Laura R. Wherry

Health and Access to Care during the First 2 Years of the ACA Medicaid Expansions

Background By September 2015, a total of 29 states and Washington, D.C., were participating in Medicaid expansions under the Affordable Care Act. We examined whether Medicaid expansions were associated with changes in insurance coverage, health care use, and health among low‐income adults. Methods We compared changes in outcomes during the 2 years after implementation of the Medicaid expansion (2014 and 2015) relative to the 4 years before expansion (2010 through 2013) in states with and without expansions, using data from the National Health Interview Survey. The sample consisted of 60,766 U.S. citizens who were 19 to 64 years of age and had incomes below 138% of the federal poverty level. Outcomes included insurance coverage, access to and use of medical care in the past 12 months, and health status as reported by the respondents. Results A total of 29 states and Washington, D.C., expanded Medicaid by September 1, 2015. In year 2 after implementation, uninsurance rates were reduced in expansion states relative to nonexpansion states (difference‐in‐differences estimate, ‐8.2 percentage points; P<0.001) and rates of Medicaid coverage were increased (difference‐in‐differences estimate, 15.6 percentage points; P<0.001). Expansions were not associated with significant changes in the likelihood of a doctor visit or overnight hospital stay or health status as reported by the respondent. However, as compared with nonexpansion states, expansion states had a decrease in reports of inability to afford needed follow‐up care (difference‐in‐differences estimate, ‐3.4 percentage points; P=0.002) and in reports of worry about paying medical bills (difference‐in‐differences estimate, ‐7.9 percentage points; P=0.002) and an increase in reports of medical care being delayed because of wait times for appointments (difference‐in‐differences estimate, 2.6 percentage points; P=0.02). Conclusions Medicaid expansion was associated with increased insurance coverage and access to care during the second year of implementation, but it was also associated with longer wait times for appointments, which suggests that challenges in access to care persist.

Saving Teens: Using a Policy Discontinuity to Estimate the Effects of Medicaid Eligibility

We examine the immediate and longer-term mortality effects of public health insurance eligibility during childhood. Our identification exploits expansions in Medicaid eligibility that applied only to children born after September 30, 1983. This feature resulted in a large discontinuity in the cumulative years of eligibility of children at this birth date cutoff. Under the expansions, black children gained twice the years of Medicaid eligibility as white children. We find a later-life decline in the rate of disease-related mortality for black cohorts born after the cutoff. We find no evidence of a similar mortality improvement for white children.

Childhood Medicaid Coverage and Later Life Health Care Utilization

Exploiting a discontinuity in childhood Medicaid eligibility based on date of birth, we find that more years of childhood eligibility are associated with fewer hospitalizations in adulthood. For blacks, we find a 7% to 15% decrease in hospitalizations and a suggestive 2% to 5% decrease in emergency department visits, but no similar effect for nonblacks. The effects are pronounced for utilization related to chronic illnesses and for patients living in low-income postal codes. Calculations suggest that lower rates of hospitalizations during one year in adulthood for blacks offset between 2% and 4% of the initial costs of expanding Medicaid for all children.

Using self-reported health measures to predict high-need cases among Medicaid-eligible adults.

OBJECTIVE To assess the ability of different self-reported health (SRH) measures to prospectively identify individuals with high future health care needs among adults eligible for Medicaid. DATA SOURCES The 1997-2008 rounds of the National Health Interview Survey linked to the 1998-2009 rounds of the Medical Expenditure Panel Survey (n = 6,725). STUDY DESIGN Multivariate logistic regression models are fitted for the following outcomes: having an inpatient visit; membership in the top decile of emergency room utilization; and membership in the top cost decile. We examine the incremental predictive ability of six different SRH domains (health conditions, mental health, access to care, health behaviors, health-related quality of life [HRQOL], and prior utilization) over a baseline model with sociodemographic characteristics. Models are evaluated using the c-statistic, integrated discrimination improvement, sensitivity, specificity, and predictive values. PRINCIPAL FINDINGS Self-reports of prior utilization provide the greatest predictive improvement, followed by information on health conditions and HRQOL. Models including these three domains meet the standard threshold of acceptability (c-statistics range from 0.703 to 0.751). CONCLUSIONS SRH measures provide a promising way to prospectively profile Medicaid-eligible adults by likely health care needs.

Medicaid Family Planning Expansions and Related Preventive Care

I examined the impact of state expansions in eligibility for Medicaid family planning services on the utilization of Papanicolaou (Pap) tests, clinical breast examinations, HIV testing, and routine doctor check-ups among women aged 21 to 44 years using the Behavioral Risk Factor Surveillance System (1993-2009). Using a natural experiment approach, I found significant increases in Pap tests and clinical breast examinations among women eligible for services under the expansions but no significant change in HIV testing or routine doctor check-ups.

The Role of Public Health Insurance in Reducing Child Poverty

Over the past 30 years, there have been major expansions in public health insurance for low-income children in the United States through Medicaid, the Childrens Health Insurance Program (CHIP), and other state-based efforts. In addition, many low-income parents have gained Medicaid coverage since 2014 under the Affordable Care Act. Most of the research to date on health insurance coverage among low-income populations has focused on its effect on health care utilization and health outcomes, with much less attention to the financial protection it offers families. We review a growing body of evidence that public health insurance provides important financial benefits to low-income families. Expansions in public health insurance for low-income children and adults are associated with reduced out of pocket medical spending, increased financial stability, and improved material well-being for families. We also review the potential poverty-reducing effects of public health insurance coverage. When out of pocket medical expenses are taken into account in defining the poverty rate, Medicaid plays a significant role in decreasing poverty for many children and families. In addition, public health insurance programs connect families to other social supports such as food assistance programs that also help reduce poverty. We conclude by reviewing emerging evidence that access to public health insurance in childhood has long-term effects for health and economic outcomes in adulthood. Exposure to Medicaid and CHIP during childhood has been linked to decreased mortality and fewer chronic health conditions, better educational attainment, and less reliance on government support later in life. In sum, the nations public health insurance programs have many important short- and long-term poverty-reducing benefits for low-income families with children.

The Long-Term Effects of Early Life Medicaid Coverage

ABSTRACT:In this study, we evaluate how an expansion of Medicaid coverage for pregnant women and infants affected the adult outcomes ofindividuals who gained access to coverage in utero and during the first year oflife. We find that cohorts whose mothers gained eligibilityfor prenatal coverage under Medicaid have lower rates ofchronic conditions as adults and fewer hospitalizations related to diabetes and obesity. We also find that the expansions increased high school graduation rates. Our results indicate that expanding Medicaid prenatal coverage had long-term benefits for the next generation.

Predicting high-cost pediatric patients: derivation and validation of a population-based model.

Background:Health care administrators often lack feasible methods to prospectively identify new pediatric patients with high health care needs, precluding the ability to proactively target appropriate population health management programs to these children. Objective:To develop and validate a predictive model identifying high-cost pediatric patients using parent-reported health (PRH) measures that can be easily collected in clinical and administrative settings. Design:Retrospective cohort study using 2-year panel data from the 2001 to 2011 rounds of the Medical Expenditure Panel Survey. Subjects:A total of 24,163 children aged 5–17 with family incomes below 400% of the federal poverty line were included in this study. Measures:Predictive performance, including the c-statistic, sensitivity, specificity, and predictive values, of multivariate logistic regression models predicting top-decile health care expenditures over a 1-year period. Results:Seven independent domains of PRH measures were tested for predictive capacity relative to basic sociodemographic information: the Children with Special Health Care Needs (CSHCN) Screener; subjectively rated health status; prior year health care utilization; behavioral problems; asthma diagnosis; access to health care; and parental health status and access to care. The CSHCN screener and prior year utilization domains exhibited the highest incremental predictive gains over the baseline model. A model including sociodemographic characteristics, the CSHCN screener, and prior year utilization had a c-statistic of 0.73 (95% confidence interval, 0.70–0.74), surpassing the commonly used threshold to establish sufficient predictive capacity (c-statistic>0.70). Conclusions:The proposed prediction tool, comprising a simple series of PRH measures, accurately stratifies pediatric populations by their risk of incurring high health care costs.

State Medicaid Expansions for Parents Led to Increased Coverage and Prenatal Care Utilization among Pregnant Mothers

OBJECTIVE To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant. DATA SOURCES/STUDY SETTING Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System. DATA COLLECTION/EXTRACTION METHODS The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents. STUDY DESIGN I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion. PRINCIPAL FINDINGS I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization. CONCLUSIONS Expanded Medicaid coverage for low-income adults has the potential to increase a womans health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy.

The Impact of Insurance Expansions on the Already Insured: The Affordable Care Act and Medicare

Some states have not adopted the Affordable Care Act (ACA) Medicaid expansions due to concerns that the expansions may impair access to care and utilization for those who are already insured. We investigate such negative spillovers using a large panel of Medicare beneficiaries. Across many subgroups and outcomes, we find no evidence that the expansions reduced utilization among Medicare beneficiaries, and can rule out all but very small changes in utilization or spending. These results indicate that the expansions in Medicaid did not impair access to care or utilization for the Medicare population.