The Transition from Medicaid to Medicare and Impacts on Disparities in Coverage and Care

从医疗补助到医疗保险的过渡以及对覆盖范围和护理差异的影响

• 批准号: 10588198
• 负责人: Vicki Fung
• 金额: $ 59.63万
• 依托单位: MASSACHUSETTS GENERAL HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-03-08 至 2026-11-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10588198
• 关键词: Adopted; Adult; Age; Attention; Awareness; Black race; COVID-19 pandemic effects; Caring; Clinical; Color; Complex; Control Groups; Cost Sharing; Data; Diagnosis; Disadvantaged; Disadvantaged minority; Disparity; Disparity population; Drug Prescriptions; Economics; Eligibility Determination; Emergency department visit; Enrollment; Ethnic Origin; Event; Face; Financial Support; Health; Health Services; Health system; Healthcare Systems; Hispanic; Hospitalization; Household; Income; Individual; Inpatients; Insurance; Insurance Coverage; Link; Longevity; Low income; Machine Learning; Managed Care; Measures; Medicaid; Medicaid eligibility; Medicaid services; Medical Care Costs; Medicare; Medicare Part A; Medicare/Medicaid; Minority; Outcome; Outpatients; Pharmaceutical Preparations; Policies; Population; Qualifying; Quality of Care; Race; Research; Services; Surveys; Testing; Time; Visit; access disparities; adverse outcome; aged; barrier to care; beneficiary; cost; ethnic disparity; ethnic minority; federal poverty level; health care availability; health care disparity; health care service; human old age (65+); low socioeconomic status; mortality; outcome disparities; poor communities; programs; racial disparity; racial minority; social culture; socioeconomics

Many Medicaid expansion enrollees with incomes less than 138% of the federal poverty level (FPL) face greater cost-sharing and higher out-of-pocket costs when they tum 65 years old and transition to Medicare. In Medicare, there is a subsidy cliff at 100% FPL, above which beneficiaries are not eligible for comprehensive subsidies that cover medical cost-sharing in Medicare Parts A (inpatient) and B (outpatient). Beneficiaries with incomes between 100-150% FPL and limited assets can qualify for partial financial assistance through a complex set of programs. Take-up of these subsidies is limited, and evidence suggests that Black and Hispanic beneficiaries are more likely to be eligible for but less likely to be aware of subsidy programs vs. White beneficiaries. Moreover, higher cost-sharing has been associated with reductions in necessary care and worse outcomes, and in some cases, widening of racial/ethnic disparities in care. Sixteen states have expanded income and asset eligibility for comprehensive cost-sharing subsidies above federal minimums, but there is little evidence on whether such policies mitigate racial/ethnic disparities. In Aims 1 and 2, we will use linked, individual-level Medicaid and Medicare enrollment, claims, and encounter data from 2016-2023 to follow beneficiaries as they transition from Medicaid to Medicare at age 65 and examine whether the transition between programs leads to disparities in the receipt of Medicare subsidies and contributes to disparities in use, clinical event outcomes, and spending. For Aim 1, we will examine if there are racial/ethnic disparities in Medicare coverage among Medicaid expansion beneficiaries that transition to Medicare-only and use machine learning approaches to identify factors (e.g., policy, health care system, individual) that predict receipt of subsidies among minority vs. White beneficiaries. For Aim 2, we will assess if increases in cost-sharing upon entry to Medicare contribute to racial/ethnic disparities in service use (e.g., outpatient visits), clinical event outcomes (e.g., emergency department visits, hospitalizations, mortality), and spending (out-of-pocket and total costs). We will use a difference-in-difference approach to compare changes in outcomes for beneficiaries just above vs. below income limits for comprehensive cost-sharing subsidies, after vs. before entering Medicare. For Aim 3, we focus on a subset of states that expanded income or asset eligibility for Medicare subsidies above federal minimums in 2008 or later to assess if these policy changes reduce racial/ethnic disparities associated with Medicare cost-sharing. We will use 2006-2023 Medicare data and a difference-indifference approach to examine changes in outcomes for beneficiaries who gain comprehensive cost-sharing subsidies before vs. after state subsidy expansions. In all aims, we will examine whether effects differ for Black and Hispanic vs. White beneficiaries. Findings from this study will inform coverage policies that could reduce adverse outcomes and racial/ethnic disparities in care as beneficiaries transition across these two public programs.

许多医疗补助扩张招待会少于联邦贫困水平（FPL）面对的138％ 当TUM 65岁并过渡到Medicare时，成本分布和更高的自付费用。在 Medicare，有100％FPL的补贴悬崖，上面是受益人没有资格综合的。 涵盖Medicare部分A（住院）和B（门诊）的医疗成本分担的补贴。受益人 100-150％FPL和有限资产之间的收入可以通过 复杂的程序集。这些补贴的获取是有限的，证据表明黑色和 西班牙裔受益人更有可能有资格获得资格，但不太可能意识到补贴计划与。 白人受益人。此外，更高的成本分布与必要的护理中的减少有关 结果较差，在某些情况下，医疗中种族/种族差异的扩大。 16个州有 扩大收入和资产资格，以超过联邦最低限度的全面成本分担补贴，但 几乎没有证据表明此类政策是否减轻了种族/种族差异。在目标1和2中，我们将使用 从2016 - 2023年到 关注受益人在65岁时从医疗补助到医疗保险的受益人，并检查过渡是否 计划之间导致收到Medicare补贴的差异，并导致差异 使用，临床事件结果和支出。对于AIM 1，我们将检查是否存在种族/种族差异 医疗补助扩张受益人之间的医疗保险覆盖范围，这些受益人过渡到仅医疗保险和使用机器 学习方法以识别预测收到的因素（例如，政策，医疗保健系统，个人） 少数民族与白人受益人之间的补贴。对于AIM 2，我们将评估成本分担的提高 进入医疗保险有助于服务使用的种族/种族差异（例如门诊就诊），临床活动 成果（例如急诊室就诊，住院，死亡率）和支出（自付费用和 总成本）。我们将使用差异差异方法来比较受益人的结果的变化 恰好高于低于收入限制的全面成本分担补贴，而在进入之前 Medicare。对于AIM 3，我们专注于扩大收入或资产资格医疗保险的一部分国家 2008年或更高版本的联邦最低限度以上的补贴，以评估这些政策变化是否减少了种族/族裔 与Medicare成本分担有关的差异。我们将使用2006-2023 Medicare数据和差异差异 检查获得全面成本分担的受益人的结果变化的方法 在国家补贴扩张之后的补贴。总的来说，我们将检查黑色效果是否有所不同 和西班牙裔与白人受益人。这项研究的发现将为覆盖范围政策提供信息，以减少 作为受益人的过渡，不利的结果和种族/种族差异 程序。