121 research outputs found
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The Policy Argument for Healthcare Workforce Diversity
This perspectives article considers the potential implications an affirmative action ban would have on patient care in the US. A physician’s race and ethnicity are among the strongest predictors of specialty choice and whether or not a physician cares for Medicaid and uninsured populations. Taking this into account, research suggests that an affirmative action ban in university admissions would sharply reduce the supply of primary care physicians to Medicaid and uninsured populations over the coming decade. Our article compares current conditions to the potential effect of an affirmative action ban by projecting how many future medical students will become primary care physicians for Medicaid and uninsured patients by 2025. Based on previous evidence and current medical student training patterns, we project that a ban could deny primary care access for 1.25 million of our nation’s most vulnerable patients, considerably worsening existing healthcare disparities. More broadly, we argue that the effects of eliminating affirmative action would be fundamentally contrary to the Association of American Medical Colleges’ stated goal of medical education—“to improve the health of all.
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Measuring Medicaid Physician Participation Rates & Implications for Policy
Policymakers continue to debate Medicaid expansion under the ACA, and concerns remain about low provider participation in the program. However, there has been little research on how various measures of physician participation may reflect different elements of capacity for care within the Medicaid program, and how these distinct measures correlate with one another across states. Our objective was to describe several alternative measures of provider participation in Medicaid using recently publicly available data; to compare state rankings across these different metrics; and to discuss potential advantages and disadvantages of each measure for research and policy purposes. Overall, we find that Medicaid participation as measured by raw percentages of physicians taking new Medicaid patients is only weakly correlated with population-based measures that account for both participation rates and the numbers of physicians per capita or physicians per Medicaid beneficiary. Participation rates for all physicians versus primary care physicians also offer different information about state-level provider capacity. Policymakers should consider multiple dimensions of provider access in assessing policy options in Medicaid, and further research is needed to evaluate the linkages between these provider-based measures and beneficiaries’ perceptions of access to care in the program
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Federal Funding Insulated State Budgets From Increased Spending Related To Medicaid Expansion
As states weigh whether to expand Medicaid under the Affordable Care Act (ACA) and Medicaid reform remains a priority for some federal lawmakers, fiscal considerations loom large. As part of the ACA’s expansion of eligibility for Medicaid, the federal government paid for 100 percent of the costs for newly eligible Medicaid enrollees for the period 2014–16. In 2017 states will pay some of the costs for new enrollees, with each participating state’s share rising to 10 percent by 2020. States continue to pay their traditional Medicaid share (roughly 25–50 percent, depending on the state) for previously eligible enrollees. We used data for fiscal years 2010–15 from the National Association of State Budget Officers and a difference-in-differences framework to assess the effects of the expansion’s first two fiscal years. We found that the expansion led to an 11.7 percent increase in overall spending on Medicaid, which was accompanied by a 12.2 percent increase in spending from federal funds. There were no significant increases in spending from state funds as a result of the expansion, nor any significant reductions in spending on education or other programs. States’ advance budget projections were also reasonably accurate in the aggregate, with no significant differences between the projected levels of federal, state, and Medicaid spending and the actual expenses as measured at the end of the fiscal year
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On the Outskirts of National Health Reform: A Comparative Assessment of Health Insurance and Access to Care in Puerto Rico and the United States
Context: Puerto Rico is the U.S.’s largest territory, home to nearly 4 million American
citizens. Yet it has remained largely on the outskirts of U.S. health policy, including the
Affordable Care Act (ACA). This paper presents an overview of Puerto Rico’s health
care system and a comparative analysis of coverage and access to care in Puerto Rico
versus the mainland U.S.
Methods:
We analyzed 2011-2012 data from the Behavioral Risk Factor and Surveillance System,
and 2012 data from the American Community Survey and its counterpart the Puerto
Rican Community Survey. Among adults 18 and over, we examined the following
outcomes: health insurance coverage; access measures such as having a usual source of
care and cost-related delays in care; self-reported health; and the receipt of recommended
preventive services such as cancer screening and glucose testing. We used multivariate
regression models to compare Puerto Rico and the U.S., adjusted for age, income,
race/ethnicity, and other demographic variables.
Findings: Uninsured rates were significantly lower in Puerto Rico (unadjusted 7.4% vs.
15%, adjusted difference -12.0%, p<0.001). Medicaid was far more common in Puerto
Rico. Puerto Rican residents were more likely than those in the mainland U.S. to have a
usual source of care and a check-up within the past year, and fewer experienced costrelated
delays in care. Screening rates for diabetes, mammograms, and Pap smears were
comparable or better in Puerto Rico, while colonoscopy rates were lower. Self-reported
health was slightly worse, while obesity and smoking rates were lower.
Conclusions: Despite its far poorer population, Puerto Rico outperforms the mainland
U.S. on several measures of coverage and access. However, Congressional policies
capping federal Medicaid funds to the territory have contributed to budgetary challenges.
While the ACA significantly increases federal resources in Puerto Rico, ongoing
restrictions on Medicaid funding and premium tax credits pose substantial health policy
challenges in the territory
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Access and Quality of Care by Insurance Type for Low-Income Adults Before the Affordable Care Act
Objectives. To compare access to care and perceived health care quality by insurance type among low-income adults in 3 southern US states, before Medicaid expansion under the Affordable Care Act.
Methods. We conducted a telephone survey in 2013 of 2765 low-income US citizens, aged 19 to 64 years, in Arkansas, Kentucky, and Texas. We compared 11 measures of access and quality of care for respondents with Medicaid, private insurance, Medicare, and no insurance with adjustment for sociodemographics and health status.
Results. Low-income adults with Medicaid, private insurance, and Medicare reported significantly better health care access and quality than uninsured individuals. Medicaid beneficiaries reported greater difficulty accessing specialists but less risk of high out-of-pocket spending than those with private insurance. For other outcomes, Medicaid and private coverage performed similarly.
Conclusions. Low-income adults with insurance report significantly greater access and quality of care than uninsured adults, regardless of whether they have private or public insurance. Access to specialty care in Medicaid may require policy attention.
Public Health Implications. Many states are still considering whether to expand Medicaid under the Affordable Care Act and whether to pursue alternative models for coverage expansion. Our results suggest that access to quality health care will improve under the Affordable Care Act's coverage expansions, regardless of the type of coverage
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Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act
Using premium subsidies for private coverage, an individual mandate, and Medicaid expansion, the Affordable Care Act (ACA) has increased insurance coverage. We provide the first comprehensive assessment of these provisions’ effects, using the 2012-2015 American Community Survey and a triple-difference estimation strategy that exploits variation by income, geography, and time. Overall, our model explains 60% of the coverage gains in 2014-2015. We find that coverage was moderately responsive to price subsidies, with larger gains in state-based insurance exchanges than the federal exchange. The individual mandate’s exemptions and penalties had little impact on coverage rates. The law increased Medicaid among individuals gaining eligibility under the ACA and among previously-eligible populations (“woodwork effect”) even in non-expansion states, with essentially no crowd-out of private insurance. Overall, exchange premium subsidies produced 40% of the coverage gains explained by our ACA policy measures, and Medicaid the other 60%, of which 1/2 occurred among previously-eligible individuals
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Changes in Mortality After Massachusetts Health Care Reform
Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.
Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.
Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.
Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.
Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.
Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention's Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.
Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.
Limitations: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.
Conclusion: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.
Primary Funding Source: None
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Mortality and Access to Care among Adults after State Medicaid Expansions
Background: Several states have expanded Medicaid eligibility for adults in the past decade, and the Affordable Care Act allows states to expand Medicaid dramatically in 2014. Yet the effect of such changes on adults’ health remains unclear. We examined whether Medicaid expansions were associated with changes in mortality and other health related measures.Methods:We compared three states that substantially expanded adult Medicaid eligibility since 2000 (New York, Maine, and Arizona) with neighboring states without expansions. The sample consisted of adults between the ages of 20 and 64 years who were observed 5 years before and after the expansions, from 1997 through 2007. The primary outcome was all-cause county-level mortality among 68,012 year- and countyspecific observations in the Compressed Mortality File of the Centers for Disease Control and Prevention. Secondary outcomes were rates of insurance coverage, delayed care because of costs, and self-reported health among 169,124 persons in the Current Population Survey and 192,148 persons in the Behavioral Risk Factor Surveillance System.Results Medicaid expansions were associated with a significant reduction in adjusted allcause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%;P=0.001). Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties. Expansions increased Medicaid coverage (by 2.2 percentage points, for a relative increase of 24.7%; P=0.01), decreased rates of uninsurance (by 3.2 percentage points, for a relative reduction of 14.7%; P<0.001), decreased rates of delayed care because of costs (by 2.9 percentage points, for a relative reduction of 21.3%; P=0.002), and increased rates of self-reported healthstatus of “excellent” or “very good” (by 2.2 percentage points, for a relative increase of 3.4%; P=0.04). Conclusions State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and selfreported health
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Both The 'Private Option And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults
Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the “private option”). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November–December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky’s traditional Medicaid expansion and Arkansas’s private option, which suggests that both approaches improved access among low-income adults
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