Healthcare Rationing in Public Insurance Programs: Evidence from Medicaid.
Ontology highlight
ABSTRACT:
SUBMITTER: Layton TJ
PROVIDER: S-EPMC9945909 | biostudies-literature | 2022 Nov
REPOSITORIES: biostudies-literature
Publications
Healthcare Rationing in Public Insurance Programs: Evidence from Medicaid.
Layton Timothy J TJ Maestas Nicole N Prinz Daniel D Vabson Boris B
American economic journal. Economic policy 20221101 4
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Project description:BackgroundIt is impossible to meet all healthcare demands, but an open and fair rationing process may improve the public acceptability of priority setting in healthcare. Decision-making is subject to scrutiny by newspaper media, an important public institution and information source for discussions about rationing. In Norway, healthcare rationing has been subject to public debate both before and after the establishment of "The National System for Managed Introduction of New Health Technologies within the Specialist Health Service" (New Methods) in 2013.AimTo describe and assess the development of the public debate on Norwegian healthcare rationing through three cases in print media.MethodsWe purposively sampled Norwegian newspaper articles between 2012 and 2018 concerning three reimbursement decisions in the Norwegian system. The reimbursement decisions were ipilimumab (Yervoy, n = 45) against metastatic melanoma, nivolumab (Opdivo, n = 23) against non-small cell lung cancer, and nusinersen (Spinraza, n = 68) against spinal muscular atrophy. Cases were analysed separately using the qualitative method of systematic text condensation.ResultsOur analysis highlighted four common themes-money, rationales, patient stories, and process-and a unique theme for each case. Ipilimumab was uniquely themed by rationing rejection, nivolumab by healthcare two-tiering, and Spinraza by patients' rights. We found wide media deliberation among a multitude of stakeholders in all cases. Perceptions of rationing were found to be chiefly aligned with previous empirical research. We found that the media reported more frequently on opposition to rationing compared to findings from previous studies on Norwegian healthcare decision-making attitudes. We think this was influenced by our selection of cases receiving extraordinary media attention, and from media sources being subject to political communication from special interest groups.ConclusionWe observed that the introduction of New Methods institutionalised Norwegian healthcare rationing and isolated the public debate into conversations between stakeholders and decision makers outside the political sphere. The findings from these three extraordinary debates are not generalisable and should be seen as a stakeholder learning opportunity regarding media coverage and engagement with expensive specialist healthcare decision-making in Norway.
| S-EPMC8962557 | biostudies-literature
Project description:BackgroundIt is ethically controversial whether medical doctors are morally permitted to ration the care of their patients at the bedside. To explore whether general practitioners in fact do ration in this manner we conducted a study within primary care in the Danish public healthcare system. The purpose of the study was to measure the extent to which general practitioners (GPs) would be willing to factor in cost-quality trade-offs when prescribing medicine, and to discover whether, and if so to what extent, they believe that patients should be informed about this.MethodsPostal survey of 600 randomly selected Danish GPs, of which 330 responded to the questionnaire. The Statistical Package for the Social Sciences (SPSS, version 14.0) was used to produce general descriptive statistics. Significance was calculated with the McNemar and the chi-square test. The main outcome measures of the study were twofold: an assessment of the proportion of GPs who, in a mainly hypothetical setting, would consider cost-quality trade-offs relevant to their clinical decision-making given their economic impact on the healthcare system; and a measure of the extent to which they would disclose this information to patients.ResultsIn the hypothetical setting 95% of GPs considered cost-quality trade-offs relevant to their clinical decision-making given the economic impact of such trade-offs on the healthcare system. In all 90% stated that this consideration had been relevant in clinical decision-making within the last month. In the hypothetical setting 55% would inform their patients that they considered a cost-quality trade-off relevant to their clinical decisions given the economic impact of such trade-offs on the healthcare system. The most common reason (68%) given for not wanting to inform patients about this matter was the belief that the information would not prove useful to patients. In the hypothetical setting cost-quality trade-offs were considered relevant significantly more often in connection with concerns about costs to the patient (86%) than they were in connection with concerns about costs to the healthcare system (55%; p < 0.001).ConclusionAlthough readiness to consider cost-quality trade-offs relevant to clinical decisions is prevalent among GPs in Denmark, only half of GPs would disclose to patients that they consider this relevant to their clinical decision-making. The results of this study raise two important ethical problems. First, under Danish law physicians are required to inform patients about all equal treatments. The fact that only a few GPs would inform their patients about all of the relevant treatments therefore seems to contravene Danish law. Second, it is ethically controversial that physicians act as economic gatekeepers.
| S-EPMC2567318 | biostudies-literature
Project description:ObjectivesThis study is the first rigorous evaluation of the impact of Jaminan Kesehatan Nasional (JKN) on improving access to outpatient and inpatient care, utilising longitudinal data from the Indonesian Family Life Survey.MethodsTwo treatment groups were identified: a contributory group (N = 982), who paid the premium voluntarily, and a subsidised group (N = 2503), paid by government. Each group was compared with the uninsured group (N = 8576). Propensity score matching combined with difference-in-difference approaches was used to estimate the causal effect of the JKN programme.ResultsThe results found that JKN increased the probability of inpatient admission for the contributory and subsidised groups by 8.2% (95% CI 5.9-10.5%) and 1.8% (95% CI 0.7-2.82%), respectively. The contributory group had an increase in probability of an outpatient visit of 7.9% (95% CI 4.3-11.4%).ConclusionsThe JKN programme has increased the utilisation of outpatient and inpatient care in the contributory group. Those with subsidised insurance have an increase in access to inpatient facilities only, and this is of a smaller magnitude. Hence, while JKN has improved average utilisation, inequity in access to both outpatient and inpatient care may remain.
| S-EPMC6517357 | biostudies-literature
Project description:In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage by using a randomized controlled design. By using the randomization provided by the lottery and emergency-department records from Portland-area hospitals, we studied the emergency department use of about 25,000 lottery participants over about 18 months after the lottery. We found that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40% relative to an average of 1.02 visits per person in the control group. We found increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.
| S-EPMC3955206 | biostudies-literature
Project description:ObjectiveTo evaluate the effect of the Oregon and New Mexico Health Insurance Flexibility and Accountability (HIFA) demonstrations. HIFA is an optional state Medicaid expansion targeted at adults and children with incomes below 200 percent of the federal poverty level (FPL). The study has five research questions: What type of health insurance do HIFA enrollees self report in surveys? What are the demographic characteristics of these enrollees? What type of health insurance coverage, if any, did HIFA enrollees have just prior to enrollment in the HIFA program? Among those with prior coverage, what prompted participation in the HIFA program? What type of health insurance, if any, would HIFA enrollees have in the absence of HIFA?MethodsData were collected via telephone interviews with a total of 406 enrollees from Oregon and 409 enrollees from New Mexico. The survey was conducted between July 7 and September 20, 2009, for both states. The sample frame for the survey was based on administrative records of adults enrolled in June 2009. After completion of the survey, active enrollment status as of the date the telephone interview was confirmed. Respondents no longer enrolled at the time of the survey (7 cases in NM and 14 in OR) were excluded from the analysis. The final sample size was 794 verified HIFA enrollees.ResultsHIFA enrollees tended to be middle-aged, male, and relatively unhealthy. Employment status varied tremendously from the self-employed to retired to unable to work. HIFA enrollees were reasonably well educated with 80 percent having at least a high school education. Most HIFA enrollees (90 percent) reported being uninsured just prior to participation in HIFA. Of those who were uninsured, most reported having been uninsured for an extended time-a year or more. Most enrollees joined HIFA because they lacked access to health insurance or could not afford insurance on the private market. The overwhelming majority (76 percent) of respondents believed that they would be uninsured in the absence of HIFA, with few considering either an employer plan or private purchase to be a viable option. Over 90 percent of enrollees correctly indicated they had insurance coverage. However, characterization of the type of coverage was problematic, particularly in the absence of the program-specific name.ConclusionsHIFA enrolled a relatively sick, male, middle-aged population that tended to have been long-term uninsured--the kind of enrollees for which the programs were designed--with little apparent crowd-out of private insurance. The reported health status coupled with low incomes suggests that individual purchase is unlikely, a sentiment echoed by the respondents. In the absence of HIFA, most enrollees believed they would rejoin the ranks of the uninsured from where they came.
| S-EPMC4722208 | biostudies-literature
Project description:BackgroundIn Iowa from 2014 to 2017, there were 2 separate public dental benefit programs for Medicaid-enrolled adults: one for the Medicaid expansion population called the Dental Wellness Plan (DWP), and one for the traditional, non-expansion adult Medicaid population. The programs differed with respect to reimbursement, administration, and benefit structure. This study explored differences in patterns and predictors of dentist participation in the two programs.MethodsAuthors sent a survey to all private practice dentists in Iowa (n = 1301) 2 years after DWP implementation. Descriptive, bivariate, and logistic regression analyses were used to examine patterns and predictors of dentist participation in Medicaid and DWP.ResultsOverall rates of dentists' acceptance of new Medicaid and DWP patients were 45 and 43%, respectively. However, Medicaid participants were much more likely than DWP participants to place limits on patient acceptance. Adjusting for other factors, practice busyness was the only significant predictor of DWP participation, and practice location was the only significant predictor of Medicaid participation. Dentists who were not busy enough were more than twice as likely to participate in DWP compared to others, and dentists in rural areas were almost twice as likely to participate in Medicaid compared to dentists in urban areas.ConclusionsDentist participation in Medicaid is an ongoing concern for states aiming to ensure access to dental care for low-income populations. We found distinct participation patterns and predictors between a traditional Medicaid dental program and the DWP, suggesting different motivations for participation between the two programs.
| S-EPMC6534867 | biostudies-literature
Project description:ImportanceEvaluating the availability of dentists to provide dental care services to children is important for identifying interventions for improving access.ObjectiveTo assess dental care availability for children in the US by public insurance participation, rural-urban setting, and dentist taxonomy (general, pediatric, or specialized).Design, setting, and participantsThis cross-sectional study analyzed the availability of dentists from matching 3 data sets: the 2020 National Plan and Provider Enumeration System, the 2019-2020 State Board of Dentistry information acquired from each state, and the 2019 InsureKidsNow.org database. Data on active dentists in most states (including the District of Columbia [combined hereinafter with states] and excluding Hawaii and Washington) were included in the analysis. The study was conducted from January 2019 to March 2022.Main outcomes and measuresThe number and percentage of dentists participating in public insurance programs (Medicaid and/or Children's Health Insurance Program [CHIP]) were aggregated at the dental office and stratified by the rurality of their practice and taxonomy. State-level comparisons were derived between this study and reports from the Health Policy Institute of the American Dental Association, along with maps and summary statistics disseminated through a data portal and state reports.ResultsAmong 204 279 active dentists, participation in public insurance varied widely across states, especially for the states that manage the Medicaid and CHIP programs separately. Participation rates in Medicaid and CHIP varied substantially from those of the Health Policy Institute of the American Dental Association. Participation in Medicaid and CHIP was lowest among urban dentists (Medicaid, 26%; CHIP, 29%) and highest among rural dentists (Medicaid, 39%; CHIP, 40%), while urban dentists accounted for most of the dentist population (urban, 84%; rural, 5%). Similarly, participation in Medicaid and CHIP was substantially lower among general dentists (Medicaid, 28%; CHIP, 29%) vs pediatric dentists (57% in both programs), while each state's dentist population consisted of notably more general (84%) than pediatric (3%) dentists. Nearly half of the states revealed wide variations in Medicaid and CHIP participation between counties, ranging from no participation (21 states) to full participation (22 states).Conclusions and relevanceThe findings of this study suggest that disparities in the availability of dentists for pediatric dental care are extensive, particularly for Medicaid- and CHIP-insured children, those living in rural communities, and those receiving specialized care. Lack of dentist availability for Medicaid- and CHIP-insured children appears to deter access to receiving dental care.
| S-EPMC9274318 | biostudies-literature
Project description: Not available
| S-EPMC11675956 | biostudies-literature
Project description:In 2008, a group of uninsured low-income adults in Oregon was selected by lottery for the chance to apply for Medicaid. Using this randomized design and state administrative data on voter behavior, we analyze how a Medicaid expansion affected voter turnout and registration. We find that Medicaid increased voter turnout in the November 2008 Presidential election by about 7 percent overall, with the effects concentrated in men (18 percent increase) and in residents of Democratic counties (10 percent increase); there is suggestive evidence that the increase in voting reflected new voter registrations, rather than increased turnout among pre-existing registrants. There is no evidence of an increase in voter turnout in subsequent elections, up to and including the November 2010 midterm election.
| S-EPMC8021132 | biostudies-literature
Project description:Hispanic families have historically used means-tested assistance less than high-poverty peers, and one explanation for this may be that anti-immigrant politics and policies are a barrier to program participation. We document the participation of Hispanic children in three antipoverty programs by age and parental citizenship and the correlation of participation with state immigrant-based restrictions. Hispanic citizen children with citizen parents participate in Supplemental Nutrition Assistance Program (SNAP) and Medicaid more than Hispanic citizen children with noncitizen parents. Foreign-born Hispanic mothers use Medicaid less than their socioeconomic status would suggest. However, little evidence exists that child participation in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) varies by mother's nativity: foreign-born mothers of Hispanic infants participate in WIC at higher rates than U.S.-born Hispanic mothers. State policies that restrict immigrant program use correlate to lower SNAP and Medicaid uptake among citizen children of foreign-born Hispanic mothers. WIC participation may be greater because it is delivered through nonprofit clinics, and WIC eligibility for immigrants is largely unrestricted.
| S-EPMC10241469 | biostudies-literature