Incentives and Operations of Medicaid Managed Care Plans in New York State: Implications for Procurement Design and Market Evolution.

Several states are considering competitive procurement to help shape Medicaid managed care markets. In New York state, the focus of our study, regulators propose contracts that reward quality improvement and simplify state administration by rewarding plans that operate across several of the state's 62 counties. This case analysis uses novel regulatory data from New York state, obtained via public records request, to examine incentives underlying Medicaid markets and help inform contracting design. The data report plan enrollment by county and plan spending across administrative activities for all 16 Medicaid plans in New York state for 2018. We examine the counties in which plans operate, profitability, and administrative resource allocation. We compare outcomes by tertile of plan profitability, measured as net income per member-month. Plan profitability ranged widely, with the most profitable plan realizing nearly $30 per member-month while the least profitable 5 plans realized net negative earnings. Operational differences across plan profitability emerged most clearly in administrative spending. The most profitable plans reported greater spending on salaries overall and for executive management, and taxes, while the least profitable plans spent more on operational functions including utilization management/ quality improvement, claims processing, and informational systems. We observe modest differences in county rurality and little in geographic breadth. Procurement design that rewards capacity-building in key administrative functions might impact market evolution, given that on average, highly profitable firms spent less on these activities in New York's Medicaid managed care market in 2018.

Does Private Insurance Provide More Care?

Medicaid provides virtually no-cost coverage to millions of low-income Americans. This study examines whether its beneficiaries realize similar health care access as their counterparts with private insurance. We draw on the 2014-2017 Medical Expenditure Panel Survey and control for observable confounding factors across coverage types by estimating and applying entropy weights. Medicaid beneficiaries were moderately more likely to report a usual source of care (74.5% vs 68.1%, p<.01) and approximately equally as likely to report a checkup in the past year as the privately insured (43.5% vs 44.5%, p>.1), each significantly more likely than the uninsured. Medicaid beneficiaries had significantly more prescription fills (12.6 vs 8.2) and emergency-care visits (.26 vs .15) annually than the privately-insured on average, with similar numbers of physician visits. On balance, we did not find evidence that Medicaid was associated with diminished access or utilization relative to private insurance, while both had more access than the uninsured.

Impact of the 2008 Recession on Wealth-Adjusted Income and Inequality for U.S. Cohorts.

OBJECTIVE: To examine the distributional effects of the 2008 recession and subsequent recovery across generational cohorts. METHODS: Using data from the Survey of Consumer Finances (2007-2016), we constructed a measure of economic well-being accounting for income, household size, and annuitized value of assets. We examine trajectories of adjusted income and inequality, using Gini coefficients and income shares by decile, for the overall population and by cohort during the recession and recovery. RESULTS: Inequality declined temporarily during the recession, but reached new highs during the recovery. During recovery, population-level increases in economic resources were not reflected among below-median households, as the more concentrated financial assets rose while broader-based home equity and employment fell or remained stagnant. Inequality measures increased for cohorts in their primary working years (Generation-X and Baby Boomers), but not among the younger Millennials, who were at early stages of education, workforce entry, and household formation. DISCUSSION: The study illustrates an integrative approach to analyzing cumulative dis/advantage by considering interactions between historically consistent macrolevel events, such as economic shocks or policy choices affecting all cohorts, and the persistent life-course processes that tend to increase heterogeneity and inequality as cohorts age over time. Although recovery policies led to rapid recovery of financial asset values, they did not proportionately reach those below the median or their economic resource types. Results suggest that in a high-inequality environment, recovery policies from economic shocks may need tailoring to all levels of resources in order to achieve more equitable recovery outcomes and prevent exacerbating cohort inequality trajectories.

Improving estimates of Medicaid's effect on poverty: Measures and counterfactuals.

OBJECTIVE: To re-evaluate the effect of Medicaid on poverty using a poverty measure that accounts for health insurance needs and benefits and an evaluation approach that reflects disparities in access to alternative coverage. DATA SOURCES: The Current Population Survey (CPS) for calendar year 2015. STUDY DESIGN: We estimate the effect of losing Medicaid on poverty, combining two previous approaches: (1) A propensity impact, which simulates a no-Medicaid counterfactual incorporating changes to health insurance and medical out-of-pocket spending, using the Supplemental Poverty Measure (SPM). This measure does not reflect a need for health care access nor how health benefits meet that need. (2) An accounting impact, which assumes that those losing Medicaid remain uninsured and does not incorporate any behavioral changes, using the health-inclusive poverty measure (HIPM). This measure includes a need for health insurance in the threshold and health insurance benefits in resources. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Using the propensity-matched approach, we attributed a 2.5 percentage point reduction in health-inclusive poverty among those younger than age 65 to the Medicaid program, between the 1.0-point SPM propensity-match impact and the 3.9-point HIPM accounting impact. Medicaid's antipoverty impact and HIPM-SPM differences are greater among those who would become uninsured. HIPM propensity-matched estimates reveal much larger impacts of Medicaid on poverty disparities linked to race/ethnicity and single parenthood than SPM-based propensity estimates. CONCLUSIONS: Both the poverty measure and the method used to estimate the counterfactual make substantial, policy-relevant differences to estimates of Medicaid's impact on poverty. A poverty measure that fails to incorporate health insurance needs and benefits substantially underestimates Medicaid's effect. Failing to consider adjustments in insurance coverage and out-of-pocket spending substantially overestimates Medicaid's effect and underestimates its reduction of disparities.

The individual welfare effects of the Affordable Care Act for previously uninsured adults.

The Affordable Care Act (ACA) improved welfare by expanding, subsidizing, and standardizing healthcare coverage. At the same time, the law also penalizes the remaining uninsured and establishes a benchmark private policy that charges premiums and cost-sharing expenses in the non-group market. This paper introduces a conceptual and empirical framework for evaluating the net effects of ACA coverage expansions for the individual welfare of previously uninsured adults. Using restricted-access data from the 2010-2012 Medical Expenditure Panel Survey, I evaluate the short-term welfare effect as a function of health and non-medical consumption. I simulate post-ACA insurance status then evaluate the change in expected medical consumption and the utility of consumption by estimating parameter values for a generalized gamma distribution of the ex-ante spread of healthcare and medical spending for each person. The ACA generates a modest net improvement in individual welfare on average (+ $91). While low-income individuals realize gains (+ $539), all other income-groups realize increasingly large losses. The uninsured majority (65%) realize average losses (- $158). Medicaid beneficiaries realize substantial gains (+ $1309). While in most specifications, exchange enrollees realize average gains (+ $146), just under a quarter (24%) realizes any improvement. The chronically-ill realize substantial gains (+ $1065). The non-chronically-ill majority (71%) realize average losses (- $312). Despite weakly lower risk premiums (- $28), medical spending increases in catastrophic scenarios on average. The ACA improves the welfare of some, especially the low-income and chronically-ill. Medicaid generates unequivocal gains for beneficiaries. Most previously uninsured adults remain uninsured, some of whom pay a penalty. The subsidized cost of ACA private insurance outweighs its benefits for most exchange enrollees.

Can Medicaid Expansion Prevent Housing Evictions?

Evictions are increasingly recognized as a serious concern facing low-income households. This study evaluated whether expansions of Medicaid can prevent evictions from occurring. We examined data from a privately licensed database of eviction records in fourteen states (286 counties) and used a difference-in-differences research design to compare rates of eviction before and after California's early Medicaid expansion (51 counties). Early Medicaid expansion in California was associated with a reduction in the number of evictions, with 24.5 fewer evictions per month in each county from a pre-expansion average of 224.7. These results imply that for every thousand new Medicaid enrollees in California, Medicaid expansion was associated with roughly twenty-two fewer evictions per year. Additionally, we found a 2.9-percentage-point reduction in evictions per capita associated with early expansion. The effects were concentrated among counties with the highest pre-expansion rates of uninsurance. We conclude that health insurance coverage is associated with improved housing stability.

The Effects of the ACA Medicaid Expansion on Nationwide Home Evictions and Eviction-Court Initiations: United States, 2000-2016.

Objectives. To evaluate the effect of the Affordable Care Act (ACA) Medicaid expansions on national rates of home eviction and eviction initiation in the United States.Methods. Using nationally representative administrative data from The Eviction Lab at Princeton University, we estimated the effects of the ACA Medicaid expansions on county-level evictions and filings from 2000 to 2016 with a difference-in-difference regression design.Results. We found that Medicaid expansions were associated with an annual reduction in the rate of evictions by 1.15 per 1000 renter-occupied households (P < .001), a reduction of 1.59 eviction filings per 1000 renter-occupied households (P < .001), and a reduction in the average number of evictions by 46 (P < .05). We found additional evidence that increasing rates of African American residents in a county was associated with a greater rate of evictions filed, and increased rates of poverty and rent burdens relative to income were associated with more evictions both filed and completed.Conclusions. Evictions decreased after Medicaid expansion, demonstrating further evidence of the substantive financial protections afforded by this coverage. The reduction in the eviction filing rate suggests that Medicaid expansion could be reducing evictions by preventing the court proceeding entirely.

Antipoverty Impact Of Medicaid Growing With State Expansions Over Time.

Out-of-pocket spending on health care pushed over 10.5 million Americans into poverty in 2016. Medicaid helps offset this risk by providing medical coverage to millions of poor and near-poor children and adults and thereby constraining out-of-pocket medical spending. This article examines whether recent state-level expansions to the Medicaid program resulted in reductions in poverty and whether future changes to the program are likely to have similar impacts on poverty. Using a difference-in-differences research design, we found that the recent Medicaid expansion caused a significant reduction in the poverty rate. Moreover, by simulating a counterfactual poverty rate for a hypothetical world without Medicaid coverage, we found that the program's antipoverty impact grew over the past decade independent of expansion, by shielding beneficiaries from growing out-of-pocket spending. Future expansions or retractions of Medicaid are likely to produce associated effects on poverty.