• Healthcare Triage News: Health Care Reform, Medicaid Expansion, and Hospital Finances

    This election season has seen relatively little campaigning on health care reform. Short of the occasional cry to “repeal Obamacare” or the offhand complaint about how much health care costs, there’s been relatively little focus on how reform, of health care in general, must be addressed in the next Presidential administration.

    What little news there is seems to focus on the exchanges, as I’ve noted over at other venues. Almost no attention is being paid to Medicaid, or its expansion as part of the Affordable Care Act. A newly released study in JAMA focuses on how the Medicaid expansion affected hospital finances in the US, though, and it’s worth our time. This is Healthcare Triage News.

    This episode was adapted from a post I wrote for the AcademyHealth blog. Links to further reading and sources can be found there.

    @aaronecarroll

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  • AcademyHealth: How has the Medicaid expansion affected hospital finances?

    This election season has seen relatively little campaigning on health care reform. Short of the occasional cry to “repeal Obamacare” or the offhand complaint about how much health care costs, there’s been relatively little focus on how reform, of health care in general, must be addressed in the next Presidential administration.

    What little news there is seems to focus on the exchanges, as I’ve noted over at other venues. Almost no attention is being paid to Medicaid, or its expansion as part of the Affordable Care Act. A newly released study in JAMA focuses on how the Medicaid expansion affected hospital finances in the US, though, and it’s worth our time.

    Go read more in my latest post over at the AcademyHealth blog!

    @aaronecarroll

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  • Healthcare Triage: Medicaid has a Huge Return on Investment

    As we pass the 3-year anniversary of the opening of the insurance exchanges, most news seems to focus on the private insurance people can purchase there. In recent months, many have complained about private insurers exiting the exchanges, networks being narrowed, premiums rising, and competition dwindling out of existence.

    But it’s important to remember that many, if not most, of the newly insured are part of the Medicaid expansion. As of today, 19 states have still refused to participate in that program. Some cite reports and news that Medicaid offers poor quality and little choice of providers. But most seem to cite the cost of Medicaid, claiming that its growing cost will eventually bankrupt states.

    Such declarations only consider one side of the equation, though. In most ways, Medicaid offers an excellent return on investment. That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from a column I wrote for the Upshot. Links to further reading and sources can be found there.

    @aaronecarroll

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  • It’s Easy for Obamacare Critics to Overlook the Merits of Medicaid Expansion

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company)

    Three years into Obamacare and it seems as if much of the news is bad: private insurers exiting the exchanges, networks being narrowed, premiums rising and competition dwindling out of existence.

    But it’s important to remember that many, if not most, of the newly covered Americans became insured through an expansion of Medicaid. Here, too, you hear a lot of bad news: that Medicaid offers poor quality and little choice of providers, that it is expensive for the states to administer and that its growing cost will eventually bankrupt states. As of today, 19 states have still refused to participate in the expansion.

    Such declarations consider only one side of the equation, though. In most ways, Medicaid offers an excellent return on investment.

    A rigorous analysis of the health benefits of being insured shows that Medicaid works on a number of levels. Critics of the program will point to studies that show that having Medicaid is associated with poor outcomes, even worse than those for the uninsured. Such studies are often flawed, however, in that those on Medicaid are often poorer and sicker than those who are uninsured.

    Some good randomized trials do exist. The Oregon Health Insurance Experiment is one of the most recent and best known. Many news articles have been written on the short-term findings of that study, which have been interpreted in many ways, both good and bad. But even that study couldn’t answer many of the long-term, holistic questions about its effects on health.

    To see the longer-term benefits across a wider population, we need to turn to other types of studies. They exist as well, usually taking advantage of changes in policy. Medicaid coverage of children and births expanded rapidly from the late 1970s through the early 1990s. When expectant mothers got early prenatal coverage, babies were less likely to be obese when they grew up. They had fewer hospitalizations, especially preventable hospitalizations, for any number of chronic disorders.

    Another study from last fall went further. By exploiting new Medicaid eligibility policies, researchers were able to closely compare people with and without benefits. They found that African-Americans who had more years of Medicaid eligibility as children had fewer hospitalizations and emergency department room visits as adults. More years of coverage achieved better results, even with respect to mortality.

    Benefits from Medicaid extend beyond health. A 2016 National Bureau of Economic Research working paper examined the effect of the Medicaid expansion on financial outcomes of beneficiaries. Using credit report data, researchers showed that the expansion was associated with a reduction of collection balances of as much as $1,000 for those receiving Medicaid.

    The financial benefits extend to society. A study from early 2015 looked at how expanding coverage to children in the 1980s and 1990s affected long-term finances. The analysis showed that children whose eligibility increased were more likely to go to college, earn higher wages and pay more taxes by the time they were 28 years old.

    In fact, after accounting for other factors, the researchers estimated that the government would recoup 56 cents on each dollar spent on childhood Medicaid by the time beneficiaries reached age 60. Other studies confirm that Medicaid in childhood makes children more likely to finish high school and college.

    At a national level, the expansion of Medicaid continues to yield benefits. Its coverage was increased, and its quality raised. Some states that have expanded Medicaid are even expecting net savings for the next few years. In states where Medicaid was expanded, hospitals had fewer uninsured visits.

    Focusing on only the positives can be as misleading as focusing on only the negatives. Policy decisions, including those involving health, need to be considered in terms of trade-offs. It is true that providing Medicaid can cost the federal government, and even states, a lot of money, which can’t then be spent on other worthy pursuits. It is true that Medicaid reimburses physicians and hospitals less generously, and that it often leaves beneficiaries with fewer choices than private insurance might.

    But when we look at the balance sheet for Medicaid — health benefits, financial security, societal improvements through education — it’s not hard to argue that money allocated to Medicaid is well spent.

    @aaronecarroll

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  • Healthcare Triage News: The Medicaid Expansion and Its Effects

    So often, when we implement new policy, I wish we had better ways to capture its effects so that we could expand our knowledge base as to how decisions change health and health care. The Oregon Health Insurance Experiment, and its older brother the RAND HIE, were RCTs designed to look at how insurance affected utilization and health. While these were impressive studies, they had their flaws.

    RCTs are hard to do, though; they’re also expensive. Sometimes, other designs are necessary. Recently, in Annals of Internal Medicine, Laura Wherry and Sarah Miller looked at how the Medicaid expansion has changed things. Let’s discuss. This is Healthcare Triage News.

    This was adapted from a post I wrote for AcademyHealth.

    @aaronecarroll

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  • AcademyHealth: So what did the Medicaid expansion actually do?

    So often, when we implement new policy, I wish we had better ways to capture its effects so that we could expand our knowledge base as to how decisions change health and health care. The Oregon Health Insurance Experiment, and its older brother the RAND HIE, were RCTs designed to look at how insurance affected utilization and health…

    Recently, in Annals of Internal Medicine, Laura Wherry and Sarah Miller looked at how the Medicaid expansion has changed things. “Early Coverage, Access, Utilization, and Health Effects Associated With the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study“:

    Go read more in my latest post over at the AcademyHealth blog.

    @aaronecarroll

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  • Medicaid programs can’t withhold a Hep C cure.

    It was only a matter of time. Last Friday, a federal judge in Washington State entered a preliminary injunction ordering the state’s Medicaid program to pay for direct-acting antivirals—think Harvoni or Sovaldi—for any beneficiary diagnosed with Hepatitis C.

    Like many states, Washington has a policy of refusing to supply the drugs until the disease has progressed far enough to seriously scar the patient’s liver. The reason is money: state Medicaid programs all over the country are buckling under the cost of paying for the new Hep C drugs. Limiting their availability is a rough-and-ready way to spread the costs of the new drugs over a number of years.

    But it’s not good medical care. Prominent clinical guidelines say that the new direct-acting antivirals should be offered to anyone with Hep C—no matter what their stage of disease. Why should your liver have to start turning into a raisin before you’re cured?

    In a clash between financial and medical necessity, the Medicaid statute sides with medical necessity. Under §1927(d), a state Medicaid program can decline to cover a drug if “the prescribed use is not for a medically accepted indication” or if the drug doesn’t have a “clinically meaningful therapeutic advantage” over alternatives. You can’t withhold cures just because they’re expensive.

    CMS apparently thinks so too. Back in November of last year, the agency published a letter expressing its “concer[n] that some states are restricting access to [direct-acting antivirals] drugs contrary to the statutory requirements in section 1927 of the Act by imposing conditions for coverage that may unreasonably restrict access to these drugs.”

    For the Washington judge, then, this was an easy case. Although the state argued that monitoring was medically appropriate for people with early-stage Hep C, it didn’t “address the liver damage that enrollees could suffer during this ‘monitoring’ period.” The state also claimed that limiting availability of the Hep C drugs might avoid “the currently ill-defined risks of these new medications.” The judge was scornful: “This assertion of ‘ill-defined risks’ is not supported by any clinical evidence and is contradicted by the [state’s] own documents.”

    A similar lawsuit has already been brought against Indiana’s Medicaid program, and I expect the outcome to be the same. The legal question here is not remotely difficult: under federal law, Medicaid beneficiaries diagnosed with Hepatitis C are entitled to a cure. The states may be under fiscal pressure, but that doesn’t make the drugs any less medically necessary. (Other cases have been brought against state prison systems for withholding the drugs, including in Pennsylvania. Those cases present somewhat different legal questions.)

    That’s not to slight Washington’s concerns with the extraordinary one-time costs of the new therapies. As Austin has written recently, innovation is likely to yield breakthrough drugs that puts even greater pressure on state budgets: “The day that [a] life-extending $1 million ‘miracle’ pill arrives (or the precision-medicine equivalent of a collection of drugs), we may look back on the current hepatitis C treatment funding problems nostalgically.”

    Before that day arrives, we need to think hard about how to afford state Medicaid programs more flexibility to spread the one-time costs of a breakthrough drug over a number of years. More generally, we’ll need to have a difficult conversation about how much we’re willing to spend on new therapies given other, competing priorities.

    In the meantime, though, I expect that the states will keep losing these Hep C lawsuits.

    @nicholas_bagley

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  • Should we help poor, sick people in Indiana get to the doctor? Discuss.

    I rewrote the title to this post eight times before I gave up. I’m too tired, frustrated, and annoyed with this week and this issue. Nonetheless, let’s dive in.

    As part of Medicaid, beneficiaries are eligible for a non-emergency medical transportation (NEMT) benefit. They get a ride to the doctor. They get this because people generally understand that if we don’t poor provide people, especially sick people, a way to get to the doctor, they can’t go.

    But in 2007, as part of their negotiation for the Healthy Indiana Plan (HIP), Indiana got a waiver for this benefit. The waiver was approved again in 2013, 2014, and 2015. As part of their negotiation to accept the Medicaid expansion in 2015, they got a waiver for HIP 2.0 for all beneficiaries except pregnant women, the medically frail, and certain smaller categories.

    But this waiver depended on them studying a “demonstration year”. They had to conduct an independent evaluation of the NEMT to see that the impact was. They hired the Lewin Group, and that report has now been published. The conclusion:

    In sum, the member survey shows a relatively small number of HIP 2.0 members missed appointments due to transportation-related issues. Also, members without NEMT benefits did not appear to be substantially more likely to report transportation problems relative to those with [managed care entitiy] MCE-provided or state-provided NEMT benefits. However, due largely to the limitations of the analysis, particularly the lack of comparable comparison groups, the picture is less clear regarding the extent to which the provision of NEMT coverage affects this issue. Future research could explore the use of a control group. In particular, if the NEMT benefits are similarly operationalized by the MCE and the state, it may be possible to conduct more robust comparisons of members within the population of members without state-provided NEMT based on whether their MCE provided NEMT or not.

    In other words, it seems fine not to cover transportation. This is the state-sponsored report, though. Others, including Marsha Simon, beg to differ:

    The evaluation found a significant number of individuals on Medicaid are missing appointments because they lack transportation.  According to survey results, 6 percent of Medicaid recipients under the waiver missed an appointment because they lacked the transportation benefit states are required to provide to Medicaid beneficiaries throughout the country. Even though this accounts for a relatively small proportion of enrollees, this figure nonetheless suggests there is unmet need for transportation to care among a portion of enrollees in the Healthy Indiana Program. Addressing this unmet need is the very rational[e] of the federal NEMT policy, a feature of the Medicaid program for the poor since it’s beginning in 1965. An entitlement to medical services is meaningless with no way to access the services.

    Further, the question of whether an appointment was missed is too narrow a measure of access to care, as it fails to identify Medicaid enrollees that do not schedule an appointment because they know they cannot get to the doctor’s office. With this in mind, those evaluating Iowa’s NEMT waiver asked beneficiaries whether they had an “unmet need for transportation to or from a health care visit.”  There, researchers found that 15 percent of those with incomes under 100% of poverty had an unmet need for transportation.

    One of the state’s managed care plans, Anthem, is continuing to provide this benefit even though the state refuses to reimburse the cost. I imagine they recognize that this probably improves outcomes. Maybe they even see that it is cost-saving because people who can get to the doctor in a cab might be less likely to call an ambulance (MUCH MORE EXPENSIVE) to go the emergency room (MUCH MORE EXPENSIVE) later. Other states agree:

    When considering a similar waiver, Arkansas hired The Stephen Group (TSG) to offer a recommendation on waiving NEMT benefits.  Their recommendation warned against dropping the benefit. Far from being an additional expense, TSG argued that NEMT benefits were a good investment for the state, citing a Florida State University study showing a return on investment factor of 11:1 for as well as a Transportation Research Board study finding a 10:1 return on investment. Providing Medicaid enrollees with transportation benefits allows them to access preventative care that forestalls more costly interventions down the road. After this recommendation, Arkansas quickly dropped their proposal to waive NEMT.

    Indiana’s waiver is set to expire in November. It’s up to the Obama administration whether to allow it to continue. We’ll see, I guess.

    @aaronecarroll

    P.S. As this focuses on Indiana, I feel the need to direct you to my always-true-disclaimer: The views in Aaron’s posts represent his views only.  They do not represent the views of Indiana University, any funding agencies or foundations,  any organizations, or especially any of his friends or family.

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  • Healthcare Triage News: Lots of People Are Still Uninsured

    Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.

    It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that. So do we, in this episode of Healthcare Triage News.

    This is based on Friday’s post over at AcademyHealth. Go read that, too!

    @aaronecarroll

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  • AcademyHealth: Who are the remaining uninsured?

    Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.

    It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that.

    So do I, over at the AcademyHealth blog in my latest post. Go read it!

    @aaronecarroll

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