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States are increasingly the focus of health care spending reform efforts given political deadlock at the federal level. Using the Rhode Island All-Payer Claims Database (APCD) from 2016 to 2019, a modified National Uniform Claim Committee (NUCC) provider taxonomy, and the 2021 Restructured BETOS Classification System (RBCS), we evaluate professional spending trends in commercial and Medicaid populations, identify specialties and clinical service categories driving trends, and examine price and volume contributions to spending changes. We found that professional spending from 2016-2019 in Medicaid is increasing faster than professional spending in commercial (5.2% vs. 2.7% annually). We also found that nurse practitioner and physician assistant evaluation and management (E&M), behavioral health services E&M, anesthesia, diagnostic radiology imaging, and orthopedic procedures were among the largest areas of spending increase during the study period in Rhode Island. Three-year trends showed heterogeneity in whether volume or price was primarily responsible for these spending increases.

Research Objective: To explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID-19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss., Data Source: Phase 1 of the Census Bureau's Experimental Household Pulse Survey covering April 23, 2020-July 21, 2020., Study Design: We compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID-19 pandemic in states that expanded Medicaid against states that did not expand Medicaid., Data Collection/extraction Methods: Our analytical dataset was limited to 733,181 non-elderly adults aged 20-64., Principal Findings: Twenty-six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey-16% experienced job losses (e.g., layoff, furlough) due to the COVID-19 crisis, and 11% had other reasons they were not working. COVID-linked job losses were associated with a 20 (p < 0.01) percentage-point (PPT) lower likelihood of having employer-sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID-linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously., Conclusions: Our findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed., (© 2022 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

In the past 5 years, Medicaid programs have implemented administrative barriers to enrollment. The impact of these provisions on access to mental health and substance use disorder treatment has been largely unstudied. This column reviews the literature on the previous changes to Medicaid enrollment and treatment use, current policy landscape, and steps that states or localities may take to offset these administrative burdens. Redirecting savings to other safety-net programs may increase access to care, but these programs lack the comprehensive benefits provided by Medicaid. Without another backstop, the implementation of these barriers will likely exacerbate the United States' behavioral health crises.

Objective: We examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007-2009 Great Recession., Data Source: 2004-2010 Behavioral Risk Factor Surveillance System (BRFSS)., Study Design: Flexible difference-in-difference regressions were used to compare the impact of county-level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines., Data Collection/extraction Methods: Nonelderly adults (aged 19-64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics' Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state's 2007 Medicaid guidelines using data from the 2007 Current Population Survey's Annual Social and Economic Supplement., Principal Findings: A percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9-1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6-1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county-level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost-a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines., Conclusions: Increased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income., (© 2021 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies. Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers' experiences and perspectives into their program design and governance., Context: Consumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient-centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done., Methods: We conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio-recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses., Findings: First, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer-term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers' participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement., Conclusions: Sharing best practices across states could help strengthen programs' engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice., (© 2020 The Authors. The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Millbank Memorial Fund.)

Context: States face increasing Medicaid expenditures largely as a result of growing dual-eligible populations. In this article we examine self-reported community-based Medicaid participation among Medicare recipients 65 and older in California and Texas, with a particular focus on the older Mexican-origin population., Methods: We use six waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) covering the period from 1993-94 to 2010-11., Findings: The data reveal relatively high Medicaid participation rates by older individuals of Mexican origin, but significant differences between the two states. At baseline, 30% of older Mexican-origin Medicare beneficiaries in California reported receiving Medicaid compared to 41% in Texas., Conclusions: Despite California's more liberal eligibility criteria, community-dwelling Texans were more likely than Californians to report coverage at some point during the 17-year follow-up. Our data, as well as administrative data, reveal that California classifies nearly all of its community-dwelling Medicaid recipients as "full duals," meaning that they receive full benefits, whereas Texas is more likely to classify similarly poor and disabled individuals as "partial duals," meaning that they receive less coverage, thereby lowering overall program expenditures. Cost containment strategies that restrict access may be especially consequential for vulnerable Hispanic populations., (Copyright © 2019 by Duke University Press.)

To evaluate the association of state-level lack of health insurance among women of reproductive age with variation in state low birth weight (LBW) rates. This cross-section study analyzes data from the 2016–2019 Pregnancy Risk Assessment Monitoring Survey for respondents with singleton, live births. Respondents were divided into groups by state-level percent of uninsured women aged 19–44 years. Poisson regression was used to model the association between state percent uninsured and likelihood of LBW, controlling for individual sociodemographic and clinical risk factors. Sensitivity analyses were done for Medicaid and non-Hispanic Black subpopulations and alternative state characteristics, including Gini coefficients, total and public welfare expenditures, and state reproductive rights rankings. In adjusted multiple regression analyses, compared to respondents from states with <7% uninsured, respondents from states with 7% or more uninsured had an increased risk of LBW status (7–8.99% uninsured: adjusted incidence rate ratio [aIRR] 1.11, 95% confidence interval [CI] 1.04–1.18; 9–11.99% uninsured: aIRR 1.09, 95% CI 1.02–1.17; >11.99% uninsured: aIRR 1.15, 95% CI 1.08–1.22). However, there was no evident dose–response gradient. Sensitivity analyses produced virtually identical findings for subpopulations, and no other state characteristics were significant. States with the highest level of insurance coverage had a significantly lower LBW rate than other states. However, there was little evidence for greater odds of LBW with the highest levels of uninsured. Individual risk factors dominated LBW models, while state differences in income inequality, reproductive health policy, and per capita spending explained little of the variance in LBW. [ABSTRACT FROM AUTHOR]

Background: In the United States, the Affordable Care Act (ACA) pursued equity in healthcare access and treatment, but ACA implementation varied, especially limiting African Americans' gains. Marketplaces for subsidized purchase of coverage were sometimes implemented with limited outreach and enrollment assistance efforts. Reflecting state's ACA receptivity or reluctance, state's implementation may rest on sociopolitical stances and racial sentiments. Some states were unwilling to provide publicly supported healthcare to nonelderly, non-disabled adults— "the undeserving poor" —who evoke anti-black stereotypes. The present study assessed whether some states shunned Affordable Care Act (ACA) marketplaces and implemented them less vigorously than other states, leading to fewer eligible persons selecting insurance plans. It assessed if states' actions were motivated by racial resentment, because states connote marketplaces to be government assistance for unworthy African Americans. Methods: Using marketplace and plan selection data from 2015, we rated states' marketplace structures along a four-level continuum indicating greater acceptance of marketplaces, ranging from states assuming sole responsibility to minimal responsibility. Using national data from a four-question modern racism scale, state-wide racial resentment estimates were estimated at the state level. Analysis assessed associations between state levels of racial resentment with states' marketplace structure. Further analysis assessed relationships between both state levels of racial resentment and states' marketplace structure with states' consumer plan selection rates—representing the proportion of persons eligible to enroll in insurance plans who selected a plan. Results: Racial resentment was greater in states with less responsibility for the administration of the marketplaces than actively participating states. States higher in racial resentment also showed lower rates of plan selection, pointing to less commitment to implementing marketplace provisions and fulfilling the ACA's coverage-improvement mission. Differences persisted after controlling for differences in conservatism, uninsurance, poor health, and rejection of Medicaid expansion. Conclusions: Resentment of African Americans' purported irresponsibility and entitlement to government assistance may interfere with states structuring and operating marketplaces to maximize health insurance opportunities for everyone available under the ACA. Trial registration: N/A. [ABSTRACT FROM AUTHOR]

The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p <.001), SIM Round 2 (4.7 vs. 7.0 capabilities, p <.001), and non-SIM (4.2 vs. 6.3 capabilities, p <.001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends. [ABSTRACT FROM AUTHOR]

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state offi- cials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects. [ABSTRACT FROM AUTHOR]

The article discusses a study focusing on the views of state legislators on the Medicaid program in the U.S. Topics discussed include the legislators' priorities for Medicaid reform and policy changes; the difference in views of Democrats and Republicans regarding healthcare spending; and the preference of Republicans for cost-sharing for Medicaid recipients.

State health policy making is rarely based on evidence derived from empirical analysis. An exception is an innovative policy established in 2005 in Washington State (Senate Bill [SB] 5763) to provide funding (approximately $30 million) to expand access to substance abuse (SA) treatment for Medicaid beneficiaries. The authors analyzed Medicaid claims data and other administrative data over a 7-year period, July 2001 through June 2008, for three cohorts of welfare clients (n ≈ 44,000) to assess the effect of SA treatment on health care expenditures. Regression analysis showed SA treatment to be associated (p < .001) with per member per month expenditure savings of approximately $160 to $385 depending on the welfare cohort. The aggregate annualized estimated saving ($16.8 million) equaled the cost-saving goal of SB 5763. While it may be tempting for policy makers to cut funding for SA treatment, this may be counterproductive and in the long-run increase Medicaid costs. [ABSTRACT FROM PUBLISHER]

This quasi-experimental study examines the impact of Idaho’s wellness incentive program, which rewards children with CHIP (Children’s Health Insurance Programs) who are up-to-date with well-child visits with $30 in credits per quarter for use toward their CHIP premiums. Between baseline and the second year of implementation, the percentage of CHIP children who were up-to-date with well-child visits increased by 116% (from 23% to 49%), compared with a 13% increase (from 29% to 32%) among children with Medicaid, who were not eligible for the incentive. The incentive program had a greater impact on children who were recommended to have one annual well-child visit compared with those recommended to have two to four annual visits. The program was not, however, more effective for those whose premiums were fully covered by the reward compared with those whose premiums were partially covered. This study provides encouraging evidence to states about using consumer financial incentives for increasing preventive care use. [ABSTRACT FROM PUBLISHER]