A guest newsletter from health policy experts
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Friday, January 27, 2023 | The Latest Research, Commentary, And News
From Health Affairs
Dear John,
Today's newsletter includes a guest essay by Sujoy Chakravarty of
Rutgers University and Asako Moriya from the Agency for Healthcare
Research and Quality.
ACA Medicaid Expansion And Preventable Hospitalizations
In a recently published Health Affairs article, we presented evidence
that the 2014 Affordable Care Act (ACA) Medicaid expansions decreased
disparities in preventable hospitalizations and emergency department
(ED) visits
<[link removed]>
between non-Hispanic Black and White adults by 10-14 percent. Our
analysis used hospital discharge data from twenty-nine states
<[link removed]>.
The effects are significant in the context of the large disparities that
existed prior to 2014. Rates of preventable hospitalizations and ED
visits for non-Hispanic Black adults were 2.1 to 2.7 times those of
non-Hispanic White adults in 2011-13.
Our study period, which extended to five years post-ACA, was designed to
capture effects on disparities that may have occurred with a substantial
lag following policy implementation.
Our analysis of disparities across all payers captured the direct impact
of Medicaid expansion on individuals with Medicaid coverage, as well as
the spillover effect on others, including uninsured people, for whom
increased demand in the face of physician supply constraints may result
in decreased access and worsening disparities.
Preventable hospitalizations and ED visits can occur due to inadequate
access to ambulatory or primary care in the community, and minority
populations are likely to experience disproportionate barriers to such
services.
Our results suggest that the increase in coverage from the Medicaid
expansion facilitated access to community-level care, thus addressing
some of these disparities.
Encouraging as these findings are, the substantial increase in the
number of Medicaid beneficiaries, due to the 2014 Medicaid expansions,
underscores the importance of focusing on service delivery processes
that need to be optimized to improve access to care, quality of care,
and health.
We identify two notable efforts in this direction.
First is the shift toward Medicaid value-based purchasing programs that
have potential to improve population health management through state
initiatives such as Health Homes, Behavioral Health Integration, Sharing
Savings Programs and Delivery System Reform Incentive Programs.
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Second is the inclusion of social determinants of health (SDOH) or
health-related social needs in Medicaid-covered services by the Centers
for Medicare and Medicaid Services, recognizing their importance for
improving health outcomes and reducing health disparities
<[link removed]>.
Fruitful avenues for future research include examining the effectiveness
of ongoing and proposed delivery system and payment reforms, their
potential for improving population health, and the ways in which
patient, provider, community, and health system factors determine
health.
Medicaid 1115 demonstrations offer states flexibility
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beyond the original statutes to provide upstream services including
housing, transportation, and nutrition support. An important area of
future research would examine the impact of such SDOH on health and
equity. AHRQ's SDOH database
<[link removed]> provides a rich source
of information for tracking this at the county, ZIP code, and census
tract level.
Finally, some salient points related to our study on health care reforms
and racial/ethnic disparities are worth noting:
1. Increases in access occurred with a time lag: Increased insurance
coverage can improve access to ambulatory care, which could lead to
better management of chronic care and hence decrease preventable
hospitalizations or ED visits, but this process can take time.
We found in our study that the change in ED visits was close to zero
from 2013 to 2014 and a statistically significant decrease in ED visits
did not occur until 2017 to 2018.
2. Benefits of all-payer analysis: We studied the effects of the ACA
Medicaid expansion, using the population-based rates of preventable
hospitalizations (or ED visits) aggregated across payers.
Reviewers and seminar attendees sometimes asked, "Why not use the rate
of Medicaid-covered preventable hospitalizations (ED visits) rates as an
outcome?" One reason is that the Medicaid-covered rates would exclude
utilization by newly ACA enrolled beneficiaries in the pre-expansion
period.
Additionally, as our anonymous reviewer helpfully pointed out,
Medicaid-covered rates may not be suitable even for examining ambulatory
care changes within the Medicaid system.
This is because they were driven by inadequate ambulatory care
<[link removed]>
among people who were uninsured but transitioned to Medicaid at the time
of hospitalization.
3. Patterns of racial/ethnic disparities: While we found large
disparities between non-Hispanic Black and White non elderly adults
prior to the ACA, differences in preventable hospitalization/ED visit
rates between Hispanic and non-Hispanic White adults were small or
nonexistent.
These patterns are in contrast to the large disparities in COVID-19
hospitalization rates
<[link removed]>
documented between both racial/ethnic minority groups and non-Hispanic
White individuals.
Future research may shed light on how the patterns of disparities differ
by the nature of the condition(s) that caused the hospitalization, what
factors drive these different patterns (for example, employment or other
SDOH <[link removed]>),
and the ways in which the disparities can be addressed.
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Elsewhere At Health Affairs
Today in Forefront, Sara Rosenbaum and coauthors take a deep dive into
federally qualified health center alternative payment reform.
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T. Joseph Mattingly II and C. Daniel Mullins discuss how interpretation
and implementation of the Inflation Reduction Act, which mandated the
creation of a Drug Price Negotiation Program, creates new opportunities
for engaging patients
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and caregivers in a meaningful way.
Stan Dorn and Timothy Jost argue that strictly enforcing ACA pricing
requirements
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can yield significant savings for consumers, especially in communities
of color, and fixing risk adjustment can incentivize insurers to align
premiums with coverage generosity.
Read more on Forefront
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and learn more about how you can contribute
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to the publication.
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The Problem With Provider Directories
Listen to Health Affairs' Leslie Erdelack and Jessica Bylander discuss
the latest efforts to fix problems with directories of health care
providers and the potential for a national provider directory.
Listen Here
<[link removed]>
Daily Digest
Racial And Ethnic Disparities In Preventable Hospitalizations And ED
Visits Five Years After ACA Medicaid Expansions
<[link removed]>
Asako S. Moriya and Sujoy Chakravarty
Community Health Centers And Medicaid: A Deeper Dive Into FQHC
Alternative Payment Reform
<[link removed]>
Sara Rosenbaum et al.
Achieving Patient-Centeredness In Medicare's New Drug Price
Negotiation Program
<[link removed]>
T. Joseph Mattingly II and C. Daniel Mullins
ACA Metal-Tier Mispricing: Improving Affordability By Solving An
Actuarial Mystery
<[link removed]>
Stan Dorn and Timothy Jost
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mailto:
[email protected]
About Health Affairs
Health Affairs is the leading peer-reviewed journal
<[link removed]> at the intersection of health,
health care, and policy. Published monthly by Project HOPE, the journal
is available in print and online. Late-breaking content is also found
through healthaffairs.org <healthaffairs.org>, Health Affairs Today
<[link removed]>, and Health Affairs Sunday
Update <[link removed]>. Â
Project HOPE <[link removed]> is a global health and
humanitarian relief organization that places power in the hands of local
health care workers to save lives across the globe. Project HOPE has
published Health Affairs since 1981.
Copyright © Project HOPE: The People-to-People Health Foundation, Inc.
Health Affairs, 1220 19th Street, NW, Suite 800, Washington, DC 20036, United States
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