Effects of State-level Medicaid Expansion on Veterans Health Administration Dual Enrollment and Utilization

Abstract

Objective: The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care. Research Design: We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants’ dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services. Measures: Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA’s Corporate Data Warehouse and Medicaid Analytic Extract files. Results: For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48–5.25), a 4.63-point decline in VA proportion of admissions (−5.87 to −3.38), and a 11.70-point decrease in the VA proportion of ED visits (−13.06 to −10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion. Conclusions: This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.

Medicaid Expansion and Veterans’ Reliance on the VA for Depression Care

“…8,9 Understanding which of these systems veter-ans choose to use, and under which circumstances, is essential in guiding the allocation of limited health care resources. 10 Beyond Medicaid, alternatives to VA care may include TRICARE, Medicare, Indian Health Services, and employer-based or selfpurchased private insurance. While these options potentially increase convenience, choice, and access to health care practitioners (HCPs) and services not available at local VA systems, cross-system utilization with poor integration may cause care coordination and continuity problems, such as medication mismanagement and opioid overdose, unnecessary duplicate utilization, and possible increased mortality.…”

“…Prior studies have used this method to evaluate post-Medicaid expansion mortality changes and changes in veteran dual enrollment and hospitalizations. 10,19 While a study of ACA Medicaid expansion states would be ideal, Medicaid data from most states were only available through 2014 at the time of this analysis. Our study offers a quasi-experimental framework leveraging longitudinal data that can be applied as more post-ACA data become available.…”

Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19

“…These services reduce barriers to care. [43][44][45][46] The strong social and behavioral support programs in the VA may explain why we did not observe an association between social and behavioral risk factors and mortality. Studies that are designed to assess the potential reasons for this finding are needed.…”

“…Case managers connect veterans with social and behavioral risk factors to other support services, including mental health treatment and substance use counseling. These services reduce barriers to care . The strong social and behavioral support programs in the VA may explain why we did not observe an association between social and behavioral risk factors and mortality.…”

An Alternative Method of Public Reporting of Comparative Hospital Quality and Performance Data for Transparency Initiatives

“…Many Veterans use non-VA services funded by Medicare and Medicaid. [20][21][22][23][24] On the basis of input from VA stakeholders, a major shortcoming of existing OPES groups was that focus on hospital characteristics neglected the community context in which a given VA operates. More outside services and Veteran access to outside health service will lead to a different case mixture and volume of VA users.…”