Medicaid Managed Care and Health
Care Access for Adult Beneficiaries
Marguerite E. Burns
Objective. To evaluate the impact of Medicaid managed care organizations (MCO)
on health care access for adults with disabilities (AWDs).
Data Sources. Mandatory and voluntary enrollment data for AWDs in Medicaid
Area Resource File for 1996–2004.
Study Design. I use logit regression and two evaluation perspectives to compare
access and preventive care for AWDs in Medicaid MCOs with FFS. From the state’s
perspective, I compare AWDs in counties with mandatory, voluntary, and no MCOs.
From the enrollee’s perspective, I compare AWDs who must enroll in an MCO or FFS
to those who may choose between them.
Principal Findings. Mandatory MCO enrollees are 24.9 percent more likely to wait
430 minutes to see a provider, 32 percent more likely to report a problem accessing a
specialist, and 10 percent less likely to receive a flu shot within the past year. These
differences persist from the state evaluation perspective.
Conclusions. States should not expect a dramatic change in health care access when
they implement Medicaid MCOs to deliver care to the adult disabled population.
KeyWords. Medicaidmanagedcare,evaluationmethods,health careaccess,high-
After more than a decade of experimentation with Medicaid managed care
(MMC) for adults with disabilities (AWD), there is little evidence about how
thispolicychange influencesbeneficiaries’accessto health care (Ireys, Thorn-
ton, and McKay 2002). Yet the health and quality of life of persons with
disabilities is particularly sensitive to the accessibility of their health care
(Iezzoni 2002; Lawthers et al. 2003; U.S. Department of Health and Human
Services 2005; Iezzoni and O’Day 2006). While the relative effects of MMC
on care access for nondisabled adults have been well studied (Zuckerman,
rHealth Research and Educational Trust
Brennan, and Yemane 2002; Garrett, Davidoff, and Yemane 2003; Garrett
and Zuckerman 2005; Kaestner, Dubay, and Kenney 2005; Le Cook 2007),
substantially different health profile (Rowland et al. 1995; Sisk et al. 1996;
Currie and Fahr 2005). Recognizing this gap between research and practice,
Medicaid programs and the research community are building an evidence
base to inform decisions about how best to care for this population (Landon
et al. 2004; California Department of Health Services 2005; Volpel, O’Brien,
and Weiner 2005; Center for Health Care Strategies Inc. 2006).
This study contributes to that effort by assessing health care access and
relative to fee-for-service (FFS). I apply two evaluation strategies to a nationally
representative sample in an effort to reconcile the extant population-specific
findings (Lo Sasso and Freund 2000; Coughlin, Long, and Graves 2009). First, I
assess the effect of being enrolled in an MCO relative to FFS, an evaluation
perspective that may be most relevant to beneficiaries, advocacy groups, and to
the effect of MCO implementation on the total eligible population, including
beneficiaries who opt out of MCOs or choose FFS where it is an option. This
Medicaid programs because it captures the overall impact of this programmatic
change, including any potential spillover effects (Currie and Fahr 2005).
In response to the population’s disproportionate impact on the Medicaid
budget, states have expanded MMC programs to include AWDs (United
States General Accounting Office 1996; Congressional Budget Office 2006).
By 2004, MMC was available for AWDs in 66 percent of U.S. counties, up
from 43 percent in 1996 (Burns 2008). While Medicaid regulations support a
variety of health plan types, Medicaid MCOs have been a popular choice
among states for their beneficiaries, with disabilities also growing in preva-
lence from 14 percent of counties in 1996 to 25 percent in 2004 (Burns 2008).
Address correspondence to Marguerite E. Burns, Ph.D., Department of Ambulatory Care and
Boston, MA 02215; e-mail: firstname.lastname@example.org
1522HSR: Health Services Research 44:5, Part I (October 2009)
defined provider networks, comprehensive services, and capitated financ-
for AWDs (Tanenbaum and Hurley 1995; United States General Accounting
Office 1996, 2004; Fox et al. 1997; Regenstein 2000; Bachman, Drainoni, and
Tobias 2004). For example, capitated financing, combined with imperfect risk
adjustment, may provide MCOs with an incentive to avoid the most costly
Accounting Office 1996, 2004; Meyers, Glover, and Master 1997). Alterna-
tively, that same incentive may encourage MCOs to monitor health more
aggressively, facilitate the use of services appropriate to patient needs, and
avoid more serious and costly health issues later (Master et al. 1996). Finally,
adequate network of ancillary service and specialty care providers (Tan-
enbaum and Hurley 1995).
Medicaid MCOs and Health Care Access among Nondisabled Adults
The relative effects of Medicaid MCOs on care access for nondisabled ben-
eficiaries are mixed. Relative to FFS Medicaid, Medicaid MCO programs are
associated with an equal or improved likelihood of having a usual source of
care (USC), and an equal or a lower probability of emergency room (ER) use
among adults (Coughlin and Long 2000; Garrett, Davidoff, and Yemane
2003; Garrett and Zuckerman 2005), although this relationship varies de-
pending on the length of Medicaid enrollment (Lo Sasso and Freund 2000).
and shorter wait times once there to see their provider (Sisk et al. 1996;
Coughlin and Long 2000). Preventive care use outcomes vary by the recall
period. Medicaid MCOs are associated with lower or no difference in the
likelihood of receiving a Pap smear or breast exam in the past 12 months
(Zuckerman, Brennan, and Yemane 2002; Garrett and Zuckerman 2005), but
Medicaid MCOs and Health Care Access among Disabled Adults
Relative to FFS, mandatory Medicaid MCOs are associated with diminished
Medicaid Managed Care and Disabled Adults1523
at the programmatic level, that is, for the total eligible AWD population
(Lo Sasso and Freund 2000; Coughlin, Long, and Graves 2009). These mixed
findings may be a function of the evaluation strategies deployed. Lo Sasso and
Freund (2000) assessed the relative effects of mandatory enrollment in a Med-
icaid MCO and found a higher probability of inpatient admissions for am-
bulatory care sensitive conditions and a higher rate of ER visits among MCO
enrollees. Coughlin, Long, and Graves (2009) assessed the relative effects of
living in a county with voluntary or mandatory Medicaid MCOs on Medicaid
beneficiary outcomes. In this program approach, they observed a greater
likelihood of having a USC for preventive health care among beneficiaries in
MCO counties relative to those in FFS counties. Additionally, they found a
greater likelihood of contact with a variety of providers relative to FFS county
beneficiaries when the sample was restricted to urbanites.
Each perspective addresses distinct policy-relevant questions and could
legitimately yield different findings. However, the enrollment evaluation was
conducted in two California counties using administrative claims data from
1989 to 1992, while the program evaluation was national in scope, collapsed
both mandatory and voluntary MCO programs into one category, and used
survey data from 1997 to 2004. The different measures used, geographic
variation in markets and Medicaid programs, and secular changes in MMC
study offersa potentialreconciliationofthehistorical findingswhileproviding
national estimates for each evaluation approach.
DATA AND METHODS
Four data sources are merged by the year and subject’s county of residence. I
pool data from the Household Component of the Medical Expenditure Panel
Survey (MEPS) (1996–2004), a nationally representative survey of the U.S.
civilian noninstitutionalized population. From the MEPS, Medicaid benefi-
ciary enrollment status in FFS or an MCO is identified. To identify MMC
county status and if enrollment is voluntary or mandatory, I use documents
from the Centers for Medicare and Medicaid Systems (Centers for Medicare
and MedicaidServices 2004, 2005) to build a datasetthat describesthecounty
Medicaid MCO status and enrollment mechanism in each U.S. county for the
adult disabled population between 1996 and 2004 following a modified ver-
sionofGarrettetal.’sdata collection protocol (Garrett,Davidoff,and Yemane
1524HSR: Health Services Research 44:5, Part I (October 2009)
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Additional supporting information may be found in the online version of this
Appendix SA1: Author Matrix.
Table S1: Unadjusted Health Care Access by Plan Type: SSI/Medicaid
Beneficiaries Ages 18–64, MEPS 1996–2004.
Table S2: Access Associated with Enrollment in Medicaid MCO
Relative to Medicaid FFS: SSI/Medicaid Beneficiaries Ages 18–64, MEPS
1996-2004 (Average Marginal Effects %).
Table S3: Access Associated with County Program Status, Medicaid
MCO Relative to Medicaid FFS: SSI/Medicaid Beneficiaries Ages 18–64,
MEPS 1996–2004 (Average Marginal Effects %).
Please note: Wiley-Blackwell is not responsible for the content or func-
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for the article.
Medicaid Managed Care and Disabled Adults 1541