Person: Epstein, Arnold
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Epstein, Arnold
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Publication Thirty-day hospital re-admission for Medicaid enrollees with schizophrenia: the role of patient comorbidity and local health-care systems(BioMed Central, 2015) Busch, Alisa; Epstein, Arnold; McGuire, Thomas; Normand, Sharon-Lise; Frank, RichardPublication New Approaches In Medicaid: Work Requirements, Health Savings Accounts, And Health Care Access(Health Affairs (Project Hope), 2018) Sommers, Benjamin; Fry, Carrie; Blendon, Robert; Epstein, ArnoldAlternative approaches in Medicaid are proliferating under the Trump Administration. Using a novel telephone survey, we assessed views on health savings accounts, work requirements, and private vs. public coverage. Our sample included low-income non-elderly adults (N=2739) in three Midwestern states with different policies: 1) Ohio, which expanded traditional Medicaid; 2) Indiana, which expanded using health savings accounts (“POWER” Accounts); and 3) Kansas, which has not expanded. We found that coverage and access to care in 2017 were significantly higher in expansion states than in Kansas. However, compared to Ohio’s traditional expansion, cost-related barriers were more common in Indiana. Among beneficiaries eligible for Indiana’s program, 39% had not heard of POWER Accounts, and only 36% were making their required payments, meaning that nearly two-thirds were potentially subject to loss of benefits or coverage. Meanwhile, in Kansas, 77% supported expanding Medicaid, with similar attitudes towards Medicaid or private insurance. 49% of potential Medicaid enrollees in Kansas were already working, 34% were disabled, and only 11% were unemployed and would seek work if required by Medicaid. These findings suggest that currentPublication New Evidence On The Affordable Care Act: Coverage Impacts Of Early Medicaid Expansions(Health Affairs (Project Hope), 2014) Sommers, Benjamin; Epstein, Arnold; Kenney, GenevieveThe Affordable Care Act expands Medicaid in 2014 to millions of low-income adults in states that choose to participate in the expansion. Since 2010 California, Connecticut, Minnesota, and Washington, D.C., have taken advantage of the law’s option to expand coverage earlier to a portion of low-income childless adults. We present new data on these expansions. Using administrative records, we documented that the ramp-up of enrollment was gradual and linear over time in California, Connecticut, and D.C. Enrollment continued to increase steadily for nearly three years in the two states with the earliest expansions. Using survey data on the two earliest expansions, we found strong evidence of increased Medicaid coverage in Connecticut (4.9 percentage points; \(p<0.001\)) and positive but weaker evidence of increased coverage in D.C. (3.7 percentage points; \(p=0.08\)). Medicaid enrollment rates were highest among people with health-related limitations. We found evidence of some crowd-out of private coverage in Connecticut (30–40 percent of the increase in Medicaid coverage), particularly for healthier and younger adults, and a positive spillover effect on Medicaid enrollment among previously eligible parents.Publication U.S. Governors and the Medicaid Expansion — No Quick Resolution in Sight(New England Journal of Medicine (NEJM/MMS), 2013) Sommers, Benjamin; Epstein, ArnoldPublication Medicaid on the eve of expansion: a survey of state Medicaid officials on the Affordable Care Act(Allen Press, 2014) Sommers, Benjamin; Gordon, Sarah; Somers, Stephen; Ingram, Carolyn; Epstein, ArnoldTwenty-five states and Washington D.C. are expanding Medicaid in 2014 under the Affordable Care Act. We surveyed Medicaid directors in expanding states to assess expectations and implementation strategies regarding enrollment, costs, and access. Telephone interviews were conducted between July and November 2013, with most occurring before open enrollment began October 1. The response rate was 88%. Overall, expectations were a mixture of optimism and caution. Predicted enrollment was high: 86% of officials projected at least 50% participation among newly-eligible uninsured adults. Officials predicted most Medicaid applications will come via statebased Exchanges (32%), navigators (23%), or directly to Medicaid (45%); none thought Healthcare.gov would be the primary means of Medicaid enrollment. Over 95% think expanded coverage will improve beneficiaries’ health care and health. 57% expect the expansion to produce state savings; however, 29% expect net costs to their state over the next decade. 73% viewed it as “possible” or “likely” that the federal government will reduce the federal share of costs due to budget pressures. Lack of specialists accepting Medicaid (50%) and coverage churning (45%) were described as the most likely potential barriers to care. States are taking a range of approaches to facilitate enrollment and promote continuity of coverage between Medicaid and Exchanges.Publication Insurance Churning Rates For Low-Income Adults Under Health Reform: Lower Than Expected But Still Harmful For Many(Project HOPE, 2016) Sommers, Benjamin; Gourevitch, Rebecca; Maylone, Bethany; Blendon, Robert; Epstein, ArnoldChanges in insurance coverage over time, or “churning,” may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a “private option” expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months—a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts.Publication The Impact Of State Policies On ACA Applications And Enrollment Among Low-Income Adults In Arkansas, Kentucky, And Texas(Health Affairs (Project Hope), 2015) Sommers, Benjamin; Maylone, Bethany; Nguyen, Kevin; Blendon, Robert; Epstein, ArnoldStates are taking variable approaches to the Affordable Care Act (ACA) Medicaid expansion, Marketplace design, enrollment outreach, and application assistance. We surveyed nearly 3,000 low-income adults in late 2014 to compare experiences in three states with markedly different policies: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed restrictions on navigators. We found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst. Limited awareness remains a critical barrier: Fewer than half of adults had heard some or a lot about the coverage expansions. Application assistance from navigators and others was the strongest predictor of enrollment, while Latino applicants were less likely than others to successfully enroll. Twice as many respondents felt that the ACA had helped them as hurt them (although the majority reported no direct impact), and advertising was strongly associated with perceptions of the law. State policy choices appeared to have had major impacts on enrollment experiences among low-income adults and their perceptions of the ACA.Publication Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance(American Medical Association (AMA), 2016) Sommers, Benjamin; Blendon, Robert; Orav, Endel; Epstein, ArnoldImportance Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the “private option”). In addition, while coverage gains from the ACA’s Medicaid expansion are well documented, impacts on utilization and health are unclear. Objective To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA. Design, Setting, and Participants Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016. Exposures Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas. Main Outcomes and Measures Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health. Results Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (−11.6 percentage points; P < .001), reduced out-of-pocket spending (−29.5%; P = .02), reduced likelihood of emergency department visits (−6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (−7.1 percentage points with “fair/poor quality of care”; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences. Conclusions and Relevance In the second year of expansion, Kentucky’s Medicaid program and Arkansas’s private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.Publication Why States Are So Miffed about Medicaid — Economics, Politics, and the “Woodwork Effect”(New England Journal of Medicine (NEJM/MMS), 2011) Sommers, Benjamin; Epstein, ArnoldPublication Three-Year Impacts Of The Affordable Care Act: Improved Medical Care And Health Among Low-Income Adults(Health Affairs (Project Hope), 2017) Sommers, Benjamin; Maylone, Bethany; Blendon, Robert; Orav, Endel; Epstein, ArnoldMajor policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA’s coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in “excellent” self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health.