Sayeh Nikpay

Affordable Care Act Medicaid Expansion Reduced Uninsured Hospital Stays In 2014

In states that expanded Medicaid, uninsured hospital stays decreased sharply and Medicaid stays increased sharply in the first two quarters of 2014. There was no change in payer mix in states that ...

Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases

Study objective We assess whether the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) results in changes in emergency department (ED) visits or ED payer mix. We also test whether the size of the change in ED visits depends on the change in the size of the Medicaid population. Methods Using all‐capture, longitudinal, state data from the Agency for Healthcare Research and Quality’s Fast Stats program, we implemented a difference‐in‐difference analysis, which compared changes in ED visits per capita and the share of ED visits by payer (Medicaid, uninsured, and private insurance) in 14 states that did and 11 states that did not expand Medicaid in 2014. Analyses controlled for state‐level demographic and economic characteristics. Results We found that total ED use per 1,000 population increased by 2.5 visits more in Medicaid expansion states than in nonexpansion states after 2014 (95% confidence interval [CI] 1.1 to 3.9). Among the visit types that could be measured, increases in ED visits were largest for injury‐related visits and for states with the largest changes in Medicaid enrollment. Compared with nonexpansion states, in expansion states the share of ED visits covered by Medicaid increased 8.8 percentage points (95% CI 5.0 to 12.6), whereas the uninsured share decreased by 5.3 percentage points (95% CI –1.7 to –8.9). Conclusion The ACA’s Medicaid expansion has resulted in changes in payer mix. Contrary to other studies of the ACA’s effect on ED visits, our study found that the expansion also increased use of the ED, consistent with polls of emergency physicians.

Per Capita Caps in Medicaid — Lessons from the Past

Analysis of U.S. experience with a pre-Medicaid financing system suggests that Speaker of the House Paul Ryan’s proposal for per capita caps in Medicaid would result in restrictions on coverage and benefits rather than state innovations to reduce program costs.

The Growing Integration of Physician Practices: With a Medicaid Side Effect.

Background:Strategic alignment and integration is currently in vogue throughout the health care industry, but its diffusion and pace have not been documented in recent years. The full range of downstream implications from greater alignment between hospitals and physicians has also not been completely explored. Objectives:We track the organizational landscape among all office-based US physician practices from 2009 to 2015 and document the degree of vertical integration over time. Then, we examine the implications of vertical integration on practices’ acceptance of publicly insured patients. Research Design:We use descriptive trends and linear regression models with practice level fixed effects to capture the relationships between within-office changes in integration behavior and changes in public payer acceptance. Results:Independent (nonintegrated) physician practices are still the most common organizational type, but their share is declining as the share of practices integrated with a health system increases 3-fold between 2009 and 2015. Although >80% of practices that are part of a health system accept Medicaid, <60% of independent practices will see these patients. Vertically integrating with a health system makes it more likely a practice will start seeing Medicaid patients. Conclusions:Integration—and possibly consolidation—appears to be occurring and may be increasing over time in the United States. However, it also seems to increase the number of physician practices participating in the Medicaid program. This beneficial side effect has not been previously documented and should be kept in mind as policymakers weigh the pros and cons of a more integrated health care system.

Hospital Charity Care--Effects of New Community-Benefit Requirements.

U.S. nonprofit hospitals must now have written policies regarding charity care, charge reasonable amounts for it, refrain from extraordinary bill-collection practices, and assess community health needs every 3 years. The effects on charity care are likely to be mixed.

The Changing Dynamics Of US Health Insurance And Implications For The Future Of The Affordable Care Act

The introduction of Medicaid expansions and state Marketplaces under the Affordable Care Act (ACA) have reduced the uninsurance rate to historic lows, changing the choices Americans make about coverage. In this article we shed light on these changing dynamics. We drew upon multistate transition models fit to nationally representative longitudinal data to estimate coverage transition probabilities between major insurance types in the years leading up to and including 2014. We found that the ACAs unprecedented coverage changes increased transitions to Medicaid and nongroup coverage among the uninsured, while strengthening the existing employer-sponsored insurance system and improving retention of public coverage. However, our results suggest possible weakness of state Marketplaces, since people gaining nongroup coverage were disproportionately older than other potential enrollees. We identified key opportunities for policy makers and insurers to improve underlying Marketplace risk pools by focusing on people transitioning from employer-sponsored coverage; these people are disproportionately younger and saw almost no change in their likelihood of becoming uninsured in 2014 compared to earlier years.

Health Reform and Retirement

Objective To analyze whether there was an increase in retirement or in part-time work among older workers after January 2014, when new health insurance coverage options became available because of the Affordable Care Act (ACA). Method We analyze trends in retirement and part-time work for individuals aged 50-64 years in the basic monthly Current Population Survey from January 2008 through June 2016. We test for a break in trend in January 2014. We also test for differences in trends, both before and after 2014, in states that expanded their Medicaid programs in January 2014 under the ACA compared with those that did not. Results We find that there was no change in the probability of retirement or part-time work among older workers in 2014 and later, either overall or in Medicaid expansion states relative to nonexpansion states. Discussion Although many observers had predicted that an unintended consequence of health reform would be reduced labor supply, we find no evidence of this for older workers in the first 2.5 years after the laws major coverage provisions took effect.

Diversity of Participants in the 340B Drug Pricing Program for US Hospitals

increasing overall rates of prophylaxis rather than overall appropriateness. Although overall rates have improved, the unintended consequence may be excess administration of VTE prophylaxis among low-risk patients. The major drawback to pharmacologic overprophylaxis is major bleeding.5 Patient discomfort, potential risk of falls and impaired mobility with mechanical prophylaxis, medication cost, and risk for heparin-induced thrombocytopenia are additional concerns. Limitations of this study include its observational design subject to inherent biases. Furthermore, this analysis did not incorporate VTE events, so it is unknown whether 1 specific VTE prophylaxis strategy was superior to another. After years of promoting aggressive VTE prophylaxis strategies for hospitalized patients, renewed effort to scale back—or “deimplement”—this practice in low-risk patients may be necessary.6 Discontinuing conventional practices, however, can be difficult, even in the presence of newer compelling data.

Patient Protection and Affordable Care Act Medicaid expansion and gains in health insurance coverage and access among cancer survivors: ACA Medicaid Expansion and Cancer Survivors

The Patient Protection and Affordable Care Act extends Medicaid coverage to millions of low‐income adults, including many survivors of cancer who were unable to purchase affordable health insurance coverage in the individual health insurance market.

Federal Support for Family Planning Clinics Associated with Dramatic Gains in Cervical Cancer Screening

BACKGROUND Since the 1990s, policymakers have successfully increased cervical cancer screening through federal and state public policies. However, the most dramatic gains in Pap smear use occurred in the 1960s and 70s, during the establishment of federal support for family planning clinics through the War on Poverty and Title X. This study estimated the effect of this support on cervical cancer screening, and quantified its role in dramatic increases in Pap smear use. METHODS Using a natural experiment in the timing and receipt of federal family planning grants, the screening behavior of women who did and did not have access to a federally funded family planning clinic were analyzed. Cross-sectional probability models of annual and lifetime Pap smear use using the 1970 National Fertility Survey were estimated and linked to administrative data on grant timing and receipt between 1964 and 1973. FINDINGS Federal support for family planning clinics was associated with a 7-percentage point increase in annual use (p < .01), and a 5-percentage point decrease in never use of the Pap smear (p < .001). Scaled by the fraction of women who used funded clinics, federal support for family planning was associated with a roughly 70% increase in Pap smear use. Estimates suggest that the establishment of federal support could explain as much as 15% of the national increase in Pap smear use between 1966 and 1973. CONCLUSIONS Federal support for family planning played an important--and previously unacknowledged--role in promoting cervical cancer screening and investments in future health.