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Fast Track Eases Medicaid Enrollment, but Implementation Matters Too

July 29, 2014
Publication Image Relatively simple policy changes can make a big difference in helping people get access to health insurance – and health coverage helps many families stay afloat in the wake of a medical issue. In the span of just a few months, approximately 750,000 people were newly identified as eligible for Medicaid in California. How? California recently implemented a new, streamlined approach to let people know they qualify for Medicaid. In anticipation of the increasing number of adults applying for health coverage due to the Medicaid expansion under the Affordable Care Act, Centers for Medicare and Medicaid Services (CMS) promoted a strategy called Fast Track to accelerate eligibility and enrollment processes. Fast Track has been highly successful in connecting more families with services they qualify for and states have also saved significantly because of its efficiency; however, California has provided a textbook example of how implementation challenges influence a policy’s effectiveness.

Integrating Public Assistance Programs: A Perspective from the Field

May 8, 2014
Publication Image This past fall I worked with the San Diego Hunger Coalition as a fellow of the National Emerson Hunger Fellowship, which trains leaders to fight domestic hunger, poverty, and racism at both the local and policy levels.  At the San Diego Hunger Coalition we looked at how nonprofit organizations offering application assistance provide both CalFresh (SNAP) and Medi-Cal (Medicaid) programs in San Diego County, CA. We found that the best way to connect more eligible people to CalFresh and Medi-Cal is to integrate the programs: one application assister helps applicants complete a combined CalFresh and Medi-Cal application. It was a critical time to research integration practices since the implementation of the Affordable Care Act (ACA) began in October. Given the low CalFresh participation rate in San Diego County, our work aimed to help leverage the opportunities for integration that the ACA created.  It was through my experience in San Diego that I learned how streamlining CalFresh and Medi-Cal application assistance improves participants’ overall wellbeing.  

What a week!

May 2, 2013
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Medicaid in Oregon


First, the big one: yesterday afternoon kicked off a flurry of discussion - some of it rather heated - about the most recent paper (ungated version) to come out of Oregon’s Medicaid program. In case you’ve forgotten: a few years ago, Oregon had money to expand Medicaid enrollment - but they didn’t have enough to cover everyone who was eligible. So the state created a list of around 90,000 people, and enrolled 10,000 - giving people the opportunity to apply through a random lottery. That created an incredible research opportunity - the randomized design allows researchers to really see the effect of Medicaid enrollment on people’s health, and hopefully put to bed the nonsense idea that Medicaid is bad for people’s health.

The new publication is mildly disappointing in that regard - but the reaction to it has been way overblown. While the first study (which we wrote about in 2011) showed clear improvements in self-reported health, this paper is the first to report actual clinical data from the experiment. It did not find that Medicaid decreased average blood pressure, cholesterol levels, or HbA1c (glycated hemoglobin, a measure of blood sugar used as a diagnostic criterion for diabetes). The Medicaid group was far more likely to be formally diagnosed with and in treatment for diabetes. They also had much lower rates of depression (9% absolute risk reduction, meaning roughly one in eleven people was no longer depressed), and drastically lower rates of catastrophic medical spending.

As we noted, the results on cholesterol, blood pressure, and blood sugar are somewhat disappointing. But it’s crucial to put those measures in context. As usual, Aaron Carroll and Austin Frakt of The Incidental Economist have done incredible work pointing out the limits of the study, and the ways that it’s been over-interpreted. You should absolutely readtheirposts. They’ve also been active on Twitter, where Aaron has pointed out that the study may not have beenlarge enough to detect important effects on those variables, even if they were there, and that it’s not easy to reduce HB even when that’s what a study is specifically intended to do! We won’t spoil all of their points, but they’re excellent. Go read the post, and direct your friends to it.

As a final note on the Medicaid experiment, we’d like to point out that (while we appreciate the solid methodology) this is not the kind of study health care needs most. There is ample evidence that people benefit from insurance, both financially and medically. But our ability to benefit from access to medical care is currently limited by the massive flaws in the delivery system. Providing insurance to low-income people is great, but its value is drastically reduced when we’re spending a lot of that money on screening tests that cause overdiagnosis, unwanted elective surgeries, and expensive drugs that are no better than existing options. Eliminating the waste from the system is crucial to making universal coverage sustainable and affordable; we need RCTs of programs that focus on eliminating overtreatment and improving how we care for patients.

Elsewhere in the news...

This week, The New York Times Magazine featured a piece by Peggy Orenstein entitled,“Our Feel-Good War on Breast Cancer.”  The article couldn’t be more timely, as research on overdiagnosis continues to highlight the downsides of widespread screening. It’s a nuanced discussion of Orenstein’s personal experience with breast cancer, and the “survivor” culture surrounding the disease.  Definitely worth a read!

The Fountain of Youth

Last weekend, Ezra Klein posted a great example of how politics, money, and bureaucracy influence the kind of health care we receive. Health Quality Partners (HQP), created by Medicare with funds allocated by the 1997 Balanced Budget Act, provides seniors with a home visit from a nurse on either a monthly or weekly basis. The program was an incredible success, lowering spending on enrollees’ health care by 22%, improving their quality of life, and reducing their hospitalizations by 33%. But even though it’s been labeled “The Fountain of Youth,” HQP’s funding is due to expire in June of this year and it’s unlikely that a similar program will take its place.  Even more unfortunate is that HQP’s success won’t be used to inform future programs.  Instead, Medicare is creating a new generation of programs meant to shift from a fee-for-service system to a pay-for-quality system, arguing that the results of HQP were limited by its small size and that to scale-up the program would be less cost-effective than to change the payment structure that governs the entire program.  Perhaps this analysis is valid, but the situation highlights the difficulty of reshaping an existing healthcare system in which so many have a stake.  


"We torture people before they die.”

Jonathan Rauch profiles Dr. Angelo Volandes, creator of a series of videos showing patients the reality of aggressive end-of-life treatment, in this month’s Atlantic magazine.  For the last several years, Volandes has been working on a series of videos showing patients what it's like to receive intense medical treatments like CPR, feeding tubes, and being placed on a ventilator, and helping them understand what benefits they can actually gain from medical treatment - and what they can't.  When patients see those videos, the reality of aggressive end-of-life care hits home - and they're much less likely to choose aggressive, expensive, and often futile treatments.


Volandes's work highlights the importance of talking about death with patients and their families, and illustrates how much of end-of-life care is actually unwanted care. His videos help doctors and patients have what Volandes refers to as “The Conversation,” a necessary but often avoided discussion about the imminence of death and the need for a patient and his or her family to decide how far they want to push the boundaries of life-saving medicine. It's good to see docs like Volandes stepping up and pushing their profession toward having more honest, productive conversations about end-of-life care. We'll all die better - and live better - for it.

California End-of-Life Care

Unfortunately, patients don't always get what they want. In fact, many dying patients are subjected to far more intense treatment than they would have chosen. The new report "End-of-Life Care in California: You Don't Always get What You Want," by Senior Fellow Shannon Brownlee, highlights those discrepancies.  Most people say they would prefer to die at home - yet huge fractions end up dying in a hospital. Hospice has been shown to have positive effects on quality of life without reducing lifespans, yet adoption of hospice remains slow.

The report also highlights the huge geographical variations in how much treatment dying people receive. In nearly every category, California lags behind other parts of the country. In many cases, Southern California particularly sticks out as a hotbed of intense treatment. Patients in that area should pay particularly close attention to this report - it has important implications for what their last few months might look like, and what we might do to make the medical system serve their needs better.

For more on the CHCF atlas, and how it connects to Rauch's story, see our post on In the Tank.

Medicaid Is Asset Building?

May 2, 2013

A new study came out this week evaluating the impact Medicaid coverage has on participants' health, financial lives, and general well-being. Sarah Kliff describes the study design:

The research uses data from Oregon, where the state held a lottery among low-income adults in 2008 for a limited Medicaid expansion. Of the 90,000 people who applied, 10,000 ultimately gained coverage. The lottery gave researchers a unique opportunity to conduct the first randomized experiment on Medicaid coverage, by studying those who gained insurance through the lottery and comparing them against a similar group of adults who did not.

The randomization of the study is an important feature: other studies have struggled to control for the differences in people who seek out Medicaid coverage and those who do not (but may be eligible). As Joe Colucci from New America's Health Policy team explains, "That created an incredible research opportunity - the randomized design allows researchers to really see the effect of Medicaid enrollment on people’s health, and hopefully put to bed the nonsense idea that Medicaid is bad for people’s health."

The study looked at what impact Medicaid coverage has on people's physical health, as measured by things like blood pressure, cholesterol levels and other "easy to obtain" indicators. In the two year study period, the researchers found "few short-term physical health gains," which came as a surprise and disappointment to some and as fodder for others to decry the program as ineffective. (The results on the physical health side are complicated and mixed, but I would refer you to Kevin Drum's analysis for more on some of the statistical issues at play. A question posed Aaron Carroll and Austin Frakt is also relevant here: "How many people saying that are ready to give up insurance for themselves or their family?") 

From an asset-building perspective, the really amazing finding from the study is on the impact Medicaid coverage had on participants' financial security. Jonathan Cohn explains:

The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses.

I bolded parts of that because I really want to emphasize what a striking impact having health insurance had on people's financial situations. On top of the benefits to low-income people's financial security, the study also reported "significant improvements in mental health outcomes, with rates of depression falling by 30 percent."

Health Wonk Review: Summertime Edition

July 19, 2012
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Health Wonk Review is back with a summer edition packed with links to a myriad of topics. Check it out!

Health Wonk Review: SCOTUS edition

July 2, 2012
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The health wonks have responded en masse to the Supreme Court's decision on the ACA.  Here are the links to this special edition of Health Wonk Review.

Part 1

Part 2

Lifting the Medicaid Asset Test: A Step in the Right Direction

April 9, 2012
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Last week the Washington Post featured a piece focusing on the complexities of navigating the safety net – in particular, deciphering the eligibility rules in Medicaid as they apply to different individuals in the same family. I’ve written before about the inequities and frustrations in the public benefits system that result from different programs and different states applying remarkably varied income and asset tests. Currently, Medicaid is an especially egregious example; not only are there discrepancies among what types of resources are countable and which states have asset tests and which don’t, but also discrepancies regarding eligibility within the same household. Though upcoming reforms will vastly improve equity with respect to Medicaid access, greater coordination among means-tested programs—and ultimately the removal of asset tests altogether—is essential to creating a safety net that functions reliably and effectively for all.

Final Round: FIGHT!

March 28, 2012
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Wow. Over six hours of argument later, we're left with... well, a little over six hours of audio. Now we get to wait for the decision--only 89 days to go! (The opinion will almost certainly be issued on the last day of the term, which is scheduled for Monday, June 25th.)

We haven't had a chance to listen to today's arguments yet, so without comment: this morning, in National Federation of Independent Businesses v. Sebelius, the Court considered whether the remainder of the Affordable Care Act can stand if the Court finds the individual mandate unconstitutional. This afternoon, again in Florida v. Department of Health and Human Services, the Court heard argument about the Medicaid expansion in the law--specifically, whether it amounts to an impermissible coercion of the states by the federal government. Remember, this one is incredibly important for the federal-state balance. The Supreme Court has never struck down spending as coercive before, and it would be shocking if they did now. See Aaron Carroll's piece over at JAMA if you're interested in more.

We'll be back with more blogging soon (and probably more commentary on the arguments), but in the meantime, check out the recordings! Happy listening.

Medicaid Is Still Not Worse Than Being Uninsured

July 13, 2011
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Forbes blogger Avik Roy commented during yesterday’s IPAB hearing that “studies show that health outcomes for many Medicaid patients are worse than those who have no insurance at all.” That assertion has been around for a while. Unfortunately for Roy, it’s been frequently refuted, with a new study out of Oregon containing further evidence that patients do, in fact, benefit from Medicaid coverage.

The National Bureau of Economic Research study, released earlier this month, details results from  a study of Oregon’s Medicaid program. Three years ago, the state discovered that it had additional funds for Medicaid and wanted to enroll more people. But there were more eligible recipients than there was money, so the state created a lottery to decide who could apply and who couldn't.   The study, conducted by researchers from Harvard, MIT and other institutions, is the only randomized experiment ever done on the effects of having insurance compared to no insurance.* It compared utilization, health outcomes and self-reported health status, and financial hardship due to medical expenses among people who won the eligibility lottery and those who did not.

One key result: The authors describe an “overwhelming sense from the survey outcomes that individuals feel better about their health.

Individuals who won the lottery also used more medical services, had improved self-assessed physical and mental health, and reduced likelihood of medical debts being sent to a collections agency. While none of the results directly relate to mortality or other measures of actual health (because mortality among the adult population is extremely low, even without insurance), there is a clear benefit to Medicaid in terms of beneficiaries’ general well-being. (Future papers will present more data on traditional measures of health outcomes.)

So much for the claim that Medicaid makes people sicker.

*The RAND Health Insurance Experiment(the only other randomized trial looking at the effects of insurance) examined the effects of different amounts of insurance, using different cost-sharing arrangements, but did not include any participants with no insurance at all.

NUMBER OF THE DAY: 41% of Births Covered by Medicaid

July 8, 2011
Medicaid Births Map

Number of the Day: 41%

Medicaid has been in the news a lot lately.  A new study was released yesterday showing the mental health and financial benefits experienced by recipients of Medicaid. Meanwhile, Medicaid continues to face big cuts in the ongoing debt ceiling talks.

With this in mind, we set out to take a quick look at the scope of Medicaid’s impact.  We discovered Medicaid covers more than four in ten births in the United States.  Surprised? We were, too.  It amounts to about 1.68 million births a year out of the over four million annual births nationwide.

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