Fulfilling States' Duty to Evaluate Medicaid Waivers

Food Is Medicine: A Presidential Advisory From the American Heart Association

Unhealthy diets are a major impediment to achieving a healthier population in the United States. Although there is a relatively clear sense of what constitutes a healthy diet, most of the US population does not eat healthy food at rates consistent with the recommended clinical guidelines. An abundance of barriers, including food and nutrition insecurity, how food is marketed and advertised, access to and affordability of healthy foods, and behavioral challenges such as a focus on immediate versus delayed gratification, stand in the way of healthier dietary patterns for many Americans. Food Is Medicine may be defined as the provision of healthy food resources to prevent, manage, or treat specific clinical conditions in coordination with the health care sector. Although the field has promise, relatively few studies have been conducted with designs that provide strong evidence of associations between Food Is Medicine interventions and health outcomes or health costs. Much work needs to be done to create a stronger body of evidence that convincingly demonstrates the effectiveness and cost-effectiveness of different types of Food Is Medicine interventions. An estimated 90% of the $4.3 trillion annual cost of health care in the United States is spent on medical care for chronic disease. For many of these diseases, diet is a major risk factor, so even modest improvements in diet could have a significant impact. This presidential advisory offers an overview of the state of the field of Food Is Medicine and a road map for a new research initiative that strategically approaches the outstanding questions in the field while prioritizing a human-centered design approach to achieve high rates of patient engagement and sustained behavior change. This will ideally happen in the context of broader efforts to use a health equity-centered approach to enhance the ways in which our food system and related policies support improvements in health.

Tying Innovation to Evaluation and Accountability in Programs to Address Intersecting Health and Social Needs

This JAMA Forum advocates for rigorous assessment of the effectiveness of programs and initiatives addressing health-related social needs to improve health outcomes.

Many States Were Able To Expand Medicaid Without Increasing Administrative Spending

With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.

The design of a randomized controlled trial to evaluate multi-dimensional effects of a section 1115 Medicaid demonstration waiver with community engagement requirements

Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization - the gold standard for assessing causality - has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of beneficiaries deemed able-bodied to maintain eligibility for benefits. Beneficiaries were randomized 9:1 to the new waiver program or a control group who would retain their current benefits as part of the existing Medicaid expansion program. To address potential bias from differential attrition from the Medicaid program that would accrue from solely analyzing administrative data, our team designed a rich, prospective, longitudinal survey to collect primary and secondary outcomes from six categories of interest to policymakers: insurance coverage, health care utilization and quality, health behaviors, socioeconomic measures, personal finances, and health outcomes. At baseline, a subset of survey participants was invited to participate in the collection of biometric samples via in-person follow-up visits, and a cross-section were also invited to participate in qualitative interviews. While the demonstration waiver was terminated before the program began, our study design illustrates that it is possible for other researchers and state agencies seeking to evaluate Medicaid demonstration waivers and other demonstration policies to work together to implement high quality randomized trials - even for controversial policies.

Increasing Access to Opioid Use Disorder Treatment: Assessing State Policies and the Evidence Behind Them

OBJECTIVE

Combatting the opioid epidemic requires systemic policy changes that address the underutilization of medication-assisted treatment, a therapy that is effective in treating opioid use disorder. In this study, we present approaches used in five states to increase medication-assisted treatment financing and access.

METHOD

We conducted case studies in five U.S. states, interviewing key informants and reviewing the published literature and unpublished documents.

RESULTS

In these states, Medicaid expansion was the most significant lever available to expand financing and access to medication-assisted treatment. Other key levers include Medicaid Section 1115 SUD demonstrations, State Targeted Response to the Opioid Crisis and State Opioid Response grants, state contracting mechanisms, and other state regulations.

CONCLUSIONS

States in this study reported substantial progress in increasing access to medication-assisted treatment, but empirical evidence of their effects is still emerging.