcomes for older dual‐eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect.Data SourcesWe use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable.Study DesignWe model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long‐term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated.Population Studied1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long‐term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia.Principal FindingsHCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending.ConclusionsShifting Medicaid long‐term care funding for older adults from nursing homes to HCBS, while well‐motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes—not just expansion—need more attention.     

Improving target price calculations in Medicare bundled payment programs

ObjectiveTo compare the predictive accuracy of two approaches to target price calculations under Bundled Payments for Care Improvement‐Advanced (BPCI‐A): the traditional Centers for Medicare and Medicaid Services (CMS) methodology and an empirical Bayes approach designed to mitigate the effects of regression to the mean.Data sourcesMedicare fee‐for‐service claims for beneficiaries discharged from acute care hospitals between 2010 and 2016.Study designWe used data from a baseline period (discharges between January 1, 2010 and September 30, 2013) to predict spending in a performance period (discharges between October 1, 2015 and June 30, 2016). For 23 clinical episode types in BPCI‐A, we compared the average prediction error across hospitals associated with each statistical approach. We also calculated an average across all clinical episode types and explored differences by hospital size.Data collection/extraction methodsWe used a 20% sample of Medicare claims, excluding hospitals and episode types with small numbers of observations.Principal findingsThe empirical Bayes approach resulted in significantly more accurate episode spending predictions for 19 of 23 clinical episode types. Across all episode types, prediction error averaged $8456 for the CMS approach versus $7521 for the empirical Bayes approach. Greater improvements in accuracy were observed with increasing hospital size.ConclusionsCMS should consider using empirical Bayes methods to calculate target prices for BPCI‐A.     

Community Health Center Use After Oregon’s Randomized Medicaid Experiment

PURPOSEThere is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon’s 2008 randomized Medicaid expansion (the “Oregon Experiment”).METHODSWe probabilistically matched demographic data from adults (aged 19–64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008–2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging.RESULTSThe intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05–1.55) for laboratory tests to 1.58 (95% CI, 1.10–2.28) for referrals.CONCLUSIONSOur results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.