State Medicaid Eligibility and Care Delayed Because of Cost
ABSTRACT This study showed wide geographic variation in how often people delayed care because of cost, with prevalence across U.S. counties ranging from 6.5% to 40.6%. Delaying care because of cost was more common in states with more restrictive Medicaid eligibility criteria.
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ABSTRACT: Multilevel models (MLM) offer complex survey data analysts a unique approach to understanding individual and contextual determinants of public health. However, little summarized guidance exists with regard to fitting MLM in complex survey data with design weights. Simulation work suggests that analysts should scale design weights using two methods and fit the MLM using unweighted and scaled-weighted data. This article examines the performance of scaled-weighted and unweighted analyses across a variety of MLM and software programs. Using data from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN: n = 40,723) that collected data from children clustered within states, I examine the performance of scaling methods across outcome type (categorical vs. continuous), model type (level-1, level-2, or combined), and software (Mplus, MLwiN, and GLLAMM). Scaled weighted estimates and standard errors differed slightly from unweighted analyses, agreeing more with each other than with unweighted analyses. However, observed differences were minimal and did not lead to different inferential conclusions. Likewise, results demonstrated minimal differences across software programs, increasing confidence in results and inferential conclusions independent of software choice. If including design weights in MLM, analysts should scale the weights and use software that properly includes the scaled weights in the estimation.BMC Medical Research Methodology 02/2009; 9(1):49. DOI:10.1186/1471-2288-9-49 · 2.17 Impact Factor
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ABSTRACT: On March 23, 2010, President Obama signed into law the first U.S. comprehensive health care reform bill, the Patient Protection and Affordable Care Act (PPACA). After almost a century of failed attempts, the U.S. now has a national health care system which promises to increase access to care, increase consumer choice, and ban insurance discrimination for individuals with preexisting medical conditions. The PPACA is expected to expand insurance coverage to 32 million individuals by 2019 through a variety of measures. At a cost of $938 billion over 10 years, the PPACA is projected to reduce the deficit by $143 billion in the first decade and $1.2 trillion over the second. Almost everyone will be required to purchase health insurance by 2014, with certain exceptions, or face a penalty. The mandate is coupled with sliding scale subsidies to make the purchase more affordable, and it limits annual and out of pocket spending. If the penalty is strong enough, the mandate will be effective in expanding the pool of insured people, spreading the health risk, and eventually decreasing premiums. Key coverage expansions, such as expanding Medicaid benefits to individuals and families with incomes up to 133% of the federal poverty line (FPL), are critical, but access to providers must also be ensured. By 2014, states must set up exchanges where consumers can shop for health insurance at competitive rates. Subsidies will be provided to individuals and families under 400% of the FPL and not eligible under Medicaid to help purchase insurance in the exchange. Additionally, small businesses with fewer than 100 employees will receive tax credits for offering insurance. The PPACA reverses common industry practices that have, in the past, created barriers to coverage. It prohibits insurers from denying coverage to those with preexisting conditions and allows young adults to remain on their parents’ plans up to age 26. For Medicare patients, the Part D coverage gap is closed and cost sharing for preventative care is eliminated, while the amount of out-of-pocket costs paid per year is limited. This historic legislation takes great strides towards providing everyone with medical care, irrespective of income or health status. It will improve public health, and place more emphasis on primary and preventive care. However, issues still remain surrounding difficult choices on how to reduce increasing costs, improve quality, and ensure appropriate payment reimbursement for providers.JAMA The Journal of the American Medical Association 06/2010; 303(24):2521-2. DOI:10.1001/jama.2010.856 · 30.39 Impact Factor
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ABSTRACT: In National Federation of Independent Business v. Sebelius, the US Supreme Court upheld the constitutionality of the requirement that all Americans have affordable health insurance coverage. But in an unprecedented move, seven justices first declared the mandatory Medicaid eligibility expansion unconstitutional. Then five justices, led by Chief Justice John Roberts, prevented the outright elimination of the expansion by fashioning a remedy that simply limited the federal government's enforcement powers over its provisions and allowed states not to proceed with expanding Medicaid without losing all of their federal Medicaid funding. The Court's approach raises two fundamental issues: First, does the Court's holding also affect the existing Medicaid program or numerous other Affordable Care Act Medicaid amendments establishing minimum Medicaid program requirements? And second, does the health and human services secretary have the flexibility to modify the pace or scope of the expansion as a negotiating strategy with the states? The answers to these questions are key because of the foundational role played by Medicaid in health reform.Health Affairs 08/2012; 31(8):1663-72. DOI:10.1377/hlthaff.2012.0766 · 4.64 Impact Factor