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
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.
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.
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 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 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 weredriven by inadequate ambulatory care 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.
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), and the ways in which the disparities can be addressed.
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 and caregivers in a
meaningful way.
Stan Dorn and Timothy Jost argue that strictly enforcing ACA pricing requirements can yield significant savings for consumers, especially in communities of color, and fixing risk adjustment can incentivize insurers to align premiums with coverage generosity.
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.
Health Affairs is the leading peer-reviewedjournalat 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, Health Affairs Today, and Health Affairs Sunday Update.
Project HOPE 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.
