The Transition from Medicaid to Medicare and Impacts on Disparities in Coverage and Care

许多收入低于联邦贫困线（FPL）138%的医疗补助扩展注册者面临 当他们65岁并过渡到医疗保险时，会有更大的成本分摊和更高的自付成本。在 医疗保险，在100% FPL时有一个补贴悬崖，超过这个悬崖，受益人没有资格获得全面的医疗保险。 医疗保险A部分（住院）和B部分（门诊）的医疗费用分摊补贴。受益人 收入在100-150% FPL和有限资产之间的人可以通过以下方式获得部分财政援助： 一套复杂的程序。这些补贴的使用是有限的，有证据表明，布莱克和 西班牙裔受益人更有可能有资格获得补贴，但不太可能意识到补贴计划。 白色受益人。此外，较高的费用分摊与必要护理的减少有关， 更糟糕的结果，在某些情况下，扩大了护理中的种族/民族差异。16个州有 扩大收入和资产资格，以获得高于联邦最低标准的综合费用分摊补贴， 几乎没有证据表明这种政策是否会减少种族/族裔差异。在目标1和2中，我们将使用 2016年至2023年的个人医疗补助和医疗保险登记、索赔和遭遇数据 跟踪受益人在65岁时从医疗补助过渡到医疗保险，并检查过渡是否 项目之间的差异导致医疗保险补贴的差异，并导致 使用、临床事件结局和支出。就目标1而言，我们将研究是否存在种族/民族差异， 过渡到仅使用Medicare并使用机器的Medicaid扩展受益人的Medicare覆盖范围 学习方法以识别因素（例如，政策、卫生保健系统、个人）， 少数族裔与白色受益人之间的补贴。对于目标2，我们将评估是否会增加费用分摊， 加入Medicare会导致服务使用中的种族/民族差异（例如，门诊访视），临床事件 结果（例如，急诊科就诊、住院、死亡率）和支出（自付和 总费用）。我们将使用差异中的差异方法来比较受益人的结果变化 略高于或低于综合费用分摊补贴的收入限额，加入后或加入前 医疗保险对于目标3，我们关注的是那些扩大了医疗保险收入或资产资格的州 在2008年或以后，补贴高于联邦最低标准，以评估这些政策变化是否减少了种族/族裔 与医疗费用分摊有关的差异。我们将使用2006-2023年的医疗保险数据和一个差异--无差别 审查获得全面费用分摊的受益人的成果变化的办法 国家补贴扩大之前与之后的补贴。在所有的目标中，我们将检查黑色的效果是否不同 以及西班牙裔和白色受益人的对比。这项研究的结果将为覆盖政策提供信息， 在这两个公共部门，受益人在过渡期的护理方面存在不利结果和种族/族裔差异， 程序.

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.