Impacts of the Affordable Care Act's Medicaid Expansion on Women of Reproductive Age: Differences by Parental Status and State Policies

Introduction

We use data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2012 to 2015 to estimate the effects of the Affordable Care Act's (ACA) Medicaid expansions on insurance coverage and access to care for low-income women of reproductive age (19–44).

Post-Acute Care and ACOs — Who Will Be Accountable?

Objective

To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs).

Data Sources

Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation.

Study Design

We calculated the fraction of community-dwelling beneficiaries whose assignment shifted, as a consequence of including post-acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post-acute care.

Principal Findings

Assignment shifts occurred for 27.6 percent of 25,992 community-dwelling beneficiaries with at least one post-acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community-dwelling beneficiaries cared for by large ACO-eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population.

Conclusions

Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post-acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions.     

Reforming Access: Trends in Medicaid Enrollment for New Medicare Beneficiaries, 2008–2011

Objective

To evaluate whether aligning the Part D low‐income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries.

Data Sources

Medicare enrollment records for years 2007–2011.

Study Design

We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008–2011).

Data Extraction Methods

We identified new Medicare beneficiaries in the years 2008–2011 and their participation in Medicaid based on Medicare enrollment records.

Principal Findings

The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions.

Conclusions

Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries’ access to benefits.     

Comparison of survival outcomes among older adults with major trauma after trauma center versus non-trauma center care in the United States

Objective

To compare level 1 and 2 trauma centers with similarly sized non-trauma centers on survival after major trauma among older adults.

Data Sources and Study Setting

We used claims of 100% of 2012–2017 Medicare fee-for-service beneficiaries who received hospital care after major trauma.

Study Design

Survival differences were estimated after applying propensity-score-based overlap weights. Subgroup analyses were performed for ambulance-transported patients and by external cause. We assessed the roles of prehospital care, hospital quality, and volume.

Data Collection

Data were obtained from the Centers for Medicare and Medicaid Services.

Principal Findings

Thirty-day mortality was higher overall at level 1 versus non-trauma centers by 2.2 (95% confidence interval [CI]: 1.8, 2.6) percentage points (pp). Thirty-day mortality was higher at level 1 versus non-trauma centers by 2.3 (95% CI: 1.9, 2.8) pp for falls and 2.3 (95% CI: 0.2, 4.4) pp for motor vehicle crashes. Differences persisted at 1 year. Level 1 and 2 trauma centers had similar outcomes. Hospital quality and volume did not explain these differences. In the ambulance-transported subgroup, after adjusting for prehospital variables, no statistically significant differences remained.

Conclusions

Trauma centers may not provide longer survival than similarly sized non-trauma hospitals for severely injured older adults.     

Spillover benefit of improved access to healthcare on reducing worry about housing and meal affordability

Background

The Affordable Care Act Medicaid expansion improved access to health insurance among low-income populations. We sought to examine the spillover benefits of the ACA Medicaid expansion on ability to afford rent/mortgage and purchase of nutritious meals.

Methods

Using data from the Behavioral Risk Factor Surveillance System (BRFSS) we analyzed individuals aged 18–64 years residing in 12 U.S. states (including five ACA Medicaid expansion states) in 2015. Our treatment of interest was access to health insurance, instrumented by the ACA Medicaid expansion. Our outcome variables were: worry or stress about having sufficient money to pay the rent or mortgage and to purchase nutritious meals. We conducted a two-stage least squares instrumental variables regression.

Results

A 10%-point increase in the proportion of those who obtained health insurance following the ACA Medicaid expansion reduced the probability of being worried and stressed related to purchasing nutritious meals by 7.2% points (95% CI: 1.3–13.2) as well as paying the rent or mortgage by 8.6% points (95% CI: 2.5–14.7) among people living below 138% of the federal poverty level (FPL). The ACA Medicaid expansion was not associated with access to health insurance among those living over 138% of FPL, and obtaining health insurance did not influence stress or worry in relation to affording rent/mortgage or meals in this income group.

Conclusions

Improved access to health insurance contributed to reducing worry and stress associated with paying rent/mortgage or purchasing meals among low-income people. Expanding health insurance access may have contributed to increasing the disposable income of low income groups.

     

Higher Medicare SNF Care Utilization by Dual-Eligible Beneficiaries: Can Medicaid Long-Term Care Policies Be the Answer?

Objective

To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states'' Medicaid long-term care policies.

Data Sources/Collection

We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.

Study Design

We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.

Principal Findings

Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.

Conclusions

Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.     

Comparing the Cost of Caring for Medicare Beneficiaries in Federally Funded Health Centers to Other Care Settings

Objective

To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics.

Data Sources/Study Settings

Part A and B fee‐for‐service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC.

Study Design

We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects.

Data Collection

Data were obtained from the Centers for Medicare & Medicaid Services.

Principal Findings

Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs.

Conclusions

HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients.     

Factors Associated with Inpatient Hospital (Re)admissions in Medicare Beneficiaries in Need of Food Assistance

Little is known about pathways underlying inpatient hospital (re)admissions in older adults unable to meet basic needs. This study examined the factors associated with (re)admissions in a sample of low-income older Medicare beneficiaries in need of food assistance in Georgia in 2008 (N = 892, mean age 75.4 ± 8.8 years, 30.3% Black, 68.5% female). About 35.3% of the sample experienced 1 + hospital (re)admissions. (Re)admissions were significantly more likely in individuals who requested Older Americans Act Nutrition Program Home Delivered Meals services (OR 2.3; 95% CI 1.4, 3.8), had more outpatient emergency room visits (1 visit: OR 2.1; 95% CI 1.4, 3.1; 2+ visits: OR 3.6; 95% CI 2.4, 5.4), and experienced greater multimorbidity (OR 1.6; 95% CI 1.4, 3.1). Support for home and community-based services may be critical in reducing potentially avoidable inpatient hospital (re)admissions.     

Medicaid's role in ambulatory health care

Medicaid plays an enormously important role in ambulatory care financing, both primary and specialized, for patients with routine health needs, as well as individuals with chronic illness and disability. Nearly all Medicaid beneficiaries receive the vast bulk of their health care in ambulatory settings. Medicaid plays a critical role for low-income persons, including children, pregnant women and families, and elderly and disabled Medicare beneficiaries. The Bush administration's proposal to subject federal Medicaid spending to annual aggregate limits could be expected to have especially severe effects on states' capacity to support ambulatory services and achieve innovations in community-based care.     

Participation in a Medicare advanced primary care model and the delivery of high-value services

Objective

To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services.

Data Sources

Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare.

Study Design

We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year.

Data Collection/Extraction Methods

Secondary data are linked at the provider level.

Principal Findings

We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening.

Conclusions

CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.     

The Opportunity for Health Plans to Improve Quality and Reduce Costs by Embracing Primary Care Medical Homes

Background

The large and growing costs of healthcare will continue to burden all payers in the nation''s healthcare system—not only the states that are struggling to meet Medicaid costs and the federal government, but also the private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries. Cost will increasingly become a concern as millions more people become newly insured as a result of the Patient Protection and Affordable Care Act (ACA). Primary care delivery through patient-centered medical homes (PCMHs) and other coordinated-care models have improved care and reduced costs. Health plans have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Health plans can play an important role in transforming the US healthcare system, as well as better position themselves for long-term corporate success.

Objectives

To discuss several examples of organizations that serve a variety of beneficiaries and have been successful in promoting medical homes and coordinated primary care, and to suggest steps that health plans can take to improve the quality of care and reduce costs.

Discussion

The models discussed in this article take a number of different approaches to create incentives for high-quality, cost-effective, coordinated primary care. Several health plans and groups use enhanced fee-for-service or per-member per-month payment models for primary care physician (PCP) practices that reach a specified level of medical home or electronic health record certification. Most of the examples addressed in this article also include an additional payment to encourage care management and coordination. The results showed a significant decline in costs and in the use of expensive medical services. One Medicaid coordinated-care program we reviewed saved almost $1 billion in reduced spending over 4 years, and achieves savings of approximately 15% within 6 months of the beneficiaries'' enrollment into their program. Another PCMH payer program led to an approximate 28% reduction in acute care hospital admissions among Medicare beneficiaries and an approximate 38% reduction in admissions among commercial beneficiaries.

Conclusion

Based on the review of real-world examples, we recommend 6 steps that health plans can use to take advantage of the opportunity to embrace medical homes as a means to improve healthcare quality and to reduce costs. These recommendations include getting feedback from PCPs to improve plan provider networks, creating value-based primary care reimbursement systems, encouraging biannual visits with high-risk patients, funding case managers for high-risk patients, considering Medicaid coordinated-care models, and promoting ACA policies that support primary care.The large and growing cost of healthcare, which amounted to 17.9% of the gross domestic product in 2011,1 will continue to be a burden for all payers in the US healthcare system, not only for states that are struggling to meet Medicaid costs and the federal government''s requirements, but also for private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries.2,3 Costs will continue to grow as millions more people become newly insured because of the Patient Protection and Affordable Care Act (ACA).Primary care that is delivered through patient-centered medical homes (PCMHs) and other coordinated-care models has served as a means to improve care and to reduce costs.4,5 Health plans, therefore, have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Using this strategy would enable health plans to play an important role in transforming the US healthcare system, and to be better positioned for long-term corporate success.Large business groups already have taken note of the potential for primary care and medical homes to reduce their healthcare costs. The National Business Group on Health (NBGH), which has more than 300 large corporate members that provide health insurance for 50 million Americans, has made primary care, and more recently the PCMH model, a priority “for years,” said NBGH Vice President Veronica Goff in an April 18, 2012, telephone interview. Several large employers are conducting PCMH pilot programs, including IBM, Boeing, Whirlpool, Dow Chemical, and Perdue Farms. Some state Medicaid programs and private health plans have also launched efforts to establish medical homes.In this article, we discuss several examples of organizations that serve a variety of beneficiaries and that have been successful in promoting medical homes and coordinated primary care. We review their results and make recommendations to health plans that are interested in seizing this opportunity.     

An Economic Evaluation of the Impact,Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds

Objective

The aim of this study was to determine the cost of chronic wound care for Medicare beneficiaries in aggregate, by wound type and by setting.

Market Variations in Intensity of Medicare Service Use and Beneficiary Experiences with Care

Objective

Examine associations between patient experiences with care and service use across markets.

Data Sources/Study Setting

Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index.

Study Design

We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets.

Data Collection/Extraction

We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid.

Principal Findings

Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care.

Conclusions

Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.     

Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act

BackgroundEnsuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods.MethodsWe used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services.ResultsWomen who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use.ConclusionsOhio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.     

The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

Objective

To assess the impact of the Patient Protection and Affordable Care Act''s (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.

Data Sources

Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010–2011.

Study Design

We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.

Principal Findings

Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.

Conclusions

The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.