Expansion Enrollees Research Articles

Inequities in Telehealth Use Associated with Payer Type During the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic has prompted a shift in health care delivery and compelled a heavier reliance on telehealth. The objective of this study was to determine if differences in coverage policies by payer type resulted in differential telehealth use during the first 3 months of the COVID-19 pandemic. In this population-based cohort study of low-income Arkansans, Medicaid beneficiaries enrolled in the traditional Primary Care Case Management (PCCM) program were compared with Medicaid beneficiaries covered through premium assistance in private Qualified Health Plans (QHPs). Methods: A retrospective review was conducted of insurance claims records from June 1, 2019, to June 30, 2020, for synchronous telehealth and mobile health (m-health) visits, as well as other forms of telehealth. To establish the baseline equivalence of enrollees in the two groups, propensity score matching design was used on demographic and geographic characteristics, Charlson Comorbidity Index, broadband availability, and prior service utilization. Results: Compared with enrollees in the PCCM program, Medicaid expansion enrollees in QHPs had higher odds of having had at least one telehealth visit (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.29-1.42) during the early phase of the COVID-19 pandemic. Categorizing utilizations by domain, QHP enrollees were more likely to use synchronous telehealth (aOR = 1.31; 95% CI: 1.25-1.37) and m-health (aOR = 5.91; 95% CI: 4.25-8.21). A higher proportion of QHP enrollees also had at least one mental or behavioral health telehealth session (aOR = 1.13; 95% CI: 1.07-1.19). Conclusions: Our study demonstrated that within low-income populations, payer type was associated with inequitable access to telehealth during the early phase of the COVID-19 pandemic.

Longitudinal trends in enrollees\u2019 employment and student status after Medicaid expansion

BackgroundMedicaid community engagement requirements previously received federal approval in 12 states, despite limited data on their impact on enrollees’ employment-related activities. Our objective was to assess longitudinal changes in enrollees’ employment and student status after implementation of Michigan’s Medicaid expansion.MethodsLongitudinal telephone survey of Michigan Medicaid expansion enrollees in 2016 (response rate [RR] = 53.7%), 2017 (RR = 83.4%), and 2018 (N = 2,608, RR = 89.4%) serially assessing self-reported employment or student status. Survey responses were benchmarked against statewide changes in assessed similar low-income adults in the U.S. Census Bureau Current Population Survey. We used mixed models with individual random effects to assess changes in the proportion of enrollees who were employed or students by year.ResultsMost respondents had incomes < 100% FPL (61.7% with 0–35% of the federal poverty level [FPL], 22.9% with 36–99% FPL, and 15.4% with 100–133% FPL), 89.3% had at least a high school diploma/equivalent, and they ranged in age (39.6% age 19–34, 34.5% age 35–50, 25.9% age 51–64). Employment or student status increased significantly among Michigan Medicaid expansion respondents, from 54.5% in 2016 to 61.4% in 2018 (P < 0.001), including among those with a chronic condition (47.8% to 53.8%, P < 0.001) or mental health/substance use disorder (48.5% to 56.0%, P < 0.001). In contrast, the statewide proportion of low-income non-elderly adults who were employed or students did not change significantly (from 42.7% in 2016 to 46.0% in 2018, P = 0.57).ConclusionsMedicaid expansion, absent a community engagement requirement, was associated with increased employment and related activities. The role of Medicaid in providing safety-net coverage to individuals during times of economic stress is likely to grow.

A bridge too far? Distance to waivered physicians and utilization of buprenorphine treatment for opioid use disorder in West Virginia Medicaid

Background: Travel distance to medication treatment for opioid use disorder (OUD) is a challenge for many patients, but little is known about how distance is associated with medication treatment utilization. This study examines the association between distance to the nearest physician waivered to prescribe buprenorphine and patient-level buprenorphine treatment among West Virginia Medicaid expansion enrollees with diagnosed OUD. Methods: We conducted a cross-sectional spatial analysis with 2016 Medicaid claims data, separately examining individuals living in metropolitan and non-metropolitan areas. We calculated the driving distance from the centroid of patients’ residential ZIP codes to the street address of the nearest waivered physician derived from the 2015 Drug Enforcement Administration listing. Regression models examined the association between distance and initiation and duration of buprenorphine (among those initiating). Results: We focused on 8,008 individuals with OUD in 2016. The nearest waivered prescriber in metropolitan areas was an average of 7.13 miles away from patients’ residential ZIP codes and 14.54 miles in non-metropolitan areas. The providers they actually visited were a mean of 33.63 miles away in metro areas and 46.36 in non-metropolitan areas. In multivariable analyses, compared to those living <10 miles from a waivered physician, living >20 miles from a waivered physician was associated with −32.13 fewer days of treatment (95% CI: −57.86, −6.40) in metro areas and −16.70 fewer days in non-metro areas (95% CI: −32.32, −1.08). Conclusions: Longer travel distance to buprenorphine treatment is associated with a shorter duration of care that is likely to be clinically meaningful.

Emergency Department and Ambulatory Care Visits in the First Twelve Months of Coverage Under Medicaid Expansion: A Group-Based Trajectory Analysis

More than 17 million people have gained health insurance coverage through the Patient Protection and Affordable Care Act's Medicaid expansion. Few studies have examined heterogeneity within the Medicaid expansion population. We do so based on time-varying patterns of emergency department (ED) and ambulatory care use, and characterize diagnoses associated with ED and ambulatory care visits to evaluate whether certain diagnoses predominate in individual trajectories. We used group-based multitrajectory modeling to jointly estimate trajectories of ambulatory care and ED utilization in the first 12 months of enrollment among Pennsylvania Medicaid expansion enrollees from 2015 to2017. Among 601,877 expansion enrollees, we identified 6 distinct groups based on joint trajectories of ED and ambulatory care use. Mean ED use varied across groups from 3.4 to 48.7 visits per 100 enrollees in the first month and between 2.8 and 44.0 visits per 100 enrollees in month 12. Mean ambulatory visit rates varied from 0.0 to 179 visits per 100 enrollees in the first month and from 0.0 to 274 visits in month 12. Rates of ED visits did not change over time, but rates of ambulatory care visits increased by at least 50% among 4 groups during the study period. Groups varied on chronic condition diagnoses, including mental health and substance use disorders, as well as diagnoses associated with ambulatory care visits. We found substantial variation in rates of ED and ambulatory care use across empirically defined subgroups of Medicaid expansion enrollees. We also identified heterogeneity among the diagnoses associated with these visits. This data-driven approach may be used to target resources to encourage efficient use of ED services and support engagement with ambulatory care clinicians.

Longitudinal Trends in Enrollees’ Employment and Student Status after Medicaid Expansion

Medicaid “community engagement” requirement (work, school, job training, job searching, or volunteering) waivers have received CMS approval in nine states, but there are little data on current trends in Medicaid enrollees’ engagement in these activities. Our objective was to assess longitudinal changes in enrollees’ employment and student status after implementation of Michigan’s Medicaid expansion, which expanded coverage in 2014 and now covers ~664,000 individuals.We conducted a longitudinal telephone survey in English, Spanish, and Arabic with a cohort of Medicaid expansion enrollees at 3 time points in 2016 (N = 4090, RR = 53.7%), 2017 (N = 3104; RR = 83.4%), and 2018 (N = 2608, RR = 89.4%). Survey items measured employment status and student status; demographic characteristics were obtained from Michigan Medicaid program files. We used mixed models with year as a fixed effect to assess changes in the proportion of enrollees who were employed or students, incorporating weights adjusting for sample design and nonresponse.Enrollees aged 19‐64, with incomes up to 133% of the federal poverty level (FPL).Most respondents had incomes under 100% FPL (61.7% with 0‐35% FPL, 22.9% with 36‐99% FPL, and 15.4% with 100‐133% FPL), 89.3% had at least a high school diploma/equivalent, and respondents ranged in age (39.6%, age 19‐34; 34.5%, age 35‐50; and 25.9%, age 51‐64). From 2016 to 2018, the proportion of enrollees who were employed or students increased from 54.5% to 61.4% (P &lt; .001). Increases were observed in subgroups with lower baseline rates of employment or student status, including those with a chronic condition (47.8% to 53.8%, P &lt; .001) and those with a mental health or substance use disorder (48.5% to 56.0% P &lt; .001). Employed enrollees worked 34.7 mean hours per week on all paid jobs in 2018. Among enrollees who were in school, 57.7% were full‐time and 42.3% were part‐time students. Enrollees who were not employed or students in 2018 (38.6%) reported being unable to work (47.3%), out of work (40.4%), or retired (12.3%). Among enrollees who reported being unable to work, primary reasons included poor health/disability (91.4%) and caregiving responsibilities (7.1%). Among all enrollees who were not employed in 2018, 36.8% were searching for a job and 9.1% had completed or were enrolled in job training.From 2016 to 2018, employment or student status increased among Michigan Medicaid expansion enrollees, including among subgroups with comorbidities. This occurred prior to implementation of the state’s planned community engagement requirement in January 2020.Federal courts are currently weighing whether community engagement requirements will promote the Medicaid program’s goals of improved coverage and health, as well as associated improvements in employment and related activities. Three of the approved state waivers have been set aside by the courts and two have been delayed or suspended, while nine additional states have pending waivers seeking approval for similar requirements. Our findings suggest that Medicaid expansion itself was associated with the desired outcome of employment and related activities. The value of Medicaid community engagement requirements should be considered along with the additional administrative burden on individuals and states.The University of Michigan Institute for Healthcare Policy and Innovation (IHPI) is conducting the evaluation required by the Centers for Medicare and Medicaid Services (CMS) of the Healthy Michigan Plan (HMP) under contract with MDHHS. Data collected for this paper were funded by MDHHS and CMS for the purposes of the evaluation but do not represent the official views of either agency.

Examination of Changes in Health Status Among Michigan Medicaid Expansion Enrollees From 2016 to 2017

Evidence about the health benefits of Medicaid expansion has been mixed and has largely come from comparing expansion and nonexpansion states. To examine the self-reported health of enrollees in Michigan's Medicaid expansion, the Healthy Michigan Plan (HMP), over time. A telephone survey from January 1 to October 31, 2016 (response rate, 53.7%), and a follow-up survey from March 1, 2017, to January 31, 2018 (response rate, 83.4%), were conducted in Michigan, which expanded Medicaid in 2014 through a Section 1115 waiver permitting state-specific modifications. Four thousand ninety HMP beneficiaries aged 19 to 64 years with at least 12 months of HMP coverage and at least 9 months in a Medicaid health plan were eligible to participate. Data were analyzed from April 1 to November 30, 2018. Surveys measured demographic characteristics and health status. Analyses included weights for sampling probability and nonresponse. Comparisons between 2016 and 2017 included those who responded to both surveys (n = 3097). Of the 3097 respondents to the 2017 follow-up survey, 2388 (77.1%) were still enrolled in HMP (current enrollees) and 709 (22.9%) were no longer enrolled when surveyed (former enrollees). Among all follow-up respondents, a weighted 37.5% (95% CI, 35.3%-39.9%) were aged 19 to 34 years, 34.0% (95% CI, 31.8%-36.2%) were aged 35 to 50 years, and 28.5% (95% CI, 26.7%-30.3%) were aged 51 to 64 years; 53.0% (95% CI, 50.8%-55.3%) were female. Respondents who reported fair or poor health decreased from 30.7% (95% CI, 28.7%-32.8%) in 2016 to 27.0% (95% CI, 25.1%-29.0%) in 2017 (adjusted odds ratio [AOR], 0.66 [95% CI, 0.53-0.81]; P < .001), with the largest decreases observed in respondents who were non-Hispanic black (from 31.5% [95% CI, 27.1%-35.9%] in 2016 to 26.0% [95% CI, 21.9%-30.1%] in 2017; P = .009), from the Detroit metropolitan area (from 30.7% [95% CI, 27.0%-34.4%] in 2016 to 24.9% [95% CI, 21.6%-28.3%] in 2017; P = .001), and with an income of 0% to 35% of the federal poverty level (from 37.6% [95% CI, 34.2%-40.9%] in 2016 to 32.3% [95% CI, 29.1%-35.5%] in 2017; P < .001). From 2016 to 2017, the mean number of days of poor physical health in the past month decreased significantly from 6.9 (95% CI, 6.5-7.4) to 5.7 (95% CI, 5.3-6.0) (coefficient, -6.10; P < .001), including among current (from 7.0 [95% CI, 6.5-7.5] to 5.6 [95% CI, 5.1-6.0]; P < .001) and former (from 6.8 [95% CI, 5.9-7.7] to 5.8 [95% CI, 5.0-6.7]; P = .02) enrollees, those with 2 or more chronic conditions (from 9.9 [95% CI, 9.3-10.6] to 8.5 [95% CI, 7.8-9.1]; P < .001), across all age groups (19-34 years, from 4.3 [95% CI, 3.7-4.9] to 3.0 [95% CI, 2.5-3.5]; P < .001; 35-50 years, from 8.2 [95% CI, 7.3-9.0] to 6.9 [95% CI, 6.1-7.7]; P = .002; 51-64 years, from 9.0 [95% CI, 8.2-9.8] to 7.6 [95% CI, 6.9-8.3]; P = .001), and among non-Hispanic white (from 7.5 [95% CI, 7.0-8.1] to 6.1 [95% CI, 5.6-6.6]; P < .001) and black (from 5.9 [95% CI, 5.1-6.8] to 4.4 [95% CI, 3.6-5.1]; P < .001) respondents. No changes in days of poor mental health or usual activities missed owing to poor physical or mental health were observed. These findings suggest that HMP enrollees in Michigan have experienced improvements in self-reported health over time, including minority groups with a history of health disparities and enrollees with chronic health conditions.

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan

Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear. To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion. This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018. Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students. The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status. Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.

Ohio medicaid expansion enrollees: Impact of loss of coverage on access to care, 2018

Ohio medicaid expansion enrollees: Impact of loss of coverage on access to care, 2018

Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study.

It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions. Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being. Mixed-methods study including a telephone survey and semi-structured interviews. Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP). 4090 survey respondents (response rate 54%) with ≥ 12months HMP enrollment and 67 interviewees with ≥ 6months enrollment. Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status. Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health. Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.

Identification of Cross-sector Service Utilization Patterns Among Urban Medicaid Expansion Enrollees.

The expansion of Medicaid as part of the Affordable Care Act opened new opportunities to provide health coverage to low-income adults who may be involved in other public sectors. The main objective of this study was to describe cross-sector utilization patterns among urban Medicaid expansion enrollees. We merged data from 4 public sectors (health care, human services, housing, and criminal justice) for 98,282 Medicaid expansion enrollees in Hennepin County, MN. We fit a latent class model to indicators of cross-sector involvement. Indicator variables described involvement levels within each sector from March 2011 through December 2014. Demographic and chronic condition indicators were included post hoc to characterize classes. We found 6 archetypes of cross-sector involvement: The "Low Contact" class (33.9%) had little involvement in any public sector; "Primary Care" (26.3%) had moderate, stable health care utilization; "Health and Human Services" (15.3%) had high rates of health care and cash assistance utilization; "Minimal Criminal History" (11.0%) had less serious criminal justice involvement; "Cross-sector" (7.8%) had elevated emergency department use, involvement in all 4 sectors, and the highest prevalence of behavioral health conditions; "Extensive Criminal History" (5.7%) had serious criminal justice involvement. The 3 most expensive classes (Health and Human Services, Cross-sector, and Extensive Criminal History) had the highest rates of behavioral health conditions. Together, they comprised 29% of enrollees and 70% of total public costs. Medicaid expansion enrollees with behavioral health conditions deserve focus due to the high cost-reduction potential across public sectors. Cross-sector collaboration is a plausible path to reduce costs and improve outcomes.

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.

Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy. To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities. Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO.

Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.

Affordable Care Act Impact on Medicaid Coverage of Smoking-Cessation Treatments

Four sections of the Affordable Care Act address the expansion of Medicaid coverage for recommended smoking-cessation treatments for: (1) pregnant women (Section 4107), (2) all enrollees through a financial incentive (1% Federal Medical Assistance Percentage increase) to offer comprehensive coverage (Section 4106), (3) all enrollees through Medicaid formulary requirements (Section 2502), and (4) Medicaid expansion enrollees (Section 2001). The purpose of this study is to document changes in Medicaid coverage for smoking-cessation treatments since the passage of the Affordable Care Act and to assess how implementation has differentially affected Medicaid coverage policies for: pregnant women, enrollees in traditional Medicaid, and Medicaid expansion enrollees. From January through June 2017, data were collected and analyzed from 51 Medicaid programs (50 states plus the District of Columbia) through a web-based survey and review of benefits documents to assess coverage policies for smoking-cessation treatments. Forty-seven Medicaid programs have increased coverage for smoking-cessation treatments post-implementation of the Affordable Care Act by adopting one or more of the four smoking-cessation treatment provisions. Coverage for pregnant women increased in 37 states, coverage for newly eligible expansion enrollees increased in 32 states, and 15 states added coverage and/or removed copayments in order to apply for a 1% increase in the Federal Medical Assistance Percentage. Coverage for all recommended pharmacotherapy and group and individual counseling increased from seven states in 2009 to 28 states in 2017. The Affordable Care Act was successful in improving and expanding state Medicaid coverage of effective smoking-cessation treatments. Many programs are not fully compliant with the law, and additional guidance and clarification from the Centers for Medicare and Medicaid Services may be needed.

Cross-Sector Service Use Among High Health Care Utilizers In Minnesota After Medicaid Expansion.

Childless adults in the Medicaid expansion population have complex social and behavioral needs. This study compared the cross-sector involvement of Medicaid expansion enrollees who were high health care utilizers to that of other expansion enrollees in Hennepin County, Minnesota. We examined forty-six months of annualized utilization and cost data for expansion-eligible residents with at least twelve months of enrollment (N = 70,134) across health care, housing, criminal justice, and human service sectors. High health care utilizers, approximately 7percent of our sample, were disproportionately American Indian, younger, and significantly more likely than other expansion enrollees to have mental health (88.1percent versus 48.0percent) or substance use diagnoses (79.2percent versus 29.6percent). Total cross-sector public spending was nearly four times higher for high health care users ($25,337 versus $6,786), and their non-health care expenses were 2.4 times higher ($7,476 versus $3,108). High levels of cross-sector service use suggest that there are opportunities for collaboration that may result in cost savings across sectors.

Employment Status and Health Characteristics of Adults With Expanded Medicaid Coverage in Michigan

This survey study examines the demographic and health characteristics associated with the employment status of current Medicaid expansion enrollees in Michigan.

Identifying Homeless Medicaid Enrollees Using Enrollment Addresses.

To design and test the validity of a method to identify homelessness among Medicaid enrollees using mailing address data. Enrollment and claims data on Medicaid expansion enrollees in Hennepin and Ramsey counties who also provided self-reported information on their current housing situation in a psychosocial needs assessment. Construction of address-based indicators and comparison with self-report data. Among 1,677 enrollees, 427 (25 percent) self-reported homelessness, of whom 328 (77 percent) had at least one positive address indicator. Depending on the type of addresses included in the indicator, sensitivity to detect self-reported homelessness ranged from 30 to 76 percent and specificity from 79 to 97 percent. An address-based indicator can identify a large proportion of Medicaid enrollees who are experiencing homelessness. This approach may be of interest to researchers, states, and health systems attempting to identify homeless populations.

Medicaid Expansion and ACA Repeal: Evidence From Ohio.

To examine the health insurance coverage options for Medicaid expansion enrollees if the Affordable Care Act (ACA) is repealed, using evidence from Ohio, where more than half a million adults have enrolled in the state's Medicaid program through the ACA expansion. The Ohio Medicaid Assessment Survey interviewed 42 000 households in 2015. We report data from a unique battery of questions designed to identify insurance coverage immediately prior to Medicaid enrollment. Ninety-five percent of new Medicaid enrollees in Ohio did not have a private health insurance option immediately before enrollment. These new enrollees are predominantly older, low-income Whites with a high school education or less. Only 5% of new Medicaid enrollees were eligible for an employer-sponsored insurance plan to which they could potentially return in the case of repeal of the ACA. The vast majority of Medicaid expansion enrollees would have no plausible pathway to obtaining private-sector insurance if the ACA were repealed. Demographic similarities between the expansion population and 2016 exit polls suggest that coverage losses would fall disproportionately on members of the winning Republican coalition.

State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage - United States, 2016.

In 2015, 27.8% of adult Medicaid enrollees were current cigarette smokers, compared with 11.1% of adults with private health insurance, placing Medicaid enrollees at increased risk for smoking-related disease and death (1). In addition, smoking-related diseases are a major contributor to Medicaid costs, accounting for about 15% (>$39 billion) of annual Medicaid spending during 2006-2010 (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications are effective treatments for helping tobacco users quit (3). Insurance coverage for tobacco cessation treatments is associated with increased quit attempts, use of cessation treatments, and successful smoking cessation (3); this coverage has the potential to reduce Medicaid costs (4). However, barriers such as requiring copayments and prior authorization for treatment can impede access to cessation treatments (3,5). As of July 1, 2016, 32 states (including the District of Columbia) have expanded Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA),*,† which has increased access to health care services, including cessation treatments (5). CDC used data from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES) and the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the number of adult smokers enrolled in Medicaid expansion coverage. To assess cessation coverage among Medicaid expansion enrollees, the American Lung Association collected data on coverage of, and barriers to accessing, evidence-based cessation treatments. As of December 2015, approximately 2.3 million adult smokers were newly enrolled in Medicaid because of Medicaid expansion. As of July 1, 2016, all 32 states that have expanded Medicaid eligibility under ACA covered some cessation treatments for all Medicaid expansion enrollees, with nine states covering all nine cessation treatments for all Medicaid expansion enrollees. All 32 states imposed one or more barriers on at least one cessation treatment for at least some enrollees. Providing barrier-free access to cessation treatments and promoting their use can increase use of these treatments and reduce smoking and smoking-related disease, death, and health care costs among Medicaid enrollees (4,6-8).

Enrollment, Expenditures, and Utilization After CHIP Expansion: Evidence From Alabama

ObjectiveIn October 2009, Alabama expanded eligibility in its Children's Health Insurance Program (CHIP), known as ALL Kids, from 200% to 300% of the federal poverty level (FPL). We examined the expenditures, utilization, and enrollment behavior of expansion enrollees relative to traditional enrollees (100–200% FPL) and assessed the impact of expansion on total program expenditures. MethodsWe compared unadjusted mean person-month-level expenditures and utilization of expansion enrollees and various categories of existing enrollees and used a 2-part modeling strategy to examine differences after controlling for enrollee characteristics. We used probit models to examine adjusted differences in reenrollment behavior by eligibility category. ResultsExpansion enrollees had higher total monthly expenditures ($10.33, P < .05) than traditional ALL Kids enrollees, including higher outpatient ($5.35, P < .001) and dental ($0.85, P < .01) expenditures but lower emergency department (−$1.34, P < .001) expenditures. Expansion enrollees had marginally lower utilization of emergency department services for low-severity conditions and higher utilization of physician outpatient visits. Expansion enrollees were 4.47 percentage points (P < .001) more likely to reenroll before their contract expiration date than traditional ALL Kids enrollees. As of October 2012, expansion enrollees accounted for approximately 20% of ALL Kids enrollment and expenditures. ConclusionsThe expansion population was characterized by moderately higher health expenditures and utilization, and more persistent enrollment relative to fee group enrollees who are subject to the same levels of cost sharing and annual premiums. Although states are prohibited from changing program eligibility until 2019, the costs associated with the expansion population will be important to future policy decisions.

Can States Stretch The Medicaid Dollar Without Passing The Buck? Lessons From Utah

In 2002, Utah became the first state to reduce benefits and increase cost sharing for existing Medicaid beneficiaries, to finance a primary care benefit expansion for previously ineligible, low-income adults. Through a 2004 survey of beneficiaries, we found that expansion enrollees were predominantly poor and that most suffered from chronic conditions or disabilities, or both. Parents whose coverage was reduced to finance the expansion were extremely poor, were in poor health, and faced major financial challenges. Findings suggest that a coverage expansion approach that relies on savings from reducing coverage for current beneficiaries and solely covers primary care has important limitations.