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Looking Into ACA Medicaid ExpansionResearch Paper

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Medicaid Expansion (Effects on the Elderly Due to the States That Did Not Expand)

The aim of Medicaid expansion is extending Medicaid eligibility and including all people and families whose income is less than 138% of FPL (Federal Poverty Line). The expansion covers a large number of people (including groups such as bachelors) who were not eligible earlier (Graves, 2012).

States get to decide Medicaid expansion eligibility. All the legal residents, of states expanding Medicaid, with income below 15,302 dollars (individuals) and 31,155 dollars (family of four members) are entitled to Medicaid enrolment under the expansion program. For other states (which decided against expanding Medicaid), enrolment covers a very narrow societal cross-section; some states have income limits as small as 50% of FPL (Lanford & Quadagno, 2015).

A total of 29 states implemented Medicaid expansion by April of this year; the remaining 21 states chose not to adopt the expansion (Buettgens, Holahan & Recht, 2015). One of ACA's (Affordable Care Act) key goals is to considerably diminish the share of uninsured persons, by offering affordable healthcare coverage alternatives via newly-instituted health insurance exchanges and Medicaid. The ACA, as enacted, would succeed in expanding Medicaid for almost every low-income citizen of the U.S. (whose earnings are no more than 138% FPL, i.e., 16,242 dollars/annum for one person in the year 2015) (Buettgens et al., 2015). This expansion endeavor is an essential element of the Act, and is among the most vital of its mechanisms for ensuring a significant rise in healthcare insurance coverage. In particular, it is crucial for diseased low-income adults as well as ethnic and racial minorities, whose probability of Medicaid eligibility is higher than that of White citizens (Lanford & Quadagno, 2015).

II. The Importance of the Problem

Since June 2012, when a Supreme Court ruling allowed states the choice of accepting or declining ACA's Medicaid eligibility expansion, the issue has become highly controversial, and gained increasing prominence (Graves, 2012). The theory of the welfare state helps account for factors that govern Medicaid expansion. The theory facilitates determination of factors accounting for variations among states in moving towards expansion under ACA provisions. First is the critical expansion-partisanship link, followed by other factors which may affect the compliance decision of a state, even where there is consolidation of partisan control. The factors include Medicaid policy legacy of a state before ACA enactment, provider group influence, state capacity, impact of conformist political values, and racial antipathy levels (Lanford & Quadagno, 2015).

III. Articles review

Mortality and Access to Care among Adults after State Medicaid Expansions by Sommers et al., (2012).

Methodology: This research undertook a comparison of three states --New York, Arizona, and Maine -- known for substantial expansion of adult Medicaid entitlement since the year 2000, with nearby states that chose not to expand. Study sample comprised adults aged from 20 to 64 years, observed for five years prior to, and following, expansion (i.e., from 1997 to 2007). The main outcome was county-level all-cause death among 68,012 county- and year- specific observations in CDC (Centers for Disease Control and Prevention) Compressed Mortality database. Secondary outcomes included insurance coverage rates, self-reported status of health, and delayed care owing to expenses among 192,148 individuals in the Behavioral Risk Factor Surveillance System (BRFSS) and 169,124 individuals in the Current Population Survey (CPS).

Analysis: Adjusted and unadjusted results for secondary and primary outcomes with time were scrutinized by the study, comparing control and expansion states. The study utilized multivariable regression for principal analyses, with generalized linear model (GLM) and state level-clustered Huber -- White robust standard errors, to explain serial correlation and intervention at state level. Interaction between expansion state and timing following expansion constituted the independent variable, comparing average mortality difference among control and expansion states prior to expansion with average difference following expansion; adjustments were made for year and county fixed effects and covariates. Finally, the CPS information was applied for deriving descriptive data for new Medicaid enrollees (post-expansion enrollees), to estimate which people would most likely join up during expansion.

Finding: There was an appreciable drop in all-cause adjusted mortality linked to Medicaid expansions (i.e., drop by 19.6 mortalities for every 100,000 adults; relative 6.1% reduction; P = 0.001). These reductions were highest in non-Whites, elderly people, and poor-county inhabitants. The expansion program brought about a 2.2 pp (percentage-point) improvement in coverage (for a relative 24.7%rise; P = 0.01), 2.9 pp drop in cost-effected delayed care rates (for a relative 21.3%drop; P = 0.002), 3.2 pp drop in noninsurance rates (for a relative 14.7% drop; P<.001), and 2.2 pp rise in self-reported "very good" or "excellent" health status rates (for a relative 3.4% rise; P = 0.04).

Conclusions: Medicaid expansions by individual states that covered adults with low earnings were linked substantially to decreased mortality, and better self-reported health, coverage, and care access.

Perspectives of Physicians and Nurse Practitioners on Primary Care Practice, by Donelanet a., (2013).

Methodology: A country-wide mail survey was conducted between 23rd November, 2011, and 9th April, 2012; survey participants included 972 primary healthcare professionals (of which 467 were nurse practitioners (NPs) and 505 were physicians), with 61.2% response rate. The survey covered aspects such as characteristics and scope of practice, as well as attitudes with regard to impact of increasing NPs' primary care role.

Analysis: This study utilized information from the whole study sample (i.e., 467 NPs and 505 doctors; sampling error= ±3.1%) for analyzing attitudinal measures as well as clinical-practice and personal characteristics. Researchers' main emphasis was primary care NPs', physicians' experiences, and attitudes in their work settings. The research investigated bivariate and univariate relationships, comparing NPs and physicians by employing chi-square tests (in case of categorical variables) and 2-sample t-tests (in case of continuous variables) on measures inquired of both groups. Also analyzed were differences between and within both professional groups in regard to gender, age, region, and collaborative practice. All results were tested for the aforementioned relationships; all significant outcomes (P<.05) were reported.

Finding: Doctors reported extended working hours, seeing a greater number of patients, and increased earnings than NPs. 80.9% of participating NPs self-reported working with a doctor in a clinical practice, while 41.4% participating physicians self-reported working with an NP. Physicians were less inclined to think they need to head medical homes, be given equal pay for identical services, and be granted hospital admittance privileges, than NPs. Further, the questionnaire asked participants if they were in agreement with the idea that physicians could offer better consultation and examination in terms of quality, when compared with NPs, during similar primary healthcare visits; 75.3% NPs did not agree, while 66.1% physicians were in agreement.

Conclusion: Present policy recommendations endeavoring to expand primary care NPs' practice scope and supply are contentious. NPs and physicians disagree with their corresponding current roles in primary healthcare delivery.

Changes in Payer Mix and Physician Reimbursement after the Affordable Care Act and Medicaid Expansion, by Jones et al., (2015).

Methodology: Analysis, in this historical cohort study, was carried out on a University of Colorado Hospital database, which included information on every general-medicine inpatient discharge in 2013-14. The study classified payers into the following categories: Medicaid, Medicare, Medicaid, Medicare + Medicaid, uninsured, private-insured, and other. The last category was included for analyzing primary payer mix; it was, however, omitted from analysis of reimbursement because of variability in payer reimbursement within the category group (e.g., Tricare, worker's compensation). The study calculated encounters from each admission's calendar days. An admission's first, intervening and final calendar days were taken as preliminary, subsequent and discharge encounters, respectively.

Analysis: Individual payers' encounter proportions in 2013-14 were compared by employing chi-square tests. Kolmogorov -- Smirnov (K-S) tests assessed average encounter/reimbursement distribution. Owing to the non-parametric nature of encounter/reimbursement, Wilcoxon rank sum tests were conducted for comparing encounter/reimbursement in the two years. Post hoc analyses were utilized for evaluating factors, which possibly brought about encounter/reimbursement changes. The relative influence of each change factor, stated as follows, in encounter/reimbursement was evaluated by the study: (1) duration of hospitalization, (2) payer mix (or total encounter proportion attributed to individual payers), (3) encounter-type proportion by payer, and (4) encounter-type reimbursement by payer.

Finding: 6395 discharges (37,540 encounters) were performed among inpatients for general medicine in 2013 and 6483 in 2014 (40,397 encounters). Medicaid encounters rose from 17.3% in 2013 to 30.0% in 2014 (P < .001); there was a decline in uninsured encounters from 18.4% (2013) to 6.3% (2014) (P < .001); and private encounters declined from 14.1% (2013) to 13.3% (2014) (P = .001). For all other payer categories, encounters during the study period remained constant.

Conclusion: A significant rise can be observed in Medicaid-payer encounters, accompanied by decreases in private-payer and uninsured-payer encounters. Medicaid encounter increases and uninsured encounter drops are steady with nationally-observed trends; they offer a sharp local picture of projected insurance coverage changes under ACA.

IV. Literature Review

State Medicaid expansion programs were linked to an appreciable decrease in all-cause adjusted mortality. These reductions were highest in non-Whites, elderly people, and poor-county populations. The… [END OF PREVIEW]

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