The Effects of Community Health Center Care on Medical Expenditures for Children and Adults: Propensity Score Analyses.

This study examines whether community health center (CHC) patients have lower medical expenditures. Using 2011-2012 Medical Expenditure Panel Survey data, propensity score methods are used to compare annual expenditures for adults and children receiving at least half their ambulatory care at CHCs versus those who did not. For children, CHC use was associated with 35.3% lower total medical expenditures ($627), 40.0% lower ambulatory expenditures ($279), and 49.1% lower prescription drug expenditures ($157) (all Ps < .05). For adults, the reduction in hospital expenditures for CHC users ($529) was statistically significant at a P < .10 threshold. Estimated differences in total expenditures and other expenditure categories were not statistically significant for adults.

Policies Affecting Medicaid Beneficiaries' Smoking Cessation Behaviors.

Introduction: Smoking rates for Medicaid beneficiaries have remained flat in recent years. Medicaid may support smokers in quitting by covering a broad array of tobacco cessation services without barriers such as copays. This study examines the impact of increasing generosity in Medicaid tobacco cessation coverage policies on smoking and cessation behaviors. Methods: We used 2010 and 2015 National Health Interview Survey data merged with information on state tobacco, Medicaid cessation, and Medicaid eligibility policies to estimate state fixed effects models of cessation medication use, counseling use, quit attempts, and current smoking. Results: Smokers living in states that cover cessation medications but not counseling services were less likely to use counseling. Smokers were more likely to report having tried to quit in states with higher rates of use of cessation medications among Medicaid beneficiaries. We found no impact of Medicaid policies on use of cessation medications. States that impose copays had higher rates of smoking, while those that require counseling as a condition of receiving medication had lower rates of smoking. Additionally, we found that expanding Medicaid eligibility under the Affordable Care Act is associated with decreased smoking prevalence among Medicaid beneficiaries. Conclusion: Covering cessation counseling may encourage smokers that want to quit to use this service. Promoting the use of cessation medications may improve the likelihood that smokers try to quit. Medicaid coverage of cessation services is an important but incomplete strategy in addressing smoking among low-income populations. Implications: States may be able to improve utilization of cessation counseling by providing Medicaid reimbursement for this service. Encouraging utilization of tobacco cessation medications may help more smokers quit. States should consider how to promote effective cessation methods among clinicians and patients.

Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?

Issue: The Centers for Medicare and Medicaid Services approved Medicaid work requirement demonstration projects in four states, and other states also have applied. However, the future of these projects has been clouded by legal and policy challenges. Goal: To assess whether state Medicaid work requirement projects are designed for success in promoting employment among unemployed Medicaid beneficiaries. Methods: To examine the design of new work requirement projects, we reviewed the evidence, analyzed the overlap of Medicaid and Supplemental Nutrition Assistance Program (SNAP) work requirements, and convened a roundtable of seven experts who have research or implementation experience with work programs for Medicaid and public assistance recipients. Findings and Conclusion: Mandatory work programs would be less effective and efficient than well-administered voluntary programs. Far more people will be subject to Medicaid work requirements than are currently subject to them in SNAP. This surge could overwhelm the limited resources of existing employment training and support programs. Medicaid demonstration projects contribute almost no additional funding to train the unemployed or provide necessary social supports. Medicaid work requirement programs are not well designed to help people get jobs or improve health and are more likely to lead to a loss of health insurance coverage.

The American Health Care Act: economic and employment consequences for states.

ISSUE: The American Health Care Act (AHCA), passed by the U.S. House of Representatives, would repeal and replace the Affordable Care Act. The Congressional Budget Office indicates that the AHCA could increase the number of uninsured by 23 million by 2026. GOAL: To determine the consequences of the AHCA on employment and economic activity in every state. METHODS: We compute changes in federal spending and revenue from 2018 to 2026 for each state and use the PI+ model to project the effects on states' employment and economies. FINDINGS AND CONCLUSIONS: The AHCA would raise employment and economic activity at first, but lower them in the long run. It initially raises the federal deficit when taxes are repealed, leading to 864,000 more jobs in 2018. In later years, reductions in support for health insurance cause negative economic effects. By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses.

Crossing Boundaries.

OBJECTIVES: Previous state interagency collaborations have led to successful tobacco cessation initiatives. The objective of this study was to assess the roles and interaction of state Medicaid and public health agency efforts to support tobacco cessation for low-income Medicaid beneficiaries. METHODS: We interviewed Medicaid and state public health agency officials in 8 states in September and October 2015 about collaborations in policy development and implementation for Medicaid tobacco cessation, including Medicaid coverage policies, quitlines, and monitoring. RESULTS: Collaboration between Medicaid and public health agencies was limited. Smoking cessation quitlines were the most common area of collaboration cited. Public health officials were typically not involved in developing Medicaid coverage policies. States covered a range of US Food and Drug Administration-approved tobacco cessation medications, but 7 of the 8 states imposed limitations, such as charging copayments or requiring previous authorization. States generally lacked data to monitor implementation of tobacco cessation efforts and had little ability to determine the effectiveness of their policies. CONCLUSIONS: To strengthen efforts to reduce smoking and tobacco-related health burdens and to monitor the effectiveness of policies and programs, Medicaid and public health agencies should prioritize tobacco cessation and develop and analyze data about smoking and cessation efforts among Medicaid beneficiaries. Recent multistate initiatives from the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services seek to promote stronger collaborations in clinical prevention activities, including tobacco cessation.

How Medicaid and Other Public Policies Affect Use of Tobacco Cessation Therapy, United States, 2010-2014.

INTRODUCTION: State Medicaid programs can cover tobacco cessation therapies for millions of low-income smokers in the United States, but use of this benefit is low and varies widely by state. This article assesses the effects of changes in Medicaid benefit policies, general tobacco policies, smoking norms, and public health programs on the use of cessation therapy among Medicaid smokers. METHODS: We used longitudinal panel analysis, using 2-way fixed effects models, to examine the effects of changes in state policies and characteristics on state-level use of Medicaid tobacco cessation medications from 2010 through 2014. RESULTS: Medicaid policies that require patients to obtain counseling to get medications reduced the use of cessation medications by approximately one-quarter to one-third; states that cover all types of cessation medications increased usage by approximately one-quarter to one-third. Non-Medicaid policies did not have significant effects on use levels. CONCLUSIONS: States could increase efforts to quit by developing more comprehensive coverage and reducing barriers to coverage. Reductions in barriers could bolster smoking cessation rates, and the costs would be small compared with the costs of treating smoking-related diseases. Innovative initiatives to help smokers quit could improve health and reduce health care costs.

Potentially preventable dental care in operating rooms for children enrolled in Medicaid.

BACKGROUND: In this study, the authors examined the prevalence and cost of care for children enrolled in Medicaid for potentially preventable dental conditions who receive surgical care in hospital operating rooms (ORs) or ambulatory surgery centers (ASCs). METHODS: The authors analyzed Medicaid data from 8 states to find cases in which children aged 1 to 20 years received surgical care in ORs or ASCs in 2010 and 2011 for potentially preventable diagnoses, as defined with diagnostic codes. RESULTS: For 6 states with complete data, there were 26,373 cases in 2011 in which children received OR or ASC surgical care for potentially preventable conditions. These cases represent approximately 0.5% of all children enrolled in Medicaid in these states and approximately 1% of children enrolled in Medicaid who received any dental care. There were $68 million in total Medicaid payments for these cases, with an average of $2,581 per case. Diagnostic codes indicated that 98% of cases were related to treatment of dental caries. More than two-thirds of the cases (71%) were children aged 1 to 5 years. CONCLUSIONS: Extrapolation to the United States suggests that approximately $450 million in additional expenditures occurred in 2011 because of OR or ASC surgical care for potentially preventable pediatric dental conditions, primarily related to early childhood caries. PRACTICAL IMPLICATIONS: Strategies to improve prevention of early childhood caries, including community- and family-based education, and to increase access to timely and early dental care for low-income children could reduce the burdens and costs of these dental problems.

Health Reform, Medicaid Expansions, and Women's Cancer Screening.

BACKGROUND: Health reform, including Medicaid expansion, is increasing insurance coverage and financial access to breast and cervical cancer screening for low-income women, although services for low-income uninsured women are still needed. METHODS: American Community Survey and administrative data about Medicaid and health insurance enrollment are used to estimate the number of low-income women who will be uninsured in 2017, focusing on the age ranges 21 to 64, 40 to 64, and 50 to 64. RESULTS: Assuming that 29 states expand Medicaid (as of June 2015), the national percentage of low-income women 21 to 64 who are uninsured will fall from 32.2% in 2013 to 14.6% by 2017. Among Medicaid-expanding states, the percentage of uninsured will decrease from 28.7% to 8.0%, whereas in non-expanding states, the level will decrease from 36.9% to 23.3%. About 5.7 million women 21 to 64 and 2.6 million women 40 to 64 will remain uninsured in 2017. The size of the uninsured low-income population will remain much larger than the 659,000 women who have previously received Pap tests and 548,000 obtaining mammograms under the National Breast and Cervical Cancer Early Detection Program in 2013. DISCUSSION: Even before 2014, women living in states that are not expanding Medicaid were less likely to get mammograms and Pap tests than women in expanding states. Affordable Care Act-related insurance expansions will lower financial barriers to screening and should boost overall screening rates. But disparities in insurance coverage and cancer screening across Medicaid-expanding and non-expanding states could widen. CONCLUSIONS: Programs to support cancer screening for low-income uninsured women will still be needed.

Medicaid Tobacco Cessation: Big Gaps Remain In Efforts To Get Smokers To Quit.

Medicaid enrollees are about twice as likely as the general US population to smoke tobacco: 32 percent of people in the program identify themselves as smokers. This article provides the first data about the effectiveness of state Medicaid programs in promoting smoking cessation. Our analysis of Medicaid enrollees' use of cessation medications found that about 10 percent of current smokers received cessation medications in 2013. Every state Medicaid program covers cessation benefits, but the use of these medications varies widely, with the rate in Minnesota being thirty times higher than that in Texas. Most states could increase their efforts to help smokers quit, working with public health agencies, managed care plans, and others. In 2013 Medicaid spent $103 million on cessation medications-less than 0.25 percent of the estimated cost to Medicaid of smoking-related diseases. Additionally, states that have not expanded Medicaid eligibility in the wake of the Affordable Care Act have higher smoking prevalence and lower utilization rates of cessation medication, compared to expansion states. Given these factors, nonexpansion states will have a greater public health burden related to smoking. Medicaid and public health agencies should work together to make smoking cessation a priority for Medicaid beneficiaries.

Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension.

INTRODUCTION: Hypertension is a risk factor for cardiovascular disease (CVD), the leading cause of death in the United States. The treatment and control of hypertension is inadequate, especially among patients without health insurance coverage. The Affordable Care Act offered an opportunity to improve hypertension management by increasing the number of people covered by insurance. This study predicts the long-term effects of improved hypertension treatment rates due to insurance expansions on the prevalence and mortality rates of CVD of nonelderly Americans with hypertension. METHODS: We developed a state-transition model to simulate the lifetime health events of the population aged 25 to 64 years. We modeled the effects of insurance coverage expansions on the basis of published findings on the relationship between insurance coverage, use of antihypertensive medications, and CVD-related events and deaths. RESULTS: The model projected that currently anticipated health insurance expansions would lead to a 5.1% increase in treatment rate among hypertensive patients. Such an increase in treatment rate is estimated to lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and 95,000 fewer CVD-related deaths by 2050. The estimated benefits were slightly greater for men than for women and were greater among nonwhite populations. CONCLUSION: Federal and state efforts to expand insurance coverage among nonelderly adults could yield significant health benefits in terms of CVD prevalence and mortality rates and narrow the racial/ethnic disparities in health outcomes for patients with hypertension.

Continuous-eligibility policies stabilize Medicaid coverage for children and could be extended to adults with similar results.

A key method of stabilizing Medicaid coverage is to provide beneficiaries with twelve months of continuous eligibility. Following the passage of the Children's Health Insurance Program Reauthorization Act in 2009, seven states adopted the continuous-eligibility option for children. That policy change led to a 1.8-percentage-point increase in the average length of child enrollment during fiscal year 2010 and increased annual costs for children by about 2.2 percent. The Medicaid and CHIP Payment and Access Commission has recommended offering states the option of giving adults twelve-month continuous eligibility for Medicaid. Our findings suggest that continuous eligibility could promote more stable coverage for adults enrolled in Medicaid at a modest cost.

No evidence that primary care physicians offer less care to Medicaid, community health center, or uninsured patients.

The Affordable Care Act increases US investment in Medicaid and community health centers, yet many people believe that care in such safety-net programs is substandard. Using data from more than 31,000 visits to primary care physicians in the period 2006-10, we examined whether the length or content of a visit was different for safety-net patients-those insured by Medicaid, those who are uninsured, and those seen in a community health center-compared to patients with private insurance. We found no significant differences in the average length of a primary care visit or in the likelihood of a patient's receiving preventive health counseling. Medicaid patients received more diagnostic and treatment services, and uninsured patients received fewer services, compared to privately insured patients, but the differences were small. This analysis indicates that length and content of primary care visits are comparable for safety-net and other patients. The main factors that contribute to differences in visit length and content are patients' health needs and the type of visit involved.

Health care reform and women's insurance coverage for breast and cervical cancer screening.

INTRODUCTION: The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services. METHODS: We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services. RESULTS: Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for NBCCEDP cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care. CONCLUSION: Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.

More than four in five office-based physicians could qualify for federal electronic health record incentives.

Our analyses of federal survey data show that more than four in five office-based physicians could qualify for new federal incentive payments to encourage the adoption and "meaningful use" of electronic health records, based on the numbers of Medicare or Medicaid patients they see. The incentives are thus likely to accelerate the spread of electronic health records. However, our analyses also indicate that eligibility for the incentives is likely to vary by specialty: 90.6 percent of physicians working in general or family practice or internal medicine could qualify for incentives, but fewer than two-thirds of pediatricians, obstetrician-gynecologists, and psychiatrists may qualify. Eligibility and use will also vary by factors such as size and type of practice; physicians in solo practice are much less likely to use electronic health records than physicians in other practice settings. We suggest actions that policy makers can take to lessen disparities and increase the adoption and meaningful use of electronic health records.

Changes in Medicaid prescription volume and use in the wake of Medicare Part D implementation.

Implementation of the Medicare drug benefit resulted in a major shift of prescription drug spending from Medicaid to Medicare. Data indicate that Medicaid programs experienced substantial changes in the volume and types of prescriptions used by enrollees. Medicaid prescription volume and total payments to pharmacies dropped by almost 50 percent in 2006. Generic dispensing rates increased 4.6 percentage points nationally. The mix of drug classifications also shifted, reflecting the younger makeup of the population that remains eligible for Medicaid prescription drug benefits. Still, patterns of use reflect the major mental and physical health needs of Medicaid enrollees.

States' use of Medicaid UPL and DSH financing mechanisms.

Using data from a 2002 survey, we look at the design and operation of disproportionate-share hospital (DSH) and upper payment limit (UPL) programs in thirty-four states. We find that more of the available DSH gains are paid to safety-net hospitals than occurred in the late 1990s. By contrast, survey data suggest that the bulk of available UPL gains are being kept by states and not by providers. Using simulation analyses, we estimate that because of DSH and UPL practices among the survey states, the effective 2001 federal Medicaid match rate was about three percentage points higher on average in these states than it would have been otherwise.