Learning from Program Differences between Medicaid and Medicare

摘要 医疗保险和医疗补助是美国最大的社会健康保险计划， 为超过1.3亿美国人提供医疗保险。虽然这些程序共享一些关键属性，但它们 在重要方面也有所不同，主要的制度差异是国家对 他们的医疗补助计划的设计，而医疗保险是在国家一级管理。尽管他们 重要性，美国的医疗保健系统，很少有严格的准实验工作，研究如何 两个项目在对卫生保健获得、质量和结果的影响方面进行了比较， 注册者。在这个项目中，我们将通过跟踪成年人， 在65岁之前参加医疗补助的残疾人在65岁及以后参加医疗保险-也就是说， 只有医疗补助的残疾成年人变成了医疗补助和医疗保险的双重杀手。 在65岁之前同时参加医疗补助和医疗保险的残疾成年人将担任 对照组，因为他们在65岁时没有经历过程序之间的过渡。研究这些变化， 双重资格将使我们能够隔离州医疗补助计划对病人护理的平均影响， 相对于结构上不同的医疗保险计划的结果（例如，与更多的参与供应商 比医疗补助），以及探索这些影响的变化在国家医疗补助计划的功能。在 目标1，我们将估计如何登记的照顾和结果不同，在这两个计划。在目标2中，我们 探索程序差异背后的机制。为了做到这一点，我们将利用这样一个事实， 一个医疗补助计划，但51，与不同级别的提供者访问和支付。具体来说，我们将分析 医疗补助-医疗保险过渡在提供者支付较高的州（相对于医疗保险）与 低供应商付款的国家。我们将做同样的比较国家承包的规定， 医疗补助福利私人管理医疗计划与国家不。这将提供新的证据， 这两个重要因素在多大程度上解释了整体医疗补助-医疗保险的差异， 对程序设计的影响。在目标3中，我们专注于医疗补助和医疗保险的一个特定组成部分， 福利：处方药。我们将使用医疗保险D部分的介绍（它转移了双重， 从医疗补助药物覆盖范围到医疗保险药物覆盖范围），以评估药物福利组成部分 这两个项目对参加者的药物使用和相关健康结果的影响不同。在这里，我们将 我还利用各州医疗补助计划的差异来探索机制，重点是各州医疗补助计划的差异。 对受益人可以填写的处方数量和事先授权的要求设置上限。这些 分析将为重要的计划设计决策（支付率， 管理式护理、药物上限、事先授权）对低收入和低收入人群的保健服务和健康结果的影响， 残疾美国人

ABSTRACT Medicare and Medicaid are the largest social health insurance programs in the United States, together providing health insurance for over 130 million Americans. While the programs share some key attributes, they also differ in important ways, with the key institutional difference being that states have significant control over the design of their Medicaid programs while Medicare is managed at the national level. Despite their importance to the U.S. health care system, there is little rigorous quasi-experimental work studying how the two programs compare to each other in terms of their effects on health care access, quality, and outcomes for enrollees. In this project, we will examine the relative effects of these two programs by following adults with disabilities who are enrolled in Medicaid before age 65 into Medicare at age 65 and beyond—that is, as disabled adults with only Medicaid switch to become dual-eligibles enrolled in both Medicaid and Medicare. Adults with disabilities who are dually enrolled in both Medicaid and Medicare before age 65 will serve as the control group, as they do not experience a transition between programs at age 65. Studying these changes to dual eligibility will allow us to isolate the average effects of state Medicaid programs on patient care and outcomes relative to a structurally different Medicare program (e.g., with a wider set of participating providers than Medicaid), as well as to explore variation in these effects across features of state Medicaid programs. In Aim 1, we will estimate how enrollees' care and outcomes differ in these two programs. In Aim 2, we will explore the mechanisms behind the program differences. To do this, we will leverage the fact that there is not one Medicaid program but 51, with varying levels of provider access and payment. Specifically, we will analyze how the Medicaid-Medicare transition differs in states with high provider payments (relative to Medicare) vs. states with low provider payments. We will do the same to compare states that contract out the provision of Medicaid benefits to private managed care plans vs. states that do not. This will provide new evidence on the extent to which these two important factors explain overall Medicaid-Medicare differences and will have implications for program design. In Aim 3, we focus on one specific component of the Medicaid and Medicare benefit packages: prescription drugs. We will use the introduction of Medicare Part D (which shifted dual- eligibles from Medicaid drug coverage to Medicare drug coverage) to assess how the drug benefit component of these two programs differentially affects enrollees' use of drugs and related health outcomes. Here, we will also leverage variation across state Medicaid programs to explore mechanisms, focusing on variation in state use of caps on the number of prescriptions beneficiaries can fill and prior authorization requirements. These analyses will provide critical lessons for the effects of important program design decisions (payment rates, managed care, drug caps, prior authorization) on health care delivery and health outcomes for low-income and disabled Americans.