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Between 1996 and 2015, mean annual increases in per visit emergency department (ED) expenditures were significantly greater for private insurance than Medicare, Medicaid, and no insurance, with no corresponding difference in ED charges. Expenditures as a proportion of charges decreased for all insurers over time. Private insurance had the highest expenditure-to-charge ratio in each year.

Delivering food to nutritionally vulnerable patients is important for addressing these patients' social determinants of health. However, it is not known whether food delivery programs can reduce the use of costly health services and decrease medical spending among these patients. We sought to determine whether home delivery of either medically tailored meals or nontailored food reduces the use of selected health care services and medical spending in a sample of adults dually eligible for Medicare and Medicaid. Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program. Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending. These findings suggest the potential for meal delivery programs to reduce the use of costly health care and decrease spending for vulnerable patients.

Decisions by states about whether to expand Medicaid under the Affordable Care Act (ACA) have implications for hospitals' financial health. We hypothesized that Medicaid expansion of eligibility for childless adults prevents hospital closures because increased Medicaid coverage for previously uninsured people reduces uncompensated care expenditures and strengthens hospitals' financial position. We tested this hypothesis using data for the period 2008-16 on hospital closures and financial performance. We found that the ACA's Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion. Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

Medicaid expansion in Arizona has helped the Indian Health Service and tribally run health systems improve access., (Project HOPE—The People-to-People Health Foundation, Inc.)

As the US health sector evolves and changes, it is informative to estimate and analyze health spending trends at the state level. These estimates, which provide information about consumption of health care by residents of a state, serve as a baseline for state and national-level policy discussions. This study examines per capita health spending by state of residence and per enrollee spending for the three largest payers (Medicare, Medicaid, and private health insurance) through 2014. Moreover, it discusses in detail the impacts of the Affordable Care Act implementation and the most recent economic recession and recovery on health spending at the state level. According to this analysis, these factors affected overall annual growth in state health spending and the payers and programs that paid for that care. They did not, however, substantially change state rankings based on per capita spending levels over the period., (Project HOPE—The People-to-People Health Foundation, Inc.)

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7 percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs., (Project HOPE—The People-to-People Health Foundation, Inc.)

Eligibility for and enrollment in Medicaid can vary with economic recessions, recoveries, and changes in personal income. Understanding how Medicaid responds to such forces is important to budget analysts and policy makers tasked with forecasting Medicaid enrollment. We simulated eligibility for Medicaid for the period 2005-14 in two scenarios: assuming that each state's eligibility rules in 2009, the year before passage of the Affordable Care Act (ACA), were in place during the entire study period; and assuming that the ACA's expanded eligibility rules were in place during the entire period for all states. Then we correlated the results with unemployment rates as a measure of the economy. Each percentage-point increase in the unemployment rate was associated with an increase in the share of people eligible for Medicaid of 0.32 percentage point under the 2009 eligibility rules and 0.77 percentage point under the ACA rules. Our simulations showed that the ACA expansion increased Medicaid's responsiveness to changes in unemployment. For states that have not expanded Medicaid eligibility, our analysis demonstrates that increased responsiveness to periods of high unemployment is one benefit of expansion., (Project HOPE—The People-to-People Health Foundation, Inc.)

After accounting for supplemental payments, we found that in 2011, disproportionate-share hospitals, on average, received gross Medicaid payments that totaled 108 percent of their costs for treating Medicaid patients but only 89 percent of their costs for Medicaid and uninsured patients combined. However, these payments were reduced by approximately 4-11 percent after we accounted for provider taxes and local government contributions that are used to help finance Medicaid payments., (Project HOPE—The People-to-People Health Foundation, Inc.)

Substance use disorders affect 12% of Medicaid beneficiaries. The prescription drug epidemic and growing need for treatment of alcohol and opioid dependence have refocused states' attention on their provision of substance use disorder treatment services, including medications. This study characterized how Medicaid programs cover these treatment medications. Data were from 2013 Medicaid pharmacy documents, 2011 and 2012 Medicaid state drug utilization records, and a 2013 American Society of Addiction Medicine survey. Results showed that only 13 state Medicaid programs included all medications approved for alcohol and opioid dependence on their preferred drug lists. The most commonly excluded were extended-release naltrexone (19 programs), acamprosate (19 programs), and methadone (20 programs). For combined buprenorphine-naloxone, 48 Medicaid programs required prior authorization, and 11 programs used 1- to 3-year lifetime treatment limits. Given the chronic nature of substance use disorders and the overwhelming evidence supporting ongoing coverage for many of these medications, states may want to reexamine substance use disorder benefits., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Medicaid has grown exponentially since the mid-1980s, during both conservative Republican and liberal Democratic administrations. How has this happened? The answer is rooted in three political variables: interest groups, political culture, and American federalism. First, interest-group support (from hospitals, nursing homes, and insurers) is more influential than the fragmented group opposition (from underpaid office-based physicians). Second, Medicaid provides a partial counterweight to conservative charges of a federal health care takeover because of the states' roles in administering the program. Third, Medicaid's intergovernmental fiscal partnership creates financial incentives for state and federal officials to expand enrollment-expansions that these policy makers often favor, given the program's increasingly important role in the nation's health care system. This institutional dynamic is here called catalytic federalism., (Project HOPE—The People-to-People Health Foundation, Inc.)

Medicaid disproportionate-share hospital (DSH) payments are expected to decline by $35.1 billion between fiscal years 2017 and 2024, a reduction brought about by the Affordable Care Act (ACA) and recent congressional action. DSH payments have long been a feature of the Medicaid program, intended to partially offset uncompensated care costs incurred by hospitals that treat uninsured and Medicaid populations. The DSH payment cuts were predicated on the expectation that the ACA's expansion of health insurance to millions of Americans would bring about a decline in many hospitals' uncompensated care costs. However, the decision of twenty-five states not to expand their Medicaid programs, combined with residual coverage gaps, may leave as many as thirty million people uninsured, and hospitals will bear the burden of their uncompensated care costs. We sought to identify the hospitals that may be the most financially vulnerable to reductions in Medicaid DSH payments. We found that of the 529 acute care hospitals that will be particularly affected by the cuts, 225 (42.5 percent) are in weak financial condition. Policy makers should recognize that decreases in revenue may affect these hospitals' ability to give vulnerable populations access to care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion., (Project HOPE—The People-to-People Health Foundation, Inc.)

Starting in 2014, many low-income adult residents of states that forgo the Affordable Care Act's expansion of Medicaid would be eligible for that program if they moved to a state that had chosen to expand its coverage. Some of these people may migrate to receive coverage, thereby increasing costs for states that have expanded the program. This is known as the "welfare magnet" hypothesis, a claim that geographic variation in social programs induces the migration of welfare recipients to places with more generous benefits or eligibility. To investigate whether such spillover effects are likely, we used data from the Current Population Survey to examine the migration patterns of low-income people before and after recent expansions of public insurance in Arizona, Maine, Massachusetts, and New York. Using difference-in-differences analysis of migration in expansion and control states, we found no evidence of significant migration effects. Our preferred estimate was precise enough to rule out net migration effects of larger than 1,600 people per year in an expansion state. These results suggest that migration will not be a common way for people to obtain Medicaid coverage under the current expansion and that interstate migration is not likely to be a significant source of costs for states choosing to expand their programs.