Person:

Epstein, Arnold

Twenty-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.

Background: The Affordable Care Act (ACA) dramatically expands Medicaid in 2014 in participating states. Meanwhile, six states have already expanded Medicaid since 2010 to some or all of the low-income adults targeted under health reform. We undertook an in-depth exploration of these six “early-expander” states—California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington—through interviews with high-ranking Medicaid officials. Methods: We conducted semi-structured interviews with 11 high-ranking Medicaid officials in six states and analyzed the interviews using qualitative methods. Interviews explored enrollment outreach, stakeholder involvement, impact on beneficiaries, utilization and costs, implementation challenges, and potential lessons for 2014. Two investigators independently analyzed interview transcripts and iteratively refined the codebook until reaching consensus. Results: We identified several themes. First, these expansions built upon pre-existing state-funded insurance programs for the poor. Second, predictions about costs and enrollment were challenging, indicating the uncertainty in projections for 2014. Other themes included greater than anticipated need for behavioral health services in the expansion population, administrative challenges of expansions, and persistent barriers to enrollment and access after expanding eligibility—though officials overall felt the expansions increased access for beneficiaries. Finally, political context—support or opposition from stakeholders and voters—plays a critical role in shaping the success of Medicaid expansions. Conclusions: Early Medicaid expansions under the ACA offer important lessons to federal and state policymakers as the 2014 expansions approach. While the context of each state’s expansion is unique, key shared experiences were significant implementation challenges and opportunities for expanding access to needed services.

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.

States 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.

Changes 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.

Importance 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.