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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
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Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Specialty Care Access for Medicaid Enrollees in Expansion States
Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Health Insurance Literacy: Disparities by Race, Ethnicity, and Language Preference
Victor G. Villagra, MD; Bhumika Bhuva, MA; Emil Coman, PhD; Denise O. Smith, MBA; and Judith Fifield, PhD

Did Medicaid Expansion Matter in States With Generous Medicaid?

Alina Denham, MS; and Peter J. Veazie, PhD
Medicaid expansion significantly increased Medicaid coverage of the low-income population in New York and, specifically, that among the working poor in New York and Massachusetts.

Objectives: It is unclear whether the Medicaid expansion under the Affordable Care Act had an effect on coverage in states with relatively generous pre-expansion Medicaid eligibility levels. We examined the effect of the Medicaid expansions on Medicaid coverage in 4 generous states: New York, Vermont, Massachusetts, and Delaware.

Study Design: We used the American Community Survey (2011-2016) to estimate effects on coverage among nonelderly adults with incomes up to 138% of the federal poverty level.

Methods: We estimated differences in differences (DID) in marginal probabilities following probit models, comparing New York, Vermont, Massachusetts, and Delaware with nonexpansion states on the East Coast.

Results: There is strong evidence of the effect in New York: DID estimates ranged from 3.3 to 5.2 percentage points. There is weak or no evidence of coverage gains in the other 3 states. Pronounced effects were found among the racial/ethnic majority (white, non-Hispanic white, and nonblack populations) in New York, as well as the working poor and previously eligible in New York and Massachusetts.

Conclusions: Even in states with relatively generous pre-expansion Medicaid programs, the expansion can produce nontrivial coverage gains, as evidenced by New York. Our findings of spillover effects may indicate the relative importance and success of a simplified enrollment process and increased media coverage in boosting enrollment in Medicaid. Our subgroup analyses highlight a potential need to improve access to office-based care to accommodate the growing population of the working poor on Medicaid and potential changes in the Medicaid risk pool served by managed care organizations and subsequent decreases in capitated payments.

Am J Manag Care. 2019;25(3):129-134
Takeaway Points
  • New York, which had generous pre-expansion Medicaid eligibility levels, experienced nontrivial gains in Medicaid coverage following the Affordable Care Act Medicaid expansion.
  • Together with Vermont, Massachusetts, and Delaware, New York has been neglected in some Medicaid expansion research; however, given the coverage gains, it should be seen as a legitimate expansion state.
  • Our findings of spillover effects suggest that a simplified enrollment process and increased media coverage had a strong impact on Medicaid uptake; these could be effective strategies to boost enrollment.
  • Coverage gains among the working poor were large in New York and Massachusetts. Managed care organizations may expect an improved Medicaid risk pool after state Medicaid expansions and need to emphasize access to office-based care.
As of January 2019, 36 states and the District of Columbia have adopted or chosen to adopt Medicaid expansion under the Affordable Care Act (ACA).1 For most states, the ACA Medicaid expansion signified substantial increases in eligibility thresholds for nonelderly adults. One of the main groups to which the ACA Medicaid expansion extends coverage is childless adults—a category that was not previously mandated to be covered by Medicaid and was not eligible for Medicaid in 44 states as of 2011.2 Under the ACA, in states that choose to expand Medicaid, individuals with incomes at or below 133% (138% under the new income formula) of the federal poverty level (FPL) are eligible for Medicaid, including childless adults and parents.

There is compelling evidence that Medicaid expansion resulted in significant reductions in the uninsured rate and gains in Medicaid coverage nationally. Results from studies comparing Medicaid expansion states with nonexpansion states have shown greater decreases in the uninsured rate in states with expansions after 2 years,3-9 with the coverage gains sustained through the beginning of 2018.10,11 One analysis found that roughly 60% of the reduction in the uninsured rate in 2014-2015 was due to increases in Medicaid coverage.12 Increases in overall insurance coverage or Medicaid coverage have been reported for such demographic groups as low-income nonelderly adults13-15 and more specifically among low-income nonelderly childless adults,6,14,16 both in rural and urban areas17; low-income nonelderly parents6,16,18; nonelderly adults with low educational attainment6,16,19; and groups of different races and ethnicities: white,19-21 Hispanic,19-22 and black19,21 individuals.

The majority of the existing studies have focused on the effects of the ACA Medicaid expansion on coverage across the nation; however, questions remain as to whether states that had relatively generous Medicaid programs before the ACA expansion also experienced coverage gains. We sought to improve our understanding of the impact of the ACA Medicaid expansion in 4 such states: New York, Vermont, Massachusetts, and Delaware. These states had extensive health insurance coverage of their low-income populations by the time that federally funded Medicaid expansion through the ACA became available in 2014. New York’s Family Health Plus program covered childless adults with incomes up to 100% of the FPL and parents with incomes up to 150% of the FPL. Vermont Health Access Plan provided coverage to childless adults with incomes up to 150% of the FPL and parents with incomes up to 185% of the FPL. In Massachusetts, parents with incomes up to 133% of the FPL were eligible for Medicaid, and childless adults with incomes below 100% of the FPL were able to obtain limited coverage under the MassHealth program. In Delaware, nonelderly adults, whether childless or parents, with incomes up to 100% of the FPL were covered prior to 2014.23

Because of these generous eligibility levels prior to the ACA Medicaid expansion, some researchers have assumed that New York, Vermont, Massachusetts, and Delaware did not have true Medicaid expansions in 2014: These states have been viewed as nonexpansion, control states in some analyses6,19,24 and have been excluded from others, seen as neither true expansion nor nonexpansion states.13,25 Medicaid decision makers could be misled by this research if the assumption did not hold that these states were not, in effect, Medicaid expansion states. Furthermore, if these generous states did in fact experience gains in Medicaid coverage, national analyses that fail to include them as expansion states may underestimate the effects of Medicaid expansion on other outcomes, such as healthcare utilization, quality of care, and health.

The purpose of our study was to examine whether Medicaid expansion had an effect on Medicaid coverage in states with previously generous Medicaid programs: New York, Vermont, Massachusetts, and Delaware. Although Washington, DC, has also been treated as a control state or excluded from analyses by some researchers, we chose not to include it because it represents an early Medicaid expansion under the ACA, rather than a prior generous Medicaid or Medicaid-like program, and its effect on coverage has been investigated previously.26 In this study, we present evidence that Medicaid expansion resulted in significant coverage gains in New York.

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