Continuous Eligibility And Coverage Policies Expanded Children's Medicaid Enrollment.

We examined children's Medicaid participation during 2019-21 and found that as of March 2021, states newly adopting continuous Medicaid coverage for children during the COVID-19 pandemic experienced a 4.62 percent relative increase in children's Medicaid participation compared to states with previous continuous eligibility policies.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.

Importance: Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources. Objective: To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program. Design, Setting, and Participants: This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees. Main Outcomes and Measures: Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness). Results: Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food. Conclusions and Relevance: This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.

Health Insurance For People Younger Than Age 65: Expiration Of Temporary Policies Projected To Reshuffle Coverage, 2023-33.

The Congressional Budget Office estimates that in 2023, 248 million people in the US who are younger than age sixty-five have health insurance coverage (mostly through employment-based plans), and twenty-three million people, or 8.3 percent of that age group, are uninsured-with significant variations in coverage by income and, to a lesser extent, by race and ethnicity. The unprecedented low uninsurance rate is largely attributable to temporary policies that kept beneficiaries enrolled in Medicaid and enhanced the subsidies available through the health insurance Marketplaces during the COVID-19 pandemic. As the continuous eligibility provisions unwind in 2023 and 2024, an estimated 9.3 million people in that age group will transition to other forms of coverage, and 6.2 million will become uninsured. If the enhanced subsidies expire after 2025, 4.9 million fewer people are estimated to enroll in Marketplace coverage, instead enrolling in unsubsidized nongroup or employment-based coverage or becoming uninsured. By 2033 the uninsurance rate is projected to be 10.1 percent, which is still below the 2019 rate of about 12 percent.

Patient Characteristics Associated with Telehealth Scheduling and Completion in Primary Care at a Large, Urban Public Healthcare System.

Understanding patient characteristics associated with scheduling and completing telehealth visits can identify potential biases or latent preferences related to telehealth usage. We describe patient characteristics associated with being scheduled for and completing audio and video visits. We used data from patients at 17 adult primary care departments in a large, urban public healthcare system from August 1, 2020 to July 31, 2021. We used hierarchical multivariable logistic regression to generate adjusted odds ratios (aOR) for patient characteristics associated with having been scheduled for and completed telehealth (vs in-person) visits and for video (vs audio) scheduling and completion during two time periods: a telehealth transition period (N = 190,949) and a telehealth elective period (N = 181,808). Patient characteristics were significantly associated with scheduling and completion of telehealth visits. Many associations were similar across time periods, but others changed over time. Patients who were older (≥ 65 years old vs 18-44 years old: aOR for scheduling 0.53/completion 0.48), Black (0.86/0.71), Hispanic (0.76/0.62), or had Medicaid (0.93/0.84) were among those less likely to be scheduled for or complete video (vs audio) visits. Patients with activated patient portals (1.97/3.34) or more visits (≥ 3 scheduled visits vs 1 visit: 2.40/1.52) were more likely to be scheduled for or complete video visits. Variation in scheduling/completion explained by patient characteristics was 7.2%/7.5%, clustering by provider 37.2%/34.9%, and clustering by facility 43.1%/37.4%. Stable and dynamic associations suggest persistent gaps in access and evolving preferences/biases. Variation explained by patient characteristics was relatively low compared with that explained by provider and facility clustering.

The Differential Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among US Women by Medicaid Expansion and Race and Ethnicity.

BACKGROUND: The 2014 Medicaid expansion improved racial and ethnic equity in insurance coverage and access to maternal care among women of reproductive age. This study examines differential effects of the COVID-19 pandemic on prenatal care utilization by Medicaid expansion and by race and ethnicity. METHODS: Using the pooled 2019-2020 National Natality file (N = 7 361 190), logistic regression was used to estimate the effect of COVID-19 on prenatal care utilization among US women aged 10 to 54 years after controlling for maternal age, race, ethnicity, marital status, parity, nativity/immigrant status, education, payment type, and smoking during pregnancy. Outcome measures were having no care and delayed prenatal care (third trimester or no care). Stratified models by race/ethnicity and Medicaid expansion status yielded the differential effects of COVID-19 on prenatal care utilization. RESULTS: During the COVID-19 pandemic, the adjusted odds of having no prenatal care decreased by 4% (adjusted odds ratio [AOR] = 0.96; 95% confidence interval [CI], 0.94-0.97) in expansion states but increased by 13% (AOR = 1.13; 95% CI, 1.11-1.15) in nonexpansion states. While most racial and ethnic groups in expansion states experienced a decrease in having no prenatal care, the adjusted odds of having no prenatal care increased by 15% for non-Hispanic Whites, 9% for non-Hispanic Blacks, 33% for American Indians/Alaska Natives, 25% for Asian/Pacific Islanders, and 13% for Hispanics in nonexpansion states. Women in expansion states experienced no change in delayed prenatal care during the pandemic, but women in nonexpansion states experienced an increase in delayed care. CONCLUSIONS: Prenatal care utilization decreased during the pandemic among women in nonexpansion states, particularly for American Indians/Alaska Natives and Asian/Pacific Islanders, compared with expansion states.

National trends in psychotropic medication prescribing before and during the COVID-19 pandemic.

The early months of the COVID-19 pandemic saw a decline in psychotropic medication use; however, little is known about how this trend evolved as the pandemic progressed and how it varied across different payers in the United States. Using a national multi-payer pharmacy claims database and adopting a quasi-experimental research design, this study examines trends in psychotropic medication prescriptions dispensed from July 2018 - June 2022. The study finds that the number of patients with dispensed psychotropic medications and the number of psychotropic medications dispensed declined during the early months of the pandemic but experienced a statistically significant growth in later periods compared to the pre-pandemic rate. Average days supply of psychotropic medications dispensed increased significantly throughout the pandemic. Commercial insurance remained the primary payer for psychotropic medication during the pandemic, but there was a significant increase in the number of prescription fills covered under Medicaid. This implies that public insurance programs played an increasing role in financing psychotropic medication use during the COVID-19 pandemic.

Changes In Health Coverage During The COVID-19 Pandemic.

The COVID-19 pandemic had the potential to alter patterns of health insurance coverage in the US. Using data from the Medical Expenditure Panel Survey, we found increased stability of Medicaid coverage for children and nonelderly adults during the first year of the pandemic. Fewer people who had Medicaid in 2019 became uninsured in 2020 (4.3 percent) than in 2018-19 (7.8 percent).

Supplemental Nutrition Assistance Program Participation is Associated with Lower Health Care Spending among Working Age Adults without Dependents.

Prior evidence suggests an association among food insecurity, poor health, and increased health care spending. In this study, we are using a natural experiment to confirm if longer participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with reduced Medicaid spending among a highly impoverished group of adults. In 2013, the mandatory work requirements associated with SNAP benefits were lifted for able-bodied adults without dependents (ABAWDs). Using 2013 to 2015 Medicaid and SNAP data of 24,181 Minnesotans aged 18-49, we examined if changes in SNAP enrollment duration affect health care expenditures. In fully adjusted within-participant regression models, for each additional month of SNAP, average annual health care spending was $98.8 lower (95% CI: -131.7, -66.0; p<.001) per person. Our data suggests that allowing ABAWDs to receive SNAP even in months they are not working may be critical to their health as well as cost-effective.

Regulation of provider networks in response to COVID-19.

In public health insurance programs, federal and state regulators use network adequacy standards to ensure that health plans provide enrollees with adequate access to care. These standards are based on provider availability, anticipated enrollment, and patterns of care delivery. We anticipate that the coronavirus disease 2019 pandemic will have 3 main effects on provider networks and their regulation: enrollment changes, changes to the provider landscape, and changes to care delivery. Regulators will need to ensure that plans adjust their network size should there be increased enrollment or increased utilization caused by forgone care. Regulators will also require updated monitoring data and plan network data that reflect postpandemic provider availability. Telehealth will have a larger role in care delivery than in the prepandemic period, and regulators will need to adapt network standards to accommodate in-person and virtual care delivery.

Telemedicine Use by Age in Louisiana Medicaid During COVID-19: Claims-Based Longitudinal Analysis.

BACKGROUND: Limited availability of in-person health care services and fear of contracting COVID-19 during the pandemic promoted an increased reliance on telemedicine. However, long-standing inequities in telemedicine due to unequal levels of digital literacy and internet connectivity among different age groups raise concerns about whether the uptake of telemedicine has exacerbated or alleviated those inequities. OBJECTIVE: The aim of this study is to examine changes in telemedicine and in-person health service use during the COVID-19 pandemic across age groups for Medicaid beneficiaries in the state of Louisiana. METHODS: Interrupted time series models were used on Louisiana Medicaid claims data to estimate trends in total, in-person, and telemedicine monthly office visit claims per 1000 Medicaid beneficiaries between January 2018 and December 2020. Changes in care pattern trends and levels were estimated around the infection peaks (April 2020 and July 2020) and for an end-of-year infection leveling off period (December 2020). Four mutually exclusive age categories (0 to 17, 18 to 34, 35 to 49, and 50 to 64 years) were used to compare the differences. RESULTS: Prior to the COVID-19 pandemic, telemedicine services accounted for less than 1% of total office visit claim volume across the age groups. Each age group followed similar patterns of sharp increases in April 2020, downward trends until sharp increases again in July 2020, followed by flat trends thereafter until December 2020. These sharp increases were most pronounced for older patients, with those aged 50 to 64 years seeing increases of 184.09 telemedicine claims per 1000 Medicaid beneficiaries in April 2020 (95% CI 172.19 to 195.99) and 120.81 in July 2020 (95% CI 101.32 to 140.31) compared with those aged 18 to 34 years, seeing increases of 84.47 (95% CI 78.64 to 90.31) and 57.00 (95% CI 48.21 to 65.79), respectively. This resulted in overall changes from baseline to December 2020 levels of 123.65 (95% CI 112.79 to 134.51) for those aged 50 to 64 years compared with 59.07 (95% CI 53.89 to 64.24) for those aged 18 to 34 years. CONCLUSIONS: Older Medicaid beneficiaries in Louisiana had higher rates of telemedicine claim volume during the COVID-19 pandemic compared with younger beneficiaries.

Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021.

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

COVID-19 unemployment and access to statin medications in the United States.

Objective: To quantify the effect of the unemployment created by COVID-19 on access to (sales of) statin drugs in the United States population. Methods: Approximately half a billion transactions for statin drugs in the United States between January 2018 and September 2020 are analyzed. We studied the potential causal relation between abnormal levels of unemployment during the first wave of COVID-19 in the U.S. and abnormal levels of sales of statin products (both variables defined at the state/week level). Variables are analyzed using the Two-Stage Least Squares (2SLS) method, which exploits comparisons of statin sales between states where, given the occupational distribution of their workforce, unemployment was more structurally vulnerable to mobility restrictions derived from COVID-19 against states where it was less structurally vulnerable. Results: While we do not find unemployment effects on statin sales on most of the population, our estimates link COVID-fueled unemployment with a sharp sales reduction among Medicaid-insured populations, particularly those in working age. For the period between March and August of 2020, these estimates imply a 31% drop of statin sales among this population. Discussion: COVID-fueled unemployment may have had a negative and significant effect on access to statin populations among Medicaid-insured populations.

Evaluating Emergency Medicaid Program Policy Changes During the COVID-19 Pandemic.

INTRODUCTION: Trauma patients are twice as likely to be uninsured as the general population, which can lead to limited access to postinjury resources and higher mortality. The Hospital Presumptive Eligibility (HPE) program offers emergency Medicaid for eligible patients at presentation. The HPE program underwent several changes during the COVID-19 pandemic; we quantify the program's success during this time and seek to understand features associated with HPE approval. METHODS: A mixed methods study at a Level I trauma center using explanatory sequential design, including: 1) a retrospective cohort analysis (2015-2021) comparing HPE approval before and after COVID-19 policy changes; and 2) semistructured interviews with key stakeholders. RESULTS: 589 patients listed as self-pay or Medicaid presented after March 16, 2020, when COVID-19 policies were first implemented. Of these, 409 (69%) patients were already enrolled in Medicaid at hospitalization. Among those uninsured at arrival, 160 (89%) were screened and 98 (61%) were approved for HPE. This marks a significant improvement in the prepandemic HPE approval rate (48%). In adjusted logistic regression analyses, the COVID-19 period was associated with an increased likelihood of HPE approval (versus prepandemic: aOR, 1.64; P = 0.005). Qualitative interviews suggest that mechanisms include state-based expansion in HPE eligibility and improvements in remote approval such as telephone/video conferencing. CONCLUSIONS: The HPE program experienced an overall increased approval rate and adapted to policy changes during the pandemic, enabling more patients' access to health insurance. Ensuring that these beneficial changes remain a part of our health policy is an important aspect of improving access to health insurance for our patients.

The risk of losing health insurance in the United States is large, and remained so after the Affordable Care Act.

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID United States, we estimate that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many-one in four-are uninsured at some point over a 2-y period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA. Risk of insurance loss is particularly high for those with health insurance through Medicaid or private exchanges; they have a 20% chance of losing coverage at some point over a 2-y period, compared to 8.5% for those with employer-provided coverage. Those who lose insurance can experience prolonged periods without coverage; about half are still uninsured 6 mo later, and almost one-quarter are uninsured for the subsequent 2 y. These facts suggest that research and policy attention should focus not only on the "headline number" of the share of the population uninsured at a point in time, but also on the stability and certainty (or lack thereof) of being insured.

Medicaid, the Supreme Court, and Safe Care for Nursing Home Residents.

This Viewpoint details the risk to Medicaid beneficiaries if the Supreme Court supports a decision that will allow states to deny benefits to eligible recipients and deny beneficiaries' ability to hold states accountable in federal court.