The study by Nelson et al. seeks to evaluate the health effects of Section 1115 waiver-associated healthy behavior incentive (HBI) programs, as a path to expand Medicaid, compared to traditional Medicaid expansion.1 Given the lack of studies differentiating types of expansion, the authors performed a difference-in-difference analysis using two national survey databases to assess insurance coverage, access to care, and health outcomes among low-income adults in states that implemented HBI or traditional expansion relative to non-expansion states.
When examining coverage and access outcomes, important findings were noted. Relative to non-expansion states, expansion states were associated with gains in insurance coverage and having a regular doctor, reduced smoking rate, and increased use of some preventive services including cancer screening. Interestingly, these outcome changes did not differ by expansion types. Conversely, there was a larger increase in health checkup rates in HBI states relative to traditional expansion states. These findings indicate that HBI programs have the great potential to improve healthy behaviors but there is still limited evidence suggesting the extra health benefits compared to traditional expansion.
When examining health outcomes, both physical and mental, neither expansion types had an effect. However, a growing number of studies suggested positive health changes following expansion.2 The data period post-expansion in the current evaluation may be relatively short to detect measurable changes in health outcomes that potentially occur over a longer time horizon. As recent data become available, further research is needed to evaluate the ultimate health impacts of different types of expansion.
Recent national proposals would cut federal funding while granting states flexibility to restructure Medicaid programs.3, 4 To date, 14 states have not adopted Medicaid expansion, while 10 of the 37 expansion states have used Section 1115 waivers to operate their expansion programs.5 In a changing policy landscape, this study provides important evidence of potential gains in coverage and access to care in non-expansion states considering HBI or traditional expansion in the future. To inform state policymaking, more studies are needed to fully understand whether expansion through HBI or other waiver programs brings adequately additional health benefits while considering program costs.
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References
- 1.Nelson DB, Sommers BD, Singer PM, Arntson EK, Tipineni R. Changes in Coverage, Access, and Health Following Implementation of Healthy Behavior Incentive Medicaid Expansions vs. Traditional Medicaid Expansions. J Gen Intern Med. doi:10.1007/s11606-020-05801-6 [DOI] [PMC free article] [PubMed]
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- 4.Centers for Medicare & Medicaid Services. State Medicaid Director Letter #20-001: Healthy Adult Opportunity; 2020. Available at: https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/smd20001.pdf.
- 5.Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision; 2020. Available at: https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed March 15, 2020.