Document text
Principal Investigator: Vicki Fung
Organization: MASSACHUSETTS GENERAL HOSPITAL
Fiscal Year: 2024
Award: $526,296
Funding agency: National Institute on Minority Health and Health Disparities
Many Medicaid expansion enrollees with incomes less than 138% of the federal poverty level (FPL) face
greater cost-sharing and higher out-of-pocket costs when they tum 65 years old and transition to Medicare. In
Medicare, there is a subsidy cliff at 100% FPL, above which beneficiaries are not eligible for comprehensive
subsidies that cover medical cost-sharing in Medicare Parts A (inpatient) and B (outpatient). Beneficiaries with
incomes between 100-150% FPL and limited assets can qualify for partial financial assistance through a
complex set of programs. Take-up of these subsidies is limited, and evidence suggests that Black and
Hispanic beneficiaries are more likely to be eligible for but less likely to be aware of subsidy programs vs.
White beneficiaries. Moreover, higher cost-sharing has been associated with reductions in necessary care and
worse outcomes, and in some cases, widening of racial/ethnic disparities in care. Sixteen states have
expanded income and asset eligibility for comprehensive cost-sharing subsidies above federal minimums, but
there is little evidence on whether such policies mitigate racial/ethnic disparities. In Aims 1 and 2, we will use
linked, individual-level Medicaid and Medicare enrollment, claims, and encounter data from 2016-2023 to
follow beneficiaries as they transition from Medicaid to Medicare at age 65 and examine whether the transition
between programs leads to disparities in the receipt of Medicare subsidies and contributes to disparities in
use, clinical event outcomes, and spending. For Aim 1, we will examine if there are racial/ethnic disparities in
Medicare coverage among Medicaid expansion beneficiaries that transition to Medicare-only and use machine
learning approaches to identify factors (e.g., policy, health care system, individual) that predict receipt of
subsidies among minority vs. White beneficiaries. For Aim 2, we will assess if increases in cost-sharing upon
entry to Medicare contribute to racial/ethnic disparities in service use (e.g., outpatient visits), clinical event
outcomes (e.g., emergency department visits, hospitalizations, mortality), and spending (out-of-pocket and
total costs). We will use a difference-in-difference approach to compare changes in outcomes for beneficiaries
just above vs. below income limits for comprehensive cost-sharing subsidies, after vs. before entering
Medicare. For Aim 3, we focus on a subset of states that expanded income or asset eligibility for Medicare
subsidies above federal minimums in 2008 or later to assess if these policy changes reduce racial/ethnic
disparities associated with Medicare cost-sharing. We will use 2006-2023 Medicare data and a difference-indifference
approach to examine changes in outcomes for beneficiaries who gain comprehensive cost-sharing
subsidies before vs. after state subsidy expansions. In all aims, we will examine whether effects differ for Black
and Hispanic vs. White beneficiaries. Findings from this study will inform coverage policies that could reduce
adverse outcomes and racial/ethnic disparities in care as beneficiaries transition across these two public
programs.
Terms: <21+ years old><65 and older><65 or older><65 years of age and older><65 years of age or more><65 years of age or older><65+ years><65+ years old><> 65 years><Adopted><Adult><Adult Human><Age><Aged 65 and Over><Attention><Awareness><Black><Black race><COVID-19 pandemic affected><COVID-19 pandemic consequence><COVID-19 pandemic effects><COVID-19 pandemic impact><COVID-19 pandemic impacted><Caring><Clinical><Color><Complex><Control Groups><Cost Sharing><Data><Diagnosis><Disadvantaged><Disadvantaged minority><Disparities><Disparity><Disparity population><Drug Prescribing><Drug Prescriptions><Drugs><ED visit><ER visit><Economic Income><Economical Income><Economics><Eligibility><Eligibility Determination><Emergency care visit><Emergency department visit><Emergency hospital visit><Emergency room visit><Enrollment><Ethnic Origin><Ethnicity><Event><Face><Financial Support><Health><Health Care Systems><Health Insurance for Aged and Disabled, Title 18><Health Insurance for Disabled Title 18><Health Services><Health system><Healthcare Systems><Hispanic><Hospital Admission><Hospitalization><Household><Income><Individual><Inpatients><Insurance><Insurance Coverage><Insurance Status><Link><Low income><Machine Learning><Managed Care><Measures><Medicaid><Medicaid eligibility><Medicaid services><Medical Care Costs><Medicare><Medicare Hospital Insurance Program><Medicare Part A><Medicare/Medicaid><Medication><Minority><Out-of-Pocket Expense><Out-patients><Outcome><Outpatients><Pharmaceutical Preparations><Policies><Population><Protocol Screening><QOC><Qualifying><Quality of Care><Race><Races><Research><Services><Survey Instrument><Surveys><Testing><Time><Title 18><Uncovered Medical Expenses><Uncovered Uninsured Medical Expense><Uninsured Medical Expense><Visit><above age 65><access disparities><access to health care><access to healthcare><accessibility disparities><accessibility of health care><accessibility to health care><accessibility to healthcare><adulthood><adverse consequence><adverse outcome><after age 65><age 65 and greater><age 65 and older><age 65 or older><age > 65><age of 65 years onward><aged><aged 65 and greater><aged 65+><aged ≥65><ages><barrier to care><barrier to health care><barrier to healthcare><barrier to treatment><beneficiary><coronavirus disease 2019 pandemic consequence><coronavirus disease 2019 pandemic impact><cost><disadvantaged group><disadvantaged individual><disadvantaged people><disadvantaged population><disadvantaged subgroup><disparate effect><disparate impact><disparate result><disparities across groups><disparities in access><disparities in race><disparity across subgroups><disparity among groups><disparity among subgroups><disparity between groups><disparity between subgroups><disparity due to race><disparity in care><disparity in ethnic><disparity in healthcare><drug/agent><economic><effects following the COVID-19 pandemic><enroll><ethnic based disparity><ethnic disadvantage><ethnic disparity><ethnic inequality><ethnic inequity><ethnic minority><ethnicity disparity><faces><facial><federal poverty level><financial assistance><group disparity><group inequality><group inequity><health care access><health care availability><health care disparity><health care inequality><health care inequity><health care service><health care service access><health care service availability><health insurance for disabled><healthcare access><healthcare accessibility><healthcare availability><healthcare disparity><healthcare inequality><healthcare inequity><healthcare service><healthcare service access><healthcare service availability><human old age (65+)><impact of the SARS-CoV-2 pandemic><impoverished communities><incomes><inequalities among populations><inequalities between populations><inequalities in populations><inequality across populations><inequality among groups><inequality between groups><inequality due to race><inequality in access><inequality in groups><inequitable effect><inequitable impact><inequitable outcome><inequities among populations><inequities between populations><inequities in populations><inequity across groups><inequity across populations><inequity between groups><inequity due to race><inequity in access><inequity in accessibility><inequity in groups><life span><lifespan><low SES><low socio-economic position><low socio-economic status><low socioeconomic position><low socioeconomic status><machine based learning><medical costs><medical expenses><medical expenses not covered by insurance><medication prescription><mortality><obstacle to care><obstacle to healthcare><old age><out-of-pocket costs><out-of-pocket health care costs><outcome disparities><outcome inequality><outcome inequity><over 65 years><poor communities><population inequality><population inequity><poverty communities><prescribed medication><programs><race based disparity><race based inequality><race based inequity><race disparity><race related disparity><race related inequality><race related inequity><racial><racial background><racial disparity><racial inequality><racial inequity><racial minority><racial origin><racially unequal><social culture><socio-cultural><socio-economic><socio-economically><sociocultural><socioeconomically><socioeconomics><subgroup disparity><total medical expenditure><unequal effect><unequal group><unequal impact><unequal outcome><unequal population><≥65 years>