Leighton Ku

Policy Points: Medicaid Section 1115 demonstration projects have been used to test innovative strategies to modify Medicaid programs but must demonstrate “budget neutrality” with respect to federal Medicaid expenditures. But this limitation ignores the intertwined nature of Medicaid and Medicare. Extending Section 1115 budget neutrality policies to include Medicare expenditure savings could create incentives to develop novel Medicaid policies that could improve the health of Medicare beneficiaries and lower Medicare expenditures as well. Context: Medicaid Section 1115 demonstration projects are widely used to test innovative policies but are subject to “budget neutrality” limits so that federal expenditures do not exceed what the federal government would have spent if the project was not adopted. Potential savings to Medicare are not considered, despite the fact that millions of beneficiaries are enrolled in both programs and virtually all middle‐aged Medicaid beneficiaries will eventually enroll in Medicare. Methods: Relevant federal policies are analyzed to examine the potential impact of expanding Section 1115 budget neutrality policies to include potential Medicare savings. Findings: Historically, budget neutrality policies were not set by statute but were administratively established. Allowing Medicare savings to be counted is a more holistic approach to budgeting that would allow states to develop innovations like Medicaid long‐term care or diabetes prevention policies that have repercussions for Medicare. However, in 2025 Congress approved an amendment (Section 71118) that limits budget neutrality calculations to Medicaid savings alone. Conclusions: While there is a reasonable policy basis to include Medicare savings in Section 1115 budget neutrality calculations to improve health for millions of Medicare beneficiaries and to increase federal savings, this would require modifying the limitations imposed by Section 71118.

Although ample evidence exists that community health centers lower federal medical expenditures, it has been hypothesized that the eligibility assistance offered by staff at health centers could also increase insurance enrollment and federal costs. We analyzed the effects of eligibility assistance on insurance enrollment at both the health center and state levels. Using multivariate panel analysis with two-way fixed effects, we examined effects of eligibility assistance during the period 2016-23 to determine how insurance enrollment is affected at the health center and state levels. Data sources were administrative data from health centers and state-level enrollment data from Medicaid, the Children's Health Insurance Program (CHIP), and health insurance Marketplaces. Higher levels of eligibility assistance staffing are associated with modest increases in numbers of Medicaid and CHIP enrollees at health centers and modest reductions in numbers of uninsured patients. However, neither eligibility assistance nor overall health center size significantly affect state-level enrollment for any of the programs. Eligibility assistance modestly increases insurance coverage among health center patients, which improves health centers' financial status and patient care capacity. But this assistance does not significantly increase overall Medicaid, CHIP, or Marketplace enrollment, nor does it raise federal expenditures.

Medicaid and the Supplemental Nutrition Assistance Program were developed during the Civil Rights era to help poor people and reduce racial and ethnic differences in health care access and food security. Although the two programs have succeeded in narrowing health and nutrition disparities, certain policies hinder goals of racial and ethnic equity, even though they do not explicitly mention race or ethnicity. These policies, including administrative policies (such as work requirements) and more basic decisions about whether to cover immigrants or expand Medicaid, can create barriers that promote racial and ethnic disparities, contrary to the programs' underlying goals.

Many seek to improve the quality of primary care in the United States, particularly for Medicaid patients. This paper revisits the question of whether Medicaid patients receive less primary care, such as the length or scope of services per visit, than commercial patients. Analyses of 2016–2019 National Ambulatory Medical Care Survey data, the most recent available, find there were no significant differences in the average length of ambulatory care visits, or of primary care visits in particular, between Medicaid and commercial care, nor differences in the scope, based on the number of diagnostic and treatment services, health education topics covered, or the number of medications prescribed in the visit. Only small differences were found for uninsured patients. The duration and scope of ambulatory and primary care visits were primarily related to the characteristics of patients, visits, and the physicians’ practices. To improve primary and ambulatory care for disadvantaged patients, it may be more important to focus on increasing access to care by reducing insurance and cost-related barriers and on broad-based efforts to improve quality.

In their article, Ndumele and colleagues examined the long-term stability of health insurance coverage for Medicaid beneficiaries in Michigan during the prepandemic period, from 2011 to 2020. The e...

Importance: COVID-19 relief legislation created a temporary moratorium on Medicaid disenrollment, but when the public health emergency ends, states will begin to “unwind” Medicaid enrollment. Prepandemic data shed light on factors that can affect Medicaid coverage stability.Objective: To assess factors associated with the duration and continuity of Medicaid enrollment.Design, Setting, and Participants: In this cross-sectional analyses of a Medicaid data set for 2016 that was released by the Agency for Healthcare Research and Quality in June of 2022, we analyze a nationally representative data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016. We focus on 22 million nondisabled, nonelderly adults for this analysis. The data were analyzed between July and September of 2022.Main Outcomes and Measures: The main outcomes were the average months of Medicaid enrollment in 2016 and the probability of churning, defined as a break in coverage between 2 periods of enrollment during the calendar year. We compared these outcomes by eligibility category, state, demographic characteristics, and key Medicaid policies, including whether the state expanded Medicaid and whether it used ex parte reviews (automated reviews of other administrative data to reduce renewal paperwork burdens).Results: In this cross-sectional analysis, we analyze a nationally representative Medicaid data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016, released by the Agency for Healthcare Research and Quality in June of 2022. The analysis focused on nonelderly, nondisabled adults (aged 18-64 years) with a weighted population size of 22.7 million, of which 18.4% were Black, 19.2% were Latino, 39.5% were White, 7.3% were other/Asian/Native American, and 15.5% had unknown race. Multivariable regression analysis indicated that those living in states that expanded Medicaid but did not use ex parte reviews had longer average duration (0.31 months longer; 95% CI, 0.03-0.59) and lower risk of churning(odds ratio [OR], .40; 95% CI, 0.39-0.40), whereas those living in nonexpansion states that used ex parte reviews had lower odds of churning (OR, .68; 95% CI, 0.66-0.70) but also had shorter average duration (3.1 months shorter; 95% CI, −3.4 to −2.8). Those living in expansion states that used ex parte reviews also had reduced churning (OR, .83; 95% CI, 0.82-0.85). The average duration varied widely by state, even after adjustments for demographic and state policy factors.Conclusions and Relevance: If state Medicaid programs revert to prepandemic policies after the temporary moratorium ends, Medicaid coverage, particularly for nondisabled, nonelderly adults, is likely to become less stable again. Medicaid expansions are associated with improved continuity, but ex parte review may have a more complex role.

The cross-sectional study by Ommerborn et al analyzes medical expenditures from public and private insurers as well as payments by immigrants, particularly undo

Background The lack of racial and ethnic concordance between patients and their physicians may contribute to American health disparities. Objective To examine the level of racial and ethnic concordance for patients and primary care clinicians and its association with measures of patient experience. Design Multivariate cross-sectional analysis of nationally representative data. Participants Adults 18 to 64 in the 2019 Medical Expenditure Panel Survey who had at least one medical visit in the past year. Main Measures Key independent variables include having a racially/ethnically concordant primary care clinician, lacking a usual source of care, and having a usual source that is a place rather than a person. Outcomes include overall satisfaction with health care, number of medical visits, having enough time in care, ease of understanding the clinician, and receiving respect. Key Results The comparison between the actual level of concordance with an expected distribution if all patients had the same probability of having a clinician of a given race or type indicates that Black, Latino, and Asian patients are three or more times as likely to have a concordant clinician than expected, suggesting a strong preference for clinicians of the same race or ethnicity. Racial or ethnic concordance has a modest positive association with overall health care satisfaction and respect but is not significantly associated with the number of medical visits or other outcomes. Poor health status, being uninsured, and lacking a usual source of care are more strongly associated with patient experience. Discussion Efforts to increase the diversity of the primary care workforce could increase racial/ethnic concordance but may have only modest effects on patients’ experience of care. Policies like lowering the number of uninsured or increasing those with a usual source of care may be more salient in improving experience of care.