@article {Sneed2022.02.07.22270614, title = {Chronic Disease and Workforce Participation Among Medicaid Enrollees Over 50: The Potential Impact of Medicaid Work Requirements Post-COVID-19}, journal = {medRxiv}, year = {Forthcoming}, abstract = {As the COVID-19 pandemic wanes, states may reintroduce Medicaid work requirements to reduce enrollment. Using the Health and Retirement Study, we evaluated chronic disease burden among beneficiaries aged \>50 (n=1460) who might be impacted by work requirements (i.e. working \<20 hours per week). Seven of eight chronic conditions evaluated were associated with reduced workforce participation, including history of stroke (OR: 7.35; 95\% CI: 2.98-18.14) and lung disease (OR: 4.39; 95\% CI: 2.97-7.47). Those with more severe disease were also more likely to work fewer hours. Medicaid work requirements would likely have great impact on older beneficiaries with significant disease burden.Key PointsChronic disease linked to reduced work among older Medicaid beneficiaries.Work requirements would greatly impact those aged \>50 with chronic conditions.Coverage loss would have negative implications for long-term disease management.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis work was supported by the Robert Wood Johnson Foundation{\textquoteright}s (RWJF) Policies for Action program under grant number 77342. This is a secondary analysis that uses data from the Health and Retirement Study, (2016 HRS Core and RAND HRS Longitudinal File 2018), sponsored by the National Institute on Aging under grant number NIA U01AG009740 and conducted by the University of Michigan.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This study involved only openly available human data, which can be obtained from: https://hrsdata.isr.umich.edu/data-products/rand-hrs-longitudinal-file-2018 and https://hrsdata.isr.umich.edu/data-products/2016-hrs-coreI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll data are available online at: https://hrsdata.isr.umich.edu/data-products/rand-hrs-longitudinal-file-2018 and https://hrsdata.isr.umich.edu/data-products/2016-hrs-core}, keywords = {Chronic disease, COVID-19, health policy, Medicaid}, doi = {10.1101/2022.02.07.22270614}, author = {Rodlescia S. Sneed and Stubblefield, Alexander and Gardner, Graham and Jordan, Tamara and Briana Mezuk} } @article {13578, title = {The impact of a long-term care information campaign on insurance coverage.}, journal = {Journal of Health Economics}, volume = {92}, year = {Forthcoming}, pages = {102822}, abstract = {

I estimate the impact of an information campaign on long-term care planning behaviors. I identify this effect using the staggered timing of the federal-state "Own Your Future" campaign, which urged individuals to plan ahead for long-term care needs and reached 26 states over five years. I find the campaign increased long-term care insurance coverage for individuals in the top quintile of the asset distribution by four percentage points, or seventeen percent. A back-of-the-envelope calculation indicates Medicaid savings of $483 million in present value.

}, keywords = {Information campaigns, Insurance, Long-term Care, Medicaid}, issn = {1879-1646}, doi = {10.1016/j.jhealeco.2023.102822}, author = {Brown, Jessica H} } @article {12313, title = {Public spending on acute and long-term care for Alzheimer{\textquoteright}s disease and related dementias.}, journal = {Alzheimer{\textquoteright}s \& Dementia}, year = {Forthcoming}, abstract = {

INTRODUCTION: We estimate the spending attributable to Alzheimer{\textquoteright}s disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis.

METHODS: Using data from the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims-based ADRD diagnosis along with matched controls.

RESULTS: The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer-lived beneficiaries who are more likely to need long-term care and become Medicaid eligible.

DISCUSSION: Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.

}, keywords = {longitudinal costs, Medicaid, Medicare, Spending}, issn = {1552-5279}, doi = {10.1002/alz.12657}, author = {Norma B Coe and White, Lindsay and Oney, Melissa and Basu, Anirban and Larson, Eric B} } @article {13715, title = {State home and community-based services expenditures and unmet care needs in the United States: Has everyone benefitted equally?}, journal = {health services research}, year = {Forthcoming}, abstract = {

OBJECTIVE: To test whether the impacts of Medicaid{\textquoteright}s Home and Community-Based Services (HCBS) expenditures have been equitable.

DATA SOURCES AND STUDY SETTING: This is a secondary data analysis. We linked annual data on state-level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006-2016).

STUDY DESIGN: We evaluated the association between state-level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place-based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls.

DATA COLLECTION/EXTRACTION METHODS: Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with >=1 I/ADL (n = 2607 unique respondents contributing 4719 person-wave observations).

PRINCIPAL FINDINGS: Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95\% CI: 0.84-0.98). This protective association was concentrated among non-Hispanic white respondents (Q4 vs. Q1: 0.82, 95\% CI: 0.73-0.93); estimates were imprecise for Hispanic individuals and largely null for non-Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non-Medicaid beneficiaries.

CONCLUSION: The returns to higher state-level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity.

}, keywords = {aging/elderly/geriatrics, long term care, Medicaid, Social determinants of health}, issn = {1475-6773}, doi = {10.1111/1475-6773.14269}, author = {Yang, Yulin and Lee, Ah-Reum and Rapp, Thomas and Chen, Ruijia and Glymour, M Maria and Torres, Jacqueline M} } @booklet {unknown, title = {Long Term Care Risk For Couples and Singles}, year = {2024}, abstract = {This paper compares the impact of long term care (LTC) risk on single and married households and studies the roles played by informal care (IC), consumption sharing within households, and Medicaid in insuring this risk. We develop a life-cycle model where individuals face survival and health risk, including the possibility of becoming highly disabled and needing LTC. Households are heterogeneous in various important dimensions including education, productivity, and the age difference between spouses. Health evolves stochasti-cally. Agents make consumption-savings decisions in a framework featuring an LTC state-dependent utility function. We find that household expenditures increase significantly when LTC becomes necessary, but married individuals are well insured against LTC risk due to IC. However, they still hold considerable assets due to the concern for the spouse who might become a widow/widower and can expect much higher LTC costs. IC significantly reduces precautionary savings for middle and high income groups, but interestingly, it encourages asset accumulation among low income groups because it reduces the probability of means-tested Medicaid LTC.}, keywords = {Household Risk, InformalCare, long term care, Medicaid, Precautionary Savings}, doi = {10.13140/RG.2.2.34349.87521}, author = {Capatina, Elena and Hansen, Gary and Hsu, Minchung} } @article {12606, title = {Alzheimer{\textquoteright}s disease medication use and adherence patterns by race and ethnicity.}, journal = {Alzheimer{\textquoteright}s \& Dementia}, year = {2023}, abstract = {

BACKGROUND: We examined racial and ethnic differences in medication use for a representative US population of patients with Alzheimer{\textquoteright}s disease and related dementias (ADRD).

METHODS: We examined cholinesterase inhibitors and memantine initiation, non-adherence, and discontinuation by race and ethnicity, using data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims.

RESULTS: Among newly diagnosed ADRD patients (n~=~1299), 26\% filled an ADRD prescription <=90 days and 36\% <=365 days after diagnosis. Among individuals initiating ADRD-targeted treatment (n~=~1343), 44\% were non-adherent and 24\% discontinued the medication during the year after treatment initiation. Non-Hispanic Blacks were more likely than Whites to not adhere to ADRD medication therapy (odds ratio: 1.50 [95\% confidence interval: 1.07-2.09]).

DISCUSSION: Initiation of ADRD-targeted medications did not vary by ethnoracial group, but non-Hispanic Blacks had lower adherence than Whites. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care.

HIGHLIGHTS: Initiation of anti-dementia medications among newly diagnosed Alzheimer{\textquoteright}s disease and related dementias (ADRD) patients was low in all ethnoracial groups. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care. Compared to Whites, Blacks and Hispanics had lower use, poorer treatment adherence, and more frequent discontinuation of ADRD medication, but when controlling for disease severity and socioeconomic factors, racial disparities diminish. Our findings demonstrate the importance of adjusting for socioeconomic characteristics and disease severity when studying medication use and adherence in ADRD patients.

}, keywords = {acetylcholinesterase inhibitors, Alzheimer{\textquoteright}s disease, anti-dementia medication, Cognitive health, Dementia, Health Disparities, Medicaid, Medicare}, issn = {1552-5279}, doi = {10.1002/alz.12753}, author = {Olchanski, Natalia and Daly, Allan T and Zhu, Yingying and Breslau, Rachel and Cohen, Joshua T and Neumann, Peter J and Jessica Faul and Fillit, Howard M and Freund, Karen M and Lin, Pei-Jung} } @article {12510, title = {Examining Medicaid Participation and Medicaid Entry Among Senior Medicare Beneficiaries With Linked Administrative and Survey Data.}, journal = {Medical Care Research and Review}, year = {2023}, abstract = {

Because Medicare beneficiaries can qualify for Medicaid through several pathways, duals who newly enroll in Medicaid may have experienced various financial and/or health changes that impact their Medicaid eligibility. Alternatively, new enrollment could reflect changes in awareness of the program among those previously eligible. Using monthly enrollment data linked to Health and Retirement Study survey data, we examine financial and health changes that occur around the time new Medicaid participants enter the program, and we compare those with changes experienced by both those continuously enrolled in Medicaid and those not enrolled. We find that Medicaid entry is often timed with a marked increase in out-of-pocket medical expenses, a substantial decrease in assets for some, and increases in activities of daily living (ADL) limitations. We also observe financial changes among persons continuously enrolled in Medicaid. Our results inform discussions about Medicaid eligibility policies and potential gaps in the protection that Medicaid offers from financial risk.

}, keywords = {dual eligibles, Medicaid, Medicare, program enrollment}, issn = {1552-6801}, doi = {10.1177/10775587221101297}, author = {Garrow, Renee and Mellor, Jennifer M and McInerney, Melissa and Sabik, Lindsay M} } @article {10.1257/pol.20200178, title = {Housing in Medicaid: Should It Really Change?}, journal = {American Economic Journal: Economic Policy}, volume = {15}, year = {2023}, pages = {1-36}, abstract = {Housing is mostly exempted from Medicaid and Supplemental Social Insurance means tests. Reforms of this special treatment have been debated, but little is known about its costs, benefits, and redistributive implications. I estimate a life cycle model of single retirees accounting for this exemption. It shows that the homestead exemption explains important patterns of Medicaid recipiency and that it is highly valued. It also shows that estate recovery could cover most of its costs with possibly limited negative welfare consequences. Finally, the model predicts that removing the homestead exemption or enforcing estate recovery programs would reduce redistribution toward lower-income retirees.}, keywords = {homestead exemption, lower-income, Medicaid, Retirement}, doi = {10.1257/pol.20200178}, author = {Achou, Bertrand} } @article {13237, title = {How Medicaid Financial Eligibility Rules Exclude Financially and Medically Vulnerable Older Adults.}, journal = {J Aging Soc Policy}, year = {2023}, pages = {1-16}, abstract = {

Millions of older Americans rely on Medicaid because it is the largest payer of long-term services and supports. To qualify for the program, low-income individuals age 65 and over must meet income standards based on the dated Federal Poverty Level as well as asset tests that are often viewed as quite stringent. There has long been concern that current eligibility standards exclude many adults with significant health and financial vulnerabilities. We use updated household socio-demographic and financial information to simulate the impacts of five alternative financial eligibility standards on the number and profile of older adults that would gain Medicaid coverage. The study clearly demonstrates that a large number of financially- and health-vulnerable older adults are excluded from the Medicaid program under current policy. The study highlights the implications for policymakers of updating Medicaid financial eligibility standards to assure that Medicaid benefits are targeted to vulnerable older adults who need them.

}, keywords = {Finances, Medicaid, Older Adults}, issn = {1545-0821}, doi = {10.1080/08959420.2023.2195784}, author = {Cohen, Marc A and Tavares, Jane} } @article {13248, title = {Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level.}, journal = {JAMA Intern Med}, volume = {183}, year = {2023}, pages = {534-543}, abstract = {

IMPORTANCE: Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program{\textquoteright}s income eligibility threshold (100\% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries{\textquoteright} ability to afford care.

OBJECTIVE: To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0\% to 200\% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.

MAIN OUTCOME MEASURES: Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.

RESULTS: This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200\% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1\% of beneficiaries were women, 14.8\% were non-Hispanic Black, 13.6\% were Hispanic, and 71.6\% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95\% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95\% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95\% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95\% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95\% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95\% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95\% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries.

CONCLUSIONS AND RELEVANCE: This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

}, keywords = {Aged, Cross-Sectional Studies, Female, Healthcare Disparities, Humans, Male, Medicaid, Medicare, Middle Aged, Poverty, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2023.0512}, author = {Roberts, Eric T and Kwon, Youngmin and Hames, Alexandra G and McWilliams, J Michael and Ayanian, John Z and Tipirneni, Renuka} } @article {13110, title = {Tweaking Medicaid eligibility criteria would benefit vulnerable older adults {\textquoteleft}tremendously{\textquoteright}}, year = {2023}, publisher = {McKnights }, keywords = {Healthcare, Medicaid}, url = {https://www.mcknightsseniorliving.com/home/news/tweaking-medicaid-eligibility-criteria-would-benefit-vulnerable-older-adults-tremendously/}, author = {Bonvissuto, Kimberly} } @article {13673, title = {When Disparities and Differences in Resources Abound, Medicaid Acts as Stopgap}, year = {2023}, publisher = {Skilled Nursing News}, keywords = {Disparities, Medicaid}, url = {https://skillednursingnews.com/2023/12/when-disparities-and-differences-in-resources-abound-medicaid-acts-as-stopgap/}, author = {Stulick, Amy} } @article {13395, title = {Where the government draws the line for Medicaid coverage leaves out many older Americans who may need help paying for medical and long-term care bills {\textendash} new research}, year = {2023}, publisher = {The Conversation}, keywords = {Long-term Care, Medicaid, medical bills}, url = {https://theconversation.com/where-the-government-draws-the-line-for-medicaid-coverage-leaves-out-many-older-americans-who-may-need-help-paying-for-medical-and-long-term-care-bills-new-research-208527}, author = {Cohen, Marc A and Tavares, Jane} } @article {10.1093/geroni/igac059.526, title = {DEMENTIA TRAJECTORIES, MEDICAID COVERAGE, AND HEALTHCARE SERVICES USE}, journal = {Innovation in Aging}, volume = {6}, year = {2022}, month = {12}, pages = {132-132}, abstract = {The evidence base linking dementia risk trajectories to transitions in Medicaid coverage and levels of health services is underdeveloped. We use Health and Retirement Study (2007/08-2015/16) data on adults 70-years and older (Unweighted N=8,227) at baseline to test how longitudinal dementia classifications (Langa-Weir), over 8-years, influence change in Medicaid coverage, nursing-home use (NHU) and inpatient hospitalizations (IH). We fit Joint Growth and Discrete-time Survival Mixture models to generate longitudinal risk classifications for dementia accounting for survival, and generalized linear models to test associations of these classifications with change in Medicaid coverage, NHU, and IH. Average baseline age was 78.4 years (SD=7.1), 3-in-5 were female, 1-in-4 had less than high school education, and 4-in-5 were non-Hispanic Whites. A three-class solution (C1=high dementia prevalence and mortality risk (8.6\%), C2=low prevalence (68.3\%), and C3=accelerated dementia prevalence and mortality risk (23.1\%)) provided the best fit to the data. We observed substantial increase in rates of for Medicaid coverage for C1 (21\%; 95\%CI=[18-25] to 51\%[36-65] among survivors) and C3 (12\%; 95\%CI=[10-14] to 32\%[27-37]), but not C2 (6\% to 8\%). NHU also accelerated substantially from 10 to 37\% in C1 and 7 to 38\% in C2. Rates of inpatient hospitalizations remained stable over time for all groups, with C1 and C2 being more likely to be hospitalized and have multiple re-admissions. Estimates were differentially attenuated through adjustment to covariables. We report important longitudinal dementia risk classifications, profile their socioeconomic and health attributes, and identify differential associations with critical health policy outcomes (Medicaid coverage and healthcare utilization).}, keywords = {Dementia, healthcare services, Medicaid}, issn = {2399-5300}, doi = {10.1093/geroni/igac059.526}, author = {Tarraf, Wassim and Garcia, Marc} } @mastersthesis {12644, title = {Essays in the Economics of Aging}, volume = {Ph.D.}, year = {2022}, school = {University College London}, address = {London}, abstract = {This thesis is made up of three main essays that aim to develop a deeper understanding of issues involving the public insurance programs for the elderly, and the risks they insure against. In the first essay (Chapter 2), using data from the Health and Retirement Study linked to administrative Medicare and Medicaid records, along with the Medical Expenditure Panel Survey, we estimate the stochastic process for total and out-of-pocket medical spending. By focussing on dynamics, we consider not only the risk of catastrophic expenses in a single year, but also the risk of moderate but persistent expenses that accumulate into a catastrophic lifetime cost. We also assess the reduction in out-of-pocket medical spending provided by public insurance schemes such as Medicare or Medicaid. We find that although Medicare and Medicaid pay the majority of medical expenses, households at age 65 will on average incur $59,000 in out-of-pocket costs with 10 percent of households incurring more than $121,000 in out-of-pocket expenses over their remaining lives. In the second essay (Chapter 3), we compare dementia prevalence and how it varies by socioeconomic status (SES) in the United States and England. We compare between country differences in age-gender standardized dementia prevalence, across the SES gradient. Dementia prevalence was estimated in each country using an algorithm based on an identical battery of demographic, cognitive, and functional measures. Dementia prevalence is higher among the disadvantaged in both countries, with the United States being more unequal according to four measures of SES. Once past health factors and education were controlled for, most of the within country inequalities disappeared; however, the cross-country difference in prevalence for those in the lowest income decile remained disproportionately high. This provides evidence that disadvantage in the United States is a disproportionately high risk factor for dementia. In the final essay (Chapter 4), we assess the optimal structure the U.S. Social Security system, taking into account the current system{\textquoteright}s unfunded liabilities, transition dynamics and political feasibility constraints. We base the assessment on an estimated overlapping generations general equilibrium model that features both aggregate and idiosyncratic uncertainty. The quantitative analysis establishes that although transition costs greatly restrict the U.S. government{\textquoteright}s ability to move away from the current Social Security system, ignoring the political feasibility constraints allows the government to increase welfare by transitioning to a more progressive and less costly to operate system. However, taking into account the political feasibility constraints overturns this result, as no reform is simultaneously welfare increasing and politically feasible.}, keywords = {Medicaid, Medicare administrative data, Out-of-pocket medical expenses}, url = {https://discovery.ucl.ac.uk/id/eprint/10152204/1/Thesis.pdf}, author = {Arapakis, Karolos} } @article {12012, title = {Examining variation in state spending on medicaid long-term services and supports for older adults.}, journal = {Home Health Care Services Quarterly}, volume = {41}, year = {2022}, pages = {54-64}, abstract = {

State Medicaid programs are the largest source of funding for long-term services and supports (LTSS). We characterized states across quartiles of mean LTSS spending for individuals >=65 and used the Health and Retirement Study to examine the demographic, functional, and caregiving characteristics across these quartiles. Individuals in states with lower Medicaid spending on LTSS reported more family and friend caregiving hours and were more likely to be from racial and ethnic minority groups. Continued work is needed to improve Medicaid LTSS policy to better support vulnerable populations, particularly in lower quartile states.

}, keywords = {long-term services and support, Medicaid}, issn = {1545-0856}, doi = {10.1080/01621424.2021.2004286}, author = {Mellgard, George and Claire K. Ankuda and Rahman, Omari-Khalid and Amy Kelley} } @article {12657, title = {HOW MUCH DO RETIREES SPEND ON UNCERTAIN HEALTH COSTS?}, number = {IB$\#$22-14}, year = {2022}, institution = {Center for Retirement Research at Boston College}, address = {Newton, MA}, abstract = {The brief{\textquoteright}s key findings are: One risk that retirees face is uncertain out-of-pocket health costs, over and above predictable insurance premiums. The analysis shows that total spending on retirees{\textquoteright} health care {\textendash} including long-term care and excluding premiums {\textendash} is high. But insurers like Medicare and Medicaid cover about 80 percent of the costs. As a result, 65-year-old households, on average, are estimated to pay $67,000 out-of-pocket over their remaining lifetime.}, keywords = {health cost, Medicaid, Medicare, out-of-pocket costs, Retirees}, url = {https://crr.bc.edu/briefs/how-much-do-retirees-spend-on-uncertain-health-costs/}, author = {Arapakis, Karolos} } @article {12656, title = {How Redistributive Are Public Health Care Schemes? Evidence from Medicare and Medicaid in Old Age}, number = {MRDRC WP 2022-441}, year = {2022}, institution = {Michigan Retirement and Disability Research Center, University of Michigan}, address = {Ann Arbor, MI}, abstract = {Most health care for the U.S. population 65 and older is publicly provided through Medicare and Medicaid. Despite the massive expenditures of these systems, little is known about how redistributive they are. Using data from the Health and Retirement Study matched to administrative Medicare, Medicaid, and Social Security earnings records, we estimate the distribution of lifetime Medicare and Medicaid benefits received and the distribution of lifetime taxes paid to finance these benefits. For the cohort who turned 65 between 1999 and 2004, we find that benefits are greater among those with high income, in large part because they live longer. Nonetheless, high-income people pay more in the way of taxes. Middle-income households gain the most from these programs as these people live long yet pay modest taxes. All income groups gain from these programs: This cohort{\textquoteright}s lifetime tax contribution did not cover the medical benefits it received. This deficit is paid by younger cohorts.}, keywords = {Medicaid, Medicare, public health care, Social Security earnings records}, url = {https://mrdrc.isr.umich.edu/pubs/how-redistributive-are-public-health-care-schemes-evidence-from-medicare-and-medicaid-in-old-age/}, author = {Arapakis, Karolos and Eric French and John Bailey Jones and McCauley, Jeremy} } @article {12966, title = {Improving identification of Medicaid eligible community-dwelling older adults in major household surveys with limited income or asset information}, journal = {Health Services and Outcomes Research Methodology }, year = {2022}, abstract = {Analysis of public policy affecting dual eligibles requires accurate identification of survey respondents eligible for both Medicare and Medicaid. Doing so for Medicaid is particularly challenging given the complex eligibility rules tied to income and assets. In this paper we provide guidance on how to best identify eligible respondents in household surveys that have limited income or asset information, such as the National Health Interview Survey, American Community Survey, Current Population Survey, and Medical Expenditure Panel Survey. We show how two types of errors{\textemdash}false negative and false positive errors{\textemdash}are impacted by incorporating limited income or asset information, relative to the commonly-used approach of solely comparing total income to the income threshold. With the 2018 Health and Retirement Study, which has detailed income and asset information, we mimic the income and asset information available in those other household surveys and quantify how errors change when imposing income or asset tests with limited information. We show that incorporating all available income and asset data results in the lowest number of errors and the lowest overall error rates. We recommend that researchers adjust income and impose the asset test to the fullest extent possible when imputing Medicaid eligibility for Medicare enrollees.}, keywords = {Eligibility Determination, Income, Medicaid, Socioeconomic factors}, doi = {10.1007/s10742-022-00297-5}, author = {McInerney, Melissa and Mellor, Jennifer M. and Ramamoorthy, Venkatesh and Sabik, Lindsay M} } @article {12807, title = {Integrating Medicare And Medicaid Data To Improve Care Quality And Advance Health Equity Among Dual-Eligible Beneficiaries}, year = {2022}, institution = {Health Affairs}, abstract = {Policy makers continue to test new models to integrate Medicare and Medicaid coverage for the dually eligible population, with the goal of improving quality of care and health equity. However, evaluations of these integrated models are limited by the fact that few data resources comprehensively measure need for, use of, or spending on care among dual eligibles.}, keywords = {dual-eligible beneficiaries, health equity, Medicaid, Medicare}, doi = {10.1377/hpb20221011.325614}, author = {Brown-Podgorski, Brittany and Roberts, Eric} } @mastersthesis {12015, title = {Care Work in the Woodwork: Medicaid Home Care and Family Caregivers{\textquoteright} Health}, volume = {Ph.D.}, year = {2021}, school = {Harvard University }, address = {Cambridge, MA}, abstract = {Family caregivers provide the majority of eldercare in the United States, yet little is known about how eldercare policy affects their health. For several decades, research has shown that family caregivers experience emotional, physical, and financial strain that is associated with worse mental and physical health. These harms are particularly severe for women, who are overrepresented among family caregivers, provide more hours of more intensive care, and experience worse associated declines in health. Simultaneously, U.S. eldercare policy has undergone enormous change since the 1980s, as states have shifted Medicaid long-term care spending from nursing homes to home care services. These policy changes have restructured the social, political, and economic systems that shape the realities of family caregiving. However, this dissertation is the first work to investigate how Medicaid home care affects family caregivers{\textquoteright} health.}, keywords = {caregiver, health, home care, Medicaid}, url = {https://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37370225}, author = {Unger, Emily} } @article {11670, title = {Changes in Health Care Access and Utilization for Low-SES Adults Age 51-64 after Medicaid Expansion.}, journal = {The Journal of Gerontology: Series B}, volume = {76}, year = {2021}, pages = {1218-1230}, abstract = {

OBJECTIVES: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults age 51-64 has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults age 51-64 before and after the ACA Medicaid expansion.

METHODS: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N=2,088 noninstitutionalized low-education adults age 51-64 (N=633 in Medicaid expansion states, N=1,455 in non-expansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, private), access (usual source of care, difficulty finding doctor, foregone care, cost-related medication nonadherence, out-of-pocket costs), utilization (outpatient visit, hospitalization), and health status.

RESULTS: Low-education adults age 51-64 had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in non-expansion states, DID +7.4 pp, p=0.001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in non-expansion states, DID +10.4 pp, p=0.003) in Medicaid expansion compared with non-expansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in non-expansion states (+3.6 pp in expansion states, +11.0 pp in non-expansion states, DID -7.5 pp, p=0.006). There were no other significant differences in access, utilization or health trends between expansion and non-expansion states.

DISCUSSION: After Medicaid expansion, low-education status adults age 51-64 were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.

}, keywords = {Affordable Care Act, Hospitalization, Medicaid, Retirement}, issn = {1758-5368}, doi = {10.1093/geronb/gbaa123}, author = {Tipirneni, Renuka and Helen G Levy and Kenneth M. Langa and Ryan J McCammon and Zivin, Kara and Jamie E Luster and Karmakar, Monita and John Z. Ayanian} } @article {11817, title = {Development, Validation, and Performance of a New Physical Functioning{\textendash}Weighted Multimorbidity Index for Use in Administrative Data}, journal = {Journal of General Internal Medicine}, volume = {36}, year = {2021}, pages = {2427{\textendash}2433}, keywords = {Medicaid, Medicare, multimorbidity index, physical functioning}, doi = {10.1007/s11606-020-06486-7}, author = {Melissa Y Wei and Jamie E Luster and Ratz, David and Kenneth J Mukamal and Kenneth M. Langa} } @conference {11806, title = {On the Distribution and Dynamics of Medical Expenditure among the Elderly}, booktitle = {Retirement and Disability Research Consortium 23rd Annual Meeting}, year = {2021}, month = {08/2021}, publisher = {Center for Financial Security, University of Wisconsin-Madison}, organization = {Center for Financial Security, University of Wisconsin-Madison}, address = {Virtual Event}, abstract = {Using data from the Health and Retirement Study (HRS), we estimate the stochastic process for total medical spending and its components. By focussing on dynamics, we consider not only the risk of catastrophic expenses in a single year, but also the risk of moderate but persistent expenses that accumulate into a catastrophic lifetime cost. We also assess the reduction in out-of-pocket medical spending risk provided by public insurance schemes such as Medicare or Medicaid.}, keywords = {dynamics, Medicaid, Medical spending, Medicare}, url = {https://cfsrdrc.wisc.edu/files/2021-RDRC-Meeting-Booklet.pdf$\#$page=7}, author = {Arapakis, Karolos and Eric French and John Bailey Jones and McCauley, Jeremy} } @article {11873, title = {Does the ACA Medicaid Expansion Encourage Early Retirement?}, year = {2021}, institution = {University of Wisconsin-Milwaukee}, address = {Milwaukee, WI}, abstract = {In this study, I examine the effect of the Affordable Care Act Medicaid expansion on the retirement plans of low-educated, childless adults, aged 50-64. I employ a triple-differences (DDD) methodology, exploiting variation in individuals{\textquoteright} health insurance status and the timing of the expansion decisions of states. I find that with Medicaid expansion, insured workers without retirement health insurance (RHI) prior to the expansion decreased full-time work by 7.8 percentage points relative to those with RHI and those without any employer-sponsored coverage whatsoever. Among those no longer working full-time, 94 percent transitioned to complete retirement.}, keywords = {Affordable Care Act, Labor force participation, Medicaid, Retirement}, url = {https://uwm.edu/economics/wp-content/uploads/sites/205/2021/08/Ozcan_Onal.pdf}, author = {Sezen Ozcan Onal} } @mastersthesis {13005, title = {Essays on Medicaid Aging Waivers and Informal Caregiving to the Elderly}, volume = {Ph.D.}, year = {2021}, school = {The Ohio State University}, keywords = {Aging waivers, Informal caregiving, Medicaid}, url = {https://www.proquest.com/docview/2699743018/abstract/31FBD18D8813412CPQ/1?accountid=14667}, author = {Zai, Xianhua} } @article {12026, title = {Increasing Medicaid{\textquoteright}s Stagnant Asset Test For People Eligible For Medicare And Medicaid Will Help Vulnerable Seniors.}, journal = {Health Affairs}, volume = {40}, year = {2021}, pages = {1943-1952}, abstract = {

Low-income Medicare beneficiaries rely on Medicaid for supplemental coverage but must meet income and asset tests to qualify. We examined states{\textquoteright} income and asset tests for full-benefit Medicaid during the period 2006-18 and examined how alternative asset tests would affect eligibility for community-dwelling Medicare beneficiaries ages sixty-five and older. Most states have not updated the dollar limit of Medicaid{\textquoteright}s asset test since 1989, making the asset test increasingly restrictive in inflation-adjusted terms. We estimated that increasing Medicaid{\textquoteright}s asset limit by the Consumer Price Index, to Medicare Savings Program levels, or to $10,000 for individuals and $20,000 for couples would increase Medicaid eligibility by 1.7~percent, 4.4~percent, and 7.5~percent, respectively. Simplifying Medicaid{\textquoteright}s asset test to focus only on certain high-value assets would increase eligibility by 20.5~percent. Increasing asset limits would lessen restrictions on Medicaid eligibility that arise from stagnant asset tests, broadening eligibility for certain low-income Medicare beneficiaries and allowing them to retain higher, yet still modest, savings.

}, keywords = {Eligibility Determination, Medicaid, Medicare}, issn = {1544-5208}, doi = {10.1377/hlthaff.2021.00841}, author = {Cornelio, Noelle and Melissa McInerney and Jennifer M Mellor and Roberts, Eric T and Lindsay M Sabik} } @article {11924, title = {Long-Term Care Partnership Effects on Medicaid and Private Insurance}, number = {IZA DP No. 14753}, year = {2021}, institution = {Institute of Labor Economics (IZA)}, address = {Bonn, Germany}, abstract = {Can the expansion of Medicaid, a means-tested health and long-term care insurance, be slowed down by incentivising the purchase of private long-term care insurance (LTCI)? We study the implementation of the long-term care insurance partnership (LTCIP) program, a joint federal and state-level program that intended to promote LTCI coverage. Drawing on a difference-in-differences (DD) design we study the effect of the rollout of the LTCIP program between 2005 and 2016 on both LTCI uptake and Medicaid eligibility, and we estimate the effect on Medicaid savings. Drawing on a difference-in-differences (DD) design, we find that, unlike previous estimates, the introduction of the LTCIP does significantly increase LTCI coverage and reduce the uptake of Medicaid. The effects are driven by the introduction of LTCIP in states after 2010. We estimate that the adoption of LTCIP has given rise to an average Medicaid saving of $36 for every 65-year-old. This suggests scope for LTCI arrangements to reduce Medicaid spending.}, keywords = {difference-in-differences, Long-term care insurance, long-term care partnerships, Medicaid}, url = {https://ftp.iza.org/dp14753.pdf}, author = {Costa-Font, Joan and Raut, Nilesh} } @article {11394, title = {MEDICAID AND MORTALITY: NEW EVIDENCE FROM LINKED SURVEY AND ADMINISTRATIVE DATA}, journal = {Quarterly Journal of Economics}, volume = {136}, year = {2021}, pages = {1783{\textendash}1829}, abstract = {We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic status, citizenship status, and public program participation. We find that prior to the ACA expansions, mortality rates across expansion and nonexpansion states trended similarly, but beginning in the first year of the policy, there were significant reductions in mortality in states that opted to expand relative to nonexpanders. Individuals in expansion states experienced a 0.132 percentage point decline in annual mortality, a 9.4\% reduction over the sample mean, as a result of the Medicaid expansions. The effect is driven by a reduction in disease-related deaths and grows over time. A variety of alternative specifications, methods of inference, placebo tests, and sample definitions confirm our main result.}, keywords = {administrative data, Medicaid, Mortality}, doi = {10.1093/qje/qjab004}, author = {Miller, Sarah and Johnson, Norman and Wherry, Laura R.} } @article {11547, title = {Medicaid Coverage {\textquoteright}Cliff{\textquoteright} Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries.}, journal = {Health Affairs }, volume = {40}, year = {2021}, pages = {552-561}, abstract = {

Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100~percent but less than 200~percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8~percentage points just above the eligibility threshold for Medicaid (100~percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55~percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.

}, keywords = {Medicaid, Medicare}, issn = {1544-5208}, doi = {10.1377/hlthaff.2020.02272}, author = {Roberts, Eric T and Glynn, Alexandra and Cornelio, Noelle and Donohue, Julie M and Gellad, Walid F and McWilliams, J Michael and Lindsay M Sabik} } @article {11908, title = {Medicaid Expansion and the Mental Health of Spousal Caregivers}, number = {IZA DP No. 14754}, year = {2021}, institution = {Institute of Labor Economics}, address = {Bonn, Germany}, abstract = {Health insurance expansions can exert wellbeing effects on individuals who provide informal care to their loved ones, reducing their experience of depression. This study exploits evidence from the Affordable Care Act{\textquoteright}s (ACA) Medicaid expansion to examine the effects on the mental wellbeing of informal caregivers. Drawing on an event study and a Difference-in-Differences (DID) design we investigate the policy impact of ACA Medicaid expansion using longitudinal evidence (from the Health and Retirement Study, HRS) for 2010 to 2018 for low-income individuals aged 64 or below. We find that ACA{\textquoteright}s Medicaid expansion reduced depressive symptoms among caregivers, and specifically we estimate that exposure to ACA Medicaid expansion gives rise to a 0.38 points (equivalent to 4-5\%) reduction in the CESD score (a negative scale in which the lowest scale indicates the best mental wellbeing). We also find that ACA Medicaid causes a spillover effect at the household level, improving the well-being of the spouse care recipient. Our results are robust to various specifications, and we identify several potential driving mechanisms for the findings: reductions in out-of-pocket expenses and labor supply and, as expected, increased Medicaid uptake. The evidence from falsification tests confirms that the estimated effects are purely due to ACA{\textquoteright}s Medicaid expansion and no other phenomena.}, keywords = {ACA, Informal care, insurance expansion, Medicaid, mental wellbeing, spousal mental health}, issn = {2365-9793}, url = {https://ftp.iza.org/dp14754.pdf}, author = {Costa-Font, Joan and Raut, Nilesh} } @article {10978, title = {ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study}, journal = {Inquiry : a journal of medical care organization, provision and financing}, volume = {57}, year = {2020}, abstract = {The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100\% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12\% reduction in metabolic syndrome; a 32\% reduction in complications from metabolic syndrome; an 18\% reduction in the likelihood of gross motor skills difficulties; and a 34\% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.}, keywords = {crowd-out, difference-in-differences, Health Status, Insurance Coverage, Medicaid, near-elderly adults, Patient Protection and Affordable Care Act}, isbn = {1945-72430046-9580}, doi = {10.1177/0046958020935229}, author = {Melissa McInerney and Ruth Winecoff and Padmaja Ayyagari and Kosali I. Simon and M Kate Bundorf} } @article {11088, title = {Association of Medicaid Expansion Under the Patient Protection and Affordable Care Act With Use of Long-term Care}, journal = {JAMA Network Open}, volume = {3}, year = {2020}, abstract = {Medicaid expansion is associated with increased access to health services, increased quality of medical care delivered, and reduced mortality, but little is known about its association with use of long-term care.To examine the association of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) with long-term care use among newly eligible low-income adults and among older adults whose eligibility did not change.This difference-in-difference cohort study used data from the Health and Retirement Study, a nationally representative longitudinal survey of persons 50 years or older. Long-term care use from 2008 to 2012 was compared with use from 2014 to 2016 among low-income adults aged 50 to 64 years without Medicare coverage residing in states in which Medicaid coverage expanded in 2014 and those living in states without expansion. Low-income adults who were covered by Medicare and were ineligible for expanded Medicaid were also included in the analysis. Data were analyzed from January 15, 2018, to December 31, 2019.Residence in a state with Medicaid expansion in 2014.Any home health care use or any nursing home use in 2014 or 2016. All estimates are weighted to account for the Health and Retirement Study sampling design.Among the 891 individuals likely eligible for expanded Medicaid, the mean (SD) age was 55.2 (3.1) years; 534 (53.4\%) were women, 482 (49.5\%) were married, and 661 (45.9\%) were White non-Hispanic. Before the ACA-funded Medicaid expansion, 0.4\% (95\% CI, -0.3\% to 1.1\%) in expansion states and 1.0\% (95\% CI, -0.1\% to 2.2\%) in nonexpansion states used nursing homes, and 1.9\% (95\% CI, 0.4\%-3.4\%) in expansion states and 7.1\% (95\% CI, 4.7\%-9.5\%) in nonexpansion states used any formal home care. The ACA-funded Medicaid expansion was associated with an increase of 4.4 percentage points (95\% CI, 2.8-6.1 percentage points) in the probability of any long-term care use among low-income, middle-aged adults, with increases in home health use (3.8 percentage points; 95\% CI, 2.0-5.6 percentage points) and in any nursing home use (2.1 percentage points; 95\% CI, 0.9-3.3 percentage points).In this study, ACA-funded Medicaid expansion was associated with an increase in any long-term care use among newly eligible low-income, middle-aged adults, suggesting that the population covered by the Medicaid expansion may have had unmet long-term care needs before expansion.}, keywords = {Affordable Care Act, Long-term Care, Medicaid, Patient Protection and Affordable Care Act}, isbn = {2574-3805}, doi = {https://doi.org/10.1001/jamanetworkopen.2020.18728}, author = {Courtney Harold Van Houtven and Brian E McGarry and Jutkowitz, Eric and David C Grabowski} } @mastersthesis {10882, title = {Unintended Consequences of Medicaid Policy for High-Need Beneficiaries}, volume = {Doctor of Philosophy}, year = {2020}, school = {University of Chicago}, address = {Chicago}, abstract = {This dissertation examines how two healthcare policies impact older adults and individuals with disabilities: long-term care and Medicaid managed care. The first chapter provides the first national examination of long-term care (LTC) setting, hospitalization and spending among the elderly, Medicare-Medicaid dually enrolled. Using national Medicaid claims data, we found that overall hospitalization rates were similar for HCBS and nursing facility users, despite nursing facility users generally being sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than whites, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than non-whites; higher Medicare and Medicaid spending on hospitalizations for blacks and Hispanics did not offset this difference. In the second chapter, I analyze the Health and Retirement Study (HRS) to estimate the effect of home care versus nursing home care on several measures of physical and mental health. While the analysis in Chapter 1 used claims data to study the effects of Medicaid-paid LTC, the use of the nationally representative HRS allows me to estimate effects of care setting across all payers and across a wider variety of health outcomes than can be studied in the claims data alone. Instrumental variables methods were used to estimate plausibly causal effects of care setting for a specific group of {\textquoteleft}{\textquoteleft}marginal{\textquoteright}{\textquoteright} individuals: those using home care (versus nursing home care) because of state-level Medicaid policies. I find that hospitalization rates were higher but functional decline was slower among home care users. While I find differences in observable characteristics by LTC setting by race and ethnicity, the state-level instrument lacked sufficient power in the black and Hispanic subsamples to explore differences in causal effects of care setting by race/ethnicity. Finally, in the third chapter I examine effects of another Medicaid policy change: inclusion of the Medicare-Medicaid dually enrolled (duals) in Medicaid managed care (MMC). In order to control program costs, many states have recently expanded their MMC programs to include duals. This chapter provides the first national estimates of the effects of MMC expansions from 2005 to 2012 for duals. I use difference-in-differences (DID) and instrumental variables (IV) methods to estimate plausibly causal impacts of three different types of MMC: comprehensive managed care (CMC), managed long-term service and supports (MLTSS), and primary care case management (PCCM). MLTSS plans are associated with increases in hospitalization and potentially avoidable hospitalization and these increases are concentrated among beneficiaries with many chronic conditions. I find mixed effects of CMC expansion: in mandatory enrollment settings, I find modest increased hospitalization while in voluntary enrollment settings, I find decreased hospitalization. Finally, PCCM plans are not associated with changes in hospital use. This study provides the first national estimates of how a major financing change, the inclusion of duals in MMC, impacts hospital use, providing policymakers with much needed evidence as they face the challenge of financing public health insurance programs as health care costs rise and the population ages.}, keywords = {Long-term Care, Managed care, Medicaid}, doi = {10.6082/uchicago.2238}, author = {Rebecca Jean Gorges} } @article {11345, title = {The Unintended Effect of Medicaid Aging Waivers on Informal Care}, year = {2020}, abstract = {The need for long-term care is becoming paramount as the population ages. Informal caregivers, often adult children who are 50 years old and above, take up the majority of long-term care responsibilities. Medicaid waiver programs that serve the older population (Medicaid aging waivers hereafter) are the primary program adopted by each state which covers long-term care at home or community-based setting. There is potential for the Medicaid aging waiver to affect informal care because it funds at-home formal care, allowing the older parents to age-in-place. In this paper, I will provide the first empirical work to explore the effect of Medicaid aging waivers on informal care and I will fill the gap by exploring the unique design of this policy. Using the Health and Retirement Study (HRS) data, I will employ the differences-in-differences strategy to compare changes of informal care outcomes for states who change the funding of Medicaid aging waivers versus states who do not. The identification comes from large variation in the timing of policy funding changes across states. The results of this study will have direct relevance in the discussion of containing Medicaid spending on long-term care and designing family leave policies. The findings will provide empirical evidence to guide long-term care policymaking and help internalize the effects on informal care when making long-term care policies.}, keywords = {Informal care, Medicaid, waivers}, url = {http://emmazai.com/files/JMP_EmmaZai.pdf}, author = {Zai, Emma} } @article {11105, title = {Welcome Mats and On-Ramps for Older Adults: The Impact of the Affordable Care Act{\textquoteright}s Medicaid Expansions on Dual Enrollment in Medicare and Medicaid}, journal = {Journal of Policy Analysis and Management}, year = {2020}, abstract = {Abstract For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called ?welcome mat? effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an ?on-ramp? effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.}, keywords = {Affordable Care Act, Medicaid, Medicare}, isbn = {0276-8739}, doi = {https://doi.org/10.1002/pam.22259}, author = {Melissa McInerney and Jennifer M Mellor and Lindsay M Sabik} } @article {11253, title = {Who benefits from public financing of home care for low-income seniors?}, year = {2020}, institution = {Harvard University}, address = {Cambridge, MA}, abstract = {The past few decades have seen the emergence of a large formal home care industry as a significant source of long-term care for the elderly and disabled, who previously relied heavily on unpaid family members and nursing home care. Most formal home care is financed publicly through Medicaid programs, and this paper seeks to understand the implications of this financing. Using data from the 2000-2016 waves of the Health and Retirement Study and a difference-in-difference and triple-difference design, I investigate the effects of a policy adopted at the state level that increased the use of formal home care among Medicaid-eligible seniors by more than 50\%. I show that rather than displace nursing home care or reach seniors who would otherwise be going without care, the policy{\textquoteright}s main effect is to replace informal care from family members, particularly spouses and daughters. For daughters, I find that this decrease in care supplied is accompanied by an increase in labor supply: for every 2.4-3 women whose parent receives formal home care as a result of this policy, one additional daughter works fulltime. These results suggest that daughters who care for frail seniors may be a significant and overlooked beneficiary of public efforts to increase access to home care for seniors.}, keywords = {home care, Long-term Care, Medicaid}, url = {https://scholar.harvard.edu/files/kshen/files/caregivers.pdf}, author = {Shen, Karen} } @mastersthesis {10303, title = {Essays in Macroeconomics and Labor Economics}, volume = {PhD}, year = {2019}, note = {Copyright - Database copyright ProQuest LLC; ProQuest does not claim copyright in the individual underlying works; Last updated - 2019-07-24}, pages = {119}, school = {University of Wisconsin-Madison}, type = {phd}, abstract = {The first chapter studies the interaction between family insurance and social insurance. In particular, this paper assesses the value of Medicaid for recent retirees in insuring against long-term care risks while taking into account child-to-parent transfers. Parent retirees receive substantial transfers in the forms of informal care and financial transfers from children. To understand the role of upward intergenerational insurance for old-age health risks, I develop a dynamic model for parent-child pairs and childless retirees. A vital feature of the model is that a parent and her child interact strategically to make decisions about transfers in a non-cooperative game. I estimate and calibrate the model to match the Health and Retirement Study (HRS) data. Using the calibrated model, I calculate the insurance values of Medicaid relative to its cost for retirees and child households. Compensating variation calculations suggest that childless retirees value every dollar of Medicaid insurance at $2.20, which is twice the value for parent retirees ($1.10). Furthermore, I find that middle-income parent retirees value Medicaid insurance less than poor and wealthy parent retirees. An additional result of the paper is that child households also value Medicaid. This decomposition provides a new consideration for the efficient design of Medicaid benefits, particularly in light of a growing population aging without children. The second chapter studies the role of medical expenditure risks in elderly consumption choices. Old-age medical expenditure risks have been documented to have significant impacts on elderly savings. However, little is known about the consumption effects of elderly medical expenditure risks. In this study, we examine the effect of medical expenditure risk on elderly household consumption behaviors. We identify the causal effect by exploiting the exogenous reduction in prescription drug spending risk as a result of the introduction of Medicare Part D in the U.S. in 2006. Using the Health and Retirement Study (HRS) data during 2004{\textendash}2010, we find that declining medical expenditure risks had little impact on total consumption, regardless of nondurable or durable consumption. The third chapter explores the reasons why the growth rate of non-routine cognitive occupations employment has significantly declined during 2000{\textendash}2014, compared to 1985{\textendash}2000. I propose and test the hypothesis that tasks related to information gathering and processing have been substituted by recent information technology after 2000. For that, I develop a model of production process. A novel feature of the model is that outputs are produced using a set of tasks, which combine occupation-specific labor and capital inputs. Recent information technological change is modeled as the declines in the occupation-specific cost of capital. I estimate the conditional labor and product demand using U.S. data. Results of the estimation show that the cost of capital, which is used with occupations related to information gathering and processing in production, has declined faster after 2000. My work contributes to the job polarization literature by documenting and exploring the new dynamics of technological change.}, keywords = {0501:Economics, 0510:Labor economics, Economics, Information technology, Labor economics, Life-cycle, Long-term Care, Medicaid, Medicare, Occupational employment, Social Sciences}, isbn = {9781392287149}, author = {Tan,Fu} } @article {10714, title = {Are coresidence and nursing homes substitutes? Evidence from Medicaid spend-down provisions.}, journal = {J Health Econ}, volume = {59}, year = {2018}, month = {2018 05}, pages = {125-138}, abstract = {

This paper measures the extent to which the price of nursing home care affects a potential substitute living arrangement: coresidence with adult children. Exploiting variation in state Medicaid income "spend-down" provisions over time, I find that living in a state with a spend-down provision decreases the prevalence of coresidence with adult children by 1-4 percentage points for single elderly individuals, with a corresponding increase in the use of nursing home care. These findings suggest that changes in Medicaid eligibility for long-term care benefits could have large impacts on living arrangements, care utilization patterns, and Medicaid expenditures.

}, keywords = {Adult children, Aged, Aged, 80 and over, Female, Health Expenditures, Homes for the Aged, Humans, Long-term Care, Male, Medicaid, Nursing homes, Residence Characteristics, United States}, issn = {1879-1646}, doi = {10.1016/j.jhealeco.2018.04.003}, author = {Corina D Mommaerts} } @article {12307, title = {Family, Income, \& Medicaid Policy: Multinomial Logistic Model of Long-Term Care Decisions}, year = {2018}, abstract = {Providing care for older family members is a difficult and costly decision; in 2015, 34 million Americans provided care to an elder loved one (National Alliance for Caregiving \& AARP Public Policy Institute, 2015). Formal long-term care (LTC) in a facility outside the home is expensive and caregivers that provide informal LTC at home may incur high opportunity costs, including limiting work hours or forgoing employment outside the home. Existing research focuses on this supply issue and ignores how characteristics of elders and their family members and Medicaid LTC policy jointly factor into the decision between formal and informal LTC. In this paper, I examine informal LTC in the context of all other alternatives for care (no care, informal LTC, formal LTC) and include demographic and economic measures of the elder care recipient and potential family caregivers as explanatory variables.}, keywords = {Family, Income, Long-term Care, Medicaid, medicaid beneficiaries, Policy}, url = {https://appam.confex.com/appam/2018/webprogram/Paper26576.html}, author = {Selena Caldera} } @article {9630, title = {The Lifetime Medical Spending of Retirees}, year = {2018}, month = {05/2018}, pages = {2-31}, institution = {National Bureau of Economic Research}, address = {Cambridge, MA}, abstract = {Using dynamic models of health, mortality, and out-of-pocket medical spending (both inclusive and net of Medicaid payments), we estimate the distribution of lifetime medical spending that retired U.S. households face over the remainder of their lives. We find that at age 70, households will on average incur $122,000 in medical spending, including Medicaid payments, over their remaining lives. At the top tail, 5 percent of households will incur more than $300,000, and 1 percent of households will incur over $600,000 in medical spending inclusive of Medicaid. The level and the dispersion of this spending diminish only slowly with age. Although permanent income, initial health, and initial marital status have large effects on this spending, much of the dispersion in lifetime spending is due to events realized later in life. Medicaid covers the majority of the lifetime costs of the poorest households and significantly reduces their risk}, keywords = {Medicaid, Medical Expenses, Mortality, Out-of-pocket payments}, issn = {08982937}, doi = {10.3386/w24599}, url = {http://www.nber.org/papers/w24599.pdf}, author = {John Bailey Jones and Mariacristina De Nardi and Eric French and McGee, Rory and Kirschner, Justin} } @article {8674, title = {Physical and/or Cognitive Impairment, Out-of-Pocket Spending, and Medicaid Entry among Older Adults.}, journal = {J Urban Health}, volume = {93}, year = {2016}, month = {2016 10}, pages = {840-850}, abstract = {

While Medicare provides health insurance coverage for those over 65~years of age, many still are underinsured, experiencing substantial out-of-pocket costs for covered and non-covered services as a proportion of their income. Using the Health and Retirement Study (HRS), this study found that being underinsured is a significant predictor of entering into Medicaid coverage over a 16-year period. The rate of entering Medicaid was almost twice as high for those who were underinsured and with physical and/or cognitive impairment than those who were not, while supplemental health insurance reduced the rate of entering Medicaid by 30~\%. Providing more comprehensive coverage through the traditional Medicare program, including a ceiling on out-of-pocket expenditures or targeted support for those with physical or cognitive impairment, could postpone becoming covered by Medicaid and yield savings in Medicaid.

}, keywords = {Aged, Cognitive Dysfunction, Delivery of Health Care, Disabled Persons, Eligibility Determination, Female, Financing, Personal, Humans, Insurance Coverage, Insurance, Health, Male, Medicaid, Middle Aged, United States}, issn = {1468-2869}, doi = {10.1007/s11524-016-0078-1}, url = {https://link.springer.com/article/10.1007\%2Fs11524-016-0078-1}, author = {Willink, Amber and Davis, Karen and Schoen, Cathy and Jennifer L. Wolff} } @article {8242, title = {The burden of health care costs for patients with dementia in the last 5 years of life.}, journal = {Ann Intern Med}, volume = {163}, year = {2015}, month = {2015 Nov 17}, pages = {729-36}, publisher = {163}, abstract = {

BACKGROUND: Common diseases, particularly dementia, have large social costs for the U.S. population. However, less is known about the end-of-life costs of specific diseases and the associated financial risk for individual households.

OBJECTIVE: To examine social costs and financial risks faced by Medicare beneficiaries 5 years before death.

DESIGN: Retrospective cohort.

SETTING: The HRS (Health and Retirement Study).

PARTICIPANTS: Medicare fee-for-service beneficiaries, aged 70 years or older, who died between 2005 and 2010 (n~= 1702), stratified into 4 groups: persons with a high probability of dementia or those who died because of heart disease, cancer, or other causes.

MEASUREMENTS: Total social costs and their components, including Medicare, Medicaid, private insurance, out-of-pocket spending, and informal care, measured over the last 5 years of life; and out-of-pocket spending as a proportion of household wealth.

RESULTS: Average total cost per decedent with dementia ($287~038) was significantly greater than that of those who died of heart disease ($175~136), cancer ($173~383), or other causes ($197~286) (P~< 0.001). Although Medicare expenditures were similar across groups, average out-of-pocket spending for patients with dementia ($61~522) was 81\% higher than that for patients without dementia ($34~068); a similar pattern held for informal care. Out-of-pocket spending for the dementia group (median, $36~919) represented 32\% of wealth measured 5 years before death compared with 11\% for the nondementia group (P~< 0.001). This proportion was greater for black persons (84\%), persons with less than a high school education (48\%), and unmarried or widowed women (58\%).

LIMITATION: Imputed Medicaid, private insurance, and informal care costs.

CONCLUSION: Health care expenditures among persons with dementia were substantially larger than those for other diseases, and many of the expenses were uncovered (uninsured). This places a large financial burden on families, and these burdens are particularly pronounced among the demographic groups that are least prepared for financial risk.

PRIMARY FUNDING SOURCE: National Institute on Aging.

}, keywords = {Aged, Aged, 80 and over, Cost of Illness, Dementia, Female, Health Expenditures, Humans, Insurance, Health, Male, Medicaid, Medicare, Retrospective Studies, Socioeconomic factors, Terminal Care, United States}, issn = {1539-3704}, doi = {10.7326/M15-0381}, author = {Amy Kelley and Kathleen McGarry and Rebecca Jean Gorges and Jonathan S Skinner} } @article {10490, title = {Financing Long-Term Services And Supports: Options Reflect Trade-Offs For Older Americans And Federal Spending.}, journal = {Health Affairs (Project Hope)}, volume = {34}, year = {2015}, month = {2015 Dec}, pages = {2181-91}, abstract = {

About half of older Americans will need a high level of assistance with routine activities for a prolonged period of time. This help is commonly referred to as long-term services and supports (LTSS). Under current policies, these individuals will fund roughly half of their paid care out of pocket. Partly as a result of high costs and uncertainty, relatively few people purchase private long-term care insurance or save sufficiently to fully finance LTSS; many will eventually turn to Medicaid for help. To show how policy changes could expand insurance{\textquoteright}s role in financing these needs, we modeled several new insurance options. Specifically, we looked at a front-end-only benefit that provides coverage relatively early in the period of disability but caps benefits, a back-end benefit with no lifetime limit, and a combined comprehensive benefit. We modeled mandatory and voluntary versions of each option, and subsidized and unsubsidized versions of each voluntary option. We identified important differences among the alternatives, highlighting relevant trade-offs that policy makers can consider in evaluating proposals. If the primary goal is to significantly increase insurance coverage, the mandatory options would be more successful than the voluntary versions. If the major aim is to reduce Medicaid costs, the comprehensive and back-end mandatory options would be most beneficial.

}, keywords = {Aged, Financing, Government, Humans, Insurance, Insurance Coverage, Long-term Care, Medicaid, Middle Aged, Policy Making, United States}, issn = {1544-5208}, doi = {10.1377/hlthaff.2015.1226}, author = {Melissa Favreault and Gleckman, Howard and Richard W. Johnson} } @article {LIN20131205, title = {The impact of the partnership long-term care insurance program on private coverage}, journal = {Journal of Health Economics}, volume = {32}, year = {2013}, pages = {1205 - 1213}, abstract = {We examine the impact of U.S. states{\textquoteright} adoption of the partnership long-term care (LTC) insurance program on households{\textquoteright} purchases of private coverage. Targeting middle-class households, this program increases the benefits of privately insuring via a higher asset threshold for Medicaid eligibility for LTC coverage. We find that the program generates few new purchases of LTC insurance, and that those it generates are almost entirely by wealthy individuals.}, keywords = {Insurance, Long-term Care, Medicaid, Partnership, Program}, issn = {0167-6296}, doi = {https://doi.org/10.1016/j.jhealeco.2013.09.010}, url = {http://www.sciencedirect.com/science/article/pii/S016762961300129X}, author = {Lin, Haizhen and Jeffrey T Prince} } @article {7683, title = {Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study.}, journal = {Hepatology}, volume = {55}, year = {2012}, month = {2012 Jan}, pages = {184-91}, publisher = {55}, abstract = {

UNLABELLED: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients{\textquoteright} health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person.

CONCLUSION: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.

}, keywords = {Aged, Black People, Caregivers, Comorbidity, Cost of Illness, Databases, Factual, Disability Evaluation, Female, Health Care Costs, Health Status, Hispanic or Latino, Humans, Incidence, Liver Cirrhosis, Male, Medicaid, Medicare, Prevalence, Prospective Studies, Retirement, United States, White People}, issn = {1527-3350}, doi = {10.1002/hep.24616}, author = {M. O. Rakoski and Ryan J McCammon and John D Piette and Theodore J Iwashyna and J. A. Marrero and Lok, Anna S and Kenneth M. Langa and Volk, Michael L} } @article {NBERw16406, title = {The Impact of State Tax Subsidies for Private Long-Term Care Insurance on Coverage and Medicaid Expenditures}, year = {2010}, institution = {NBER}, abstract = {In spite of the large expected costs of needing long-term care, only 10-12 percent of the elderly population has private insurance coverage. Medicaid, which provides means-tested public assistance and pays for almost half of long-term care costs, spends more than $100 billion annually on long-term care. In this paper, I exploit variation in the adoption and generosity of state tax subsidies for private long-term care insurance to determine whether tax subsidies increase private coverage and reduce Medicaid{\textquoteright}s costs for long-term care. The results indicate that the average tax subsidy raises coverage rates by 2.7 percentage points, or 28 percent. However, the response is concentrated among high income and asset-rich individuals, populations with low probabilities of relying on Medicaid. Simulations suggest each dollar of state tax expenditure produces approximately $0.84 in Medicaid savings, over half of which funnels to the federal government.}, keywords = {Long-term care insurance, Medicaid, Taxes}, doi = {10.3386/w16406}, url = {http://www.nber.org/papers/w16406}, author = {Gopi Shah Goda} } @article {7389, title = {Financial hardship and mortality among older adults using the 1996-2004 Health and Retirement Study.}, journal = {Ann Epidemiol}, volume = {19}, year = {2009}, month = {2009 Dec}, pages = {850-7}, publisher = {19}, abstract = {

PURPOSE: We investigated the effect of financial hardship on mortality risk in a community-dwelling sample of adults 50 years of age and olderin the United States.

METHOD: The 1996 Health and Retirement Study cohorts were followed prospectively to 2004 (N = 8,377). Gender-stratified grouped Cox models were used to estimate the difference in the relative risk (RR) of mortality between a specific number of financial hardships (one, two, or three or more) and no hardships; and the predictive utility of each individual financial hardship for mortality during the follow-up period.

RESULTS: Gender-stratified models adjusted for demographics, socioeconomic characteristics, and functional limitations in 1996 showed that women reporting one (hazard ratio [HR] = 1.42; 95\% confidence interval [CI]: 1.05-1.92) or three or more (HR = 1.60; 95\% CI: 1.05-2.46) and men reporting two (HR = 1.80; 95\% CI: 1.21-2.69) financial hardships had a substantially higher probability of mortality compared to those reporting no financial hardships. Individual financial hardships that predicted mortality in fully adjusted models for women included receiving Medicaid (HR = 2.23; 95\% CI: 1.68-2.98) and for men receiving Medicaid (HR = 2.11; 95\% CI: 1.57-2.84) and receiving food stamps (HR = 1.59; 95\% CI: 1.09-2.33).

CONCLUSIONS: These findings suggest that over and above the influence of traditional measures of socioeconomic status, financial hardship exerts an influence on the risk of mortality among older adults and that the number and type of hardships important in predicting mortality may differ for men and women.

}, keywords = {Aged, Female, Geriatric Assessment, Health Surveys, Humans, Male, Medicaid, Middle Aged, Mortality, Poverty, Proportional Hazards Models, Prospective Studies, Retirement, Risk, Sex Factors, United States}, issn = {1873-2585}, doi = {10.1016/j.annepidem.2009.08.003}, author = {Reginald D. Tucker-Seeley and Li, Yi and Subramanian, S V and Sorensen, Glorian} } @article {7372, title = {A new measure of medication affordability.}, journal = {Soc Work Public Health}, volume = {24}, year = {2009}, month = {2009 Nov-Dec}, pages = {600-12}, publisher = {24}, abstract = {

This study developed a new measure of medication affordability that examines out-of-pocket drug expenses relative to available household resources. The authors assessed the spending patterns of approximately 2.1 million poor households (< or =100\% federal poverty level) of adults aged 51 and older by Medicaid status. The data were drawn from the 2000-2001 Health and Retirement Study. Household spending was categorized into three broad types: basic living, health care, and discretionary. Older (aged 51 or older) poor households without Medicaid allocated about 72\% of their total resources ($17,421, SE $783) to basic living needs. In comparison, those with Medicaid had scarcer total resources ($12,498, SE $423) and allocated 85\% to basic living needs. Medication costs consumed the largest proportion of health care expenses for both types of poor households (Medicaid: $463, SE $67; non-Medicaid: $970, SE $102). After paying for basic living needs and health care costs, these families had, on average, only $16 left each week. Poor families have very few resources available for anything beyond basic living needs, even when they have Medicaid coverage. There is no great reservoir of discretionary funds to pay for increases in cost-sharing under Medicaid and Medicare Part D.

}, keywords = {Aged, Data collection, Female, Financing, Personal, Humans, Male, Medicaid, Middle Aged, Poverty, Prescription Fees, United States}, issn = {1937-1918}, doi = {10.1080/19371910802672346}, author = {Becky A. Briesacher and Ross-Degnan, Dennis and Adams, Alyce and Anita K Wagner and Jerry Gurwitz and Soumerai, Stephan} } @article {7138, title = {Risk of nursing home admission among older americans: does states{\textquoteright} spending on home- and community-based services matter?}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {62}, year = {2007}, month = {2007 May}, pages = {S169-78}, publisher = {62B}, abstract = {

OBJECTIVE: States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states{\textquoteright} generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects.

METHODS: We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier.

RESULT: State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p <.001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35\%.

DISCUSSION: Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.

}, keywords = {Aged, Aged, 80 and over, Caregivers, Cohort Studies, Cost Savings, Cost-Benefit Analysis, Female, Financing, Government, Health Expenditures, Home Care Services, Homes for the Aged, Humans, Insurance Coverage, Long-term Care, Male, Medicaid, Medicare, Nursing homes, Patient Admission, Patient Readmission, Risk Assessment, Risk Factors, State Health Plans, United States}, issn = {1079-5014}, doi = {10.1093/geronb/62.3.s169}, author = {Muramatsu, Naoko and yin, Hongjun and Richard T. Campbell and Ruby L Hoyem and Martha A. Jacob and Christopher Ross} } @article {6914, title = {Out-of-pocket health-care expenditures among older Americans with cancer.}, journal = {Value Health}, volume = {7}, year = {2004}, month = {2004 Mar-Apr}, pages = {186-94}, publisher = {7}, abstract = {

OBJECTIVE: There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS: We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS: Of the 6370 respondents, 5382 (84\%) reported No CA, 812 (13\%) reported CA/No Tx, and 176 (3\%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27\% of their yearly income on OOPE compared to only 5\% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS: Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

}, keywords = {Aged, Aged, 80 and over, Cost of Illness, Family Characteristics, Female, Financing, Personal, Health Expenditures, Health Services Research, Humans, Insurance, Health, Longitudinal Studies, Male, Medicaid, Medicare, Michigan, Neoplasms}, issn = {1098-3015}, doi = {10.1111/j.1524-4733.2004.72334.x}, author = {Kenneth M. Langa and A. Mark Fendrick and M.E. Chernew and Mohammed U Kabeto and Paisley, Kerry L. and Hayman, James A.} } @article {6723, title = {Expectations among the elderly about nursing home entry.}, journal = {Health Serv Res}, volume = {35}, year = {2000}, month = {2000 Dec}, pages = {1181-202}, publisher = {35}, abstract = {

OBJECTIVE: To assess whether the covariates that explain expectations of nursing home entry are consistent with the characteristics of those who enter nursing homes.

DATA SOURCES: Waves 1 and 2 of the Assets and Health Dynamics Among the Oldest Old (AHEAD) survey.

STUDY DESIGN: We model expectations about nursing home entry as a function of expectations about leaving a bequest, living at least ten years, health condition, and other observed characteristics. We use an instrumental variables and generalized least squares (IV-GLS) method based on Hausman and Taylor (1981) to obtain more efficient estimates than fixed effects, without the restrictive assumptions of random effects.

PRINCIPAL FINDINGS: Expectations about nursing home entry are reasonably close to the actual probability of nursing home entry. Most of the variables that affect actual entry also have significant effects on expectations about entry. Medicaid subsidies for nursing home care may have little effect on expectations about nursing home entry; individuals in the lowest asset quartile, who are most likely to receive these subsidies, report probabilities not significantly different from those in other quartiles. Application of the IV-GLS approach is supported by a series of specification tests.

CONCLUSIONS: We find that expectations about future nursing home entry are consistent with the characteristics of actual entrants. Underestimation of risk of nursing home entry as a reason for low levels of long-term care insurance is not supported by this analysis.

}, keywords = {Activities of Daily Living, Aged, Attitude to Health, Data Interpretation, Statistical, Effect Modifier, Epidemiologic, Female, Geriatric Assessment, Health Care Surveys, Health Services Research, Health Status, Homes for the Aged, Humans, Least-Squares Analysis, Longevity, Male, Medicaid, Nursing homes, Patient Admission, Probability, Risk Factors, Surveys and Questionnaires, United States}, issn = {0017-9124}, author = {Richard C Lindrooth and Hoerger, Thomas J. and Edward C Norton} } @article {6608, title = {Life transitions and health insurance coverage of the near elderly.}, journal = {Med Care}, volume = {36}, year = {1998}, month = {1998 Feb}, pages = {110-25}, publisher = {36}, abstract = {

OBJECTIVES: This study addresses three issues. (1) What are demographic wealth, employment, and health characteristics of near-elderly persons losing or acquiring health insurance coverage? Specifically, (2) what are the effects of life transitions, including changes in employment status, health, and marital status? (3) To what extent do public policies protect such persons against coverage loss, including various state policies recently implemented to increase access to insurance?

METHODS: The authors used the 1992 and 1994 waves of the Health and Retirement Study to analyze coverage among adults aged 51 to 64 years.

RESULTS: One in five near-elderly persons experienced a change in insurance coverage from 1992 to 1994. Yet, there was no significant change in the mix of coverage as those losing one form of coverage were replaced by others acquiring similar coverage.

CONCLUSIONS: Individuals whose health deteriorated significantly were not more likely than others to suffer a subsequent loss of coverage, due to substitution of retiree or individual coverage for those losing private coverage and acquisition of Medicaid and Medicare coverage for one in five uninsured. State policies to increase access to private health insurance generally did not prevent individuals from losing coverage or allow the uninsured to gain coverage. Major determinants of the probability of being insured were education, employment status of person and spouse, and work disability status. Other measures of health and functional status did not affect the probability of being insured, but had important impacts on the probability of having public coverage, conditional on being insured.

}, keywords = {Death, Employment, health policy, Health Services Research, Health Status Indicators, Humans, Insurance Coverage, Life Change Events, Medicaid, Medically Uninsured, Medicare, Middle Aged, Retirement, Spouses, United States}, issn = {0025-7079}, doi = {10.1097/00005650-199802000-00002}, author = {Frank A Sloan and Conover, C.J.} }