COVID-19 and social determinants of health: Medicaid managed care organizations' experiences with addressing member social needs.

BACKGROUND: The significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined. AIM: The purpose of this study was to describe MMCOs' experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic. METHODS: The study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis. RESULTS: Four themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners. CONCLUSION: Among MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint.

Emergency unemployment benefits and health care spending during Covid.

OBJECTIVE: To estimate the impact of the $600 per week Federal Pandemic Unemployment Compensation (FPUC) payments on health care services spending during the Covid pandemic and to investigate if this impact varied by state Medicaid expansion status. DATA SOURCES: This study leverages novel, publicly available data from Opportunity Insights capturing consumer credit and debit card spending on health care services for January 18-August 15, 2020 as well as information on unemployment insurance claims, Covid cases, and state policy changes. STUDY DESIGN: Using triple-differences estimation, we leverage two sources of variation-within-state change in the unemployment insurance claims rate and the introduction of FPUC payments-to estimate the moderating effect of FPUC on health care spending losses as unemployment rises. Results are stratified by state Medicaid expansion status. EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: For each percentage point increase in the unemployment insurance claims rate, health care spending declined by 1.0% (<0.05) in Medicaid expansion states and by 2.0% (<0.01) in nonexpansion states. However, FPUC partially mitigated this association, boosting spending by 0.8% (<0.001) and 1.3% (<0.05) in Medicaid expansion and nonexpansion states, respectively, for every percentage point increase in the unemployment insurance claims rate. CONCLUSIONS: We find that FPUC bolstered health care spending during the Covid pandemic, but that both the negative consequences of unemployment and moderating effects of federal income supports were greatest in states that did not adopt Medicaid expansion. These results indicate that emergency federal spending helped to sustain health care spending during a period of rising unemployment. Yet, the effectiveness of this program also suggests possible unmet demand for health care services, particularly in states that did not adopt Medicaid expansion.

Medical Debt in the US, 2009-2020.

Importance: Medical debt is an increasing concern in the US, yet there is limited understanding of the amount and distribution of medical debt, and its association with health care policies. Objective: To measure the amount of medical debt nationally and by geographic region and income group and its association with Medicaid expansion under the Affordable Care Act. Design, Setting, and Participants: Data on medical debt in collections were obtained from a nationally representative 10% panel of consumer credit reports between January 2009 and June 2020 (reflecting care provided prior to the COVID-19 pandemic). Income data were obtained from the 2014-2018 American Community Survey. The sample consisted of 4.1 billion person-month observations (nearly 40 million unique individuals). These data were used to estimate the amount of medical debt (nationally and by geographic region and zip code income decile) and to examine the association between Medicaid expansion and medical debt (overall and by income group). Exposures: Geographic region (US Census region), income group (zip code income decile), and state Medicaid expansion status. Main Outcomes and Measures: The stock (all unpaid debt listed on credit reports) and flow (new debt listed on credit reports during the preceding 12 months) of medical debt in collections that can be collected on by debt collectors. Results: In June 2020, an estimated 17.8% of individuals had medical debt (13.0% accrued debt during the prior year), and the mean amount was $429 ($311 accrued during the prior year). The mean stock of medical debt was highest in the South and lowest in the Northeast ($616 vs $167; difference, $448 [95% CI, $435-$462]) and higher in poor than in rich zip code income deciles ($677 vs $126; difference, $551 [95% CI, $520-$581]). Between 2013 and 2020, the states that expanded Medicaid in 2014 experienced a decline in the mean flow of medical debt that was 34.0 percentage points (95% CI, 18.5-49.4 percentage points) greater (from $330 to $175) than the states that did not expand Medicaid (from $613 to $550). In the expansion states, the gap in the mean flow of medical debt between the lowest and highest zip code income deciles decreased by $145 (95% CI, $95-$194) while the gap increased by $218 (95% CI, $163-$273) in the nonexpansion states. Conclusions and Relevance: This study provides an estimate of the amount of medical debt in collections in the US based on consumer credit reports from January 2009 to June 2020, reflecting care delivered prior to the COVID-19 pandemic, and suggests that the amount of medical debt was highest among individuals living in the South and in lower-income communities. However, further study is needed regarding debt related to COVID-19.

Medicaid Expansion: Effects On Hospital Finances And Implications For Hospitals Facing COVID-19 Challenges.

States' decisions to expand Medicaid may have important implications for their hospitals' financial ability to weather the coronavirus disease 2019 (COVID-19) pandemic. This study estimated the effects of the Affordable Care Act (ACA) Medicaid expansion on hospital finances in 2017 to update earlier findings. The analysis also explored how the ACA Medicaid expansion affects different types of hospitals by size, ownership, rurality, and safety-net status. We found that the early positive financial impact of Medicaid expansion was sustained in fiscal years 2016 and 2017 as hospitals in expansion states continued to experience decreased uncompensated care costs and increased Medicaid revenue and financial margins. The magnitude of these impacts varied by hospital type. As COVID-19 has brought hospitals to a time of great need, findings from this study provide important information on what hospitals in states that have yet to expand Medicaid could gain through expansion and what is at risk should any reversal of Medicaid expansions occur.

Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?

The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic-induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints-for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7-10 percent and hospital use by 0-3 percent. Modest administrative savings could offset the costs of such increases.

Spreading Fear: The Announcement Of The Public Charge Rule Reduced Enrollment In Child Safety-Net Programs.

Safety-net programs improve health for low-income children over the short and long term. In September 2018 the Trump administration announced its intention to change the guidance on how to identify a potential "public charge," defined as a noncitizen primarily dependent on the government for subsistence. After this change, immigrants' applications for permanent residence could be denied for using a broader range of safety-net programs. We investigated whether the announced public charge rule affected the share of children enrolled in Medicaid, the Supplemental Nutrition Assistance Program, and the Special Supplemental Nutrition Program for Women, Infants, and Children, using county-level data. Results show that a 1-percentage-point increase in a county's noncitizen share was associated with a 0.1-percentage-point reduction in child Medicaid use. Applied nationwide, this implies a decline in coverage of 260,000 children. The public charge rule was adopted in February 2020, just before the coronavirus disease 2019 (COVID-19) pandemic began in the US. These results suggest that the Trump administration's public charge announcement could have led to many thousands of eligible, low-income children failing to receive safety-net support during a severe health and economic crisis.

Contraceptive Mandate, ACA Final Rules, And COVID-19.

The Supreme Court upheld broad exemptions to the Affordable Care Act contraceptive mandate; new ACA rules were finalized.

Health Policy Perspective: Medicaid and State Politics Beyond COVID.

The COVID-19 pandemic is poised to drastically alter the Medicaid program. While state Medicaid programs are currently expanding coverage policies and enrollment to address acute public health needs, states will soon face significant budget shortfalls. These impending changes may renew partisan debates about restrictive policies like work requirements, which generally require beneficiaries to verify their participation in certain activities-such as employment, job search, or training programs-in order to receive or retain coverage. We argue that restrictive Medicaid policies are driven, to a great extent, by political party affiliation, highlighting the outsized role of partisanship in Medicaid policy adoption. To combat these dynamics, additional efforts are needed to improve community-informed decision-making, strengthen evaluation approaches to tie evidence to policymaking, and boost participation in and understanding of the political processes that affect policy change.

Emergency Flexibility for States to Increase and Maintain Medicaid Eligibility for LTSS under COVID-19.

Medicaid provides essential coverage for health care and long-term services and supports (LTSS) to low-income older adults and disabled individuals but eligibility is complicated and restrictive. In light of the current public health emergency, states have been given new authority to streamline and increase the flexibility of Medicaid LTSS eligibility, helping them enroll eligible individuals and ensure that current beneficiaries are not inadvertently disenrolled. Though state budgets are under increased pressure during the economic crisis created by the coronavirus, we caution states against cutting Medicaid LTSS eligibility or services to balance their budgets. These services are critical to an especially vulnerable population during a global pandemic.

COVID-19 and the Future of Long-Term Care: The Urgency of Enhanced Federal Financing.

The economic threat posed by responses to COVID 19 endangers financing for long-term care across the states that is already inadequate and inequitable. Increasing the federal share of Medicaid spending as unemployment rises would mitigate fiscal pressure on states and preserve public services. But unlike the demand for Medicaid's health care protections, which rises when economic activity declines, the demand for long-term care protections will grow even in a healthy economy as the population ages. Enhanced federal support is urgent not only to cope with the virus today but also to meet the long-term care needs of the nation's aging population in the years to come. Long-term care financing policy should be modified to either adjust federal matching funds by the age of each state's population, or fully federalize the funding of LTC expenses of Medicaid beneficiaries who are also eligible for Medicare.

Risk Corridors, COVID-19, And The ACA.

The Supreme Court holds that the government owes insurers the full risk corridors payments due under the Affordable Care Act.