Across the country, changes to Medicaid policy are under way. They hold the potential to dramatically alter the landscape of health care for millions of low-income individuals. Meanwhile, the 2018 midterm election results may lead to further Medicaid expansion in five states, three through ballot initiatives (Idaho, Nebraska, and Utah) and two with the election of new governors supportive of expansion, who replace outgoing governors who opposed it (Kansas and Maine). If all five states expand Medicaid, an estimated 500,000 people are expected to gain coverage.

A growing literature illustrates the benefits that low-income residents of these five states may expect to attain with new Medicaid coverage: improvements in access to care, affordability, use of preventive care, and better self-perceived physical health. Some with “pre-existing conditions” may even live longer, as shown in a recent study that found a 10% decrease in mortality rates for adults initiating dialysis after state Medicaid expansions. However, challenges remain for expanding the reach of Medicaid, and there is also substantial debate at both the federal and state levels about how programs for low-income Americans should best be designed.

In this context, we are excited to describe the launch of a new Policies for Action Research Hub based at the Harvard T.H. Chan School of Public Health, combined with research collaborators at Columbia University and the Brigham & Women’s Hospital. Our Hub will spend the next 2.5 years examining critical issues related to Medicaid policy, the Affordable Care Act (ACA), and health care for low-income populations.

Our team is examining:

Medicaid work requirements

On June 1, 2018, Arkansas became the first state to implement work requirements in Medicaid, sending out notices to nearly 100,000 enrollees informing them that its “community engagement” reporting requirements were now in effect. Since then, nearly 14,000 individuals have been removed from the program due to failure to meet the reporting requirements. Using a novel survey of 1,500 individuals in the state and 1,500 individuals in nearby states without work requirements, we will examine beneficiaries’ experience with the policy and impacts on employment and health coverage. The first round of the survey was conducted in late 2018, and we plan to conduct another round in late 2019.

Mortality changes under the ACA

Despite multiple attempts to repeal the ACA, the law remains in effect, guaranteeing health insurance to as many as 20 million previously-uninsured Americans. Numerous studies have documented the ACA’s positive effects on coverage, access, and health care quality, but changes in population mortality have not yet been rigorously assessed. Using data from a variety of sources, the team will assess the relationship between coverage expansion and population changes in mortality over time.

Public vs. private coverage

Some federal and state policymakers favor shifting Medicaid beneficiaries into private coverage. However, it’s unclear what the tradeoffs are between public vs. private coverage. Medicaid is designed to meet the needs of the poor, and as such it may offer key design elements that are important for low-income enrollees. However, private insurance enjoys higher provider participation rates and may offer consumer superior access to quality care. We created a unique dataset to compare Medicaid and Marketplace coverage, using an all-payer claims database and income data from the state of Colorado. Examining those with incomes just above and below the dividing line for Medicaid eligibility, we examine differences in health care utilization, quality, and costs in the two types of health insurance.

Our Research Hub will also be conducting rapid-turnaround analyses to inform policy-making in real time. Our interdisciplinary team will use existing data sources and credible research findings to specifically engage with current health policy proposals that hold potential to impact access to care for low-income and vulnerable populations.

Our Hub will be reaching out to solicit ideas for research questions we should prioritize to help inform ongoing or upcoming policy discussions, and you can contact us directly with any suggestions or questions.

We look forward to working with Policies for Action to provide rigorous and timely evidence to inform these critical policy debates.

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