Changes in Coverage, Access, and Health Following Implementation of Healthy Behavior Incentive Medicaid Expansions vs. T
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Department of Medicine, Brigham and Women’s Hospital, 75 Francis St., Boston, MA, USA; 2Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; 3Department of Political Science, University of Utah, Salt Lake City, UT, USA; 4 Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 5University of Michigan Medical School, Ann Arbor, MI, USA; 6Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA; 7 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; 8Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
BACKGROUND: Several states expanded Medicaid under the Affordable Care Act using Section 1115 waivers to implement healthy behavior incentive (HBI) programs, but the impact of this type of expansion relative to traditional expansion is not well understood. OBJECTIVE: To examine whether Medicaid expansion with healthy behavior incentive programs and traditional Medicaid expansion were associated with differential changes in coverage, access, and self-rated health outcomes among low-income adults. DESIGN: Difference-in-differences analysis of American Community Survey and Behavioral Risk Factor Surveillance System data from 2011 to 2017. PARTICIPANTS: Low-income adults ages 19–64 in the Midwest Census region (American Community Survey, n = 665,653; Behavioral Risk Factor Surveillance System, n = 71,959). INTERVENTIONS: Exposure to either HBI waiver or traditional Medicaid expansion in the state of residence. MAIN MEASURES: Coverage: Medicaid, private, or any health insurance coverage; access: routine checkup, personal doctor, delaying care due to cost; health: cancer screening, preventive care, healthy behaviors, selfreported health. KEY RESULTS: Healthy behavior incentive (HBI) and traditional expansion (TE) states experienced reductions in uninsurance (− 5.6 [− 7.5, − 3.7] and − 6.2 [− 8.1, − 4.4] percentage points, respectively) and gains in Medicaid (HBI, + 7.6 [2.4, 12.8]; TE, + 9.7 [5.9, 13.4] percentage points) relative to non-expansion states. Both expansion types were associated with increases in rates of having a personal doctor (HBI, + 3.8 [2.0, 5.6]; TE, + 5.9 [2.2, 9.6] percentage points) and mammography (HBI, + 5.6 [0.6, 10.6]; TE, + 7.3 [0.7, 13.9] percentage points). Meanwhile, Prior Presentations Portions of this work were presented at the 2018 SGIM Annual Meeting in Denver, CO. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-05801-6) contains supplementary material, which is available to authorized users. Received June 6, 2019 Accepted March 12, 2020
checkups increased more in HBI than in TE states (p < 0.01), but no other changes in health care services differed between expansion types. CONCLUSIONS: Medicaid expansion was associated with improvements in coverage and access to care with few differences between expans
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