David Anderson

Medicaid has a perpetual open enrollment period.  Any one who is eligible can sign up at effectively any time.  If likely to be eligible individuals are aware of this, we should expect new enrollments into Medicaid to be mostly evenly distributed throughout the year with perhaps bumps and clumps due to seasonal trends in regional economics and idiosyncratic attention shocks.  However, my colleagues Paul Shafer of Boston University and Jesse Hinde of RTI looked at when people applied to enroll in California Medicaid throughout the course of the year in a new paper.  They find that Medicaid applications spike during ACA open enrollment periods:

In some ways this is not surprising.  There has been a long conversation about “wood workers’ — people who were always eligible for Medicaid but who were not enrolled coming out of the “wood work” when there was a huge attention shock in the form of advertising and general discussion about the ACA.  In our other works, we show that ACA ads are extremely concentrated near and in the open enrollment period.  But it implies that there are a large number of people who are eligible for care but where the information hurdle which changes height throughout the year effectively acts as a gatekeeper to needed medical insurance and likely medical care.

Well functioning public programs that are intended to actually serve the eligible populations should minimize informational and administrative barriers to access.  This would mean the state would take on the responsibility of identifiying and enrolling people who are likely to be eligible based on data that the state routinely collects. This would mean regular advertising and destigmatizing messaging about programs.  This would mean we likely change financing mechanisms.  It means making enrollment in social programs and enrollment maintenance in these programs to be as easy as placing a hold mail order at the post office.

Information and enrollmentPost + Comments (9)

Last week, a federal district judge in Texas who has not seen a part of the ACA that he thinks is legal, ruled that a significant chunk of the preventive care mandates in the law are either illegal or unconstitutional.  The suit was brought by a religiously owned company that does not want to pay for mandated PrEP for AIDS/HIV prevention medication.

Judge O’Connor just held that *key parts* of the ACA’s preventive services requirement are unconstitutional. He upheld the requirements for kids, vaccines, and women (for now) but not those recommended by US Preventive Services Task Force.

Decision here: https://t.co/VvzBbe03AT pic.twitter.com/YlbDpozLGM

— Katie Keith (@Katie_Keith) September 7, 2022

In the short run it is going to get appealed and likely go to the Supreme Court in a year or two.

Insurers are mandated to provide preventive care services because the business case for high value preventive care services is not particularly good from the payer of those services even as they can produce long term societal value. Most preventive care services are not immediately cost saving. There are costs to provide a service, and then, especially for screening services, there are costs of treatment of newly discovered problems. These treatments may produce great value but most of that value is either accruing to the patient or to reduced future medical expenditures. Some vaccines are likely cost saving within a contract year but other than that, it is hard to see cost-savings that an insurer can immediately internalize.

I have a working paper currently under review that looks at the take-up of some of the common preventive care services that are mandated to be cost free. I can’t say much but a common thread in this ongoing work and that of many other researchers is that there are multiple barriers and facilitators to care. Reducing cost to zero is helpful to increase take-up but it is not the only thing that keeps people from getting recommended services.

If this ruling stands or mostly stands without a Congressional update, then insurers will have very strong business cases to impose cost-sharing on almost every preventive service except perhaps flu shots which means screening and prevention will be less common in the future.

The ACA and Preventive CarePost + Comments (24)

Building on what John wrote yesterday, US students had significant, on average, lower test scores in the past two years.

National test results released on Thursday showed in stark terms the pandemic’s devastating effects on American schoolchildren, with the performance of 9-year-olds in math and reading dropping to the levels from two decades ago.

This year, for the first time since the National Assessment of Educational Progress tests began tracking student achievement in the 1970s, 9-year-olds lost ground in math, and scores in reading fell by the largest margin in more than 30 years.

I am not an education researcher, but I am a reasonably competent causal inference researcher that can bring some general observations to this problem if the hypothesis is that school closures are to be assigned dominant responsibility. I have a strong belief that any one factor will only explain a chunk of the entire variance.

The TLDR: This is one hell of a nasty inference problem with significant confounding hovering in the background.

If we think that school closures are driving test score loss, we would expect some of the following to be true:

• Areas with more closures should have more loss “Dose-response”
• Heterogeneity needs a strong theoretical explanation

This is tough to show:

Oddly, reading scores in cities, many of which had long-lasting school closures, did not drop at all during the pandemic.

And scores in the Northeast, where school closures were common, dropped only a bit more than in the South, where closures were not. https://t.co/zewMxHMU6e

— James Surowiecki (@JamesSurowiecki) September 1, 2022

At this point the sociologists in my life are screaming in my head with the note that the most marginalized groups of a population are usually the ones who get kicked hardest first and get kicked longest by a negative shock. The methodologists in my life are now screaming that school closures are not exogenous. They don’t happen by chance. School close as a function of both local politics and local disease incidence or disease consequence. Schools closing can happen because there is massive, ongoing spread in the community killing parents, grandparents, teachers and community members. Closure may be highly correlated with systemic trauma.

Untangling the causal pathway with anything solid means dealing with massive confounding. There are designs that can get local estimates of the effects of school closures on educational outcomes but studies that use non-random choice of districts within one part of one state will have a hard time generalizing to the nation. Super sophisticated techniques can and will (eventually) get around the challenges of someone running a simple regression making huge claims.

Causal inference and education loss during a pandemicPost + Comments (16)

This is a BFD:

CMS…… hello https://t.co/61lvjSEECh pic.twitter.com/v7wWHNk4Qr

— Adrianna McIntyre (@onceuponA) August 31, 2022

Signing up and maintaining eligibility for Medicaid and CHIP tends to be a pain in the ass. It frequently leads to significant enrollment churn. The current public health emergency has frozen redetermination and termination for non-eligibility. This has led to significant increases in enrollment and a lower proportion of the US population being uninsured. However, CMS estimates that the end of the public health emergency will lead to 15 million people leaving Medicaid with some becoming uninsured. Of that 15 million, just under half (6.8 million) are still eligible for Medicaid coverage. These eligible but terminated from coverage individuals will have fallen through cracks or aggressively pushed off of coverage by onerous redetermination requirements.

Steps taken to maintain accurate and low cost to the individual eligibility determinations is a big deal. This likely means enhanced data sharing between programs that already collect income information. It could plausibly mean that more people who qualify for WIC or free and reduced lunch would be automatically maintained in Medicaid because they will have hit the income guidelines. It could mean restrictions on form length or requirements that a typical beneficiary can readily explain what is needed as the forms would be written in plain English instead of either lawyer-ese OR 1947 Louisiana voting literacy test levels.

I’m not sure what will be in these regulations, but this is part of a quiet revolution in providing public services.

Administrative burden and enrollmentPost + Comments (5)