Impact of Medicaid Expansion on Healthcare Utilization

NCT03197831 | Completed

• 1 other identifier: 206838
• Study Type: observational
• Target: 177
• Locations: 0 countries
• Sites: N/A

Brief Summary

The Patient Protection and Affordable Care Act (PPACA) came into law in 2010. Originally, according to the Act, a state would lose its federal Medicaid funding if it did not expand its Medicaid eligibility to include all persons earning below 138% of the federal poverty level on January 1, 2014. However, in a Supreme Court Case in 2012 this was ruled as unconstitutional and Medicaid expansion in 2014 was made optional. Twenty four states and the District of Columbia opted to expand their Medicaid programs on January 1, 2014 and the remaining 26 states opting against it. Section 1115 of the Social Security Act allows states to alter the federal Medicaid requirements to promote the overall state Medicaid program. Among those states that expanded Medicaid Arkansas, Arizona and Iowa adopted approved Section 115 Waivers to expand their Medicaid programs. The variability in the states' decisions regarding Medicaid expansion presented researchers with the opportunity to study the impacts of Medicaid expansion on various facets of health care. There is a growing body of evidence suggesting that implementation of the coverage expansions under the PPACA and Medicaid expansion led to significant decreases in rate of uninsured persons, increase in access to health care and improvements in affordability of healthcare. Along with improving access and affordability of health care, the PPACA aimed at reducing the growth rate of health care expenditures by reducing wasteful use of resources such as preventable inpatient and emergency department (ED) visits. According to previous research, access to primary care and insurance coverage are significantly and negatively associated with experiencing preventable inpatient and ED visits. Historically, racial/ethnic minorities have had lower rates of access to primary care and insurance and higher rates of preventable inpatient and ED visits which might change with implementation of PPACA. Within states that have expanded Medicaid, adopting different methods of expansion may also impact patterns of inpatient and ED utilization and disparities in those. In the current political scenario and looming uncertainty over the future of PPACA and the possibilities of modifying the PPACA it might benefit policy makers to gain knowledge on the early impact of Medicaid expansions and different approaches to expanding Medicaid under the PPACA. This study seeks to determine the impact of Medicaid expansion and different types of Medicaid expansion on overall and preventable inpatient and ED utilization and disparities in those through a three-state comparison between Kentucky, Arkansas and Florida. Another major reform under PPACA was in the area of substance use disorder treatment. Despite the high societal burden exerted by patients with substance use disorders treatment rates among them have been low. The most common reasons cited for the poor access to treatment have been lack of insurance coverage. The PPACA required all insurance plans sold after January 1, 2014 to cover substance use disorder treatments. Additionally, plans were required to cover screening, brief intervention and referral to treatment for substance use disorders. This might potentially lead to changes in treatment rates and sources of payments for substance use disorder treatment. Further, the promotion of integration between substance use disorder treatment and primary care might lead to increased referrals by healthcare professionals to substance use treatment. Thus, in this study we also seek to assess the impact of Medicaid expansion on admission to substance use disorder treatment facilities and changes in sources of payments and rate of health care referrals to those treatment facilities.

Conditions

Health Care Reform; Health Policy

Keywords

Medicaid Expansion, Affordable Care Act, Health Care Reform

Outcome Measures

Primary Outcomes (11)

• All-cause hospitalization

  This will be defined as all inpatient discharges for patients aged 19-64. The discharge will be excluded if the patient's residence is not from the respective state, if the age/gender/county/race/ethnicity information of the patient is missing or not specified and if the year of admission of the particular hospitalization is not the same as the calendar year.

  2013-2014

• Preventable Hospitalizations

  Admissions for conditions for which appropriate primary or outpatient care could have potentially prevented the hospitalization will be defined as preventable hospitalizations. These conditions will be selected and defined based on the Agency for Healthcare Research and Quality's (AHRQ) list of Prevention Quality Indicators. 1. PQI 01 Diabetes short term complications admission 2. PQI 02 Perforated appendix admission 3. PQI 03 Diabetes long term complications admission 4. PQI 05 Chronic obstructive pulmonary disease or asthma in older adults admission 5. PQI 07 Hypertension admission 6. PQI 08 Congestive heart failure (CHF) admission 7. PQI 10 Dehydration admission 8. PQI 11 Bacterial pneumonia admission 9. PQI 12 Urinary tract infection admission 10. PQI 14 Uncontrolled diabetes admission 11. PQI 15 Asthma in younger adults admission rate 12. PQI 16 Rate of lower extremity amputation among patients with diabetes

  2013-2014

• Emergency Department Visit

  This will be defined as any ED visit for patients aged 19-64. The ED visit will be excluded if the patient's residence is not from the respective state, if the age/gender/county/race/ethnicity information of the patient is missing or not specified, or if the admission date of the particular ED visit is not in the respective year.

  2013-2014

• Preventable/Avoidable Emergency Department Visit

  The probability of a visit being preventable/avoidable will be defined as the sum of the probabilities of the visit being NE, EPCT and EPA. We consider the calculated probability of being preventable/avoidable for each ED as the number of preventable/avoidable ED visits it represents. For example, if a visit is assigned 75% preventable/avoidable, we will consider the visit to represent 0.75 preventable/avoidable ED visits.

  2013-2014

• Emergent Emergency Department Visit

  The probability of a visit being emergent will be defined as the probability of the visit being ENPA. Again we will consider the probability of being emergent for each ED visit as the number of emergent visits it represents.

  2013-2014

• Substance Use Disorder Treatment admissions

  We will include all admissions for persons aged 12-54. We will exclude all admissions where the source of referral is missing or from criminal justice system since these admissions are most likely not voluntary and hence would not be impacted by gain in insurance, all admissions where demographic information including age-group, race/ethnicity, gender, state of residence is missing, and admissions from New Hampshire and Michigan.

  2010-2014

• Substance Use Disorder Treatment admissions privately funded:

  It will be the number admissions where expected source of payment is private health insurance.

  2010-2014

• Substance Use Disorder Treatment admissions funded by Medicaid

  It will be the number admissions where expected source of payment is Medicaid.

  2010-2014

• Substance Use Disorder Treatment admissions self-funded

  It will be the number admissions where the individual is expected to pay out of pocket for the admission.

  2010-2014

• Substance Use Disorder Treatment admissions that are free/ or funded by other government sources

  It will be the number admissions where expected source of payment is either some public program or charity.

  2010-2014

• Substance Use Disorder Treatment admissions through a health care source of referral

  It will be the number admissions where the admission resulted from a referral that was through a health care source including alcohol/drug abuse care provider.

  2010-2014

Study Arms (4)

Private Option Expansion

This group incorporates data from the state of Arkansas and is applicable only to aims 1 and 2 where we are determining the impact of difference methods of Medicaid expansion on inpatient and ED utilization.

Managed Medicaid Expansion

This group incorporates data from the state of Kentucky and is applicable only to aims 1 and 2 where we are determining the impact of difference methods of Medicaid expansion on inpatient and ED utilization.

No Medicaid Expansion

This group incorporates data from the state of Florida in aims 1 and 2 and all the states which did not expand Medicaid enrollment in 2014 for aim 3.

Medicaid Expansion

This group incorporates data from the state of Arkansas and Kentucky in aims 1 and 2 and all the states which expanded Medicaid enrollment in 2014 (except New Hampshire and Michigan) for aim 3.

Eligibility Criteria

• Age: 12 Years - 64 Years
• Sex: all
• Age Groups: Child (0-17), Adult (18-64)
• Sampling Method: Non-Probability Sample

Study Population

For Aim 1 and 2. The population will be obtained from NCHS CDC Wonder based on county of residence, gender, age-group (19-26, 27-39, 40-49 and 50-64), race/ethnicity (Non-Hispanic Whites, Non-Hispanic Black, Hispanics and Others) for each of the AR, FL and KY for 2013 and 2014. For Aim 3.

You may qualify if:

• Age 19-64 for aims 1 and 2
• Age 12-54 for aim 3

You may not qualify if:

• None

Sponsors & Collaborators

• University of Arkansas: lead
• Arkansas Center for Health Improvement: collaborator

Study Officials

• Bradley C Martin, Pharm D; PhD

  University of Arkansas

  STUDY DIRECTOR

Study Design

• Study Type: observational
• Observational Model: ECOLOGIC OR COMMUNITY
• Time Perspective: RETROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: June 21, 2017
• First Posted: June 23, 2017
• Study Start: November 1, 2016
• Primary Completion: October 30, 2017
• Study Completion: October 30, 2017
• Last Updated: November 20, 2017

Record last verified: 2017-11

Data Sharing

• IPD Sharing: Will not share