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

许多收入低于联邦贫困水平(FPL)138%的医疗补助扩大参保人面临 当他们超过65岁并过渡到联邦医疗保险时，更大的成本分担和更高的自付成本。在……里面 联邦医疗保险，有一个100%FPL的补贴悬崖，超过这个悬崖，受益人没有资格享受全面 补贴涵盖医疗保险A部分(住院患者)和B部分(门诊患者)的医疗费用分摊。受益人： 收入在100-150%FPL和有限资产之间的人可以通过 一套复杂的程序。这些补贴的接受是有限的，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，但不太可能知道补贴计划与 白人受益人。此外，更高的费用分担与减少必要的护理和 更糟糕的结果，在某些情况下，扩大了保健方面的种族/族裔差距。有16个州有 扩大了收入和资产获得综合成本分摊补贴的资格，高于联邦最低标准，但 几乎没有证据表明这些政策是否能缓解种族/民族差距。在目标1和目标2中，我们将使用 2016-2023年的链接、个人级别的Medicaid和Medicare登记、报销和遭遇数据 跟踪受益人在65岁时从医疗补助过渡到医疗保险的情况，并检查过渡是否 计划之间的差异导致了接受医疗保险补贴的差异，并导致了 使用、临床事件结果和支出。对于目标1，我们将检查是否存在种族/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，以确定预测接受治疗的因素(例如，政策、卫生保健系统、个人) 少数族裔与白人受益人之间的补贴。对于目标2，我们将评估在以下方面增加成本分担 加入联邦医疗保险会在服务使用(例如门诊)、临床事件等方面造成种族/民族差异 结果(例如，急诊科就诊、住院、死亡率)和支出(自付和 总成本)。我们将使用差异法来比较受益者结果的变化 全面成本分摊补贴的收入限额之后与进入前仅略高于或低于 医疗保险。对于目标3，我们重点关注扩大了联邦医疗保险收入或资产资格的州的子集 2008年或以后高于联邦最低标准的补贴，以评估这些政策变化是否减少了种族/民族 与医疗保险费用分担相关的差异。我们将使用2006-2023年的联邦医疗保险数据和差异-无关紧要 审查获得全面费用分担的受益者成果变化的办法 国家补贴扩大之前和之后的补贴。在所有目标中，我们将检查对黑人的影响是否不同 西班牙裔与白人受益者之争。这项研究的发现将为保险政策提供信息，这些政策可能会减少 作为受益者在这两个公共部门的过渡，不良后果和种族/民族护理方面的差异 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.