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Importance: Several state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance., Objective: To assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs., Design, Setting, and Participants: This retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023., Exposure: Initial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021., Main Outcomes and Measures: The main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs., Results: A total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (-0.01 pp; 95% CI, -0.21 to 0.19 pp) or stinting on care (-0.02 visits; 95% CI, -0.08 to 0.04 visits)., Conclusions and Relevance: In this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.

Background: Medicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. No studies have used long-run data to assess the recent use of the program by beneficiaries., Objective: To assess patterns of short- and long-term enrollment among beneficiaries, using a 10-year longitudinal panel of Michigan Medicaid eligibility data., Design: Primary analyses assessing trends in Medicaid enrollment among cohorts of existing and new beneficiaries., Setting: Administrative records from Michigan Medicaid for the period 2011 to 2020., Participants: 3.97 million Medicaid beneficiaries., Measurements: Short- and long-term enrollment in the program., Results: The sample includes 3.97 million unique beneficiaries enrolled at some point between 2011 and 2020. Among a cohort of 1.23 million beneficiaries enrolled in 2011, over half (53%) were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period (67%) on Medicaid. These beneficiaries, however, experienced substantial lapses in coverage, as only 25% were continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period., Limitation: Primary estimates from a single state., Conclusion: For many beneficiaries, Medicaid has served as their primary source of coverage for at least a decade. This pattern would justify increasing investments in the program to improve long-term health outcomes., Primary Funding Source: Self-funded.

Importance: Little is known about small-area variations in health care spending and utilization across the 3 major funders of health care in the US: Medicare, Medicaid, and private insurers., Objective: To measure regional health spending and utilization across Medicare, Medicaid, and the privately insured; to observe whether there are regions that are simultaneously low spending for all 3 payers; and to determine what factors are correlated with regional spending and utilization by payer., Design, Setting, and Participants: Observational cross-sectional analysis of the US health system in 2016 and 2017 for 241 of 306 hospital referral regions (HRRs) and 2 states. Participants include individuals with employer-sponsored coverage from Aetna, Humana, or UnitedHealth; individuals with Medicaid fee-for-service coverage in 2016 and 2017; and individuals with Medicare coverage. The analysis was carried out from January 2020 to May 2022., Main Outcomes and Measures: Spending per beneficiary and inpatient days per beneficiary by payer and overall., Results: The data include 25 381 167 individuals with employer-sponsored coverage, 69 891 299 with Medicaid coverage in 2016 and 2017, and 26 711 426 individuals with Medicare fee-for-service coverage. The percentage of enrollees who identified as female was 54.1% in the Medicaid program, 56.2% in the Medicare program, and 50.4% in private insurance. The mean (SD) age was 26.9 (21.8) years for Medicaid and 75.0 (7.9) years for Medicare enrollees; for private insurance enrollees, just age brackets were reported: 18 to 24 years (15.9%), 25 to 34 years (24.2%), 35 to 44 years (21.3%), 45 to 54 years (20.8%), and 55 to 64 years (17.8%). In 2017, the mean (SD) HRR-level spending per beneficiary was $4441 ($710) for private insurance, $10 281 ($1294) for Medicare, and $6127 ($1428) for Medicaid. Across HRRs, the correlation coefficients and 95% CIs were 0.020 (-0.106 to 0.146; P = .76) for private insurance and Medicare spending, 0.213 (0.090 to 0.330; P < .001) for private insurance and Medicaid, and 0.162 (0.037 to 0.282; P < .01) for Medicare and Medicaid. Just 3 HRRs (Boulder, Colorado; Bloomington, Illinois; and Olympia, Washington) were in the lowest spending quintile for all 3 insurance programs; 4 HRRs were in the highest (The Bronx, New York; Manhattan, New York; White Plains, New York; and Dallas, Texas). By contrast, the correlation coefficients and 95% CIs for utilization, measured in hospital days, were 0.465 (0.361 to 0.559; P < .001) for private insurance and Medicare, 0.527 (0.429 to 0.612; P < .001) for private insurance and Medicaid, and 0.278 (0.157 to 0.390; P < .001) for Medicare and Medicaid., Conclusions and Relevance: These findings suggest that payer-specific factors are correlated with health spending variation among Medicare beneficiaries, Medicaid beneficiaries, and the commercially insured and that payer-specific policies will be necessary to improve efficiency in the US health sector.

Importance: Administrative records indicate that more than half of the 80 million Medicaid enrollees identify as belonging to a racial and ethnic minority group. Despite this, disparities within the Medicaid program remain understudied. For example, we know of no studies examining racial differences in Medicaid spending, a potential measure of how equitably state resources are allocated., Objectives: To examine whether and to what extent there are differences in health care spending and utilization between Black and White enrollees in Medicaid., Design Setting and Participants: This cross-sectional study used calendar year 2016 administrative data from 3 state Medicaid programs and included 1 966 689 Black and White Medicaid enrollees. Analyses were performed between January 28, 2021, and October 18, 2021., Exposures: Self-reported race., Main Outcomes and Measures: Rates and racial differences in health care spending and utilization (including Healthcare Effectiveness Data and Information Set [HEDIS] access measures)., Results: Of 1 966 689 Medicaid adults and children (mean [SD] age, 20.3 [17.1] years; 1 119 136 [56.9%] female), 867 183 (44.1%) self-identified as non-Hispanic Black and 1 099 506 (55.9%) self-identified as non-Hispanic White. Results were adjusted for age, sex, Medicaid eligibility category, zip code, health status, and usual source of care. On average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 (95% CI, $259-$375) lower than White enrollees, a 6% difference. Among children (18 years or younger), annual spending on Black enrollees was $256 (14%) lower (95% CI, $222-$290). Adult Black enrollees also had 19.3 (95% CI, 16.78-21.84), or 4%, fewer primary care encounters per 100 enrollees per year compared with White enrollees. Among children, the differences in primary care utilization were larger: Black enrollees had 90.1 (95% CI, 88.2-91.8) fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23% difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings., Conclusions and Relevance: In this cross-sectional study of US Medicaid enrollees in 3 states, Black enrollees generated lower spending and used fewer services, including primary care and recommended care for acute and chronic conditions, but had substantially higher emergency department use. While Black enrollees had higher rates of HEDIS preventive screenings, ensuring equitable access to all services in Medicaid must remain a national priority., Competing Interests: Conflict of Interest Disclosures: Dr Wallace reported grants from Commonwealth Fund during the conduct of the study, and his spouse is the Director of Medicaid Transformation and Financing at Aurrera Health Group. Dr Lollo reported that he took a position at CVS Health after submitting the manuscript for publication. Dr Duchowny reported grants from National Institute on Aging during the conduct of the study. Mr Lavallee reported grants from the Commonwealth Fund during the conduct of the study. No other disclosures were reported., (Copyright 2022 Wallace J et al. JAMA Health Forum.)

States have increasingly outsourced the provision of Medicaid services to private managed care plans. To ensure that plans maintain access to care, many states set network adequacy standards that require plans to contract with a minimum number of physicians. In this study we used data from the period 2015-17 for four states to assess the level of Medicaid participation among physicians listed in the provider network directories of each managed care plan. We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year. Care was highly concentrated: 25 percent of primary care physicians provided 86 percent of the care, and 25 percent of specialists, on average, provided 75 percent of the care. Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries' preferences and physicians' willingness to serve Medicaid patients.

Background: Risk adjustment is used widely in payment systems and performance assessments, but the extent to which it distinguishes plan or provider effects from confounding due to patient differences is typically unknown., Objective: To assess the degree to which risk-adjusted measures of health plan performance adequately adjust for the variation across plans that arises because of differences in patient characteristics (residual confounding)., Design: Comparison between plan performance estimates based on enrollees who made plan choices (observational population) and estimates based on enrollees assigned to plans (randomized population)., Setting: Natural experiment in which more than two thirds of a state's Medicaid population in 1 region was randomly assigned to 1 of 5 plans., Participants: 137 933 enrollees in 2013 to 2014, of whom 31.1% selected a plan and 68.9% were randomly assigned to 1 of the same 5 plans., Measurements: Annual total spending (that is, payments to providers), primary care use, dental care use, and avoidable emergency department visits, all scored as plan-specific deviations from the "average" plan performance within each population., Results: Enrollee characteristics were appreciably imbalanced across plans in the observational population, as expected, but were not in the randomized population. Annual total spending varied across plans more in the observational population (SD, $147 per enrollee) than in the randomized population (SD, $70 per enrollee) after accounting for baseline differences in the observational and randomized populations and for differences across plans. On average, a plan's spending score (its deviation from the "average" performance) in the observational population differed from its score in the randomized population by $67 per enrollee in absolute value (95% CI, $38 to $123), or 4.2% of mean spending per enrollee ( P  = 0.009, rejecting the null hypothesis that this difference would be expected from sampling error). The difference was reduced modestly by risk adjustment to $62 per enrollee ( P  = 0.012). Residual confounding was similarly substantial for most other performance measures. Further adjustment for social factors did not materially change estimates., Limitation: Potential heterogeneity in plan effects between the 2 populations., Conclusion: Residual confounding in risk-adjusted performance assessments can be substantial and should caution policymakers against assuming that risk adjustment isolates real differences in plan performance., Primary Funding Source: Arnold Ventures.

Objective: To evaluate the effect of a forced disruption to Medicaid managed care plans and provider networks on health utilization and outcomes for children with persistent asthma., Data Sources: Medicaid managed care administrative claims data from 2013 to 2016, obtained from a southeastern state., Study Design: A difference-in-difference analysis compared patients' outpatient, inpatient, and emergency department (ED) utilization and receipt of recommended services before and after implementation of a statewide redistribution of patients among nine managed care plans., Data Collection/extraction Methods: Enrollment data for children with asthma were linked to the administrative claims. Children were included if they had a diagnosis of persistent asthma in 2013 and if they were enrolled continuously throughout 2014-2016., Principal Findings: Among the 28 537 children with asthma, 26% were forced to switch their managed care plan after the redistribution. Of these, 67% also switched their primary care provider (PCP). Relative to those who remained in their plan, disruption was associated with an additional 2.1 percentage-point decrease in the number of children who had an outpatient visit per quarter [95%CI -2.8, -1.3], from 71% to 66% (compared to plan stayers: 74% to 71%). Among children experiencing a change to their plan, there was overall a decrease in the proportion of children receiving an asthma-specific visit per quarter, but there was less of a decrease in children that also changed their PCP [1.6 percentage points, 95%CI 0.7, 2.5], from 9.7% to 8.3% (compared to those who did not switch their PCP: 12% to 8.6%). Indicators of asthma care quality and emergent care utilization were not significantly different between the two periods., Conclusions: While there was a decrease in the number of outpatient visits associated with forced disruption of Medicaid managed care plans for children with persistent asthma, there were no consistent associations with worse asthma quality performance or higher emergent health care utilization., (© 2021 Health Research and Educational Trust.)

Importance: Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown., Objective: To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan., Design, Setting, and Participants: This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020., Interventions: Assignment to a Medicaid-focused insurance plan or a commercial managed care plan., Main Outcomes and Measures: Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations., Results: A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching., Conclusions and Relevance: Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Background: Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain., Objectives: To investigate the association between provider cost and quality and network exit., Design: Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee's Medicaid program during the period 2010-2016., Participants: 1,966,022 recipients assigned to 9593 unique providers., Main Measures: Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers., Key Results: Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month - $21.57 [95% CI, - $41.02, - $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant., Conclusions: Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers.

Importance: Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans., Objective: To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets., Design, Setting, and Participants: This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019., Exposures: Physician participation in a Medicaid managed care or health insurance exchange plan network., Main Outcomes and Measures: The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least 1 Medicaid managed care plan or, separately, at least 1 health insurance exchange plan., Results: Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a median (interquartile range) of 63.4% (48.0%-81.3%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (31.0%-70.5%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer., Conclusions and Relevance: In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States.

Objective: To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage., Data Sources: 2011-2016 Medicaid claims from a Northeastern state., Study Design: Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis., Data Collection: We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011., Principal Findings: Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid., Conclusions: Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features., (© Health Research and Educational Trust.)

Background: Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis., Methods: We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes., Results: Providers expressed challenges effectively meeting their patients' needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice., Conclusions: Underinvestment in primary care in Medicaid may detract from providers' professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Objective: To assess the effect of the 2014 Medicaid expansion on Medicaid managed care plan quality., Data Sources: Three composite measures of plan-level quality constructed from the Health Care Effectiveness Data and Information Set., Study Setting: One hundred and sixty-three plans in 27 Medicaid expansion states and 100 plans in 14 nonexpansion states., Study Design: Quasi-experimental difference-in-differences (DID) analysis, comparing quality before (2011-13) and after (2014-15) Medicaid expansion in states that elected to expand Medicaid eligibility and those that did not., Principal Findings: Mean plan enrollment increased from 130,533 to 274,259 in expansion states and from 105,449 to 148,194 in nonexpansion states. The proportion of enrollees receiving recommended preventive care increased from 62.6 to 65.2 percent in expansion states and from 59.3 to 62.5 percent in nonexpansion states (adjusted DID: -0.7 percentage points [95% CI -2.2, 0.7]). The proportion of enrollees receiving recommended chronic disease care management increased from 65.4 to 66.0 percent in expansion states and from 62.5 to 63.1 percent in nonexpansion states (adjusted DID: 1.1 percentage points [95% CI -0.5, 2.6]). We observed similar patterns for the receipt of recommended maternity care., Conclusions: Medicaid expansion increased enrollment in managed care plans, but it did not result in erosion of quality., (© Health Research and Educational Trust.)

Health plans use selective physician networks to control costs while improving quality. However, narrow (limited) networks raise concerns about reduced access to and continuity of care. In the period 2010-15, the proportion of Medicaid managed care plans in fourteen states with narrow primary care physician networks-that is, the plans that employed 30 percent or less of those physicians in their market-declined from a peak of 42 percent in 2011 to 27 percent in 2015. On average, plans experienced a 12 percent annual turnover rate, with 34 percent of primary care physicians exiting within five years. Turnover was 3 percentage points higher in plans with narrow networks after one year, and 20 percentage points higher after five years, compared to turnover in plans with non-narrow networks. These findings suggest that efforts to maintain adequate physician networks must monitor not only the breadth of the networks, but also the continuity within them.

Importance: Medicaid recipients have consistently reported less timely access to specialists than patients with other types of coverage. By 2018, state Medicaid agencies will be required by the Center for Medicare and Medicaid Services (CMS) to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care., Objective: To compare ratings of access to specialists for adult Medicaid and commercial enrollees before and after the implementation of specialty access standards., Design, Setting, and Participants: We used Consumer Assessment of Healthcare Providers and Systems survey data to conduct a quasiexperimental difference-in-differences (DID) analysis of 20 163 nonelderly adult Medicaid managed care (MMC) enrollees and 54 465 commercially insured enrollees in 5 states adopting access standards, and 37 290 MMC enrollees in 5 matched states that previously adopted access standards., Main Outcomes and Measures: Reported access to specialty care in the previous 6 months., Results: Seven thousand six hundred ninety-eight (69%) Medicaid enrollees and 28 423 (75%) commercial enrollees reported that it was always or usually easy to get an appointment with a specialist before the policy implementation (or at baseline) compared with 11 889 (67%) of Medicaid enrollees in states that had previously implemented access standards. Overall, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences, -1.2 percentage points; 95% CI, -2.7 to 0.1), nor was there any impact of access standards on insurance-based disparities in access (0.6 percentage points; 95% CI, -4.3 to 5.4). There was heterogeneity across states, with 1 state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities., Conclusions and Relevance: Specialty access standards did not lead to widespread improvements in access to specialist physicians. Meaningful improvements in access to specialty care for Medicaid recipients may require additional interventions.

Importance: State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences., Objective: To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality., Design, Setting, and Participants: Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014., Exposures: Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program., Main Outcomes and Measures: Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries)., Results: Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience., Conclusions and Relevance: Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

The Affordable Care Act (ACA) expanded Medicaid to millions of low-income near-elderly Americans, facilitating access to health care services, but did not change income eligibility for Medicaid for those 65 years and older. Therefore, following the ACA's coverage expansion, many newly-insured older enrollees will face a complex insurance transition on their 65th birthday: they will lose Medicaid coverage and transition from Medicaid to Medicare as their primary insurer. This transition in primary health insurance coverage includes changes to benefits, patient cost-sharing, and provider reimbursement, which could have profound consequences on the use of health services and associated health outcomes for low-income seniors. Using data from 2012, we estimate that 1.6 million current Medicaid beneficiaries and an additional 1.6 to 2.9 million low-income individuals who will gain Medicaid coverage under the ACA will be likely to make this transition in the next decade. Primary care physicians and policymakers can help mitigate the potential consequences of this insurance transition by preparing patients for Medicare's more restrictive insurance coverage, encouraging patients to sign up for available low-income subsidies, and understanding how the loss of Medicaid coverage impacts out-of-pocket costs.

Importance: Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid., Objective: To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees., Design, Setting, and Participants: Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid., Main Outcomes and Measures: Self-reported access to care and annualized emergency department use., Results: Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance., Conclusions and Relevance: We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.

Importance Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans. Objective To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets. Design, Setting, and Participants This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019. Exposures Physician participation in a Medicaid managed care or health insurance exchange plan network. Main Outcomes and Measures The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least one Medicaid managed care plan or, separately, at least one health insurance exchange plan. Results Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a mean (SD) of 63.4% (20.5%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (25.2%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer. Conclusions and Relevance In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) expanded Medicaid to millions of low-income near-elderly Americans, facilitating access to health care services, but did not change income eligibility for Medicaid for those 65 years and older. Therefore, following the ACA's coverage expansion, many newly-insured older enrollees will face a complex insurance transition on their 65th birthday: they will lose Medicaid coverage and transition from Medicaid to Medicare as their primary insurer. This transition in primary health insurance coverage includes changes to benefits, patient cost-sharing, and provider reimbursement, which could have profound consequences on the use of health services and associated health outcomes for low-income seniors. Using data from 2012, we estimate that 1.6 million current Medicaid beneficiaries and an additional 1.6 to 2.9 million low-income individuals who will gain Medicaid coverage under the ACA will be likely to make this transition in the next decade. Primary care physicians and policymakers can help mitigate the potential consequences of this insurance transition by preparing patients for Medicare's more restrictive insurance coverage, encouraging patients to sign up for available low-income subsidies, and understanding how the loss of Medicaid coverage impacts out-of-pocket costs. [ABSTRACT FROM AUTHOR]