Medicaid Funding Research Articles

The Affordable Care Act Attenuates Financial Strain According to Poverty Level.

We use data from the 2011-2016 National Health Interview Survey to examine how the Patient Protection and Affordable Care Act (ACA) has influenced disparities in health care–related financial strain, access to care, and utilization of services by categories of the Federal Poverty Level (FPL). We use multivariable regression analyses to determine the ACA’s effects on these outcome measures, as well as to determine how changes in these measures varied across different FPL levels. We find that the national implementation of the ACA’s insurance expansion provisions in 2014 was associated with improvements in health care–related financial strain, access, and utilization. Relative to adults earning more than 400% of the FPL, the largest effects were observed among those earning between 0% to 124% and 125% to 199% of the FPL after the implementation of the ACA. Both groups experienced reductions in disparities in financial strain and uninsurance relative to the highest FPL group. Overall, the ACA has attenuated health care–related financial strain and improved access to and the utilization of health services for low- and middle-income adults who have traditionally not met income eligibility requirements for public insurance programs. Policy changes that would replace the ACA with less generous age-based tax subsidies and reductions in Medicaid funding could reverse these gains.

The Temporal Relationship Between Medicaid Payment Acceptance and the Implementation of Medication-Assisted Drug Treatment.

Objective:To examine the temporal relationship of Medicaid funding on the implementation of evidence-based practices (EBPs) in outpatient substance use disorder (SUD) treatment.Methods:We examined data from 61 publicly funded SUD treatment programs in 2011 and 2013 using crossed-lagged regressions. We tested the impact of Medicaid payment acceptance on 2 measures of EBP implementation—contingency management treatment (CMT) and medication-assisted treatment (MAT).Results:Medicaid payment acceptance at wave 1 was not associated with implementation of CMT at wave 2 (standardized estimate = 0.170, SE = 0.208, P > .05). However, Medicaid payment acceptance at wave 1 was associated with implementation of MAT at wave 2 (standardized estimate = 0.880, SE = 0.047, P < .001).Conclusions:Medicaid payment acceptance has a temporal relationship with the implementation of MAT in SUD treatment programs serving one of the largest racial/ethnic minority communities in the United States.

Bundling Justice: Medicaid's Support for Housing.

Should Medicaid pay for supportive housing for homeless persons? After describing current limits on how states can use Medicaid funds to support housing, this article considers whether justice requires treating Medicaid recipients residing in nursing homes and Medicaid recipients needing supportive housing similarly.

Community Integration of People with Disabilities: Can Olmstead Protect Against Retrenchment?

Since the passage of the Americans with Disabilities Act (ADA) in 1990, states have made significant progress in enabling Americans with disabilities to live in their communities, rather than institutions. That progress reflects the combined effect of the Supreme Court’s holding in Olmstead v. L.C. ex rel. Zimring, that states’ failure to provide services to disabled persons in the community may violate the ADA, and amendments to Medicaid that permit states to devote funding to home and community-based services (HCBS). This article considers whether Olmstead and its progeny could act as a check on a potential retrenchment of states’ support for HCBS in the event that states face severe reductions in federal funding for Medicaid, as was threatened by Republican efforts in 2017 to “repeal and replace” the Affordable Care Act and to restructure Medicaid. The article concludes that Olmstead provides a strong basis for challenging a state’s elimination or severe curtailment of existing HCBS programs, but that the fact-specific nature of a state’s likely “fundamental alteration” defense precludes predicting the outcome of such a challenge. Despite this legal uncertainty, protests mounted by people with disabilities, in which they demanded freedom from institutionalization, may have helped cement the idea that community integration is a civil right in the public’s mind.

Design and impact of bundled payment for detox and follow-up care

IntroductionRecent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues. MethodsMassachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010–April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session. ResultsThe mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs. ConclusionsDesigning a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care.

Population health and medicine: Policy and financial drivers.

The financial and policy levers of population health and potential opportunities for pharmacists are described. Three long-standing problems drive the focus on population health: (1) the United States suffers far worse population health outcomes compared with those of other developed nations that spend significantly less on healthcare, (2) the U.S. healthcare system's focus on "sick care" fails to address upstream prevention and population health improvement, and (3) financial incentives for healthcare delivery are poorly aligned with improvements in population health outcomes. The Patient Protection and Affordable Care Act of 2010 (ACA) was arguably the first major healthcare legislation since 1965 and had 3 main strategies for improving population health: expand health insurance coverage, control healthcare costs, and improve the healthcare delivery system. Federal and state legislation as well as Medicare and Medicaid financing strategies have designated mechanisms to reward advances in population outcomes since the passage of the ACA. States are responsible for many of the factors that affect population health, and a bipartisan effort that builds upon state and federal collaboration will likely be needed to implement the necessary health policy initiative. Population health issues affect productivity in the United States; conversely, improvements in population health may increase productivity, helping to offset the rising federal debt. Employers are in a position to improve population health and consequently help reduce the federal debt by addressing lifestyle, chronic disease, poverty, and inequality. National pharmacy organizations, regulatory bodies, and journal editors need to collectively agree to a threshold of quality and rigor for publication and endorsement. Knowledge of the policy and financial drivers of population health may both support pharmacists' efforts to improve population outcomes and identify opportunities for professional advancement.

The Expanded Public Works Programme: Perspectives of direct beneficiaries

Scholarship on the Expanded Public Works Programme (EPWP) in South Africa tends to focus on quantitative evaluation to measure the progress made in the implementation of EPWP projects. The number of employment opportunities created by EPWP, demographic profiling, skills acquired by beneficiaries and training opportunities related to the Programme form the basis of typical statistical evaluations of it, but exclude comment by the workers who participate in its projects. Based on primary sources, including in-depth interviews, newspaper reports and internet sources, this article seeks to provide a qualitative review of the EPWP from the perspective of the beneficiaries of municipal EPWP projects. Various South African government sectors hire EPWP workers to provide local services such as cleaning and maintaining infrastructure, but the employment of these workers can still be regarded as precarious, in the sense that they have no job security, earn low wages and have no benefits such as medical aid or pension fund. The interviewees indicated that, although they appreciate the temporary employment opportunities provided by the EPWP, they also experience health and safety risks and lack the advantages of organised labour groupings. Their main disadvantage, however, is that they cannot access permanent employment, which offers better wages and concomitant benefits.

Principles of Child Health Care Financing.

After passage of the Patient Protection and Affordable Care Act, more children and young adults have become insured and have benefited from health care coverage than at any time since the creation of the Medicaid program in 1965. From 2009 to 2015, the uninsurance rate for children younger than 19 years fell from 9.7% to 5.3%, whereas the uninsurance rate for young adults 19 to 25 years of age declined from 31.7% to 14.5%. Nonetheless, much work remains to be done. The American Academy of Pediatrics (AAP) believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality and comprehensive health care, regardless of their or their families' incomes. Public and private health insurance should safeguard existing benefits for children and take further steps to cover the full array of essential health care services recommended by the AAP. Each family should be able to afford the premiums, deductibles, and other cost-sharing provisions of the plan. Health plans providing these benefits should ensure, insofar as possible, that families have a choice of professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Traditional and innovative payment methodologies by public and private payers should be structured to guarantee the economic viability of the pediatric medical home and of other pediatric specialty and subspecialty practices to address developing shortages in the pediatric specialty and subspecialty workforce, to promote the use of health information technology, to improve population health and the experience of care, and to encourage the delivery of evidence-based and quality health care in the medical home, as well as in other outpatient, inpatient, and home settings. All current and future health care insurance plans should incorporate the principles for child health financing outlined in this statement. Espousing the core principle to do no harm, the AAP believes that the United States must not sacrifice any of the hard-won gains for our children. Medicaid, as the largest single payer of health care for children and young adults, should remain true to its origins as an entitlement program; in other words, future fiscal or regulatory reforms of Medicaid should not reduce the eligibility and scope of benefits for children and young adults below current levels nor jeopardize children's access to care. Proposed Medicaid funding "reforms" (eg, institution of block grant, capped allotment, or per-capita capitation payments to states) will achieve their goal of securing cost savings but will inevitably compel states to reduce enrollee eligibility, trim existing benefits (such as Early and Periodic Screening, Diagnostic, and Treatment), and/or compromise children's access to necessary and timely care through cuts in payments to providers and delivery systems. In fact, the AAP advocates for increased Medicaid funding to improve access to essential care for existing enrollees, fund care for eligible but uninsured children once they enroll, and accommodate enrollment growth that will occur in states that choose to expand Medicaid eligibility. The AAP also calls for Congress to extend funding for the Children's Health Insurance Program, a plan vital to the 8.9 million children it covered in fiscal year 2016, for a minimum of 5 years.

Comparison of Orthodontic Medicaid Funding in the United States 2006 to 2015.

Orthodontic treatment is reimbursed by Medicaid based on orthodontic and financial need with qualifiers determined by individual states. Changes in Medicaid-funded orthodontic treatment following the "Great Recession" in 2007 and the enactment of the Affordable Care Act in 2010 were compared for the 50 United States and the District of Columbia to better understand disparities in access to care. The results from this 2015 survey were compared to data gathered in 2006 (1). Medicaid officials were contacted by email, telephone, or postal mail regarding the age limit for treatment, practitioner type who can determine eligibility and provide treatment, records required for case review, and rate and frequency of reimbursement. When not attained by direct contact, the information was gleaned from online websites, provider manuals, and state orthodontists. Information gathered from 50 states and the District of Columbia documents that Medicaid program characteristics and expenditures continue to vary by state. Expenditures and reimbursement rates have decreased since 2006 and vary widely by geographic region. Some states have tightened restrictions on qualifiers and increased submission requirements by providers. The variation and lack of uniformity that still exists among Medicaid orthodontic programs in different states creates disparities in orthodontic care for US citizens. Barriers to care for Medicaid-funded orthodontic treatment have increased since 2006.

Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions.

The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care. Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.

A Day on the Hill.

This article describes the author's advocacy experience at a press briefing on Capitol Hill. At stake is the continuation of Medicaid and Children's Health Insurance Program-funded health insurance to our most vulnerable children-those living in poverty and those with chronic health conditions. Current legislation proposes to impose block grants or per capita caps on federal funding for Medicaid and will put the reauthorization of the Children's Health Insurance Program at risk. Schools stand to lose over 4 billion dollars in reimbursement for services that students need to succeed in school.

Effects of Affordable Care Act Marketplaces and Medicaid Eligibility Expansion on Access to Cancer Care.

The aim of this study was to inform oncologists about how repealing the Affordable Care Act (ACA) may affect their ability to provide cancer therapies for people with cancer enrolled in ACA health plans and why proposals to change Medicaid funding may make it even more difficult for Medicaid beneficiaries to access cancer treatments. We examined the regulations and provisions of the ACA related to how health insurance impacts access to diagnostic testing and treatments for people with cancer, including access to clinical trials. Similarly, we examined federal and state rules affecting Medicaid beneficiaries' access to cancer treatments. Repealing various provisions of the ACA will restrict who has access to both current and new cancer treatments. Such changes also will impact oncology research that depends on having heterogeneous people in clinical trials. Significant changes to the ACA will affect oncology treatment choices of everyone with health insurance-not only the 10 million people newly covered by ACA health plans and the 70 million people with Medicaid coverage.

Medicaid Block Grants and Federalism

Medicaid, the US insurance program for millions of low-income children and adults, has operated for 50 years under a joint state-federal financing system. In exchange for federal funding that covers roughly 50% to 75% of Medicaid program costs depending on the state (the so-called match rate), states agree to administer the program within broad federal guidelines. The Affordable Care Act (ACA) took this combination of federal subsidies and oversight a step further by offering 100% federal funding for those newly eligible under the law’s Medicaid expansion through 2016 (with federal funding now at 95% and ultimately declining to 90%). So far, 31 states have opted into the ACA’s Medicaid expansion, extending coverage to millions and, through heightened public awareness and a streamlined application process, drawing in millions more who were previously eligible. However, Republican leaders are proposing a fundamental reform in Medicaid financing—a shift to block grants.1 Instead of a matching subsidy and federal oversight, block grants would give states an annual lump sum with minimal conditions attached.

The New Negative Rights: Abortion Funding and Constitutional Law after Whole Woman's Health

The Hyde Amendment, a ban on the Medicaid funding of abortion, is once again at the center of the abortion wars. For the most part, critics of the Hyde Amendment argue that it authorizes discrimination against poor women. Using original archival research, this Article show that the amendment has had a far greater impact. In popular debate, proponents of the Hyde Amendment helped to forge an idea of complicity-based conscience that has recently transformed fights about everything from same-sex marriage to contraceptive access. Constitutionally, the fight for the Hyde Amendment also revolutionized the rights-privilege distinction in constitutional law. In abortion-funding cases, the Court held that there was no constitutional problem with laws that created practical obstacles to abortion access so long as the obstacles themselves were not controlled or created by the state. This approach has resonated outside the context of abortion law. The Court’s recent decision in Whole Woman’s Health v. Hellerstedt makes a challenge to the Hyde Amendment realistic and compelling. The cases upholding the Hyde Amendment regard as constitutional any burden on a woman’s right to choose that is neither created nor controlled by the government. Whole Woman’s Health explicitly rejected this approach, looking instead at how the formal terms of law interact with forces beyond the government’s control. For this reason, the Article shows that Whole Woman’s Health undermines the core premises of the Hyde Amendment and creates an opening for those seeking to revisit the distinction between negative and positive rights.

Nonprofit Matches Volunteer Physicians With Communities in Need

Back to table of contents Previous article Next article Professional NewsFull AccessNonprofit Matches Volunteer Physicians With Communities in NeedNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:26 Jan 2017https://doi.org/10.1176/appi.pn.2017.2a8AbstractThe Maven Project aims to leverage the strength of medical alumni associations to provide health care services where they are needed—but all physicians are welcome to volunteer.As the lack of access to health care continues to affect many communities in the United States, especially those in in disadvantaged or rural areas, gynecologist Laurie Green, M.D., believes that the large body of retired or semi-retired physicians in this country can provide much-needed help.Laurie Green, M.D., founded the MAVEN Project as a means to leverage the reach of medical alumni associations to find retired physicians willing to volunteer using telehealth technology.Maven ProjectThat belief led Green, a managing partner at Pacific Women’s Obstetrics & Gynecology Medical Group in San Francisco, to launch the Medical Alumni Volunteer Expert Network, or MAVEN Project.The MAVEN Project seeks to leverage the networking power of medical school alumni groups—which Green understands firsthand as a former president of the Harvard Medical School Alumni Association—to recruit retired physicians or those downsizing their practices to volunteer their services via telemedicine to community clinics or other facilities that need medical expertise. As Green described it, MAVEN is like a medical matchmaking service. The MAVEN staff align each volunteer with a clinic based on the volunteer’s area of expertise and availability. MAVEN also handles all the administrative details, such as working out any issues with cross-state licensure or malpractice insurance. They also provide the telemedicine equipment and ensure that it is compliant with patient protection laws.Both primary care physicians and specialists are being sought, and while retired professionals are the main targets of recruitment, active physicians are also welcome. To help encourage enrollment, MAVEN has flexible guidelines on time commitment, requesting that volunteers provide a minimum of four hours of service a month for at least six months. Volunteers have a range of options in how they can assist. Specialty physicians who are willing to provide remote patient consultations or evaluations are, of course, valuable, said Green. “However, volunteers can also present educational talks to community physicians or work with colleagues on case discussions in a lunch and learn format.”As Green told Psychiatric News, the MAVEN Project has been progressing well in its recruitment efforts since it was founded in 2014; it is now involved in pilot projects with four clinical partners (two centers each in Massachusetts and California), and MAVEN volunteers have completed more than 350 remote patient visits. However, physician recruitment has not been equal across the specialties, and Green said that there is an urgent need for more psychiatrist involvement. It is not that surprising that psychiatrist recruitment has been difficult, said Larry Schmitt, M.D., a child and adolescent psychiatrist who retired from UC San Diego Health in 2005. “This country is short on psychiatrists in general, and child psychiatrists, in particular,” he told Psychiatric News. This shortage, coupled with the fact that psychiatry practice is less physically demanding than some other medical specialties translates to psychiatrists’ often staying active and with busy practices longer in life. However, mental health care is especially needed in these underserved communities, and Schmitt, who began volunteering with MAVEN last year, thinks psychiatrists with even limited time should consider opportunities like these.“I have been struck at how apparently effective I have been with my limited services,” said Schmitt, who has been providing about two patient consultations a week on average for clinics in California. “And my wife says I sound 10 years younger.”Green hopes more psychiatrists will follow Schmitt’s footsteps, as the need for quality mental health care is only expected to grow in the coming years.“When MAVEN first started, the goal was to help fill the gaps that have arisen given the millions of new people insured under the Affordable Care Act,” she said. “Many of these new enrollees are able to visit only their community clinic or a hospital, and we thought that remote specialist care would hit that ‘sweet spot’ between the two, providing the comfort of a local clinic with the services of a hospital.”Following the 2016 election, Green and her team are also keeping a close eye on how funding for Medicaid and other safety-net programs might be impacted. They are poised to tackle the challenges—as well as the opportunities—that could result. ■More information about the MAVEN Project, including how to volunteer or request a medical need for a clinic, can be accessed here. Physicians interested in volunteering can also email [email protected]. ISSUES NewArchived

Differences in Living Arrangements Among Older Adults Transitioning Into the Community: Examining the Impact of Race and Choice.

The federal Money Follows the Person Rebalancing Demonstration program allows nursing home residents to use Medicaid funds for home and community-based services rather than institutional care. Race, choice in housing, and challenges faced prior to transitioning may impact living arrangements following a discharge into the community. This study examines the influence of these factors on living arrangements for 659 program participants age 65 or older. Unmarried Blacks and people with financial or legal challenges are less likely to live with a live-in caregiver or in supervised housing compared with unmarried Whites. Race did not determine living arrangements among married participants, but housing transition challenges did. Findings inform policies targeting nursing home rebalancing efforts by highlighting racial diversity in living arrangements and emphasizing the need for affordable, accessible housing options for older adults of any race seeking to live in the community rather than remain in an institutional setting.

Pay For Success And Population Health: Early Results From Eleven Projects Reveal Challenges And Promise.

Pay for success (PFS) is a type of social impact investing that uses private capital to finance proven prevention programs that help a government reduce public expenditures or achieve greater value. We conducted an analysis of the first eleven PFS projects in the United States to investigate the potential of PFS as a strategy for financing and disseminating interventions aimed at improving population health and health equity. The PFS approach has significant potential for bringing private-sector resources to interventions regarding social determinants of health. Nonetheless, a number of challenges remain, including structuring PFS initiatives so that optimal prevention benefits can be achieved and ensuring that PFS interventions and evaluation designs are based on rigorous research principles. In addition, increased policy attention regarding key PFS payout issues is needed, including the "wrong pockets" problem and legal barriers to using federal Medicaid funds as an investor payout source.

A Moral or Medical Problem? The Relationship between Legal Penalties and Treatment Practices for Opioid Use Disorders in Pregnant Women

ObjectiveThe relationship between use of medication-assisted treatment (MAT) in pregnant women with opioid use disorders, the standard of care, and state laws that permit child abuse charges for illicit drug use during pregnancy has not been described. MethodsUsing publicly available data on substance abuse treatment in the United States, we describe patterns in the use of MAT for pregnant women with opioid use disorders in states with prenatal child abuse laws compared with states without such laws. A binary logistic regression analysis was conducted to predict the presence or absence of MAT in the treatment plan of pregnant women using the following independent variables: state prenatal child abuse law, referral source, geographical region, and Medicaid coverage of methadone. ResultsIn 2012, there were 8,292 treatment episodes of pregnant women with a primary opioid use disorder in the United States for which data on MAT use were available. Among states with laws that permit child abuse charges for illicit drug use in pregnancy (18 states), MAT was used in 33.15% of treatment admissions compared with 51.33% of admissions in states without a law. The following levels of the independent variables have a greater effect on the lack of use of MAT in descending order of importance: criminal justice referral, other community referral, Southern region, Medicaid coverage, drug abuse care provider referral, unknown referral, other health care provider referral, and presence of state law that permits child abuse charges. ConclusionReferral source, geographic region, Medicaid funding, and prenatal child abuse laws were associated with significantly lower rates of use of MAT.

Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance

Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the "private option"). In addition, while coverage gains from the ACA's Medicaid expansion are well documented, impacts on utilization and health are unclear. To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA. Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016. Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas. Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health. Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (-11.6 percentage points; P < .001), reduced out-of-pocket spending (-29.5%; P = .02), reduced likelihood of emergency department visits (-6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (-7.1 percentage points with "fair/poor quality of care"; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences. In the second year of expansion, Kentucky's Medicaid program and Arkansas's private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.

Affordable Care Act Qualified Health Plan Enrollment for AIDS Drug Assistance Program Clients: Virginia's Experience and Best Practices.

With the implementation of the Affordable Care Act (ACA) in 2014, many safety net resources, including state AIDS Drug Assistance Programs (ADAPs), incorporated ACA Qualified Health Plans (QHPs) into their healthcare delivery model. This article highlights the benefits of the ACA for persons living with HIV. It also describes the range of strategies employed by state ADAPs to enroll patients in QHPs. The Virginia ADAP ACA implementation experience is described to illustrate one ADAP's shift to purchasing QHPs in addition to providing direct medications. Virginia ADAP is in a Medicaid nonexpansion state and funds the full costs of the QHP premiums, deductibles, and medication copayments. Virginia's experience is applicable to other Medicaid nonexpansion states and to state ADAPs in Medicaid expansion states, who are looking for options for their Medicaid ineligible clients. This article provides practical details of Virginia ADAP's ACA implementation as well as insights and best practices at both the state and clinic level.