@article {13248, title = {Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level.}, journal = {JAMA Intern Med}, volume = {183}, year = {2023}, pages = {534-543}, abstract = {

IMPORTANCE: Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program{\textquoteright}s income eligibility threshold (100\% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries{\textquoteright} ability to afford care.

OBJECTIVE: To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0\% to 200\% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.

MAIN OUTCOME MEASURES: Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.

RESULTS: This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200\% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1\% of beneficiaries were women, 14.8\% were non-Hispanic Black, 13.6\% were Hispanic, and 71.6\% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95\% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95\% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95\% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95\% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95\% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95\% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95\% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries.

CONCLUSIONS AND RELEVANCE: This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

}, keywords = {Aged, Cross-Sectional Studies, Female, Healthcare Disparities, Humans, Male, Medicaid, Medicare, Middle Aged, Poverty, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2023.0512}, author = {Roberts, Eric T and Kwon, Youngmin and Hames, Alexandra G and McWilliams, J Michael and Ayanian, John Z and Tipirneni, Renuka} } @article {11670, title = {Changes in Health Care Access and Utilization for Low-SES Adults Age 51-64 after Medicaid Expansion.}, journal = {The Journal of Gerontology: Series B}, volume = {76}, year = {2021}, pages = {1218-1230}, abstract = {

OBJECTIVES: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults age 51-64 has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults age 51-64 before and after the ACA Medicaid expansion.

METHODS: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N=2,088 noninstitutionalized low-education adults age 51-64 (N=633 in Medicaid expansion states, N=1,455 in non-expansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, private), access (usual source of care, difficulty finding doctor, foregone care, cost-related medication nonadherence, out-of-pocket costs), utilization (outpatient visit, hospitalization), and health status.

RESULTS: Low-education adults age 51-64 had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in non-expansion states, DID +7.4 pp, p=0.001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in non-expansion states, DID +10.4 pp, p=0.003) in Medicaid expansion compared with non-expansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in non-expansion states (+3.6 pp in expansion states, +11.0 pp in non-expansion states, DID -7.5 pp, p=0.006). There were no other significant differences in access, utilization or health trends between expansion and non-expansion states.

DISCUSSION: After Medicaid expansion, low-education status adults age 51-64 were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.

}, keywords = {Affordable Care Act, Hospitalization, Medicaid, Retirement}, issn = {1758-5368}, doi = {10.1093/geronb/gbaa123}, author = {Tipirneni, Renuka and Helen G Levy and Kenneth M. Langa and Ryan J McCammon and Zivin, Kara and Jamie E Luster and Karmakar, Monita and John Z. Ayanian} } @article {11671, title = {Trends and Disparities in Functional Impairment among US Adults Age 55-64, 2002 to 2016.}, journal = {Journal of General Internal Medicine}, volume = {36}, year = {2021}, pages = {3903-3906}, abstract = {Over the past decade, US midlife morbidity and mortality have increased, contributing to declines in life expectan cy.1 This worsening health status has been experienced disproportionately by low{\textendash}socioeconomic status (SES) and racial/ethnic minority individuals2, 3 and is associated with functional deterioration among low-SES middle-aged adults.4 Yet it is unclear if disparities in functional status are rising. Functional impairment may not be recognized as a health problem for middle-aged adults, but it is common and, as for older adults, associated with disability and death.5 Our objective was to examine functional trends among US midlife adults to determine whether and how changes in disparities are concentrated among particular demographic groups. }, keywords = {Mortality, Racial Disparities, socioeconomic status}, issn = {1525-1497}, doi = {10.1007/s11606-020-06209-y}, author = {Tipirneni, Renuka and Karmakar, Monita and Donovan T Maust} } @article {9949, title = {Reducing Disparities in Healthy Aging Through an Enhanced Medicare Annual Wellness Visit}, journal = {Public Policy \& Aging Report}, volume = {29}, year = {2019}, pages = {26-32}, abstract = {In its current form, the Medicare annual wellness visit (AWV) is not reaching most older Americans, particularly lower-income or minority adults and those served by safety-net providers (Ganguli, Souza, McWilliams, \& Mehrotra, 2018). Yet these underserved seniors face disparities in healthy aging, likely due to individual, social, and behavioral determinants of health, such as low income, limited education, social isolation, food insecurity, poor housing quality, and difficulty affording medications. New AWV models should move beyond traditional assessments of cognition, balance, and vision to identify and address important root causes of poor health, such as individual, social, and behavioral determinants of health. Incorporating these key determinants of health into AWVs has the potential to promote healthy aging among underserved seniors. In this paper, we present local opportunities for AWV-related practice transformation, including screening tools, electronic health record templates, care team member roles, and workflows. At the national level, we suggest updates to Medicare{\textquoteright}s current AWV policy guidelines with regard to visit elements and funding models.}, keywords = {Health Disparities, Medicare, Well-being}, issn = {1055-3037}, doi = {10.1093/ppar/pry048}, url = {https://academic.oup.com/ppar/advance-article/doi/10.1093/ppar/pry048/5251985http://academic.oup.com/ppar/advance-article-pdf/doi/10.1093/ppar/pry048/27184822/pry048.pdf}, author = {Tipirneni, Renuka and Ganguli, Ishani and John Z. Ayanian and Kenneth M. Langa} }