Medicaid Expansion Program Research Articles

Heterogeneous effects of Medicaid expansion on food security measures

AbstractThe 2014 Affordable Care Act (ACA) included state‐level Medicaid expansion programs, which have been credited with gains in food security for low‐income, able‐bodied, childless adults without dependents (ABAWDs). Yet, ABAWDs represent a diverse cohort who experience disparities along racial and ethnic lines, which could be partly responsible for differences in health‐related outcomes. This study uses data from the Current Population Survey Food Security Supplement to estimate the heterogeneous effect of ACA Medicaid expansion on food security among ABAWDs by race, ethnicity, and income. We find that Medicaid expansion improved food security for households headed by White ABAWDs—particularly those with incomes above 50% of the federal poverty line—but we do not find similarly significant evidence of gains among some historically marginalized populations. We find weak evidence that suggests that households headed by Hispanic ABAWDs may have experienced gains. However, Black‐headed ABAWD households had significantly worse food insecurity relative to the pooled sample of all races and ethnicities. Our results suggest that the relationship between healthcare access and food security is complex and, although spillover effects from a change in healthcare policy can influence food security status, such effects may not be equitably distributed across race, ethnicity, or income.

Is White Evangelical Antistructural Theology Related to Poor Health Outcomes?

Structural factors are important determinants of health. Because antistructuralism has been identified as a tenet of White evangelical theology, we explored if there is an association of the percentage of White evangelicals in a US county with two county health outcomes: premature mortality and percentage of fair/poor health. Regression analysis was performed with data from 2022 County Health Rankings and the American Value Atlas from the Public Religion Research Institute. Every percent of evangelicals in a county is associated with 4.01 more premature deaths per 100,000 population and 0.13% fair/poor health. After controlling for income, education, political ideology, and county school funding adequacy (a proxy for antistructuralism), the associations remain positive and significant. We hope these findings could inform dialogue and critical analysis among individuals of evangelical faith, particularly fundamental and Pentecostal subsets, regarding a belief system that is inclusive of individual dimensions and health-promoting structural policies like school funding, Medicaid expansion, and antipoverty programs. These findings also demonstrate the importance of considering cultural factors like religion and political ideology in population health outcomes research.

Evaluating the impact of the Medicaid expansion program on diabetes hospitalization.

Diabetes is the most expensive chronic disease in the United States, and hospital inpatient care accounts for 30% of the total medical expenditures. Medical costs for people withlimited resources are covered by Medicaid, a joint federal and state program, and its expansion that extent the coverage to those with incomes up to 138% of the federal poverty level. We investigated the impact of Medicaid expansion on diabetes hospitalizations by states and payer, among adults aged 19 to 64years old, 5years after the expansion. We found that Medicaid expansion decreased total diabetes hospitalization in most states and a diabetes hospitalization payer mix shifted from private insurance and uninsured to Medicaid. The percentage of diabetes hospitalizations paid by Medicaid increased by 11% (95% CI 7%, 16%), while the percentage paid by private insurance decreased by 6% (95% CI -8%, -3%) and the percentage of uninsured diabetes hospitalization decreased by 13% (95% CI -18%, -9%).

HIV pre-exposure prophylaxis provision by U.S. health centers in 2021.

The aim of this study was to assess HIV preexposure prophylaxis (PrEP) provision in U.S. health centers. The U.S. Ending the HIV Epidemic (EHE) initiative designated health centers as the main healthcare system through which PrEP scale-up occurs. Health centers offer primary care to over 30 million disproportionately uninsured, racially or ethnically minoritized, and low-income patients. This study is the first to assess PrEP provision across health centers, including characteristics of clinics, patient populations, and policies associated with PrEP prescribing. The Health Resources and Services Administration's Uniform Data System contained aggregate data on PrEP prescriptions and patient sociodemographics at health centers from January 1 through December 31, 2021, in 50 U.S. states, the District of Columbia, and eight U.S. territories. We compared patient demographics and availability of Medicaid expansion and PrEP assistance programs at health centers that prescribed vs. those that did not prescribe PrEP. Across 1375 health centers serving 30 193 278 patients, 79 163 patients were prescribed PrEP. Health centers that prescribed any PrEP had higher proportions of sexual, gender, racial, and ethnic minority patient populations compared with health centers that prescribed no PrEP. Compared with health centers that prescribed no PrEP, a higher proportion of health centers that prescribed PrEP were located in designated high-priority jurisdictions of the EHE initiative or states with Medicaid expansion or public PrEP assistance programs. Health centers are critical for scaling up PrEP in minoritized populations disproportionately affected by HIV, facilitated through federal and state-level policies. These findings highlight service gaps and inform future interventions to optimize PrEP implementation and support EHE initiative goals.

Accounting for Medicaid expansion and regional policy and programs to advance equity in cancer prevention in the United States.

Many studies compare state-level outcomes to estimate changes attributable to Medicaid expansion. However, it is imperative to conduct more granular, demographic-level analyses to inform current efforts on cancer prevention among low-income adults. Therefore, the authors compared the volume of patients with cancer and disease stage at diagnosis in Ohio, which expanded its Medicaid coverage in 2014, with those in Georgia, a nonexpansion state, by cancer site and health insurance status. The authors used state cancer registries from 2010 to 2017 to identify adults younger than 64 years who had incident female breast cancer, cervical cancer, or colorectal cancer. Multivariable Poisson regression was conducted by cancer type, health insurance, and state to examine the risk of late-stage disease, adjusting for individual-level and area-level covariates. A difference-in-differences framework was then used to estimate the differences in risks of late-stage diagnosis in Ohio versus Georgia. In Ohio, the largest increase in all three cancer types was observed in the Medicaid group after Medicaid expansion. In addition, significantly reduced risks of late-stage disease were observed among patients with breast cancer on Medicaid in Ohio by approximately 7% and among patients with colorectal cancer on Medicaid in Ohio and Georgia after expansion by approximately 6%. Notably, the authors observed significantly reduced risks of late-stage diagnosis among all patients with colorectal cancer in Georgia after expansion. More early stage cancers in the Medicaid-insured and/or uninsured groups after expansion suggest that the reduced cancer burden in these vulnerable population subgroups may be attributed to Medicaid expansion. Heterogeneous risks of late-stage disease by cancer type highlight the need for comprehensive evaluation frameworks, including local cancer prevention efforts and federal health policy reforms. This study looked at how Medicaid expansion affected cancer diagnosis and treatment in two states, Ohio and Georgia. The researchers found that, after Ohio expanded their Medicaid program, there were more patients with cancer among low-income adults on Medicaid. The study also found that, among people on Medicaid, there were lower rates of advanced cancer at the time of diagnosis for breast cancer and colon cancer in Ohio and for colon cancer in Georgia. These findings suggest that Medicaid expansion may be effective in reducing the cancer burden among low-income adults.

Characteristics and Outcomes of Medicare Patients Treated in Inpatient Rehabilitation Facilities: 2013-2018.

The aim of this study was to describe the characteristics and outcomes of Medicare patients treated in inpatient rehabilitation facilities (IRFs) in 2013 through 2018. A descriptive study was conducted. A total of 2,907,046 IRF Medicare fee-for-service and Medicare Advantage patient stays that ended in 2013 through 2018 were analyzed. The number of Medicare patients treated in IRFs increased by about 9%, from 466,092 in 2013 to 509,475 in 2018. Although IRF patients' age and racial/ethnic composition remained similar across the years, there was a shift in patients' primary rehabilitation diagnosis, with more patients with stroke, neurological conditions, traumatic and nontraumatic brain injury, fewer patients with orthopedic conditions, and fewer coded as having medically complex conditions. Across the years, the percentage of patients discharged to the community was between 73.0% and 74.4%. Rehabilitation nurses should have training and expertise in the management of patients with stroke and neurological conditions to provide high-quality IRF care. Between 2013 and 2018, the number of Medicare patients treated in IRFs increased overall. There were more patients with stroke and neurological conditions and fewer patients with orthopedic conditions. Changes to IRF and other post-acute care policies, Medicaid expansion, and alternative payment programs may partially be driving these changes.

Parental Immigration Status, Medicaid Expansion, And Supplemental Nutrition Assistance Program Participation.

Anti-immigrant public policies and rhetoric during 2017-19 may have eroded enrollment in safety-net programs, such as the enrollment of children of immigrants in the Supplemental Nutrition Assistance Program (SNAP). At the same time, states' expansion of Medicaid through the Affordable Care Act may have mitigated erosion through coordinated enrollment across safety-net programs, including SNAP and Medicaid. We examined changes in SNAP participation rates by parental immigration status among low-income households in 2015-16 versus 2017-19 for differences by child race and ethnicity or state Medicaid expansion status. Relative to those among citizen children with US-born parents, SNAP participation rates among citizen children from mixed-status families and noncitizen children significantly decreased between 2015-16 and 2017-19, with the magnitude of disparity widening over time. Declines in SNAP participation were sharper for Hispanic and Latino children from mixed-status families, Hispanic and Latino noncitizen children, and noncitizen children residing in nonexpansion states. Findings are consistent with some policy makers' concerns of erosion in SNAP participation. Mechanisms that could be employed to help reverse these trends include policies, outreach strategies, and enrollment processes.

Duration of Dementia and Social Service Use in the U.S.-Born and Foreign-Born Mexican-American Population.

The study estimates the number of years after age 65 that Mexican Americans live with likely dementia and the impact of dementia on community-based services (CBS) use by nativity. Using the Hispanic Established Populations for the Epidemiologic Studies of the Elderly Sullivan methods are employed to predict duration of dementia and logistic regressions identify the predictors of service utilization. Foreign-born women spend more years than other groups with dementia. The foreign-born are more likely to use out-of-home services, whereas U.S.-born are more likely to use in-home services. The foreign-born with dementia of relatively recent onset had the highest probability of service use. Given the high cost of institutional care and availability of family caregivers, community-based services are a potentially useful alternative for the growing Mexican-American population living with dementia. Expanded Medicaid and CBS programs could be an equitable and cost-effective alternative that should be investigated.

Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults

In the US, suicide is the 10th leading cause of death and a serious mental health emergency. National programs that address suicide list access to mental health care as key in prevention, and more large-scale policies are needed to improve access to mental health care and address this crisis. The Patient Protection and Affordable Care Act (ACA) Medicaid Expansion Program was implemented in several states with the goal of increasing access to the health care system. To compare changes in suicide rates in states that expanded Medicaid under the ACA vs states that did not. In this cross-sectional study, state-level mortality rates were obtained from the National Center for Health Statistics for US individuals aged 20 to 64 years from January 1, 2000, to December 31, 2018. Data analysis was performed from April 18, 2021, to April 15, 2022. Changes in suicide mortality rates among nonelderly adults before and after Medicaid expansion in expansion and nonexpansion states were compared using adjusted difference-in-differences analyses via hierarchical bayesian linear regression. Suicide rates using death by suicide as the primary measure. Of the total population at risk for suicide, 50.4% were female, 13.3% were Black, 79.5% were White, and 7.2% were of other races. The analytic data set contained suicide mortality data for 2907 state-age-year units covering the general US population. A total of 553 912 deaths by suicide occurred during the study period, with most occurring in White (496 219 [89.6%]) and male (429 580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100 000 increase) compared with nonexpansion states (3.10 per 100 000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100 000 individuals was found, translating to 1818 suicides that were averted in 2015 to 2018. In this cross-sectional study, although suicide rates increased in both groups, blunting of these rates occurred among nonelderly adults in the Medicaid expansion states compared with nonexpansion states. Because this difference may be linked to increased access to mental health care, policy makers should consider suicide prevention as a benefit of expanding access to health care.

Health Navigator Perspectives on Implementation of Healthy Michigan Plan Work Requirements

In 2020, Michigan Medicaid implemented a new work requirement policy for enrollees in the Healthy Michigan Plan (HMP), the state's expanded Medicaid program. Under the policy, enrollees would be required to report 80 hours of work or other qualifying activities each month or obtain an exemption to maintain health insurance coverage. To assess the experiences of health navigators (and beneficiaries by proxy) with the implementation of Michigan's Medicaid work requirement. This qualitative study included health navigators who participated in 11 focus groups from September to December 2020. Focus group questions addressed topics related to implementation and communication of the HMP work requirement policy. A survey was administered to capture background information, assess readiness to assist with navigation, and assess the quality of the state's communication about the policy. The main outcomes were general understanding of policy components, communications about the policy, navigation of the exemption process, navigation of the reporting process, and beneficiaries' ability to comply with the policy. Of 50 health navigators who participated in the focus groups, 44 (88.0%) responded to the survey and 43 provided demographic information (mean [SD] age, 44.0 [10.5] years). All 43 had at least some college or vocational education, with 27 (62.8%) reporting a 4-year degree or higher, and they resided in geographic regions across Michigan. Navigators indicated that they felt prepared to assist HMP enrollees navigate work requirements. Communication to beneficiaries regarding the new policy was viewed as an improvement compared with traditional Medicaid communications. However, the complex policy was potentially difficult for beneficiaries to understand. Limited language options besides English created barriers for some enrollees. Exemptions were confusing for beneficiaries owing to the numerous categories and sometimes vague guidelines. Those who used the online reporting system generally found the platform to be user-friendly. Navigators expressed concern regarding HMP enrollees' ability to report compliance with work requirements owing to barriers with internet access, telephone access, language challenges, and computer literacy. In this qualitative analysis of health navigators in Michigan, respondents reported overall positive feedback about many of the implementation and communication strategies, including human-centered design, automatic exemptions, and use of state administrative data to assess whether beneficiaries were in compliance with the policy; however, barriers to reporting remained for enrollees. The findings suggest that state agencies should seek to reduce administrative barriers and apply a human-centered design approach to alleviate risk of unnecessary loss of Medicaid benefits.

Abstract PR-01: Association of Affordable Care Act Medicaid expansions with healthcare access and utilization among people who smoke

Abstract Background: People who smoke have a higher risk of developing cancer and disproportionately lower incomes which worsens healthcare access and health outcomes. The Affordable Care Act expanded Medicaid eligibility to adults with income up to 138% of the federal poverty line. It is unknown if and how Medicaid expansions changed healthcare access, preventive service use, and health behaviors. Also, it is unknown whether expansions impacted income or racial/ethnic disparities in these measures, given historically lower healthcare access and utilization in lower income people and people of color. Methods: Data were from the nationally representative Behavioral Risk Factor Surveillance System surveys between 2011-2019 of adults ages 18-64 years who currently smoked cigarettes and former smokers who had quit in the past year (n=580,858). Generalized difference-in-differences (DID) analyses using logistic regression models examined the association of Medicaid expansions (staggered time-varying exposure, 34 states expanded as of December 2019) with healthcare access (insurance coverage, care affordability, usual source of care), preventive service use (routine checkup, flu shot, HIV test, breast and colorectal cancer screening, cholesterol check, dentist visit), and health/risk behaviors (heavy alcohol drinking, obesity), including cessation behaviors (past-year quit attempt, successful cessation for >3 months). Income and race/ethnicity differences were also tested. Results: Among people who smoke, Medicaid expansions were associated with healthcare access and preventive care utilization improvements, but not health behaviors, including cessation. Expansions resulted in narrowing of disparities in several measures across income levels and Black vs. White people in expansion states. For example, expansion associated gains in insurance coverage were significantly larger in low-income (expansion: 74.6% vs. nonexpansion: 60.8%; DID: 13.8% 95% CI: 12.8, 14.8%) than high-income (insurance: 87.5% vs. 93.7%, DID: -6.2% points 95% CI: -7.2, -5.2%); and in Black people (82.6% vs. 74.6%, DID: 7.9% points 95% CI: 6.3, 9.5%) than White people (79.5% vs. 75.7%; DID: 3.8%, 95% CI: 3, 4.6%). Medicaid expansions gains were also larger among lower than higher income people for all in preventive care utilization measures studied; and uptake of flu shots, mammograms, and HIV tests were larger in Black than White people. Significant gains in multiple measures were also observed for Hispanic and American Indian/Alaska Native people who smoke, but changes were generally no different than White people. Conclusions: Among people who smoke, Medicaid expansions improved healthcare access and preventive services use. Expansions were also associated with a reduction, but not elimination, of income and Black-White disparities in healthcare access and utilization. Despite insurance and preventive service gains, expansions were not associated with cessation behaviors, signaling the need for improving comprehensive cessation treatments in Medicaid expansion programs. Citation Format: Priti Bandi, Samuel Asare, J. Lee Westmaas, Nigar Nargis, Robin Yabroff, Ahmedin Jemal, Xuesong Han, Stacey Fedewa. Association of Affordable Care Act Medicaid expansions with healthcare access and utilization among people who smoke [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR-01.

Adverse Selection in Medicaid

Recent expansions of Medicaid eligibility have come with increased experimentation with enrollee cost-sharing. In this paper, we exploit a discontinuous premium increase at the federal poverty level in Michigan’s Medicaid expansion program to test low-income individuals’ sensitivity to premiums using linked enrollment and claims data. At the cutoff, average premiums increase by $3.15 and the probability of disenrollment increases by 2.3 percentage points. Increased disenrollment occurs among those with fewer documented medical needs at baseline, but not among those with greater medical needs. These results suggest that healthier low-income individuals may be sensitive to even modest health insurance premiums, and that premiums may induce adverse selection in Medicaid plans.

Medicaid Expansion’s Impact on Emergency Department Use by State and Payer

ObjectivesThe Affordable Care Act’s Medicaid Expansion Program influences healthcare use by increasing insurance coverage. Of particular interest is how this will affect inefficient and expensive emergency department (ED) visits. We estimated the impact of the Medicaid expansion on ED use by states and payer (Medicaid, private insurance, and uninsured) 5 years after the implementation of the Medicaid expansion and illustrated the use of the generalized synthetic control method. MethodsIn this quasi-experiment study, we implemented the generalized synthetic control method to compare states with Medicaid expansion and states without Medicaid expansion. Data were from the Healthcare Cost Utilization Project Fast Stats, which cover >95% of all ED visits. We included states with complete data from 2010 to 2018. ResultsOverall, the Medicaid expansion increased Medicaid share of ED visits (average treatment effect on the treated [ATT] 11.39%; 95% confidence interval [CI] 8.76-14.02) and decreased private share of ED visits (ATT −5.80%; 95% CI −7.40 to −4.12) and uninsured share of ED visits (ATT −6.66%; 95% CI −9.78 to −3.55). ConclusionsMedicaid Expansion Program shifted ED payer mix to Medicaid ED visits from private insurance and uninsured ED visits for adults at age of 19 to 64 years, whereas its effect on total ED volume is mixed among states. States that experienced the largest increase in Medicaid enrollment seem to experience an increase in ED visits although such results did not reach statistical significance.

Development and Validation of a Multivariable Prediction Model for Missed HIV Health Care Provider Visits in a Large US Clinical Cohort.

BackgroundIdentifying individuals at high risk of missing HIV care provider visits could support proactive intervention. Previous prediction models for missed visits have not incorporated data beyond the individual level.MethodsWe developed prediction models for missed visits among people with HIV (PWH) with ≥1 follow-up visit in the Center for AIDS Research Network of Integrated Clinical Systems from 2010 to 2016. Individual-level (medical record data and patient-reported outcomes), community-level (American Community Survey), HIV care site–level (standardized clinic leadership survey), and structural-level (HIV criminalization laws, Medicaid expansion, and state AIDS Drug Assistance Program budget) predictors were included. Models were developed using random forests with 10-fold cross-validation; candidate models with the highest area under the curve (AUC) were identified.ResultsData from 382 432 visits among 20 807 PWH followed for a median of 3.8 years were included; the median age was 44 years, 81% were male, 37% were Black, 15% reported injection drug use, and 57% reported male-to-male sexual contact. The highest AUC was 0.76, and the strongest predictors were at the individual level (prior visit adherence, age, CD4+ count) and community level (proportion living in poverty, unemployed, and of Black race). A simplified model, including readily accessible variables available in a web-based calculator, had a slightly lower AUC of .700.ConclusionsPrediction models validated using multilevel data had a similar AUC to previous models developed using only individual-level data. The strongest predictors were individual-level variables, particularly prior visit adherence, though community-level variables were also predictive. Absent additional data, PWH with previous missed visits should be prioritized by interventions to improve visit adherence.

Enrollee Experience with Providers in the Arkansas Medicaid Expansion Program.

Patient ratings of their healthcare experience as a quality measure have become critically important since the implementation of the Affordable Care Act (ACA). The ACA enabled states to expand Medicaid eligibility to reduce uninsurance nationally. Arkansas gained approval to use Medicaid funds to purchase a qualified health plan (QHP) through the ACA marketplace for newly eligible beneficiaries. We compare patient-reported satisfaction between fee-for-service Medicaid and QHP participants. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) was used to identifydifferences in Medicaid and QHP enrollee healthcare experiences. Data were analyzed using a regression discontinuity design. Newly eligible Medicaid expansion participants enrolled in Medicaid during 2013 completed the Consumer Assessment of Health Providers and Systems (CAHPS) survey in 2014. Survey data was analyzed for 3156 participants (n = 1759 QHP/1397 Medicaid). Measures included rating of personal and specialist provider, rating of all healthcare received, and whether the provider offered to communicate electronically. Demographic and clinical characteristics of the enrollees were controlled for in the analyses. Regression-discontinuity analysis was used to evaluate differential program effects on positive ratings as measured by the CAHPS survey while controlling for demographic and health characteristics of participants. Adjusted logistic regression models for overall healthcare (OR = 0.71, 95%CI = 0.56-0.90, p = 0.004) and personal doctor (OR = 0.68, 95%CI = 0.53-0.87, p = 0.002) predicted greater satisfaction among QHP versus Medicaid participants. Results were not significant for specialists or for use of electronic communication with provider. Using a quasi-experimental statistical approach, we were able to control for observed and unobserved heterogeneity showing that among participants with similar characteristics, including income, QHP participants rated their personal providers and healthcare higher than those enrolled in Medicaid. Access to care, utilization of care, and healthcare and health insurance literacy may be contributing factors to these results.

Adverse Selection in Medicaid: Evidence from Discontinuous Program Rules

Recent expansions of Medicaid eligibility have come with increased experimentation with enrollee cost-sharing. In this paper, we exploit a discontinuous premium increase at the federal poverty level in Michigan’s Medicaid expansion program to test low-income individuals’ sensitivity to premiums using linked enrollment and claims data. At the cutoff, average premiums increase by $3.15 and the probability of disenrollment increases by 2.3 percentage points. Increased disenrollment occurs among those with fewer documented medical needs at baseline, but not among those with greater medical needs. These results suggest healthier low-income individuals may be sensitive to even modest health insurance premiums, and that premiums may induce adverse selection in Medicaid plans. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Involvement in State and Federal Aging Policy

The fourth speaker is Dr. Erica Solway. Dr. Solway will discuss her experience working in policy at the federal level as a Health and Aging Policy Fellow and a policy advisor with the U.S. Senate Committee on Health, Education, Labor, and Pensions Subcommittee on Primary Health and Aging and in her current involvement in policy-relevant research at the state and national level at the University of Michigan Institute for Healthcare Policy & Innovation. Dr. Solway is a senior project manager forthe evaluation of the Healthy Michigan Plan, Michigan’s Medicaid expansion program, and is also an associate director of the University of Michigan National Poll on Healthy Aging.

The design of a randomized controlled trial to evaluate multi-dimensional effects of a section 1115 Medicaid demonstration waiver with community engagement requirements

Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization – the gold standard for assessing causality – has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of beneficiaries deemed able-bodied to maintain eligibility for benefits. Beneficiaries were randomized 9:1 to the new waiver program or a control group who would retain their current benefits as part of the existing Medicaid expansion program. To address potential bias from differential attrition from the Medicaid program that would accrue from solely analyzing administrative data, our team designed a rich, prospective, longitudinal survey to collect primary and secondary outcomes from six categories of interest to policymakers: insurance coverage, health care utilization and quality, health behaviors, socioeconomic measures, personal finances, and health outcomes. At baseline, a subset of survey participants was invited to participate in the collection of biometric samples via in-person follow-up visits, and a cross-section were also invited to participate in qualitative interviews. While the demonstration waiver was terminated before the program began, our study design illustrates that it is possible for other researchers and state agencies seeking to evaluate Medicaid demonstration waivers and other demonstration policies to work together to implement high quality randomized trials – even for controversial policies.

Medicaid Expansion: Is There a Storm Brewing?: Commentary on an article by Christopher J. Dy, MD, MPH, et al.: "Unmet Need for Total Joint Arthroplasty in Medicaid Beneficiaries After Affordable Care Act Expansion".

Commentary Medicaid eligibility was expanded under the U.S. Affordable Care Act in 2014. This provided coverage in participating states for citizens with incomes up to 133% of the poverty line. Previous large database studies have shown that the expansion option has led to an increase enrollment in Medicaid with a concomitant greater utilization of health-care services, including orthopaedic procedures. With limited providers accepting Medicaid, there is a concern that this influx of new patients will cause further strain on the system and potentially lead to even greater health-care disparities if measures are not taken to ensure appropriate access to care. In their study, Dy et al. attempt to understand the impact that Medicaid expansion may have on the health-care system, specifically in terms of the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA). The authors hypothesized that patients who were newly enrolled in the Medicaid expansion would proceed to a surgical procedure following enrollment in the plan sooner than traditional Medicaid beneficiaries (Supplemental Security Income [SSI] and Temporary Assistance for Needy Families [TANF]), thereby representing a pent-up demand in these patients that may strain the health-care system. In their study, the authors indeed found a shorter time from enrollment to a surgical procedure in the patients in the expansion group compared with the patients in the SSI and TANF groups. The authors concluded that health-care providers and policymakers should be aware of this earlier demand for a surgical procedure in order to anticipate future needs. Although the study covers the important topic of health-care disparities, it did have several limitations, including the small sample size. Only 663 patients across 4 states were enrolled in the expansion program and underwent a THA or TKA through the managed care company during the study period. This small sample limits the ability of the reader to understand or predict the impact that further expansion of the program will have on the health-care system. Although the authors use the shorter time from enrollment to a surgical procedure to conclude that there is a pent-up demand, this abbreviated wait time also suggests that the health-care systems in participating states are not currently overwhelmed by the new patients. As the authors discuss, the shorter wait times for the patients in the expansion group could be due to several variables, including potential differences in reimbursement between plans by the managed care company, thereby incentivizing providers to offer services to the patients in the expansion group at the expense of the patients in the SSI and TANF groups. It would be interesting to compare the mean wait time for all Medicaid patients prior to, and following, state participation in the Medicaid expansion program, as an overall increased lag time would suggest strain on the system rather than simply shifting resources away from the patients in traditional Medicaid plans to the new patients in the expansion program. Although this article is a good initial step, larger studies will be helpful to better clarify the true impact that the Medicaid expansion program has on the health-care system.

COVERAGE, ACCESS, AND MEDICAID

In June 2019, New Hampshire began requiring beneficiaries to report work and community engagement hours as a condition of eligibility for its Medicaid expansion program, Granite Advantage, becoming the second state to do so following Arkansas’s program implemented a year earlier. State officials set out to design and implement a program that would avoid the problems in Arkansas that resulted in over 18,000 Medicaid adults being disenrolled in the first six months of Arkansas Works. But after just one month, New Hampshire officials realized they had not succeeded in reaching and informing the target population, and 17,000 Granite Advantage enrollees were scheduled to receive letters saying they were out of compliance with Medicaid work rules and faced the prospect of losing coverage. However, state officials suspended the program before this occurred, and federal courts subsequently halted the program indefinitely. We studied New Hampshire’s Medicaid work requirement program to understand how it was implemented and why, like Arkansas, it apparently failed to promote work and threatened coverage.Building on a similar case study of Arkansas Works conducted earlier in 2019, we visited New Hampshire for three days in October 2019, conducting seven interviews with 13 stakeholders and two focus groups with 11 Medicaid enrollees to learn about the state’s program and its effects on beneficiaries. Nineteen additional interviews were conducted by telephone.Medicaid beneficiaries enrolled in Granite Advantage, New Hampshire’s Medicaid expansion program.Regarding outreach, New Hampshire allowed insufficient time and funding to publicize and educate beneficiaries about new work rules and relied too heavily on mail‐ and telephone‐based methods that failed to connect with a hard‐to‐reach population. In attempting to promote work, the state’s Granite Workforce pilot was crippled by very limiting eligibility requirements and a short, six‐month implementation period that helped just 120 enrollees while spending less than 13% of its budget allocation. Like Arkansas, New Hampshire tried to proactively exempt many members from work requirements (eg, those already working 100 hours/month, satisfying SNAP work requirements, who are disabled, pregnant, or caring for children under six). But also, like Arkansas, the state failed to use health plan claims data to identify “medically frail” individuals who experienced difficulties applying for exemptions. New Hampshire designed a “no wrong door” approach for reporting work and community engagement that, unlike Arkansas’s primarily online system, allowed people to report hours online, by mail, over the phone, or in‐person. However, the system was fraught with problems and only a fraction of beneficiaries was able to successfully report hours.Despite intentional efforts to design a “better” program than Arkansas’s, New Hampshire’s Medicaid work requirements produced nearly the same result in a fraction of the time, facing the disenrollment of a large share—67 percent—of persons subject to the requirement.Based on the experiences of the first two states to implement Medicaid work requirements—states that adopted considerably different approaches under different circumstances—evidence suggests that such programs cause significant harm to Medicaid beneficiaries while not appreciably supporting their ability to work.The Robert Wood Johnson Foundation.