Public Health Insurance Programs Research Articles

A welfare analysis of Medicaid and recidivism.

We present conservative estimates for the marginal value of public funds (MVPF) associated with providing Medicaid to inmates exiting prison. The MVPF measures the ratio between a policy's social benefits and its governmental costs. Our MVPF estimates suggest that every additional $1 the government spends on providing inmates exiting prison with Medicaid coverage can result in social benefits ranging between $3.45 and $10.62. A large proportion of the benefits we consider stems from the reduced future criminal involvement among former inmates who receive Medicaid. Employing a difference-in-differences approach, we find that Medicaid expansions reduce the average number of times a released inmate is reimprisoned within 1year by approximately 11.5%. By combining this estimate with key values reported elsewhere (e.g., victimization costs, data on victimization and incarceration), we quantify specific benefits arising from the policy. These encompass diminished criminal harm due to lower reoffense rates, direct benefits to former inmates through Medicaid coverage, increased employment opportunities, and reduced loss of liberty resulting from fewer future reimprisonments. Net-costs consist of the cost of providing Medicaid net of changes in the governmental cost of imprisonment, changes in the tax revenue due to increased employment, and changes in spending on other public assistance programs. We interpret our estimates as conservative since we deliberately err on the side of under-estimating benefits and over-estimating costs when data on specific items are imprecise or incomplete. Our findings align closely with others in the sparse literature investigating the crime-related welfare impacts of Medicaid access, underscoring the substantial indirect benefits public health insurance programs can offer through crime reduction, in addition to their direct health-related advantages.

Are we Missing Some Forces? An Exploratory Study Based on Twitter Analytics of Political Communication

Several governments are leveraging social media for political communication. While the phenomenon of gate-keeping in filtering information through social media has received attention from scholars, the role of diverse meso-entities (comprising pressure groups, experts, and professionals) in influencing digital political communication remains under-studied. We explore the trend in communicating a specific program for electoral gains and identify different types of entities that reshape and disseminate political communication on Twitter, with an illustration of the launch of the public health insurance program in India. We find the significant presence of meso-level entities that played an instrumental role in influencing political communication from macro to microlevel entities through the digital platform. We extend the Jungherr, Schoen, and Jürgens (2016) framework of macro to micro-level political communication in social media by recommending a few propositions to be tested in future studies. Further, this study also contributes to information diffusion theory by explicating the role of various information intermediaries in influencing information flow from macro to micro users on social media platforms.

PP64 Cost-Effectiveness Of Fractional Flow Reserve As Diagnostic Tool In Coronary Artery Disease Versus Angiogram Alone In Indian context

IntroductionFractional Flow Reserve (FFR) is a diagnostic tool that aids decision-making in the treatment of coronary artery disease (CAD). FFR provides an objective measurement and is used as an adjunct to an angiogram. The clinical and cost-benefit of using FFR have been well established across published literature. This research was aimed at evaluating the economic impact of using FFR as an adjunct to angiogram versus an angiogram alone, in the Indian healthcare context.MethodsA study from a tertiary care public hospital in India estimated the impact of using FFR as an adjunct to angiogram in management of CAD. This study was used to create a mathematical simulation model to estimate cost-effectiveness and economic impact of using FFR over seven years’ time horizon, from the Indian health systems perspective. A targeted literature review was performed to collect the clinical inputs for the model, and the national public health insurance program data was referenced to obtain the cost inputs.ResultsA hypothetical cohort of 100,000 patients in the model reported 30 percent reduction in unnecessary stenting. Moreover, 14,025 deaths were averted with the adoption of FFR. In addition, there was a cost-saving of INR46,986 (574USD) per death averted and INR5,169 (63USD) per patient treated over a seven-year time horizon. The analysis demonstrated that FFR inclusion in the current clinical practice saves INR2,651 (32USD) per patient in overall upfront cost and INR2,518 (31USD) per patient in overall follow-up cost over a seven year follow-up period owing to improved diagnosis and prognosis.ConclusionsIn conclusion, FFR prevents unnecessary stenting, reduces overall mortality, and proves to be a cost-saving intervention in the long-term when used as a decision-making criterion in CAD patients in the Indian context.

Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico.

The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population. We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations. The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears. To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.

Dynamics of Macroeconomy, Medicaid, and State Fiscal Conditions: A Role of Medicaid Expansion.

One of the main concerns of state governments about Medicaid expansion is the potential increase in state fiscal burden following the rise in enrollments. In previous literature, limited attention has been paid to the effect of macroeconomic changes, which are closely linked to Medicaid enrollments, in understanding the impact of Medicaid expansion on a state. To narrow the gap, this study establishes a synthetic model to represent the transmission channel from an unemployment shock to the Medicaid program and state expenditures. The panel vector autoregression (VAR) model is adopted for the empirical analysis using annual data from 2010 to 2019 for 50 US states and D.C. The unit root and Granger causality tests are conducted to check the model's appropriateness. The estimated results are analyzed by using impulse response functions. A sudden increase in the unemployment rate will raise the number of Medicaid enrollees and the state Medicaid expenditure, but the impact on the overall state budget is not clear. States that adopt Medicaid expansion will encounter surges in enrollment and increasing Medicaid expenditure during the economic recession, while the non-expansion states will only have moderate enrollment increases. However, an increased budgetary burden per new enrollees will not be significant at its level. Medicaid expansion will allow more people to benefit from the public health insurance program during an economic recession while the impact on states' fiscal burden will be moderate.

Gaps in monitoring global progress toward universal health coverage among disadvantaged populations: the case of people living in prison

Abstract The United Nations’ Sustainable Development Goals (SDGs) represent a sweeping initiative to create a sustainable and equitable global future. SDG 3 focuses on the health and wellbeing of the world. Expanding universal health coverage is a central component of SDG 3 and has been a focus area of the World Health Organization (WHO), which aims to expand universal health coverage to an additional 1 billion people by this year (2023). The WHO developed an index (indicator 3.8.1) intended to monitor coverage of essential health services across the globe. However, this indicator fails to incorporate health coverage for people in prisons. People incarcerated in prisons across the globe have high rates of physical health, mental health, and substance use conditions compared with the general population, and they are frequently excluded from policies and services available in the general population. For example, in some countries, like Australia and the United States, people in prison are legislatively excluded from the public health insurance programs available to the general population. Exclusion of prison health coverage from the WHO's universal health coverage indicator likely results in overestimation of health coverage in most countries and fails to identify gaps in care during and after periods of incarceration. We believe prison health coverage should be incorporated into the WHO's 3.8.1 indicator, which would more accurately capture a country's health coverage among its most disadvantaged populations. Monitoring of prison health coverage will require improved measurement of quality and service availability in prisons, which is sorely lacking in most countries.

Explainable machine learning models for Medicare fraud detection

As a means of building explainable machine learning models for Big Data, we apply a novel ensemble supervised feature selection technique. The technique is applied to publicly available insurance claims data from the United States public health insurance program, Medicare. We approach Medicare insurance fraud detection as a supervised machine learning task of anomaly detection through the classification of highly imbalanced Big Data. Our objectives for feature selection are to increase efficiency in model training, and to develop more explainable machine learning models for fraud detection. Using two Big Data datasets derived from two different sources of insurance claims data, we demonstrate how our feature selection technique reduces the dimensionality of the datasets by approximately 87.5% without compromising performance. Moreover, the reduction in dimensionality results in machine learning models that are easier to explain, and less prone to overfitting. Therefore, our primary contribution of the exposition of our novel feature selection technique leads to a further contribution to the application domain of automated Medicare insurance fraud detection. We utilize our feature selection technique to provide an explanation of our fraud detection models in terms of the definitions of the selected features. The ensemble supervised feature selection technique we present is flexible in that any collection of machine learning algorithms that maintain a list of feature importance values may be used. Therefore, researchers may easily employ variations of the technique we present.

Cost-effectiveness of alginic acid in combination with proton pump inhibitor for the treatment of gastroesophageal reflux disease in systemic sclerosis patients.

Systemic sclerosis (SSc) patients often become refractory to proton pump inhibitors (PPI)-a standard treatment for gastroesophageal reflux disease (GERD)-and intolerant to PPI in combination with domperidone. PPI with alginic acid is an alternative treatment option, but alginic acid is costly. We compared the costs and effectiveness of alginic acid plus PPI versus standard treatments (PPI with/without antacids as needed and lifestyle modifications) for GERD in SSc patients unsuitable for, or intolerant to, domperidone. An economic evaluation using the Markov model was conducted among SSc patients aged between 40 and 65 years with GERD, having a partial or non-response to 4 weeks of standard-dose omeprazole (40 mg/day) and being unsuitable for or intolerant to domperidone. Using a societal perspective, we computed the incremental cost-effectiveness ratios (ICERs) in terms of Thai baht (THB) per quality-adjusted life-year (QALY) between a combination of alginic acid plus PPI and standard treatment for GERD. The lifetime time horizon was used. The ICER for alginic acid plus PPI versus standard treatments was 377 101 THB/QALY. According to the one-way sensitivity analysis, the cost of alginic acid was the most impactful parameter. If the market prices of alginic acid plus PPI were reduced by 61%, this treatment option would become cost-effective at the willingness-to-pay threshold of 160 000 THB/QALY (34.68 THB/USD data on 25 May 2023). Furthermore, if alginic acid were included in the public health insurance program, the national budget would be increased by 66 313 THB per patient, resulting in an overall budget increase of 5 106 101 to 8 885 942 THB compared with the standard treatment. Alginic acid plus PPI does not represent good value for money compared with the standard treatment among such SSc patients in Thailand unless its price is reduced significantly.

Association of Medicaid expansion with dental emergency department visits overall and by states’ Medicaid dental benefits provision

BackgroundEvidence on the association of Medicaid expansion with dental emergency department (ED) utilization is limited, while even less is known on policy-related changes in dental ED visits by Medicaid programs’ dental benefits generosity. The objective of this study was to estimate the association of Medicaid expansion with changes in dental ED visits overall and by states’ benefits generosity.MethodsWe used the Healthcare Cost and Utilization Project’s Fast Stats Database from 2010 to 2015 for non-elderly adults (19 to 64 years of age) across 23 States, 11 of which expanded Medicaid in January 2014 while 12 did not. Difference-in-differences regression models were used to estimate changes in dental-related ED visits overall and further stratified by states’ dental benefit coverage in Medicaid between expansion and non-expansion States.ResultsAfter 2014, dental ED visits declined by 10.9 [95% confidence intervals (CI): -18.5 to -3.4] visits per 100,000 population quarterly in states that expanded Medicaid compared to non-expansion states. However, the overall decline was concentrated in Medicaid expansion states with dental benefits. In particular, among expansion states, dental ED visits per 100,000 population declined by 11.4 visits (95% CI: -17.9 to -4.9) quarterly in states with dental benefits in Medicaid compared to states with emergency-only or no dental benefits. Significant differences between non-expansion states by Medicaid’s dental benefits generosity were not observed [6.3 visits (95% CI: -22.3 to 34.9)].ConclusionsOur findings suggest the need to strengthen public health insurance programs with more generous dental benefits to curtail costly dental ED visits.

Increasingly Privatized Public Health Insurance Programs in the US

This JAMA Forum discusses the increasingly privatized public health insurance programs in the US and the current debates over payment reform and prior authorization.

Health Care Rationing in Public Insurance Programs: Evidence from Medicaid

We study two mechanisms used by public health insurance programs for rationing health care: outsourcing to private managed care plans and quantity limits for prescription drugs. Leveraging a natural experiment in Texas’s Medicaid program, we find that the shift to managed care and the relaxation of a strict drug cap increased access to high-value drugs and outpatient services and reduced avoidable hospitalizations. Program costs increased significantly, indicating a trade-off between cost and quality. We provide suggestive evidence attributing the reduction in hospitalizations to the relaxation of the drug cap and much of the spending increase to the shift to managed care. (JEL G22, H75, I13, I18, I38)

The Politics of Welfare Retrenchment: Evidence from Mass Medicaid Disenrollment in Two States

AbstractIn 2005, Missouri and Tennessee tightened eligibility for their public health insurance programs, resulting in widespread coverage losses. Leveraging county-level variation in subsequent disenrollment, I show that voters in Tennessee punished the incumbent governor for the Medicaid cuts. In Missouri, by contrast, disenrollment had no impact on the subsequent gubernatorial election but did increase support for Democrats in 2006 state legislative elections, possibly due to the strategic entry and exit of candidates. In both states, the loss of Medicaid coverage was associated with lower support for Democratic presidential candidates, although these declines appear part of a longer-term trend that preceded the coverage loss. The results speak to the potential political costs of welfare spending cuts and the electoral consequences of reducing income-targeted social programs.

Commentary] Building a digital republic to reduce health disparities and improve population health in the United States

Income, schooling, and healthcare are key ingredients for health, but most government programs that are designed to provide these social benefits are difficult to access. While many Americans struggle to pay taxes, few understand how difficult it can be for needy Americans to enroll in public social benefits such as Temporary Assistance for Needy Families (one of many income support programs), Pell grants (one of many tuition assistance programs), or Medicaid (one of many public health insurance programs). Perhaps because such programs are difficult to enroll in, only a fraction of needy families receive the social benefits to which they are entitled. That percentage is smaller for those most in need (e.g., those with disabilities or caregiving responsibilities). In this editorial, we discuss a novel method for improving health while also improving privacy, reducing fraud, and improving data system compatibility. Specifically, we propose a digital identity card that allows for the creation of a “digital republic” in which enrollment in social benefits can be automated, and the benefits can be targeted to those most in need. While there are large potential population health and health disparities benefits that could arise from a digital republic, more empirical work is needed to understand the extent to which nations have benefited from digital identity programs in the past and the political economy associated with implementing such programs.

Commentary] Building a digital republic to reduce health disparities and improve population health in the United States

Income, schooling, and healthcare are key ingredients for health, but most government programs that are designed to provide these social benefits are difficult to access. While many Americans struggle to pay taxes, few understand how difficult it can be for needy Americans to enroll in public social benefits such as Temporary Assistance for Needy Families (one of many income support programs), Pell grants (one of many tuition assistance programs), or Medicaid (one of many public health insurance programs). Perhaps because such programs are difficult to enroll in, only a fraction of needy families receive the social benefits to which they are entitled. That percentage is smaller for those most in need (e.g., those with disabilities or caregiving responsibilities). In this paper, we discuss a novel method for improving health while also improving privacy, reducing fraud, and setting standards for data use. Specifically, we propose a digital identity card that allows for the creation of a “digital republic” in which enrollment in social benefits can be automated, and the benefits can be targeted to those most in need.

Just a question of time? Explaining non-take-up of a public health insurance program designed for undocumented immigrants living in France.

State Medical Aid is a public health insurance program that allows undocumented immigrants with low financial resources to access health care services for free. However, the low take-up rate of this program might threaten its efficiency. The purpose of this study is therefore to provide the determinants of such a low take-up rate. To this end, we rely on the Premier Pas survey. This is an original representative sample of undocumented immigrants attending places of assistance to vulnerable populations in France. Determinants of State Medical Aid take-up are analyzed through probit and Cox modeling. The results show that only 51% of those who are eligible for the State Medical Aid program are actually covered, and this proportion is higher among women than among men. The length of stay in France is the most important determinant of take-up. It is worth noting that State Medical Aid take-up is not associated with chronic diseases or functional limitations and is negatively associated with poor mental health. There is, therefore, mixed evidence of health selection into the program. Informational barriers and vulnerabilities experienced by undocumented immigrants are likely to explain this low take-up.

Predicting Divertible Medicaid Emergency Department Costs

Lowering health care costs is a policy priority for public health insurance programs. Policies that divert Emergency Department (ED) care to less costly, more effective health services are a promising avenue for cost savings. Using comprehensive, anonymized administrative data from the State of Rhode Island, which includes Medicaid and other social insurance programs, we demonstrate how government can identify and conduct efficient outreach to Medicaid recipients at risk of becoming high-cost ED users for potentially divertible care. The top predictors from our models include age, Medicaid enrollment and eligibility factors, and prior medical procedures. Our predictive models capture more future divertible spending than existing methods for identifying ED “super-utilizers” based on multiple prior ED visits. By using comprehensive administrative data that includes all the state's social insurance programs, we can also establish connections between predicted high-cost ED users and existing case management in non-Medicaid programs. Policymakers could use these models to improve their identification of divertible spending and reduce the need for de novo outreach and case management programs.

Reforming Medicaid Coverage Toward Reproductive Justice.

As the United States' largest public health insurance program, Medicaid has since 1965 played a crucial role in the struggle for equitable health care access. It has the potential to be a powerful instrument of reproductive justice, yet discriminatory policies that deny coverage for vital sexual, reproductive, or other health services, or exclude entire populations of people with low incomes from coverage altogether, constrain peoples' health and reproductive futures. Resulting discrimination in Medicaid law and policy thwart the program's ability to promote intergenerational health equity and reproductive justice for underserved communities.This Article provides an account of why reproductive justice is a necessary framework for examining, reimagining, and reforming Medicaid coverage law and policy. Part I gives a brief history and overview of reproductive justice, which serves as "an open source code that people have used to pursue fresh critical thinking regarding power and powerlessness." Part II argues that we should utilize that open source code in Medicaid coverage reform. Using some of the reproductive justice movement's critiques as a starting point, it explores how reproductive oppression has shaped Medicaid coverage law, policy, and mainstream reproductive and health care reform movements' proposals, and to what effect. It argues that examining Medicaid law, policy, and proposed reforms through this lens and in collaboration with the reproductive justice movement can enable health advocates and policymakers to more fully understand, disrupt, and dismantle reproductive injustices that drive health inequities. Ultimately, it can empower reformers to build a more equitable public health insurance safety net that brings us closer to reproductive justice for all.

Delayed head and neck cancer detection and treatment by patient-insurance and community-level socioeconomic status.

e18600 Background: Health insurance helps Head and Neck Cancer (HNC) patients overcome delays for accessing treatment. To overcome gaps in access, policymakers have expanded insurance coverage. If, however, access to timely treatment still varies by insurance status, disparities may persist. Methods: I analyzed data from the Surveillance Epidemiology and End Results program’s “Specialized HNC-HPV” datafile (2010-2016), which categorizes each HNC case into a socioeconomic status (SES) quintile based on the patient’s census-tract of residence. Patients were grouped by having private insurance, Medicare, Medicaid, or being uninsured. Two binary outcome variables were analyzed for differences by insurance status across SES quintiles: a distant stage diagnosis and initiating treatment at least two months after diagnosis. To account for the dynamic nature of HNC, the sample was stratified by Human Papilloma Virus (HPV)-association. Using a linear probability regression model, I tested for differences between insurance categories within each SES quintile. Results: Across all SES quintiles, HPV-negative cancer patients insured by Medicaid had higher rates of distant stage diagnoses and delayed treatment than privately insured patients. Uninsured patients also had higher rates of delayed detection and treatment initiation than privately insured patients. There were no significant differences in the rate of distant-stage diagnoses between privately insured and Medicare patients. However, for all SES quintiles, patients insured by Medicare had higher rates of delayed treatment than privately insured patients. Results were consistent for HPV-positive HNCs, but differences were not significant across all SES quintiles. Conclusions: Even after conditioning on community-level SES, a HNC patient’s insurance type may be associated with delayed detection and treatment. While expanding insurance remains a priority, policymakers must also improve the quality of public health insurance programs to ensure equitable access to timely HNC care.[Table: see text]

Public health insurance and enrollees’ diet structure in rural China

This study examines the consumption-stimulation function of public health insurance (PHI) programs from the perspective of food consumption. We estimate the impact of enrollment in rural China's PHI program, the New Cooperative Medical Scheme (NCMS), on the insured's diet diversity and diet balance using panel data from the China Health and Nutrition Survey. Exploiting temporal and spatial variations in the program's local implementation, our difference-in-differences estimation (combined with propensity score matching in some analyses) reveals significant increases in the insured's diet diversity, overall diet balance, and nutrition intakes. However, the program's consumption-stimulation function is not entirely beneficial. While NCMS enrollment reduced the incidence of under-consumption of animal products and fruits, it raised that of over-consumption of grains, imposing potential health risks on the insured.

EFEKTIVITAS PENERAPAN PAY-FOR-PERFORMANCE PADA ASURANSI KESEHATAN DI NEGARA-NEGARA ASIA: LITERATURE REVIEW

Public health insurance programs have become a global concern, especially in program planning such as resource use, knowing the effectiveness of pay-for-performance implementation in health insurance in Asian countries. Method Research design is a library study. Search for articles using the Pubmed, Ebsco, ScienceDirect, and Proquest databases. The research questions are structured using the PICO method, a database-based keyword search in MESH terms. Inclusion criteria are focused on the application of Pay-for-performance, on health insurance, applied in Asian countries, issued the last 10 years, in English. Found 748 articles, and only 9 articles were included according to research questions. Result: There are 9 articles included in this study. The results of a critical review of published articles, the application of pay-for-performance on health insurance in Asian countries improve the achievement of indicators, incentives and payment fines, and improve the quality of health services. Conclusion The application of Pay-For-Performance to health insurance in Asian countries is based on various indicators, payment systems, and improved quality of health services. Therefore, the application of Pay-For-Performance can be recommended for healthcare facilities in Asian countries.