Health affairs scholar最新文献

Background: Hospitals make decisions about which services to provide based on a variety of factors. However, decisions to provide services based on financial or religious considerations have increasingly drawn public scrutiny. We conducted a national survey to assess public attitudes toward hospitals' financial or religious motivations for offering certain types of care.

Methods: We conducted a national, cross-sectional online survey of 1577 US adults. Respondents indicated on a 3-point, frequency-based Likert scale whether hospitals should "Never," "Sometimes," or "Always" be allowed to limit services for these reasons. Descriptive statistics and multivariable logistic regression analyses examined the demographic and experiential correlates of these attitudes.

Results: Most respondents opposed financially motivated restrictions (62%), while a plurality opposed religiously motivated restrictions (48%). Opposition differed across subgroups, with Republicans, individuals with public insurance, and health care employees more accepting of both types of restrictions, while older respondents and those with higher health literacy were more likely to oppose them.

Conclusion: Our findings reveal a notable divergence between how hospitals often operate and what the public believes hospitals should be permitted to do. Efforts to improve transparency around service limitations and ensure continuity of care may help maintain public trust when hospitals decline to provide certain services.

Introduction: While surveys suggest that many Medicaid enrollees mistakenly report that they do not have Medicaid coverage, little is known about this population. Enrollment misreporting could be associated with poorer access if enrollees delay or avoid needed care because they incorrectly believe they cannot afford it.

Methods: We exploited the COVID-19 Medicaid continuous coverage provision to identify sociodemographic and health characteristics of enrollees who initially reported Medicaid but subsequently misreported their coverage, and to characterize their patterns of health care access, utilization, and spending.

Results: We found that 11.5% of enrollees misreported their coverage, belonging to 2 distinct groups: those who reported being uninsured, and those who reported other coverage. Compared to enrollees who accurately reported having Medicaid, enrollees who reported uninsurance experienced more cost-related barriers to care, lower utilization, and $1682 less in average annual health expenditures.

Conclusion: These findings suggest that health care behaviors follow perceptions of Medicaid enrollment status. Because coverage confusion may impair access to needed services, addressing the needs of this group will require policy and programmatic strategies to ensure that enrolled individuals can benefit from their Medicaid coverage.

Introduction: The intensity of diagnostic coding in Medicare Advantage (MA) relative to Original Medicare (OM) plays an important role in Medicare's fiscal costs due to its impact on risk adjustment payments. In this article, we provide new estimates of coding differentials that differ from other prominent estimates and incorporate recent policy changes.

Methods: CMS staff recalculated payment year 2022 national average enrollment-weighted risk scores for MA and OM using the newly implemented v28 risk adjustment model and a demographic-only risk adjustment model. Following the demographic estimate of coding intensity methodology, we estimate the difference in risk scores due to differences in health status between MA and OM.

Results: Using a comparable methodology as other widely cited research, we estimate 1.5%-2.0% of "uncorrected" coding in MA relative to OM in 2022 after accounting for statutorily mandated payment adjustments and recent changes to the MA risk adjustment model.

Conclusion: Compared with alternative estimates of roughly 10%, our lower estimated uncorrected coding in MA suggests that prior policy actions may have affected federal spending in MA. These findings can help inform discussion of the overall fiscal balance between MA and OM.

In this piece, we provide context for new estimates of coding intensity in Medicare advantage (MA) and highlight how researchers can build on them to inform ongoing policy debates. In particular, we identify opportunities to study how insurer responses may affect the intended goals of the Center for Medicare and Medicaid Services's (CMS) recently introduced risk adjustment model, as well as how potential changes in insurer payments may influence plan design.

Introduction: The Centers for Medicare and Medicaid Services has made screening for health-related social needs (HRSNs) mandatory since 2024. Patients screening positive for HRSN food insecurity (FI) are connected with Supplemental Nutrition Services using 1115 Demonstration waivers. With a shift in funding, Massachusetts adopted a more stringent FI-level screening protocol (very low food security [VLFS]). To date, there is no screening tool that identifies VLFS alone; thus, we developed a sensitive, specific, and valid screen to determine risk for VLFS.

Methods: Sensitivity, specificity, and positive- and negative-predictive values were used to test combinations of questions compared with the USDA Household Food Security Survey Module using the 2022 Current Population Survey.

Results: The best VLFS screen was, "In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?" (yes/no). The screen was highly sensitive, specific, and valid for detecting VLFS risk in US households with and without children (sensitivity, 92.2% and 97.2%; specificity, 96.2% and 97.4%, respectively), and with diverse populations.

Conclusion: The VLFS screen is recommended for use by states adopting a more stringent FI-level screening protocol.

Despite substantial progress, many serious diseases continue to lack safe and effective therapies. Building on a recent National Academies consensus study report that offers several recommendations to better align investments in therapeutic development with unmet needs, in this commentary, we focus on the Food and Drug Administration's role in advancing this goal. Historically, FDA has encouraged investment where market incentives fall short, undertaken efforts to address broad scientific challenges, and administered programs to expedite development and review of drugs targeting unmet needs. Under the second Trump administration, FDA has launched several initiatives that continue these key themes, although some have been controversial, primarily due to concerns about resource sufficiency and the potential for political interference. Regarding other domains addressed by the National Academies report, FDA has recently given mixed signals on its commitment to upholding rigorous approval standards; paid limited attention to noted gaps, including improving rigorous postmarket evidence generation and validating the surrogate markers often used to support product approval; and failed to ensure adequate financial and human resources to support the agency's critical work. Engagement with the National Academies report's recommendations can help ensure that FDA continues to advance progress toward addressing unmet medical needs.

There have been notable improvements in patient safety in recent years; however, significant challenges remain in reducing the incidence of preventable patient harm. Supporting patient safety efforts is increasingly important given increasing complexity of care and changing health needs, especially with aging populations. Emerging technologies and capabilities open new possibilities to address longstanding patient safety problems. For example, predictive analytics to support provider decision-making, increased patient interest in engagement in their care, and artificial intelligence provide opportunities to further reduce harm. Many of these examples support a more proactive approach to patient safety by focusing on anticipating, predicting, and preventing patient harm; however, implementation is essential to avoid unintended consequences. Additionally, health care organizations oftentimes cannot accomplish this work on their own and strategic partnerships are crucial for continued improvement. This paper proposes a strategic focus for health care leaders as they build comprehensive plans to prevent harm from adverse events. Drawing on international case examples from the Future of Health Community, it outlines actionable approaches to partnerships that can be adapted and implemented across diverse health care organizations.

Objective: Doula support improves maternal health outcomes. States have increasingly included doula services as a covered benefit under Medicaid. We evaluated the implementation of Virginia's Medicaid doula policy and identified lessons to improve access and utilization.

Methods: This mixed-methods study used administrative data (Medicaid claims data from January 2022-December 2024 and state-certified doula registry data) and qualitative interviews with 9 doula Medicaid providers to understand the barriers and facilitators to doula care among Medicaid beneficiaries in Virginia.

Results: At the time of the study, there were 130 state-certified doula Medicaid providers in Virginia, but fewer than half billed Medicaid for services, most commonly billing for postpartum care. Additionally, utilization of doula services among beneficiaries was low (less than 1%) from 2022 to 2024. Geographic disparities showed limited doula availability in some high-need areas. Five policy lessons emerged.

Conclusion: State Medicaid programs can strengthen doula policy implementation, and in turn strengthen the doula workforce and expand access to doula care for Medicaid beneficiaries, by revising reimbursement rates and structure to better reflect the scope of doula services, recruiting doulas in underserved areas, providing technical assistance for enrollment and billing, expanding outreach to beneficiaries, and engaging a range of doulas in policy discussions.

Introduction: California's 4.8 million noncitizen adults, half of whom are undocumented, endure substantial exclusions from health care. To address this gap, California policymakers expanded full-scope, state-funded Medicaid without discriminating by immigration status, first extending coverage to undocumented young adults (18-25 years) in 2020 and then to older adults (≥50 years) in 2022.

Methods: Using the American Community Survey (2017-2023), we assessed whether California's Medicaid expansion for young and older undocumented adults was associated with changes in insurance coverage by comparing pre- and post-expansion differences between citizens and noncitizens (difference-in-differences).

Results: Compared to citizens, the expansion was not associated with increased health insurance or Medicaid enrollment among young noncitizens. However, among older adults, the expansion was associated with a modest 1.3% increase in overall insurance coverage for noncitizens, including a 2.4% increase in Medicaid. Following these expansions, noncitizens remain significantly less likely to have insurance: 28% of young noncitizens and 16% of older noncitizens lack coverage, compared to 8% and 3% for young and older citizens, respectively.

Conclusion: Given these persistent inequities-where noncitizens across nearly all sociodemographic factors are less likely to be insured-preserving and strengthening the existing pathways to insurance coverage for noncitizens, including undocumented immigrants, remains critical.