Epstein, Arnold M.

Sommers, Benjamin Daniel

New England Journal of Medicine

Harvard University - DASH 

Medicaid Expansion — The SoftUnderbelly of Health Care Reform?The Harvard community has made thisarticle openly available.  Please share  howthis access benefits you. Your story mattersCitation Sommers, Benjamin D., and Arnold M. Epstein. 2010. “MedicaidExpansion — The Soft Underbelly of Health Care Reform?” N Engl JMed 363 (22) (November 25): 2085–2087. doi:10.1056/nejmp1010866.Published Version doi:10.1056/NEJMp1010866Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:26568344Terms of Use This article was downloaded from Harvard University’s DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth at http://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAAn engl j med 363;22 nejm.org november 25, 2010PERSPECTIVE2085Medicaid Expansion — The Soft Underbelly of Health Care Reform?Benjamin D. Sommers, M.D., Ph.D., and Arnold M. Epstein, M.D.Medicaid Expansion — The Soft Underbelly of Health Care Reform?Expanding health insurance to cover Americans who are currently uninsured, with the ul­timate goal of improving access to care, is arguably the most critical objective of the recently enacted health care reform legis­lation. In large part, the success or failure of health care reform will hinge on the achievement of this goal.The Patient Protection and Af­fordable Care Act (ACA) incor­porates two strategies for expand­ing coverage. First is a mandate for all individuals to purchase in­surance, coupled with the crea­tion of state­based insurance “ex­changes” and subsidies to help individuals whose incomes are below 400% of the federal pov­erty level to purchase coverage from private companies. Second is an expansion of Medicaid, un­derwritten by the federal govern­ment, to cover all adults whose family income is below 133% of the federal poverty level; children of families with incomes below this cutoff are already eligible for public coverage.Estimates from the Congres­sional Budget Office (CBO) sug­gest that each of these approach­es will add 16 million enrollees, for a total of 32 million newly in­sured Americans. However, there is obvious cause for uncertainty about the estimates of how many will obtain coverage through the insurance exchanges. Debate is al­ready under way about the effec­tiveness of the mandate, what constitutes a sufficient subsidy, and how the exchanges will be implemented.By comparison, the effect of the Medicaid expansion would appear to be easier to predict. Because expanded coverage will be free to the states (at least through 2016) and to uninsured persons whose income qualifies them for it, it is tempting to as­sume that almost all individuals who are eligible will enroll. But eligibility for health insurance does not always translate into ac­tual enrollment — as evidenced by the millions of uninsured adults who are already eligible for Medicaid under current law. Moreover, the apparent simplici­ty of expanding Medicaid uni­formly to include people in a given income category belies the tremendous heterogeneity among the 50 state Medicaid programs, which vary in terms of enroll­ment procedures, demographics of the target population, and state politics. These differences will complicate any attempt to im­plement such a broad expansion and cast serious doubt on the precision of predictions about its outcome.Medicaid is currently charac­terized by highly variable partici­pation rates among eligible adults in different states. We used data from the 2007 through 2009 Cur­rent Population Survey (CPS), a nationally representative survey conducted by the Census Bureau, to estimate state participation rates among U.S. citizens 19 to 64 years of age who are current­ly eligible for Medicaid and have no other health insurance. The el­igibility rules come from public data sources,1-4 and our estimates were adjusted for previously doc­umented underreporting of Med­icaid coverage in the CPS.5 The scatter plot shows the Medicaid participation rates by state on the vertical axis. The horizontal axis indicates the percentage of each state’s adult population that will become newly eligible for Medicaid in 2014 under the ACA. In other words, the vertical axis measures how well states cur­rently perform in enrolling eli­gible adults and the horizontal axis measures the extent of the new task each state will face come 2014.Three key results emerge from this analysis. First, participation rates are far from ideal, with a national average of 61.7% of eli­gible individuals. Second, Med­icaid participation is highly var­iable, with rates ranging from just under 44% in Oklahoma, Oregon, and Florida to 80% in Massachusetts and 88% in the District of Columbia. Third, the states that will have the greatest number of newly eligible adults under health care reform have, if anything, been historically worse (but not significantly so) at find­ing and keeping eligible adults enrolled in Medicaid (regression coefficient, ­0.46; 95% confidence interval, ­1.13 to 0.21).Our knowledge of the factors affecting Medicaid enrollment and retention among eligible adults is incomplete. Administrative ob­stacles almost surely play a key role. Unless they complete the multipage application and provide documentation of income and residency, eligible individuals sim­The New England Journal of Medicine Downloaded from nejm.org on April 18, 2016. For personal use only. No other uses without permission.  Copyright © 2010 Massachusetts Medical Society. All rights reserved. PERSPECTIVEn engl j med 363;22 nejm.org november 25, 20102086ply never get enrolled. Maintain­ing enrollment also poses a chal­lenge, since federal law requires that states verify an enrollee’s eligibility annually, and some states choose to do so more fre­quently. The prevalence and qual­ity of Medicaid managed care, provider reimbursement rates, and outreach efforts may also play a role in enrolling and re­taining eligible adults.Official projections regarding Medicaid enrollment under the ACA come from the CBO, which does not release the details of its calculations. These projections require numerous assumptions about population growth and eco­nomic conditions over time, as well as about how many adults will switch from private cover­age to Medicaid, and results vary depending on the data source. That said, on the basis of the CPS data, we predict that enroll­ing 16 million people by 2019 will require substantial increas­es in participation among unin­sured adults and children who are already eligible, plus a take­up rate among newly eligible adults that will be much higher than the current level of 61.7%. Our estimates suggest that par­ticipation rates among all eligi­ble individuals who are not pri­vately insured would need to be in the range of 80%.Such a scenario would require a fundamental shift in Medicaid implementation, although such a shift is plausible, given the dramatic changes brought about by health care reform — in par­ticular, implementation of the individual mandate. Massachu­setts, which has such a mandate, has achieved Medicaid take­up rates of roughly 80%. Other fac­tors, such as the media atten­tion that will surround the ex­pansion and simplification of eligibility rules, may also lead to higher rates of participation than the program currently enjoys.However, other factors suggest that takeup rates under the ACA may not even reach current levels of participation, let alone far ex­ceed them. As the regression line on the scatter plot shows, the na­tional average is skewed by higher levels of Medicaid enrollment in states in which the expansion will have less impact because so many of the adults in question are al­ready eligible. Furthermore, new­ly eligible, higher­income adults may be less familiar with welfare procedures or more sensitive to the stigma of enrolling in a pub­lic program than are those who are currently eligible. Adults with disabilities make up a dispropor­tionate share of current Medicaid enrollees, with a traditionally higher participation rate (79% in our sample), whereas the over­whelming majority of adults who will become eligible for Medicaid under the ACA do not have a dis­ability. Finally, the federal man­date does not apply to adults with incomes below the Internal Rev­enue Service tax­filing threshold ($9,350 for single adults and $18,700 for married adults filing jointly, according to the 2009 rules); in our sample, this group accounted for slightly more than half of all uninsured adults who will be eligible for Medicaid.The good news is that imple­mentation of the ACA’s Medic­aid expansion is still more than 3 years away. This window cre­ates a critical opportunity for states to evaluate their Medicaid enrollment procedures and lay the groundwork for a successful ex­pansion. An important issue will Medicaid Expansion — The Soft Underbelly of Health Care Reform?Medicaid Enrollment among Eligible Adults (%)Adults Newly Eligible for Medicaid under Health Reform (%)90504007060800 5 10 15 20MEMARICTVT NYHIILINSDNDMIPADCIDWVMTNCMOKSTN KYALTXAR LAMSNMOKFLGANVORAZDEWAWIMNIACANHAKMDCOVAUTWYSCNEOHNJAUTHOR:FIGURE:RETAKE:SIZE4-C H/TLine ComboRevisedAUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset.Please check carefully.1st2nd3rdSommers1 of 1ARTIST:TYPE:ts12-02-10JOB: 36323 ISSUE:2x colMedicaid Enrollment among Currently Eligible Adults (2007 through 2009) and Percentage of Adults Who Will Become Eligible in 2014 under Health Care Reform, by State.The population sample was restricted to eligible adults with no other form of health insurance; noncitizens were excluded from the analysis. Results are based on an analysis of data from the Current Population Survey of 2007 through 2009. The red line shows the regression equation: Enrollment = 0.66 − 0.46 × Newly Eligible (P = 0.17).The New England Journal of Medicine Downloaded from nejm.org on April 18, 2016. For personal use only. No other uses without permission.  Copyright © 2010 Massachusetts Medical Society. All rights reserved. n engl j med 363;22 nejm.org november 25, 2010PERSPECTIVE2087be how states approach the in­teractions between the insurance exchanges and Medicaid; adults with incomes close to 133% of the federal poverty level may not know which program they should apply to, and states should take steps to prevent uninsured adults from falling through the cracks. Other approaches to streamlin­ing Medicaid enrollment will also need to be considered. The natu­ral experiment of having 50 dif­ferent states with highly variable participation rates offers ample opportunity for exploring the policy options.The impending Medicaid ex­pansion will be the single big­gest change in the program since its inception in 1965. The suc­cess of health care reform in im­proving access to care will large­ly depend on whether newly eligible individuals enroll in Med­icaid and remain enrolled. Though the details of enrollment out­reach, application processes, and renewal procedures may not be glamorous, they hold the key to success in expanding health in­surance coverage to millions of needy Americans.Disclosure forms provided by the au­thors are available with the full text of this article at NEJM.org.From the Department of Health Policy and Management, Harvard School of Public Health, and the Division of General Medi-cine, Brigham and Women’s Hospital — both in Boston.This article (10.1056/NEJMp1010866) was updated on December 29, 2010, at NEJM.org.1. Where are states today? Medicaid and state-funded coverage eligibility levels for low-income adults. Washington, DC: Kaiser Family Foundation, 2009. (http://www.kff.org/medicaid/upload/7993.pdf.)2. Medicaid financial eligibility: primary path-ways for the elderly and people with disabili-ties. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2010. (http://www.kff.org/medicaid/8048.cfm.)3. Ross DC, Horn A, Marks C. 2008. Health coverage for children and families in Medic-aid and SCHIP: state efforts face new hur-dles. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2008. (http://www.kff.org/medicaid/7740.cfm.)4. Ross DC, Cox L, Marks C. 2007. Resuming the path to health coverage for children and parents: a 50-state update on eligibility rules, enrollment and renewal procedures, and cost-sharing practices in Medicaid and SCHIP in 2006. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2007. (http://www.kff.org/medicaid/7608a.cfm.)5. Call KT, Davidson G, Davern M, Nyman R. Medicaid undercount and bias to estimates of uninsurance: new estimates and existing evidence. Health Serv Res 2008;43:901-14.Copyright © 2010 Massachusetts Medical Society.Medicaid Expansion — The Soft Underbelly of Health Care Reform?Pharmaceutical Marketing and the New Social MediaJeremy A. Greene, M.D., Ph.D., and Aaron S. Kesselheim, M.D., J.D., M.P.H.Facebook and Twitter, the larg­est social media Web sites, have more than 350 million users worldwide, and surveys indicate that 60% of Americans turn first to the Internet when seeking health­related information.1 It is therefore surprising that the phar­maceutical and medical­device industries have been slow to es­tablish a social media presence. The drug industry allocated less than 4% of the more than $4 bil­lion it spent on direct­to­consumer advertising to Internet outlets in 2008, and only a tiny fraction of that was for social networking sites.2 In the next year, however, the proportion may change sub­stantially.Since the Pure Food and Drug Act was passed in 1906, control by the Food and Drug Adminis­tration (FDA) over drug labels has been one of its most powerful tools for protecting the public’s health. To encourage appropriate use of prescription drugs, the FDA has sought to ensure that promo­tional statements make claims about approved indications only and neither overstate the benefits nor understate the risks. A major concern has been finding ways to ensure “fair balance,” with ade­quate attention given to informa­tion about risks as well as ben­efits. When this balance is not achieved, inappropriate promo­tional statements can contribute to misuse of drugs, with danger­ous consequences.As communications media have evolved, manufacturers have tend­ed to wait for the FDA to estab­lish explicit codes of acceptable marketing practices before devot­ing substantial resources to a new medium. Direct­to­consumer ad­vertising in print media proceed­ed tentatively until the FDA issued a guidance document in 1985 es­tablishing a standard format for providing a “brief summary” of risks.3 Prescription­drug advertis­ing in broadcast media was sim­ilarly minimal until the FDA’s guidance revised the definition of “adequate” risk information in 1997, and again in 1999, to per­mit broadcast media to include references to a toll­free number or Web site where consumers could obtain more detailed de­scriptions of a product’s adverse effects. In the wake of these FDA actions, spending on direct­to­con­sumer advertising mushroomed from $579 million in 1996 to $1.3 billion in 1998 and to over $4 billion in 2008.In November 2009, the FDA The New England Journal of Medicine Downloaded from nejm.org on April 18, 2016. For personal use only. No other uses without permission.  Copyright © 2010 Massachusetts Medical Society. All rights reserved. 

Medicaid Expansion — The Soft Underbelly of Health Care Reform?

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Medicaid Expansion — The Soft Underbelly of Health Care Reform?

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