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Abstract
Medicaid and Medicare are the two largest public health insurance programs in the US, providing coverage to people who are low-income, disabled, 65 or older, and more. For those eligible, transitioning from Medicaid to dual Medicare-Medicaid coverage at age 65 may lead to changes in health services use and costs to the healthcare system. More research is needed on the effects of this transition, especially as Medicaid expansion and restructuring Medicare benefits are both under debate. In Chapter 1, we provide context about both programs, summarize relevant evidence, and ask how different coverage status and care settings might affect continuity, access, quality, and cost of care. We describe the significance of our studies and policy implications.In Chapter 2, we use national Medicaid and Medicare claims to investigate changes in health services utilization and costs for Medicaid beneficiaries who aged into Medicare using a regression discontinuity design. We found that Medicare enrollment at 65 is associated with abrupt increases in the rates of hospital admissions and primary care visits. These discontinuities could be attributed to patients’ anticipation of more generous coverage, greater provider access under Medicare, and resulting pent-up demand. Our findings suggest that improved access under dual enrollment relative to Medicaid-only may cause delays in care near the transition.
As coverage and utilization increase, the availability of providers to meet the needs of new patients and patients’ choice of providers remain unclear. In Chapter 3, we assess continuity of care by examining the number of unique providers, average provider caseload, and percentage of patients served by the same provider before and after the transition. Compared to the number of unique primary care providers (PCPs) serving the cohort with Medicaid only, the number almost doubled after the same cohort transitioned to dual enrollment. Meanwhile, each PCP saw more patients. Among those who were hospitalized both before and after, there were more unique hospitals post-transition, but each hospital admitted fewer patients. Switching providers after the transition was fairly common. These are in line with our hypothesis that having dual coverage is associated with wider access to inpatient and primary care, which potentially reflects unmet needs under Medicaid.
As an increasing number of individuals age into Medicare from their previous coverage, including Medicaid, some may continue to seek care with their established providers. An important safety net primary care setting is federally qualified health centers (FQHCs), designated to care for underserved populations. In Chapter 4, we use national Medicare and Medicaid claims to compare annual costs for dual enrollees who primarily use FQHCs versus those who use other settings for primary care. For both the aged and the younger disabled, FQHC users experienced higher primary care cost, lower non-primary care cost, and lower total cost. The robustness of the FQHC effect suggests that the practice style of FQHCs may offer a cost-efficient setting, likely by reducing non-primary care cost. Further research is needed to confirm that the quality of care at FQHCs for duals is at least equivalent to more expensive settings.