Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

ENHANCED CITIZENSHIP VERIFICATION AND CHILDREN'S MEDICAID COVERAGE

This article examines a potential unintended consequence of the mandated Medicaid citizenship verification requirements of the 2005 Deficit Reduction Act (DRA). We investigate whether or not these new rules led to an increase in the Medicaid exit rate among enrollees using state administrative data from Georgia. We do this by comparing the exit rate for children enrolled in Medicaid whose first coverage recertification occurs just after implementation of the DRA (which we refer to as a “high impact” first recertification) with those whose first recertification occurs just prior (which we refer to as a “low impact” first recertification). Our analysis suggests that children in the high‐impact first recertification group were about 2 percentage points more likely to exit Medicaid than those in the low‐impact group. Furthermore, these additional exits occurred in racial and ethnic groups more likely to be citizens than noncitizens and prereform estimates suggest that there were very few (roughly 0.10%) noncitizen Medicaid enrollees to begin with. Taken together, our results suggest that the DRA‐enhanced citizenship verification rules led to an increase in Medicaid disenrollment, and thus a reduction in coverage, among citizens. (JEL I18, I38, J13)     

Medicaid physician fees and the quality of medical care of Medicaid patients in the USA

When enacted in 1965, the original Medicaid legislation sought to finance access to mainstream medical care for the poor. I use data on visits to office-based physicians from the National Ambulatory Medical Care Survey in four years—1989, 1993, 1998 and 2003—to test the extent to which this goal has been achieved. Specifically, I test whether this goal has been achieved more in states that pay higher fees to physicians who treat Medicaid patients compared to states that pay lower fees. By comparing the treatment of Medicaid patients to that of privately-insured patients and by using state fixed effects, I am able to estimate the effects of changes in the generosity of Medicaid physician payment within a state on changes in access to care for Medicaid patients, therefore separating Medicaid’s effect on access to health care from any correlation between the Medicaid fee and other attributes of the state in which a patient lives. Using this method, I examine the effect of Medicaid fees on whether or not an office-based physician accepts Medicaid patients, on the fraction of a physician’s practice that is accounted for by Medicaid, and on the length of visit times with physicians. Results imply that higher Medicaid fees increase the number of private physicians, especially in medical and surgical specialties, who see Medicaid patients. Higher fees also lead to visit times with physicians that are more comparable to visit times with private pay patients.

LAC and RTI: Eliminate Medicaid prior auth for bupe

Since April 2018, Medicare limited utilization management — most often done via prior authorization requirements — for buprenorphine to treat opioid use disorder (OUD). In response, virtually all plans that covered this treatment removed prior authorization requirements. Medicaid plans should do the same, according to RTI, writing in the July 9 issue of the Journal of the American Medical Association (JAMA).     

Medicaid Beneficiaries' Access to Residential Care Settings

Residential care settings (RCSs) are community-based housing and supportive services providers. Medicaid beneficiaries' access to RCSs is of concern to policymakers and other stakeholders because most people prefer community-based to institutional services and RCSs are generally less expensive than nursing homes. To better understand Medicaid beneficiaries' access to state-licensed RCSs, we examined Medicaid policies in 50 states and the District of Columbia, interviewed seven subject-matter experts, and conducted four state case studies informed by reviews of state policies and interviews with 27 stakeholders. Factors identified as influencing Medicaid beneficiaries' access to RCSs include Medicaid reimbursement rates for RCS services, the supply of Medicaid-certified RCSs and RCS beds, and policies that affect RCS room and board costs for Medicaid beneficiaries. Shifting Medicaid spending toward community-based instead of institutional care may require attention to these interrelated issues of RCS payment, supply, and room and board costs.     

Restrictiveness of Eligibility Determination and Medicaid Enrollment by Low-Income Seniors

Medicaid is an important source of supplemental health care coverage for low-income seniors, yet little is known about the effect of state policy on Medicaid enrollment by eligible elderly. Data from a nationally representative survey were used to examine Medicaid enrollment by elderly, low-income Medicare beneficiaries living in states that liberalize or restrict Medicaid eligibility criteria using the 1986 Omnibus Budget Reconciliation Act or provision 209(b) of the 1972 Social Security Act Amendment, respectively. Controlling for demographics and health status, residence in states applying these laws was significantly, though modestly, associated with Medicaid enrollment. Additionally, 73% of eligible elderly Medicare beneficiaries were not enrolled in Medicaid, and most have serious chronic health problems. These findings suggest that a significant number of eligible elderly are not enrolled in Medicaid and that liberalizing or tightening Medicaid eligibility criteria can have an impact on Medicaid enrollment by low-income elderly patients.     

Stimulants for preschool ADHD down,A2As up

The diagnosis of attention deficit hyperactivity disorder (ADHD) is decreasing among children ages 2 to 5 in Kentucky, but the use of alpha‐2 agonists (A2As, such as clonidine and guanfacine) is increasing, and the use of stimulants is decreasing. The researchers urge long‐term follow‐up of these children, as well as vigilance in checking diagnosis and treatment. For the study, published in the Journal of Child and Adolescent Psychopharmacology and based on Medicaid claims, the researchers were not able to ascertain whether the diagnoses or the treatments were appropriate.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Table of Contents

Column Promoting Suboxone Film, Criticizing Methadone, Angers Field Center Takes Proactive Approach on Integrated Care, Research Efforts States Encouraging Providers to Enroll in Medicaid Legal Action to Enforce Parity Contemplated, Ramstad Tells ADAW Journalist in Recovery Describes Her Experience in MAT Briefly Noted In the States Business Resources Coming up     

Table of Contents

Medicaid Cutbacks in Maine Leave Some OTP Patients without Coverage Online Training Helps Providers Learn Billing and Insurance Cough Syrup Abuse: It's the Codeine More on SAMHSA Numbers from 2013 Appropriations Letter to the Editor What President Obama Really Said about Marijuana Briefly Noted In the States Coming up     

SNAP EXPANSIONS AND PARTICIPATION IN GOVERNMENT SAFETY NET PROGRAMS

This paper investigates the interactions between health and nutritional assistance programs such as Medicaid, SNAP, WIC, and school lunch programs. Exploiting variation in SNAP eligibility across states and over time, I find strong evidence of program interactions: when a state moves from the federal rule to the most extensive SNAP eligibility rule, enrollment in free school lunch and WIC increases by 4.1 and 7.9 percentage points, respectively. I estimate that the federal government spends an additional 74 cents on the school lunch program and WIC for each dollar spent on SNAP due to the expansion. (JEL H53, I38, J22)     

The Effects of Unemployment on Prenatal Care Use and Infant Health

Do recessions improve birth outcomes? This study investigated the relationship between unemployment fluctuations, prenatal care utilization and infant health. Analyzing the US Natality Detail Files for the period 1989–1999 aggregated by county, year, and race, I found the overall effects of unemployment to be beneficial but concluded that at least some of the apparent benefits are attributable to the Medicaid “safety net.” In supplementary analyses stratified by socioeconomic status, Medicaid played the largest role among economically disadvantaged (single and less educated) women. Thus, unemployment seems to be good for at least some pregnancies—provided Medicaid steps in.     

Welfare Reform and Elderly Immigrants' Naturalization: Access to Public Benefits as an Incentive for Naturalization in the United States

Welfare reform in the United States restricted non‐citizens' eligibility for public assistance programs and strengthened economic benefits from naturalization. We examine the impact of these policy changes on elderly immigrants' naturalization, considering their level of need for public benefits. Using individual data from the Current Population Survey as well as state‐level data, we employ a differences‐in‐differences approach to consider variations in time, state policy, and probability of Medicaid participation. Results show that naturalization significantly increased among elderly immigrants who were likely to participate in Medicaid, suggesting that elderly immigrants in need of Medicaid became naturalized to maintain their eligibility for public benefits after welfare reform.     

State Discretion and Medicaid Program Variation in Long-Term Care

Summary

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.     

Table of Contents

CDC Issues Warning in MMWR About Rapid Opioid Detox Some Providers Will Weigh Option of Steering Workers to Exchanges One in Three Teens With BP Develops an SUD Within Four Years N.M., Vt. Get Best Scores, S.D. Worst in Rx Drug Abuse Strategies States Roll out Marketplaces; Medicaid Expansion in Only Some State News Names in the News Coming up     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

Medicaid State Plan Personal Care Services

Abstract

Policymakers face mounting pressures from consumer demand and the 1999 Olmstead Supreme Court decision to extend formal (paid) programs that deliver personal care to the elderly, chronically ill, and disabled. Despite this, very little is known about the largest program that delivers personal care: the Medicaid State Plan personal care services (PCS) optional benefit. This paper presents the latest available national program (participant and expenditure) trend data (1999–2002) on the Medicaid PCS benefit and findings from a national survey of eligibility and cost control policies in use on the program. The program trends show that, over the study period, the number of states providing the Medicaid PCS benefit grew by four (from 26 to 30), and national program participation, adjusted for population growth, increased by 27%. However, inflation-adjusted program expenditures per participant declined by 3% between 1999 and 2002. Findings from the policy survey reveal that between 1999 and 2002 there was a marked decline in the range of services provided, and by 2004, almost half the programs operated a cap on the hours of services provided.