Lindsay M. Sabik

Copayments and Emergency Department Use Among Adult Medicaid Enrollees.

A number of state Medicaid programs have recently proposed or implemented new or increased copayments for nonemergent emergency department (ED) visits. Evidence suggests that copayments generally reduce the level of healthcare utilization, although there is little specific evidence regarding the effectiveness of copayments in reducing nonurgent ED use among Medicaid enrollees or other low-income populations. Encouraging efficient and appropriate use of healthcare services will be of particular importance for Medicaid programs as they expand under the Patient Protection and Affordable Care Act. This analysis uses national data from 2001 to 2009 to examine the effect of copayments on nonurgent ED utilization among nonelderly adult enrollees. We find that visits among Medicaid enrollees in state-years where a copayment is in place are significantly less likely to be for nonurgent reasons. Our findings suggest that copayments may be an effective tool for reducing use of the ED for nonurgent care.

Changes in Insurance Coverage Among Cancer Patients Under the Affordable Care Act

This analysis uses SEER Medicaid data to quantify changes in health insurance coverage under the Affordable Care Act among nonelderly patients newly diagnosed with cancer.

Medicaid expansion and access to care among cancer survivors: a baseline overview.

PurposeMedicaid expansion under the Affordable Care Act facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Medicaid expansions may provide increased access to care for cancer survivors, a growing population with chronic conditions. We compare access to health care services among cancer survivors living in non-expansion states to those living in expansion states, prior to Medicaid expansion under the Affordable Care Act.MethodsWe use the 2012 and 2013 Behavioral Risk Factor Surveillance System to estimate multiple logistic regression models to compare inability to see a doctor because of cost, having a personal doctor, and receiving an annual checkup in the past year between cancer survivors who lived in non-expansion states and survivors who lived in expansion states.ResultsCancer survivors in non-expansion states had statistically significantly lower odds of having a personal doctor (adjusted odds ratio [AOR] 0.76, 95xa0% confidence interval [CI] 0.63–0.92, pu2009<u20090.05) and higher odds of being unable to see a doctor because of cost (AOR 1.14, 95xa0% CI 0.98–1.31, pu2009<u20090.10). Statistically significant differences were not found for annual checkups.ConclusionsPrior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors with limited access to routine care.Implications for Cancer SurvivorsExisting disparities in access to care are likely to widen between cancer survivors in Medicaid non-expansion and expansion states.

Impact of Medicaid disenrollment in Tennessee on breast cancer stage at diagnosis and treatment

States routinely may consider rollbacks of Medicaid expansions to address statewide economic conditions. To the authors knowledge, little is known regarding the effects of public insurance contractions on health outcomes. The current study examined the effects of the 2005 Medicaid disenrollment in Tennessee on breast cancer stage at the time of diagnosis and delays in treatment among nonelderly women.

Medicaid Expansions and Cervical Cancer Screening for Low‐Income Women

OBJECTIVEnMedicaid coverage for low-income women may play an important role in ensuring access to preventive care. This study examines how Medicaid eligibility expansions to nonelderly adults impact cervical cancer screening among low-income women.nnnDATA SOURCESnWe use data from the Behavioral Risk Factor Surveillance System from 2000 to 2010. The primary outcome of interest is whether women in the relevant guideline consistent age range reported having a Pap test in the previous year.nnnSTUDY DESIGNnWe use a difference-in-differences approach with matched treatment and comparison states and a simulated eligibility approach based on a continuous measure of Medicaid generosity.nnnPRINCIPAL FINDINGSnOur results indicate that cervical cancer screening increased among low-income women in expansion states relative to comparison states. Increases in screening rates are largest among low-income Hispanic women.nnnCONCLUSIONSnMedicaid expansions during the period from 2000 to 2010 were associated with improved cervical cancer screening rates, which is critical for early cervical cancer detection and prevention of cancer morbidity and mortality in women. The results suggest that more widespread Medicaid expansions may have positive effects on preventive health care for women.

The Impact of Integrated Case Management on Health Services Use and Spending Among Nonelderly Adult Medicaid Enrollees.

Background:Medicaid plans, whose patients often have complex medical, social, and behavioral needs, seek tools to effectively manage enrollees and improve access to quality care while containing costs. Objectives:The aim of this study is to examine the effects of an integrated case management (ICM) program operated by a Medicaid managed care plan on health service use and spending for nonelderly, nonpregnant adults. Research Design:We estimate the relationship between intensity of ICM program involvement and changes in utilization and spending for patients who participated in ICM. We examine whether effects differ between high-risk and lower-risk individuals and between the early and late stages of the program, given that the latter relied on more targeted and patient-centered approaches. Specifically, we estimate linear regressions modeling changes in utilization and spending outcomes as a function of number of program contacts, conditional on number of days over which contacts occurred, as well as individual-level covariates and case manager fixed effects. Results:In the late ICM program period, we observe significant decreases in outpatient utilization associated with program involvement intensity among high-risk ICM participants. We also observe decreases in spending associated with program involvement intensity among the lower-risk group in the late period, although there is no significant impact on spending among high-risk enrollees. Conclusions:ICM can be a successful strategy for impacting health services use and spending. Our findings suggest that careful program targeting, well-structured client engagement, and direct one-on-one contact are vitally important for achieving program objectives.

Effect of Medicaid Expansions of 2014 on Overall and Early-Stage Cancer Diagnoses

Objectives To determine whether the 2014 Medicaid expansions facilitated by the Affordable Care Act affected overall and early-stage cancer diagnosis for nonelderly adults. Methods We used Surveillance, Epidemiology, and End Results Cancer Registry data from 2010 through 2014 to estimate a difference-in-differences model of cancer diagnosis rates, both overall and by stage, comparing changes in county-level diagnosis rates in US states that expanded Medicaid in 2014 with those that did not expand Medicaid. Results Among the 611 counties in this study, Medicaid expansion was associated with an increase in overall cancer diagnoses of 13.8 per 100u2009000 population (95% confidence interval [CI]u2009=u20090.7, 26.9), or 3.4%. Medicaid expansion was also associated with an increase in early-stage diagnoses of 15.4 per 100u2009000 population (95% CIu2009=u20095.4, 25.3), or 6.4%. There was no detectable impact on late-stage diagnoses. Conclusions In their first year, the 2014 Medicaid expansions were associated with an increase in cancer diagnosis, particularly at the early stage, in the working-age population. Public Health Implications Expanding public health insurance may be an avenue for improving cancer detection, which is associated with improved patient outcomes, including reduced mortality.

Cost Sharing in Medicaid: Assumptions, Evidence, and Future Directions.

Several states have received waivers to expand Medicaid to poor adults under the Affordable Care Act using more cost sharing than the program traditionally allows. We synthesize literature on the effects of cost sharing, focusing on studies of low-income U.S. populations from 1995 to 2014. Literature suggests that cost sharing has a deterrent effect on initiation of treatments, and can reduce utilization of ongoing treatments. Furthermore, cost sharing may be difficult for low-income populations to understand, patients often lack sufficient information to choose medical treatment, and cost sharing may be difficult to balance within the budgets of poor adults. Gaps in the literature include evidence of long-term effects of cost sharing on health and financial well-being, evidence related to effectiveness of cost sharing combined with patient education, and evidence related to targeted programs that use financial incentives for wellness. Literature underscores the need for evaluation of the effects of cost sharing on health status and spending, particularly among the poorest adults.

Trends in Hospital Inpatient Admissions Following Early Medicaid Expansion in California.

The Affordable Care Act is expected to profoundly affect inpatient hospital utilization, both as a result of expansions in insurance coverage as well as payment and delivery system reforms. The objective of this study is to examine changes in inpatient utilization between 2010 and 2013 in California, following a Medicaid expansion and implementation of the Delivery System Reform Incentive Payment program. Findings show that between 2010 and 2013: (a) the overall number of inpatient admissions increased, mainly because an increase in Medicaid admissions exceeded the decrease in uninsured admissions; (b) the number of preventable admissions did not change; (c) preventable admissions decreased at safety net hospitals that received Delivery System Reform Incentive Payment funds relative to other safety net hospitals. The results suggest that delivery system reforms may help offset the upward pressures on utilization and costs due to coverage expansions.

Changes in Emergency Department Utilization After Early Medicaid Expansion in California

Background: Medicaid expansions aim to improve access to primary care, which could reduce nonemergent (NE) use of the emergency department (ED). In contrast, Medicaid enrollees use the ED more than other groups, including the uninsured. Thus, the expected impact of Medicaid expansion on ED use is unclear. Objectives: To estimate changes in total and NE ED visits as a result of California’s early Medicaid expansion under the Affordable Care Act. In addition to overall changes in the number of visits, changes by payer and safety net hospital status are examined. Methods: We used a quasi-experimental approach to examine changes in ED utilization, comparing California expansion counties to comparison counties from California and 2 other states in the same region that did not implement Medicaid expansion during the study period. Results: Regression estimates show no significant change in total number of ED visits following expansion. Medicaid visits increased by 145 visits per hospital-quarter in the first year following expansion and 242 visits subsequent to the first year, whereas visits among uninsured patients decreased by 129 visits per hospital-quarter in the first year and 175 visits in subsequent years, driven by changes at safety net hospitals. We also observe an increase in NE visits per hospital-quarter paid for by Medicaid, and a significant decrease in uninsured NE visits. Conclusions: Medicaid expansions in California were associated with increases in ED visits paid for by Medicaid and declines in uninsured visits. Expansion was also associated with changes in NE visits among Medicaid enrollees and the uninsured.