Medicaid Participation Research Articles

Are North Carolina clinicians delivering opioid use disorder treatment to Medicaid beneficiaries?

Medicaid is a public health insurance program in the United States that serves low-income individuals. Medicaid beneficiaries have elevated risk of opioid use disorder (OUD), yet face barriers to receiving medications for OUD (MOUD). To inform efforts to increase MOUD receipt among Medicaid beneficiaries, this study: (1) estimated Medicaid participation prevalence among clinicians authorized to prescribe buprenorphine and (2) estimated the association between clinician characteristics and OUD care delivery to Medicaid beneficiaries. Retrospective study of North Carolina, USA licensed physicians, physician assistants and nurse practitioners. Licensure data from 2018 were merged with 2019 US Drug Enforcement Administration (DEA) data to identify clinicians who received the DEA waiver required to prescribe buprenorphine (n = 1714). Medicaid claims data were used to characterize clinician engagement in OUD care delivery. Outcomes were indicators of any Medicaid professional claims and any Medicaid prescription claims for buprenorphine and/or naltrexone. Predictors included clinician characteristics (e.g. gender and race) and characteristics of clinicians' practice location (e.g. area opioid overdose death rate). Most waivered clinicians delivered services to Medicaid beneficiaries, ranging from 67.0% of behavioral health clinicians to 82.9% of specialist physicians. Among waivered clinicians with Medicaid professional claims, prevalence of prescribing buprenorphine to Medicaid beneficiaries ranged from 30.3% among specialist physicians to 51.6% among behavioral health clinicians. The probability of prescribing MOUD to Medicaid beneficiaries was higher among waivered clinicians identifying as male compared with female (8.5 percentage points, P = 0.004) or black compared with white (9.9 percentage points, P = 0.007), older clinicians (0.5 percentage point increase per year, P < 0.001) and clinicians in counties with a higher opioid overdose death rate (5.0 percentage point increase per additional death per 10 000 residents, P = 0.010). Among clinicians in North Carolina, USA who are authorized to prescribe buprenorphine, 67-83% (depending on type of specialist) deliver services to Medicaid beneficiaries, but only 30-52% of those prescribe medications for opioid use disorder (OUD) to Medicaid beneficiaries. Engagement in OUD care delivery to Medicaid beneficiaries varies by clinician demographic and area characteristics.

Promoting Child Health Equity Through Medicaid Innovation.

Black, Latino/a/e, American Indian, and Alaska Native children often receive lower quality health care than White children. As the predominant health insurer for medically underserved populations, Medicaid plays a critical role in advancing socioeconomic and racial health equity. In this article, we focus on structural barriers to health equity in the Medicaid program and potential steps for improving long-standing socioeconomic and racial health inequities through programmatic innovation. We identify opportunities for expanding care models for holistically addressing the social determinants of health, aligning clinical care delivery around health equity principles, diversifying the clinical workforce, and promoting meaningful and consistent provider participation in Medicaid. Practitioners and policy makers can start to undertake many of these steps today to set the stage for more sweeping reforms that can help achieve national health equity goals for children. [Pediatr Ann. 2022;51(3):e118-e122.].

Impacts of early ACA Medicaid expansions on physician participation.

To quantify impacts of early Affordable Care Act (ACA) Medicaid expansions on Medicaid participation for primary care physicians. The study uses secondary Medicaid Analytic eXtract (MAX) data from the United States for 2009-2012, as well as secondary National Plan and Provider Enumeration System (NPPES) data from the United States for 2015. The study uses a quasi-experimental difference-in-differences study design where the policy change is Medicaid expansion in six states that adopted early ACA Medicaid expansions during 2010 and 2011: California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington. The key outcome variables are five monthly measures of physician participation: the number of Medicaid visits, the number of Medicaid patients, seeing at least 1 Medicaid patient, seeing at least 25 Medicaid patients, and seeing at least 50 Medicaid patients. The sample consists of all physicians who were active between 2005 and 2015, according to the NPPES. For primary care physicians, Medicaid expansion led to a 29% increase in Medicaid visits (5.88 per month; 95% CI: 2.49-9.27), a 29% increase in Medicaid patients (4.59 per month; 95% CI: 2.16-7.02), and did not affect the probability of any Medicaid participation. Medicaid expansion also led to a 22% increase in the probability of seeing at least 25 Medicaid patients per month (4.58 percentage points; 95% CI: 1.27-7.89) and a 31% increase in the probability of seeing at least 50 Medicaid patients per month (2.99 percentage points; 95% CI: 0.99-4.99). Early ACA Medicaid expansions led to increased Medicaid visits for primary care physicians but did not affect the probability of any Medicaid participation. Primary care physicians who had previously served Medicaid patients responded to early ACA Medicaid expansions by serving substantially more Medicaid patients.

Limits of Prenatal Care Coordination for Improving Birth Outcomes Among Medicaid Participants

Limits of Prenatal Care Coordination for Improving Birth Outcomes Among Medicaid Participants

The Bridge Between Racial Justice and Clinical Practice.

The Bridge Between Racial Justice and Clinical Practice.

Medicaid, Earnings, and Heterogeneous Treatment Effects: Evidence from the Oregon Health Insurance Experiment

Abstract The Medicaid and labor supply empirical literature offers competing conclusions of zero effects and significant reductions in earnings. However, zero effects are only theoretically consistent with the earnings distribution’s extremes. Medicaid participants with positive pre-treatment labor supply should unequivocally decrease earnings. This paper clarifies the literature’s ambiguity by combining quantile regression with data from the Oregon Health Insurance Experiment. The distributional impacts imply that zero effects are not universally representative of Medicaid households. The annual earnings impact of Medicaid participation ranges between increases of $1400 to deceases of $3120 for single adults. Pre-existing mental illness or health constraints on work account for counterintuitive positive earnings impacts. By demonstrating that sample compositional differences determine whether Medicaid’s labor supply impact is zero or negative, this paper offers a reconciliation to the range of existing estimates in the empirical literature.

The effect of Medicaid expansion on Medicaid participation, payer mix, and labor supply in primary care

Evidence of increased health care utilization associated with the Medicaid expansion suggests that clinicians increased capacity to meet demand. However, little is known about the mechanism underlying this response. Using a novel source of all-payer data, we quantified clinicians’ response to the Medicaid expansion – examining whether and how they changed their Medicaid participation decisions, payer mix, and overall labor supply. Primary care clinicians in expansion states provided an average of 49 additional appointments per year (a 21% relative increase) for patients insured by Medicaid, compared to clinicians in non-expansion states - with new-patient visits representing half (25 appointments) of this overall increase. Clinicians did not increase their labor supply to accommodate these additional appointments. They instead offset the 1.7 percentage point average increase in Medicaid payer mix with an equivalent reduction in commercial payer mix. However, this reduction in commercial patient share represented only a 2.8% relative decrease, with commercially insured patients still comprising the majority of the average clinician's patient panel. Subsample analyses revealed a larger increase in care for Medicaid patients among clinicians with high Medicaid participation preceding the eligibility expansion.

Insurance and Employment Status Are Correlated With the Presence of Waddell Signs.

The aim of the study was to determine whether employment or insurance status is associated with the presence and number of Waddell signs. In this cross-sectional study, adult low back pain patients were seen at a tertiary academic center for thoracic or lumbar back pain, due to a degenerative condition. Frequency data were compared with contingency table analysis, including χ2 and logistic regression. Of 462 patients, 26% had any Waddell signs and 10% had clinically significant Waddell signs. Nonemployed patients had a higher prevalence of Waddell signs than employed and retired patients (P = 0.0004 and P = 0.001, respectively). Subgroups of Medicaid participants as well as patients with secondary gain issues, including worker's compensation and motor vehicle accident, had a higher prevalence of 1+ Waddell signs than patients of other insurances (P < 0.0001 and P = 0.01, respectively). Medicaid participants had a higher prevalence of 3+ Waddell signs than other insurances (P = 0.002). The presence of Waddell signs is associated with employment and insurance status. This suggests that social factors may affect patients' perceptions of their thoracic or low back pain. Clinicians aware of these factors can provide individualized care to their patients prone to poor outcomes.

Who is providing contraception care in the United States? An observational study of the contraception workforce

Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States. This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation. We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau's American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons. Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15-44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty. This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.

Applying "Stages of Readiness to Change" Model to Dentists' Decisions to Participate in Medicaid: An Exploratory Study.

BackgroundThe Stages of Readiness to Change (SOC) behavioral model describes behavior change as a process and distinguishes individuals based on their current behavior and readiness to change that behavior. SOC can be used to improve dentists’ participation in a state public dental benefit program (Medicaid) by targeting them at different SOC with interventions, strategies, and tools tailored to those stages. Therefore, this study assessed the usefulness of using SOC to describe dentists’ attitudes towards and participation in Medicaid. Dentists’ participation in Medicaid is of interest to policymakers, and this study demonstrates a method to identify potential opportunities for intervention.MethodsA modified SOC algorithm used data from a periodic survey of Iowa Dentists to categorize dentists (N=514) into: 1) pre-contemplation, 2) considering participation (SOC contemplation and preparation), 3) acting (SOC action and maintenance), and 4) risk of relapse (at risk for discontinuing participation). The four SOC stages were compared using ANOVA and post hoc Tukey’s test among: practice characteristics, Dentists Altruism scale, Attitude about Program Administration scale, Attitude about Medicaid patients scale and Perception of Importance of Medicaid Problems scale.ResultsAmong survey respondents, 36% were categorized as pre-contemplation, 6% were considering Medicaid participation, 12% were acting as Medicaid providers with minimal risk of relapse, and 46% were participating and at risk of discontinuing. Dentists’ attitudes towards program administration, Medicaid patients, and access to care varied across the SOC cycle.ConclusionNearly, 46% dentists in this analysis were identified as at risk of discontinuing participation – a much larger proportion than dentists considering Medicaid participation. Categorizing dentists using this approach has important implications for programmatic interventions. For example, policymakers targeting our study population could focus their efforts on reducing the likelihood of dentists dropping out of the program, with less emphasis targeting dentists in the precontemplation stage.

Medicaid participation among practitioners authorized to prescribe buprenorphine

IntroductionThis study examines Medicaid participation among buprenorphine waivered providers in Virginia in 2019, with a particular focus on the prescribing differences between different physician specialties, nurse practitioners and physicians assistants (NP and PA). MethodsSecondary data sources include the 2019 DEA list of buprenorphine waivered prescribers, Virginia Medicaid claims for buprenorphine, physician characteristics from the Virginia Department of Health Professions, SAMHSA Behavioral Treatment Services Locator, and area level characteristics. This cross-sectional study is based on a linkage of Medicaid claims data to a list of Virginia practitioners authorized to prescribe buprenorphine in 2019. Using a two-part logistic regression, we assess prescriber license type and local area factors that are associated with: (1) the probability of prescribing buprenorphine to any Medicaid patients in 2019; (2) the number of Medicaid patients treated by each prescriber in 2019. ResultsAdjusted odds ratios show that nurse practitioners with buprenorphine waivers are more likely to treat any Medicaid patients compared to physicians (odds ratio (OR), 2.016; p = 0.000). Among prescribers who treated any Medicaid patients, the probability of treating a large number of Medicaid patients was higher among nurse practitioners relative to physicians (OR, 2.869, p = 0.002). Medicaid participation was much higher among prescribers with patient limits of 100 and 275 compared to prescribers with patient limits of 30 (OR, 6.66, p = 0.000 and 29.40, p = 0.000, respectively). ConclusionsState Medicaid programs have been at the forefront of addressing their state's opioid epidemic, including expanding access to buprenorphine treatment. This study provides evidence that targeted outreach efforts should include NP license types as well as physicians, and is consistent with prior studies showing that NP are especially important in filling treatment gaps for underserved areas and populations.

Medicaid Expansions and Participation in Supplemental Security Income by Noncitizens.

Objectives. To estimate the effect of Medicaid expansion on noncitizens' and citizens' participation in the Supplemental Security Income (SSI) program. The Affordable Care Act (ACA) expanded Medicaid eligibility to cover low-income nonelderly adults without children, thus delinking their Medicaid participation from participation in the SSI program.Methods. Using data from the Social Security Administration for 2009 through 2018 (n = 1020 state-year observations) and the Current Population Survey for 2009 through 2019 (n = 78 776 respondents), we employed a difference-in-differences approach comparing SSI participation rates in US states that adopted Medicaid expansion with participation rates in nonexpansion states before and after ACA implementation.Results. Medicaid expansion reduced the SSI (disability) participation of nonelderly noncitizens by 12% and of nonelderly citizens by 2%. Estimates remained robust with administrative and survey data.Conclusions. Medicaid expansion caused a substantially larger decline in the SSI participation of noncitizens, who face more restrictive SSI eligibility criteria, than of citizens. Our estimates suggest an annual savings of $619 million in the federal SSI cost because of the decline in SSI participation among noncitizens and citizens.

Eligibility for and Enrollment in Medicaid Among Nonelderly Adults After Implementation of the Affordable Care Act.

The Affordable Care Act's (ACA) Medicaid expansion resulted in substantial gains in coverage. However, little research has documented eligibility or participation rates among eligible adults in the post-ACA period in part because of the complexities involved in assigning eligibility status. We used simulation modeling to examine Medicaid eligibility and participation during 2014 to 2017. More than one in five adults were Medicaid eligible in expansion states in the post-ACA period. In contrast, about one in 30 adults were Medicaid eligible in nonexpansion states. While eligibility rates differed substantially by expansion status, participation rates among Medicaid-eligible adults were similar in both sets of states (44% to 46%). These estimates indicate that differences in eligibility rather than in participation rates explained differences in enrollment between expansion and nonexpansion states during the study period. Participation in Medicaid is expected to grow during the coronavirus pandemic. Our study provides baseline estimates for future analyses of enrollment trends.

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.

Parental Factors Associated With the Decision to Participate in a Neonatal Clinical Trial

It remains poorly understood how parents decide whether to enroll a child in a neonatal clinical trial. This is particularly true for parents from racial or ethnic minority populations. Understanding factors associated with enrollment decisions may improve recruitment processes for families, increase enrollment rates, and decrease disparities in research participation. To assess differences in parental factors between parents who enrolled their infant and those who declined enrollment for a neonatal randomized clinical trial. This survey study conducted from July 2017 to October 2019 in 12 US level 3 and 4 neonatal intensive care units included parents of infants who enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial or who were eligible but declined enrollment. Data were analyzed October 2019 through July 2020. Parental choice of enrollment in neonatal clinical trial. Percentages and odds ratios (ORs) of parent participation as categorized by demographic characteristics, self-assessment of child's medical condition, study comprehension, and trust in medical researchers. Survey questions were based on the hypothesis that parents who enrolled their infant in HEAL differ from those who declined enrollment across 4 categories: (1) infant characteristics and parental demographic characteristics, (2) perception of infant's illness, (3) study comprehension, and (4) trust in clinicians and researchers. Of a total 387 eligible parents, 269 (69.5%) completed the survey and were included in analysis. This included 183 of 242 (75.6%) of HEAL-enrolled and 86 of 145 (59.3%) of HEAL-declined parents. Parents who enrolled their infant had lower rates of Medicaid participation (74 [41.1%] vs 47 [55.3%]; P = .04) and higher rates of annual income greater than $55 000 (94 [52.8%] vs 30 [37.5%]; P = .03) compared with those who declined. Black parents had lower enrollment rates compared with White parents (OR, 0.35; 95% CI, 0.17-0.73). Parents who reported their infant's medical condition as more serious had higher enrollment rates (OR, 5.7; 95% CI, 2.0-16.3). Parents who enrolled their infant reported higher trust in medical researchers compared with parents who declined (mean [SD] difference, 5.3 [0.3-10.3]). There was no association between study comprehension and enrollment. In this study, the following factors were associated with neonatal clinical trial enrollment: demographic characteristics (ie, race/ethnicity, Medicaid status, and reported income), perception of illness, and trust in medical researchers. Future work to confirm these findings and explore the reasons behind them may lead to strategies for better engaging underrepresented groups in neonatal clinical research to reduce enrollment disparities.

Screening and Treatment of Sexually Transmitted Infections Among Medicaid Populations-A 2-State Analysis.

Chlamydia, gonorrhea, and syphilis are common, treatable sexually transmitted infections (STIs) that are highly prevalent in the general US population. Costs associated with diagnosing and treating these conditions for individual states' Medicaid participants are unknown. The purpose of this study was to estimate the cost of screening and treatment for 3 common STIs for state Medicaid program budgets in Maryland and South Carolina. A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period. Claims were included based on the presence of one of the 3 study conditions in either diagnosis or procedure codes. Descriptive analyses were used to characterize the participant population and expenditures for services provided. Total Medicaid expenditures for STI care in state fiscal years 2016 and 2017 averaged $43.5 million and $22.3 million for each year in Maryland and South Carolina, respectively. Maryland had a greater proportion of costs associated with outpatient hospital and laboratory settings. Costs for care provided in the emergency department were highest in South Carolina. Diagnosis and treatment of commonly reported STIs may have a considerable financial impact on individual state Medicaid programs. Public health activities directed at STI prevention are important tools for reducing these costs to states.

Avoiding Medicaid: Characteristics Of Primary Care Practices With No Medicaid Revenue.

Primary care access for Medicaid patients is an ongoing area of concern. Most studies of providers' participation in Medicaid have focused on factors associated with the Medicaid program, such as reimbursement rates. Few studies have examined the characteristics of primary care practices associated with Medicaid participation. We used a nationally representative survey of primary care practices to compare practices with no, low, and high Medicaid revenue. Seventeen percent of practices received no Medicaid revenue; 38percent and 45percent were categorized as receiving low and high Medicaid revenue, respectively. Practices with no Medicaid revenue were more often small, independent, and located in urban areas with higher household income. These practices also have lower population health capabilities.

Association between physician practice Medicaid acceptance and employing nurse practitioners and physician assistants: A longitudinal analysis.

Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment. The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time. Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions. Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid. NP and PA employment was positively associated with increases in Medicaid participation. As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.

Improving Equitable Access to Cervical Cancer Screening and Management.

Each year, 13,000 women in the United States are diagnosed with cervical cancer and 4,000 die from it. Moreover, 8 million women 21 to 65 years of age haven't had a Pap test in five years. Hispanic women have the highest incidence of cervical cancer and are less likely to be screened or return for care. Migrant women can face additional barriers to cervical cancer screening, including federal prohibitions against their participation in public health insurance exchanges and nonemergency Medicaid. Improving cervical cancer screening rates was identified as a priority in a federally qualified health center when only 40% of eligible women were properly screened in 2016. Forty-five percent of the population the clinic serves is uninsured and 60% are Hispanic. The aim of this quality improvement project was to have 75% of the women 21 to 65 years of age who sought care at this clinic during the 60-day project period receive Pap test eligibility screening, enrollment in a state and federal screening program, and case management. Four rapid plan-do-study-act cycles were used. Tests of change included team engagement, patient engagement, eligibility screening, and case log management. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. The interventions consisted of team meetings, a patient engagement tool, an eligibility screening tool, and case log management. Among the women who completed care at the clinic during the 60-day project period, 80% were uninsured and 86% were Hispanic. A total of 87% of women received effective care, which consisted of same-day Well Woman Health Care Program enrollment and a same-day Pap test or an appointment to return for a well-woman visit. A multicomponent approach led to underserved women receiving equitable access to cervical cancer screening and timely enrollment in a cervical cancer screening program.

Welcome Mats and On-Ramps for Older Adults: The Impact of the Affordable Care Act's Medicaid Expansions on Dual Enrollment in Medicare and Medicaid.

For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called "welcome mat" effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an "on-ramp" effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.