Medicaid on the Eve of the Affordable Care Act: What are the Research Priorities? Summary of the November 6, 2013, conference held at the Urban Institute in Washington, D.C. (Released November 2014) Sponsored by the School of Public and Environmental Affairs (SPEA) at Indiana University and the Urban Institute 1 | Page Executive Summary The School of Public and Environmental Affairs (SPEA) at Indiana University and the Urban Institute cosponsored a conference to identify high-priority research questions and gaps in our research knowledge related to changes in the Medicaid program occurring under the Affordable Care Act (ACA). The conference took place in November of 2013, just as the first open enrollment period was getting underway and two months before 26 states were slated to expand Medicaid eligibility under the ACA. The conference began with a status report on the major policy changes occurring around the country in Medicaid under the ACA and an assessment of pressing research questions. The sessions that followed covered research needs and opportunities in specific Medicaid topic areas including enrollment and coverage; quality of care and outcomes; access to care; and cost impacts. The luncheon panel featured foundations that discussed their priorities and processes related to Medicaid research. The conference ended with reflections from the day. Two of these speaker summaries form the summary of the conference and appear on p.9, directly after the agenda on p.4. The speakers and participants represented a broad spectrum of perspectives and stakeholders, including those who conduct, consume, and fund research on the Medicaid program. Speaker biographies can be found on p.162 and the list of participants and their institutions on p.8. Following the synthesis comments, the chapters of this document are organized in the order of the conference. All chapters reflect comments made at the conference, with some small updates made in early to mid 2014. Synthesis Comments • Setting Research Priorities for Medicaid on Eve of ACA Health Insurance Expansions (Daniel Polsky) • Transforming Medicaid through Evidence (Andrew B. Bindman) Assessment of Where the Nation Stands Currently- ACA Medicaid Implementation • An ACA & Medicaid Research Agenda: What Can We Learn? (Alan Weil) • Reactions: Fractious Federalism and the Future of Medicaid (Frank J. Thompson) Research Needs and Opportunities in Specific Medicaid Topic Areas Enrollment and Coverage • Research Needs and Opportunities in the Area of Health Insurance Program Enrollment and Coverage Following ACA Implementation (Thomas DeLeire) • Research and Data Needs for Monitoring and Implementation of the ACA in 2014 and Beyond: Enrollment and Coverage (Julie J. Sonier) • Reactions (Sharon K. Long) Quality of Care and Outcomes • Improving the Quality of Care for Medicaid Beneficiaries (Sara Rosenbaum) 2 | Page • Does Medicaid Improve Health? Lessons from the Past and Recommendations for the Future (Robert Kaestner) • Reactions: Research on ACA’s Effect on Medicaid Quality and Outcomes (Marsha Gold) Luncheon Panel: Foundation Perspectives: Medicaid Research Priorities (Chris Perrone) • Access to Care The Affordable Care Act and Access to Care: Existing Research and Open Questions (Thomas C. Buchmueller) • Reactions: How Will the ACA Affect Access to Care for Medicaid Enrollees? (Stephen Zuckerman) • Cost Impacts The Financial Impacts of Health Reform (John Holahan) • Medicaid Expansion: State Approaches. Considerations and Questions (Deborah Bachrach) • Cost Impacts (Matt Salo) • Reactions: Cost Impacts (Judith Solomon) • Reactions: Medicaid Expansion under the ACA: Dollars and Sense? (Joseph Antos) Andy Bindman, in summarizing the discussion of the day, noted that, “The lack of understanding about the Medicaid program undermines our ability to maximize the return on the public’s investment in this program,” while Dan Polsky commented that, “A theme that was consistent across all topics was the need for data and sufficient research infrastructure to study these questions.” To address that need, Polsky remarked that, “Cooperation and strategizing will be needed ...” and suggested ways to “… begin to create the type of advocacy needed to overcome political and organization hurdles to developing better data for researchers.” We appreciate the support of our institutions in helping to define a research agenda on this large and growing healthcare program that serves so many of the nation’s most vulnerable populations. SPEA and UI, together with AcademyHealth, are continuing efforts to advance the Medicaid research field by convening a one-day workshop in November 2014, bringing state-based and national evaluation teams together to discuss ongoing and proposed evaluations of Medicaid expansions under the ACA. We plan to continue this effort through annual or biennial meetings. — Kosali Simon (SPEA) and Genevieve Kenney (Urban Institute) 3 | Page Medicaid on the Eve of the Affordable Care Act: What are the Research Priorities? Agenda of Conference Held Wednesday, November 6th 2013 Location: Urban Institute, 2100 M St NW, Washington, DC 20037 Cosponsored by The School of Public and Environmental Affairs (SPEA) at Indiana University and the Urban Institute (UI) Schedule 0. Breakfast, registration & seating (8:15am-9am) 1. Welcome— UI President Sarah Rosen Wartell, SPEA Dean John Graham, Genevieve Kenney (UI) and Kosali Simon (SPEA) (9am-9:15am) 2. Assessment of Where the Nation Stands Currently- ACA Medicaid Implementation (9:15-10:00am) Overview on ACA implementation, with a focus on Medicaid. This opening presentation will frame the discussion for the rest of the day, and provide an up-to-the-moment assessment of Medicaid policy development under the Affordable Care Act (ACA). Speaker: Alan Weil Alan Weil Executive Director National Academy for State Health Policy Reactor: Frank Thompson Frank Thompson Professor, Rutgers Center for State Health Policy and School of Public Affairs and Administration Rutgers University 3. Research Needs and Opportunities in Specific Medicaid Topic Areas In each of these four areas below, speakers will lead discussion of key research questions, data issues, and methodological challenges for assessing the impacts of the ACA in each of four different areas of potential outcomes—enrollment and coverage; quality of care and wellbeing; access to care; and costs. Presenters will kick off the sessions, with reactions following immediately, and with time reserved at the end of each section for ample Q&A. 3.1 Enrollment and Coverage (10:00am-11:00am) Discussion on expected/possible impacts of the ACA on health insurance coverage with a discussion of the roles of the Medicaid expansion, outreach, enrollment system changes, the mandate, possible variations across states, and of impacts on current and new eligibles, uninsured rates, and rates of nongroup and ESI coverage. Presenters: Tom DeLeire (Georgetown); Julie Sonier (SHADAC); Reactors: Nancy Delew (ASPE); Sharon Long (Urban Institute); Rick Kronick (AHRQ) Thomas DeLeire Professor, McCourt School of Public Policy Georgetown University 4 | Page Julie Sonier, Deputy Director State Health Access Data Assistance Center (SHADAC) at the University of Minnesota Nancy Delew Associate Deputy Assistant Secretary for Health Policy Office of Health Policy/Assistant Secretary for Planning and Evaluation (ASPE)/ US Department of Health and Human Services (HHS) Sharon Long Senior Fellow, Health Policy Center, Urban Institute Rick Kronick Director, Agency for Healthcare Research and Quality (AHRQ) Break: 11:00-11:15 3.2 Quality of Care and Outcomes: (11:15-12:30) Discussion on expected/possible impacts of the Medicaid expansion on quality of care and the health and wellbeing of individuals, with a discussion of the roles of service delivery arrangements (i.e. capitated managed care, carve outs, etc.), quality metrics, value-based purchasing and other payment and service delivery innovations, patient incentives, coverage of case management, and other social supports and contextual/social factors that could affect these outcomes. Presenters: Sara Rosenbaum (George Washington University), Robert Kaestner (University of Illinois at Chicago), Reactors: Marsha Lillie Blanton (CMS), Marsha Gold (Mathematica) Sara Rosenbaum Harold and Jane Hirsh Professor of Health Law and Policy Milken Institute School of Public Health at the George Washington University Department of Health Policy Robert Kaestner Professor, Institute of Government and Public Affairs & Department of Economics University of Illinois at Chicago Marsha Lillie-Blanton Director Division of Quality, Evaluation & Health Outcomes – Children and Adults Health Programs Group Center for Medicaid and CHIP Services Marsha Gold Senior Fellow Mathematica Policy Research Luncheon Panel 12:30pm-1:45pm [networking lunch 12:30-1pm; Foundation perspectives 1-1:30; questions 1:30-1:45; ] 5 | Page Foundations will discuss current analytic priorities with respect to Medicaid research, describe their process of deciding research priorities, evaluating proposals, what types of work they have funded recently in Medicaid, and the types of research questions they may fund in the near future. Andrew Hyman (RWJF), Barbara Lyons (Kaiser Family Foundation), Chris Perrone (CA Health Care Foundation) Andrew Hyman Senior Program Officer RWJF Barbara Lyons Director, Kaiser Commission on Medicaid and the Uninsured Chris Perrone Deputy Director, Health Reform and Public Programs Initiative Acting Director,