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Health Affairs Examines Medicaid Expansion and Vulnerable Populations


Articles in the June issue look at disparities and the face of post--Affordable Care Act implementation


Bethesda, MD --Health Affairs' June issue issue examines the challenges and benefits for states deciding whether to embrace the law's Medicaid expansion or opt out. Several studies in the issue also look at population disparities in health care, especially during the recent recession.


Selected content in the issue is supported by grants from the New York State Health Foundation and Blue Shield of California Foundation.


This month's Report From The Field, by journalist Harris Meyer, takes an in-depth look at New York State's health exchange as it gears up for enrollment. The Empire State's health insurance marketplace opens for business on October 1, with coverage beginning on January 1. Nearly 1.6 million New Yorkers are projected to seek coverage. "We're building something entirely new, and even Amazon had growing pains at the beginning," observed one key legislator. The account describes the events leading to the creation of the exchange, as well as the hopes, and fears, of residents and legislators. As another legislator observed, "It's important that we not screw it up."


Other featured articles include:


Medicaid Opt-out: What Cost to States? Last summer's US Supreme Court ruling about the Affordable Care Act allows states to decline the law's Medicaid expansion provision, something fourteen governors have chosen to do. A featured study, by Carter Price and Christine Eibner, both of the RAND Corporation, analyzed how this would affect coverage and spending. They estimate that in these states 3.6 million fewer people would be insured, and federal transfer payments to those states could fall by $8.4 billion. According to the authors, those states will be spending some $1 billion in the short term on uncompensated care. They conclude that in terms of coverage, costs, and federal payments, states and their citizens would fare better by expanding Medicaid coverage.


In a related article, Thomas DeLeire of the University of Wisconsin and coauthors looked at Wisconsin's four-year-old public insurance program--the BadgerCare Plus Core Plan--for childless adults with incomes of up to 200 percent of the federal poverty level. The authors compared administrative claims data from the first year of the program with the previous year. They found that program participants who were automatically enrolled in the program (and who tended to have very low incomes) showed a 29 percent increase in outpatient visits; a 46 percent increase in emergency department use; and a 59 percent decrease in hospitalizations, including a 46 percent decline for preventable hospitalizations. These results demonstrate that expanding public insurance coverage will increase access to outpatient care and reduce hospitalizations. The authors caution that unless consumers have sufficient access to primary care, coverage expansions may also increase emergency department visits, shrinking any corresponding cost savings.


Black Patients' Surgeries, Low-Quality Hospitals, and Segregated Neighborhoods
Using national Medicare data for all patients who had one of three high-risk surgical procedures in 2005-08, Justin Dimick of the University of Michigan and coauthors found that blacks were consistently more likely than whites to undergo major surgery in low-quality hospitals, even though blacks frequently lived closer to higher-quality hospitals than whites. The authors also demonstrated a strong relationship between residential segregation and the use of low-quality hospitals. To address these "separate but unequal" hospitalization patterns, the authors proposed two remedies: strategies directing black patients to higher-quality hospitals and improving care in low-quality hospitals that disproportionately treat black patients.


How the Recession Affected Health Spending on Special Needs Children. The recent recession led to a slowing in health care spending growth; Pinar Karaca-Mandic of the University of Minnesota and coauthors looked at Medical Expenditure Panel Survey data from 2001--09, comparing out-of-pocket costs among privately insured families with children before and during the recession to find out whether children and adults were impacted differently. They found evidence that the recession had little impact on the out-of-pocket costs of most children.


However, spending for children with special needs, always much higher than other children, had increased over time to an average of $774.00 per child in 2007. In 2009, it declined to $626.00. The authors also found that in families with children, the adults often reduced their own spending to maintain their prior level of spending on services for their children. Dental services and prescription drugs proved to be particularly vulnerable areas of care during the recent economic downturn.


Also of interest in the June issue:


  • Survey Shows Consumers Open To A Greater Role For Physician Assistants And Nurse Practitioners; Michael Dill, Association of American Medical Colleges, and coauthors

  • Fair Pricing Law Prompts Most California Hospitals To Adopt Policies To Protect Uninsured Patients From High Charges; Glenn Melnick and Katya Fonkych, University of Southern California, Los Angeles
About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a one-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.