Image created using Adobe Firefly AI

*Author's note: To see the SQL and R coding behind the visualizations in this blog post please visit my GitHub account.

I have long played with the idea of writing about prescription drug pricing, but A) I never seemed to find a related story interesting enough to use as a lens into this incredibly complicated topic and B) did I mention that it's an incredibly complicated topic?

Well, it's finally happened: I've decided to stop waiting around for a compelling story to launch me into the world of prescription drug pricing and just dive in. No more excuses. After some initial research, I thought I'd structure my first blog post about this subject by looking at trends in drug costs for people on Medicaid. As I got further into my research, I realized there will be some important changes to Medicare as well.

There are a couple of reasons for choosing to focus on Medicare and Medicaid when it comes to drug pricing. For one thing, much of the U.S. population is enrolled in one form of health insurance or the other…or both simultaneously. So the discussion is relevant to a significant number of people. Also, last year's Budget Reconciliation Act of 2025, also known as the One Big Beautiful Bill Act (OBBBA) also calls for significant changes to how prescription drugs are handled.

Before we get started, here's a quick reminder on what Medicare and Medicaid are all about.

Although much of the analysis of this post will focus on Medicaid, let's start with Medicare. As is stated at Medicare.gov, "Medicare is health insurance for people 65 or older. You may be eligible to get Medicare earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease)."

Confession time: although it's not true that Medicare is only for retired senior citizens, that's how I tend to remember the difference between the two types of insurance. For me, Medicare is for older people, and Medicaid is for adults of any age who are struggling financially. This is a vast oversimplification, but it's helpful in discussions like this.

The OBBBA makes several significant changes to Medicare, including putting in place a nine-year ban on implementing improvements to Medicare Savings Programs (MSPs) and halting the national minimum staffing requirements for nursing homes. And while the legislation makes adjustments to the 2022 Inflation Reduction Act (more on this Act in a bit), including limiting Medicare’s ability to control costs for expensive medications, its effects on prescription drugs stem mostly from constraining eligibility requirements.

There are different varieties of Medicare: Parts A, B, C, and D. Without going into too much depth, Parts A and B are considered original Medicare and are available to U.S. citizens over 65, even if they are still employed. Medicare Part A is considered "Hospital Insurance" and Part B is "Medical Insurance." Medicaid Part C is what I call "Medicare adjacent," meaning that, according to the Department of Health and Human Services website, "Medicare Advantage Plans, sometimes called 'Part C' or 'MA Plans,' are offered by private companies approved by Medicare."

I could spend a whole blog post on the nuances just within Medicare Part A, but to simplify it, "Hospital Insurance" can be broken down into a free tier (most people get this) and a premium tier. Avoiding paying a premium for Medicare Part A depends on if a person has exceeded a certain threshold either in their own earnings, or in those of a spouse, parent, or child.

This is determined by looking at a person's "quarters of coverage", or work credits, which are earned through payment of payroll taxes during their career. To say any more about Part A coverage eligibility is beyond the scope of this post, so let's move on to Medicare Part B.

Like I mentioned above, Medicare Part B is considered "Medical Insurance." It covers medically necessary and preventative services. For a more in-depth understanding of what those services entail, check out Medicare.gov, but suffice it to say that Part B covers things like ambulance services, some outpatient prescription drugs, mental health and substance use disorders, and durable medical equipment.

As an aside, there's an interesting overlap between the prior and current Administrations for Part B enrollees that you've probably heard about. The Inflation Reduction Act of 2022 (also known as the IRA) capped out-of-pocket costs for insulin for people on Medicare at $35. That policy has continued to the present day for people on Part B who are purchasing an insulin pump (durable medical equipment). That means that beneficiaries can purchase a month's supply of insulin for $35. This deal also holds true for those enrolled in a Medicare Advantage Plan.

That brings us nicely to Medicare Part C, also called "Medicare Advantage." Confusingly, Medicare Advantage combines elements of Parts A and B. As another helpful page at Medicare.gov points out: Medicare Advantage is "A type of Medicare-approved health plan from a private company that you can choose to cover most of your Part A and Part B benefits instead of Original Medicare. It usually also includes drug coverage (Part D)."

This leads us to the part of Medicare that will be most relevant to this blog post: Medicare Part D, a.k.a. prescription drug coverage.

As the AARP puts it, "The program allows private insurers that the federal government regulates to sell voluntary, stand-alone drug plans to participants in original Medicare and to incorporate this coverage into most Medicare Advantage plans."

So, this insurance plan helps people enrolled in Parts A and B (original Medicare) and Part C (Medicare Advantage) pay for a range of prescription drugs. In 2024, notes the AARP, the average Medicare beneficiary had "21 stand-alone Part D options and 36 Medicare Advantage drug plans to choose from." (This was according to KFF, a nonprofit health policy research group.) The web page goes on to say that "Each has different premiums, deductibles, copayments, preferred pharmacies and lists of covered drugs, but they all must meet federal requirements."

The IRA plays a role here, too, because aside from providing clean energy tax breaks and incentivizing people to buy electric cars, according to the U.S. Government Accountability Office, the act "requires Medicare to negotiate prices for certain high-cost drugs. It also requires manufacturers to pay Medicare a rebate if their prices for certain drugs rise faster than inflation."

I could write several blog posts about how saving money for seniors when it comes to purchasing prescription medication became a political football during the 2022 U.S. primaries and the 2024 presidential election, but suffice it to say that when the new Administration came in, they sought to put their own signature on helping seniors afford prescriptions.

Now that we've got a complete handle on Medicare (haha), let's turn to how prescription drugs work in Medicaid. I'm going to spend less time explaining the ins and outs of Medicaid (big sigh of relief, I know) and instead, dive into an analysis that will provide a baseline that will help us watch how prescription drug coverage for those on Medicaid will likely shift in the coming months.

Before we jump into the numbers, however, let's get a few basic facts out of the way. First, Medicaid is, according to Medicaid.gov, "the largest source of health coverage in the United States." It's important to note that Medicaid is a joint program between the federal government and the states. Together with the Children’s Health Insurance Program, or CHIP (more on that here, which links to other past blog posts on the topic), Medicaid provides health care coverage to over 77.9 million Americans.

Beneficiaries include "Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI)." There is a list of "mandatory eligibility groups" that details exactly who is covered. The Affordable Care Act, also known as Obamacare, allowed states to expand Medicaid to cover low-income Americans under age 65, and currently 40 states plus Washington, DC have expanded coverage.

As with Medicare, the OBBBA's impact on prescription drug affordability for those on Medicaid will largely be felt in its narrowing of eligibility criteria. According to the KFF website, the playing field is changing significantly:

"...the 2025 reconciliation law, signed by President Trump on July 4, 2025, is expected to result in significant Medicaid funding cuts and coverage losses. The loss of Medicaid coverage altogether could make it more difficult and costly for families to access the prescription drugs they need."

I won't get into previous attempts at controlling prescription drug pricing for people on Medicaid, including "Most-favored nation” drug pricing and new Medicaid drug pricing models meant to curb spending on medications, but suffice it to say that the federal government is putting a premium on reducing spending in this area.

As I indicated above and in a previous blog post, Medicaid is largely run by the states, with the federal government paying some of the bill; with the feds now contributing less, and with eligibility requirements becoming more stringent, it's likely that a smaller pool of individuals would benefit from lower prescription medication costs.

To examine the state of Medicaid prescription utilization in 2025, I looked at two massive, publicly-available federal data repositories managed by the Centers for Medicare & Medicaid Services (CMS). These are the State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data (which I'll call Medicaid and CHIP Enrollments) and State Drug Utilization Data 2025 (SDUD) datasets.

Both of these datasets deal with Medicaid (and not Medicare) beneficiaries, which is the focus of this blog post. Because of their different scales (the SDUD database has over 5.2 million rows!) and reporting intervals, it was a challenge to reconcile the numbers. The Medicaid and CHIP Enrollment database tracks overall program enrollment monthly, while the SDUD tracks an incredibly large and highly granular number of pharmaceutical transactions quarterly.

To combine this data from separate sources into a single, unified metric, i.e. the average number of prescriptions ordered per month by Medicaid beneficiaries in all 50 states, I followed these steps:

I began with the Medicaid and CHIP Enrollment data. This national repository tracks monthly enrollment counts across all 50 states. To establish a baseline, I filtered for the calendar year 2025 and restricted the dataset strictly to entries marked Final_Report = 'Y'. This ensured my analysis relied on officially audited government figures rather than preliminary counts. I then calculated the Average Monthly Enrollment for each state to serve as a stable population denominator.

Next, I turned to the SDUD, a much larger repository containing over 5.2 million rows of transaction data for 2025 alone. This dataset tracks every state-covered prescription filled by a pharmacy. To prevent data anomalies from skewing our counts, I filtered out privacy-masked records and aggregated the total volume of prescriptions filled across all reporting quarters for each state.

Because drug data is reported quarterly and enrollment data is tracked monthly, a direct comparison would be mathematically invalid. To resolve this "data resolution mismatch," I scaled the drug transactions down to a monthly pace (dividing the total prescriptions by the number of active months represented in the reporting quarters).

By dividing this monthly prescription volume by the average monthly enrollment count, I arrived at the target metric: Average Prescriptions Per Person Per Month.

With a 50-state landscape, presenting raw data can easily become overwhelming. To provide a clear benchmark, I conducted a joint statistical median analysis, ranking every state by both its overall program size and its prescription rate to find the ultimate "middle-of-the-pack" representative.

Through this objective ranking system, Nevada emerged as the nation's true statistical baseline, sitting almost perfectly at the mathematical median of the entire United States.

By synchronizing these two federal data streams for 2025, I established a clean, audited baseline of how frequently Medicaid beneficiaries rely on pharmacy benefits. This provides a snapshot for trends before the OBBBA takes full effect.

My analysis revealed several core insights:

This baseline ensures that as future finalized data is released, I can track how shifting state policies and federal eligibility adjustments impact real-world medication access against a pre-transition standard.

Here is a table of the five U.S. states with the highest average prescriptions ordered per Medicaid beneficiary per month, contrasted with the five states with the lowest average numbers of orders. The red line separates the top from the bottom states in this category.

Now let's look at the numbers for the entire country. Nevada weighs in as the most average state with .747 prescriptions ordered per Medicaid beneficiary per month, and the average ordering rate nationwide is .77 per beneficiary per month.

Image created using Adobe Firefly AI

*Author's note: To see the SQL and R coding behind the visualizations in this blog post please visit my GitHub account.

In December of last year, the Administration announced the establishment of a $50 billion initiative called the Rural Health Transformation Program (RHTP). The purpose of this program is to allocate money to the 50 U.S. states to fix what it calls "systemic problems that leave rural Americans without access to good health care."

As CBS reports, the Administration has an aggressive timeline: "Within eight months, states must submit revised budgets, begin spending, and show the money is going to good use." Funding will be announced in October of this year.

The program website notes that $50 billion will be "allocated to approved States over five fiscal years, with $10 billion of funding available each fiscal year, beginning in fiscal year 2026 and ending in fiscal year 2030."

Again quoting from the program website, the money will be assigned in the following ways:

In other words, all 50 states (excluding the District of Columbia and U.S. Territories) will receive an equal share of the first portion of funding, whereas CMS will steer "payouts from the second portion based on each state's rural score, as well as results from a 'technical' scoring system for project proposals."

Congress included the fund in last summer's One Big Beautiful Bill Act in an effort to counterbalance significant cuts to Medicaid. The race is now on to demonstrate the need for the additional $25 billion that will be allocated at the discretion of the Administration after the first 50% of funds are disbursed.

While the funds will flow to a range of rural health facilities, I want to focus on one particular category whose constituent agencies could benefit from this effort: community health centers (CHC).

In the U.S., CHCs play a major role in providing care in rural areas. Two major entities fall under the CHC umbrella, namely rural health clinics (RHCs) and federally qualified health centers (FQHCs).

With respect to RHCs, according to the National Rural Health Association (NRHA), "Over 60% of rural Americans are served by the over 5,450 RHCs across 47 states." The NRHA website states that "Rural providers with RHC status receive enhanced reimbursement rates for providing services under Medicare and Medicaid."

The Penn Leonard Davis School of Health Economics provides a nice breakdown of RHCs:

"About 65% of RHCs are provider-based, meaning they are part of a hospital, nursing home, or home health agency, while 35% are operated independently. Nearly three-quarters of independent RHCs are for-profit, compared to just 11% of provider-based RHCs. The National Association of Rural Health Clinics estimates that in 2022, RHCs served more than 37 million patients, representing about 11% of the entire population and about 62% of the 60.8 million people living in rural America."

These clinics are distinct from FQHCs, which the NRHA defines as "outpatient clinics that qualify for specific reimbursement systems under Medicare and Medicaid."

Apart from the functions they serve, RHCs and FQHCs also have somewhat distinct funding sources – or, at least, different requirements for disclosing their funding sources. Again from Penn:

"FQHCs receive substantial funding from the federal government to help cover the cost of providing free and reduced-cost care to their patients. FQHCs receive about 12% of their revenues from Section 330 grants, which amounted to an average of $3.7 million for each FQHC in 2022…More than one-quarter of their revenues come from federal, state, and local grants and contracts, which complicates FQHC participation in alternative payment models."

There is also a variety of CHC called FQHC "look-alikes." These are community-based providers that meet the requirements of the Health Center Program but don't receive funding from that source. As the HRSA website says, "They provide primary care services in underserved areas, provide care on a sliding fee scale based on ability to pay, and operate under a governing board that includes patients."

Advantages to becoming a look-alike entity are that these programs are paid for services rendered to Medicare and Medicaid patients through the FQHC Prospective Payment System (PPS), drug discounts via the 340B Drug Pricing Program, free vaccines for children without insurance or who are under-insured as part of the Vaccines for Children Program, they receive help finding and keeping primary care providers via the National Health Service Corps, and they receive technical assistance.

Again quoting from the Penn website, "Because they do not receive Section 330 grant funding, FQHC look-alikes have a slightly different mix of revenues, with nearly 20% coming from private insurance. However, they also derive a significant portion of their revenues from nonpatient care sources, including 18% from grants and contracts (primarily state, local, and foundation grants).

Now that we have a baseline understanding of what RHCs and FQHCs are, and the differences between them, let's look at how they've developed over the years. Let's start by reviewing the number of RHCs that currently exist in each state. The Centers for Medicare and Medicaid Services (CMS) only lists data for 45 states, which I've arranged in descending order from most to least number of RHCs per state:

Data courtesy of CMS

As you can see, Kentucky leads the way with 409 RHCs, followed by Texas with 349 sites and Tennessee with 320 sites. It's also interesting to look at the pace of RHC expansion among states. The area charts below track the states with the most inflows of RHCs between 1950 and 2026:

Data courtesy of CMS

Tennessee is a big outlier among the states, particularly in the 1990s. Although it's outside the scope of this blog post, it would be instructive to delve into what legislative environment existed in the state in that time period to facilitate such extensive growth.

Turning now to FQHCs, let's review how many centers there are per state (data courtesy of CMS):

Data courtesy of CMS

The list above includes U.S. Territories like the U.S. Virgin Islands, Guam, and the Northern Mariana Islands. There are far more FQHCs in California than in any other state. Interestingly, while Texas comes in second on both lists (of both RHCs and FQHCs), the top fifteen or so states on both lists have very little overlap.

Like our "top 10" (well, technically "top 11") RHCs incorporations per state charts above, I've graphed the same trends for FQHCs between 1965 and 2026 in the charts below:

Data courtesy of CMS

North Carolina is the real outlier here, with a spike in FQHC incorporations after the year 2000s, which happened in no other state in the top 10.

Keeping our focus on FQHCs for a moment, if we examine the years when the most number of FQHCs were established, we'll see that they reached their pinnacle of growth from the 1970s through the 1990s; indeed, there are only a few years since 2000 that a significant number of FQHCs were incorporated. These years are highlighted in the chart below:

Data courtesy of CMS

To consider FQHCs another way, let's look at a graph of annual FQHCs incorporated between the years 1950 and 2026. As mentioned before, the 1970s and 1980s were a boom time for these federally-funded centers, and their growth tapered off in the early 2000s. Ever since, growth has remained at a low level. Here is the current rate of incorporation of the centers:

Data courtesy of CMS

Image created using Adobe Firefly AI

*Author's note: To see the SQL coding behind the charts in this blog post please visit my GitHub account.

In the past few months, the U.S. Centers for Disease Control and Prevention has changed their guidance on universally recommending the hepatitis B vaccine for all newborns. The updated guidelines, approved based on recommendations by the CDC Advisory Committee on Immunization Practices, advise women testing negative for the virus at the time of giving birth to consult their healthcare providers to see if their babies should get their first doses within 24 hours of birth.

For infants not receiving the vaccine at birth, the CDC suggests an initial dose be given "no earlier than two months of age."

This represents a significant departure from decades' of precedent. The universal recommendation had not been reviewed in more than seven years in the U.S., and it's not clear how widely these recommendations will be followed.

The general idea behind the new recommendations is that unless a child is born into a household where a person infected with hepatitis B is present, or where a household resident is in frequent contact with someone who recently emigrated from a country where hepatitis B is prevalent, a child should not needlessly be exposed to a vaccine.

Critics of this new policy, like the American Academy of Pediatrics, worry that this approach will likely cause a rise in hepatitis B infections due to virus spread.

In light of this development, I wanted to look at how the U.S. stacks up against other so-called developed nations in terms of ensuring newborns receive the hepatitis B vaccine. In a later blog post, I may subsequently examine where this change is likely to take us as a country.

More than anything, this blog post is meant as a baseline that we'll use going forward to track how much these recommendations take hold. I want to say thanks to Kaggle user Daria Chemkaeva for pointing me to the World Health Organization's data related to hepatitis B immunization coverage among 1-year-olds, which will inform a significant portion of this post.

Although the U.S. isn't currently at the forefront of administering the hepatitis B vaccine to newborns among peer nations, it's also not at the bottom of the pack. If we look at a representative sample of these nations, this is plain to see.

Of course, the term "peer nations" can mean different things to different people, and there are all sorts of metrics for determining the most advanced economies. My favored approach is to include the countries in the Organisation for Economic Co-operation and Development (OECD). Your mileage may vary with this, and I acknowledge that there are many alternate, equally valid measures that include different countries.

At any rate, if we look just at the OECD countries, we'll see that, according to World Health Organization (WHO) data, the U.S. is in the middle of the pack in terms of administering hepatitis B vaccines to newborns across a range of years. This data isn't as accurate as it could be because certain countries (Denmark, Hungary, and Iceland) don't make their data available to the WHO. In any case, it gives us a rough idea of how the U.S. compares to like countries. The data below is for the year 2024.

Data courtesy of the WHO

Next, let's look at how each U.S. state matches up against each other, and the percentage increase or decrease in new hepatitis B cases between the years 2020 and 2023. This data comes from the Centers for Disease Control and Prevention (CDC) and is incomplete when it comes to certain states. Also, it covers hepatitis B rates across all ages, not just newborns.

Despite this, it's a good look at the trajectory states have been on between 2020 and 2023 in terms of overall infection rates. Since one of the main concerns with the new guidance is that infection rates will increase, this is valuable information to track over time.

Data courtesy of the CDC

Image created using Adobe Firefly AI

It's been a while since we looked at the State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data numbers provided by Data.Medicaid.gov. I've been analyzing this data set for the past year (in posts here, here, and here) to get a handle on how many people are enrolling their children in the Children's Health Insurance Program (CHIP), and how political maneuverings at the state and federal levels have impacted (or may soon influence) those enrollment numbers.

I've included several graphs from a range of states at the end of this post, so if you're interested in seeing overall trends and then filling in any gaps with context by reading the first part of this post, please feel free to do so. I used publicly-available data sets at Data.Medicaid.gov in my analysis, and (for anyone who might be reviewing this for certification purposes), I used both SQL and R programming to analyze the numbers and create the charts you'll find at the end of this blog post.

Let me say before we get going that the numbers on which I'm basing my analysis in this post are from September 2025, and they're slightly outdated. That's because during the course of writing this post, Medicaid released November numbers. So I decided that instead of chucking my charts, I'll plan to continue tracking CHIP enrollment trends and account for the November 2025 numbers in a later post.

As a reminder, in past posts I've chosen five states to highlight – Maine, Arizona, North Dakota, Kansas, and Colorado. I've done so because, to some degree, they represent the U.S. political spectrum: one of these states is reliably liberal (Maine), one is a swing state (Arizona), and two are reliably conservative states (North Dakota and Kansas). I also included Colorado because, like Kansas, it's geographically located in the middle of the country and, until recently, had been on an upward trajectory in terms of CHIP enrollments (more on this in a minute).

Speaking of Kansas, it's an interesting state because it represents a quickly-vanishing political model in the U.S. where, although the population tends to vote conservative in national elections, they have been known to vote more liberal on things like state constitutional amendments. Also, despite being an overall red state, the Kansas governor is a Democrat, as are the Lieutenant Governer and one of their members of the House of Representatives.

As I've mentioned before, examining these states' approaches to expanding Medicaid (or not, as with Kansas) should provide insight into the varieties of options on offer as they relate to children, and to what degree they're proving successful. This analysis will be key moving forward as cuts in Medicaid and CHIP begin to take hold in 2027 which I'll elaborate on below.

It's worth taking a slight detour before we get into our charts to explain how we got here. The Budget Reconciliation Act of 2025, also known as the One Big Beautiful Bill Act, has been grabbing headlines since its passage in July of this year. But the truth is that Medicaid and, more pertinent to our discussion, CHIP enrollment had already been enduring challenges.

These complications started back in 2023 under the Biden Administration. Beginning in 2020 and lasting into the spring of 2023, a policy of "continuous enrollment" had been adopted by the federal government where states froze Medicaid disenrollments. In other words, people who may have traditionally rolled off of Medicaid due to changing life circumstances were instead retained. This helped many people maintain a continuity of insurance coverage during difficult times. In part, this involved a suspension on Medicaid eligibility checks, also called "eligibility redeterminations."

These are regular reassessments of whether or not a person still qualifies for Medicaid, CHIP, or any other number of programs. Of note, recent legislation has put this coverage redetermination process in a new light, as we'll talk about in a minute. The continuous enrollment provision resulted in Medicaid and CHIP enrollment increasing to a high of approximately 94 million enrollees by early 2023.

But in the spring of 2023, having judged that the COVID-19 pandemic was largely behind us, the Centers for Medicare & Medicaid Services (CMS), which is the federal agency that administers programs like Medicaid and CHIP, began what is alternately called an "unwinding" or "decoupling" program.

This meant that, as of April 1, 2023, states could, as a recent KFF article stated, "resume disenrolling people after conducting renewals to verify eligibility for the program, though some states delayed the start of their unwinding periods until May, June, or July 2023. Most states took 12 months to complete unwinding renewals and nearly all states completed renewals by August 2024."

The result? Medicaid and CHIP enrollment numbers declined to 78.6 million as of March 2025. And, as we'll see in a minute, people are concerned that those numbers will decline further as a result of the Budget Reconciliation Act, also known as the One Big Beautiful Bill (BBB) Act, which tightens eligibility requirements still further.

Let's take a quick look at the legislation passed in the summer of 2025 that aims to constrain eligibility criteria for programs like Medicaid and CHIP. As mentioned above, this is called the BBB, and I covered it in terms of its potential effects on rural residents in a previous blog post. Now I'd like to zoom out and see how the BBB is affecting Medicaid and CHIP enrollment nationwide.

If we're to evaluate the likely fate of Obamacare generally and CHIP in particular. We need to have a general understanding of this bill's goals. It was signed into law on July 4 of this year and significantly amends who is eligible for health insurance through the federal government. As the authors of a recent Johns Hopkins University School of Public Health article noted, "The law, which the Center on Budget and Policy Priorities estimates will result in up to 15 million more people without health insurance in 2034, includes over $1 trillion in spending cuts to health care through 2034."

Although not directly related to CHIP enrollments, Medicaid work requirements illustrate how cuts will take place across the board starting in 2027. These requirements, which are key to people maintaining their Medicaid coverage, will play an increasingly important role in coverage redeterminations. This means that, at an ever more frequent rate than is now the case, many Medicaid enrollees will have to prove that they are either working at least part time, in school, volunteering, or in some other way contributing to the overall economy or society.

This new provision will take effect on January 1st, 2027, and it is expected to cause many current Medicaid enrollees to lose their coverage based on what some perceive as an increased paperwork burden that falls on the recipient. According to Anthem's website, "if you’re a Medicaid or CHIP member, you may need to complete a renewal every year to make sure you still qualify for your coverage." This coverage redetermination window will narrow under the BBB.

The Center for Heath Care Strategies elaborates on the period necessary for determining Medicaid enrollment eligibility: "States must perform a 'look-back' review to determine whether a Medicaid member met the work requirement in a period of between one and three months before their application. States must also verify that current enrollees continue to meet the requirements for at least one month within each six-month eligibility review period."

As the Johns Hopkins article goes on to say, "Medicaid recipients will have to verify every month that they have met this requirement, which will create a large burden on both the individual recipients and the state systems managing coverage." But even before these enhanced work requirements became law, work requirement provisions and waivers were already pending approval in states like Arizona, Arkansas, Iowa, and Ohio. Right now, Georgia is the only state with a Medicaid work requirement waiver, which began in July 2023 and has been extended to the end of 2026.

As I said, this shortened redetermination period doesn't directly affect CHIP enrollments. But it does demonstrate the kind of stringent requirements that will soon be introduced into the federal insurance landscape. In terms of CHIP, program cuts will mostly affect federal funding to those who are not fully U.S. citizens.

With those basics out of the way, let's pivot to looking at the Medicaid and CHIP Child Enrollment numbers provided by Data.Medicaid.gov for the years 2022-2025. This data comes from September of 2025 and, as I stated earlier, I'll aim to report on November numbers soon. The data set I analyzed covers enrollments through June of 2025. Here is the way CMS defines this metric:

"A point-in-time count of the number of children enrolled in Medicaid and the number of individuals enrolled in CHIP as of the last day of each month. Note that since some states use CHIP to extend coverage to adults, this measure is not strictly limited to children in all states. Includes only those individuals who are eligible for comprehensive benefits."

Data courtesy of Data.Medicaid.gov

Using CMS data, we can track this data over time as I've done in previous blog posts here, here, and here. The most current data for CHIP enrollments is for June of this year. As in past posts, aside from Arizona — which expanded its CHIP enrollment criteria in May of 2024 – we'll start tracking enrollment numbers in January of 2023. These dates represent the starting point at which the federal government started up its Medicaid redetermination process again.

The specifics around the terms of each state's expansion of enrollment criteria can be found in a previous post. I'll post a graph of each state here, starting with Arizona, followed by an overall chart tracking all five states. As you'll see, in every case enrollments have either flattened or begun to decline in recent months. What accounts for this? Although this data set is from June and the BBB didn't pass until July, are states, seeing the writing on the wall, abandoning efforts to increase CHIP enrollment?

It's an interesting question, and one I may explore in a future post. For now, we've entered a period that promises significant challenges, so it will be important to watch how these numbers change as we get closer to 2027. For now, take a look at the following graphs and let me know if you're in any of these states and are seeing patterns starting to form on the ground by contacting us.

Data courtesy of Data.Medicaid.gov

Data courtesy of Data.Medicaid.gov

Data courtesy of Data.Medicaid.gov

Data courtesy of Data.Medicaid.gov

Data courtesy of Data.Medicaid.gov

Image created using Adobe Firefly AI

Ever since the Centers for Medicare and Medicaid Services (CMS) first opened its Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) payment model to participants back in 2023, it has been making waves. Billed as a way "to improve the quality of care for people with Medicare through better care coordination," REACH ACOs are comprised of different types of providers like primary and specialty care physicians.

Traditionally, a major knock against CMS' physician payment models and ACOs is that they often favor primary care physicians (PCPs) over medical specialists. This has made it challenging for CMS to persuade specialists who work in fee-for-service models to make the leap into value-based payment structures.

Despite an inability to recruit specialists at the rate they'd anticipated, CMS remains optimistic about meeting their goal for anyone enrolled in Traditional Medicare (TM) "to be in a care relationship with accountability for quality and total cost of care by 2030." As of January 2025, CMS reports that 53.4% of TM enrollees are currently in an accountable care relationship with a provider. According to them, this "marks a 4.3 percentage point increase from January 2024," which they characterized as substantial.

Critics, however, note that a directive for CMS to create ACOs was given priority status over a dozen years ago under the Affordable Care Act (ACA). The fact that in the intervening years only 53.4% of TM enrollees have come under the umbrella of so-called "value-based care models," and that so little time remains to bring the rest of the nearly 50% of TM enrollees under the banner of such arrangements, doesn't bode well for meeting the 2030 goal.

So how can CMS tap this underutilized resource of specialist coordination to get over the finish line? Can they convince specialists to integrate into models that emphasize longitudinal care relationships? And how can they do so in a way that rebalances the relationship between providers?

Enter ACO REACH, which purports to bridge this gap. Unlike many of its predecessors, the model has been showing some success at saving money. One central reason given for this success is that specialists are integral to its operation…this is what you hear trumpeted all the time, anyway. But how popular is the effort with specialists? And has the model's implementation met expectations?

In any discussion of coordinated care models, it's important to note up front that bundled and episode-based (sometimes called episode-of-care) payment models, along with condition-specific payment models, really do seem to have the potential to spur more specialists to participate in value-based payment schemes. In reality, however, although several such models have been proposed, many have either not been implemented or have seen low participation by specialists – more on that in a minute.

Whether you listen to ACO REACH's proponents or its critics, the time does seem ripe for a new kind of reimbursement model that motivates PCPs and specialists to truly join forces to make healthcare delivery in the U.S. less fragmentary. To gain a better handle on why this new formulation represents a departure from the past, it's important to understand how we got here.

Before discussing the present state of affairs regarding specialist participation in ACOs, it's important to understand why they're so crucial to the success of value-based care models. In a December 2023 Health Affairs article, the authors said this about specialty care providers:

"Specialist engagement in these models is critical given the increasing role of specialists in managing care across the patient journey, the growing importance of specialized diagnostics and early disease interventions (such as biologics and cell and gene therapies), and an increasing array of specialty care capabilities."

Despite their important role in patient care, the authors continue, "specialty care providers have had limited opportunities to engage in accountable care models to date." The main problem is the lack of payment models that align with the healthcare context in which these physicians practice. Again from the Health Affairs article:

"Specialists focusing more on longitudinal condition management—for common cardiovascular conditions, inflammatory bowel disease, or degenerative joint disease, for example—lack alternative payment models that reflect the type of care they provide."

The authors noted that, particularly when it comes to hospital-led and integrated ACOs, adoption of specialty-relevant quality measures would facilitate coordination between primary and specialty care coordination. As it stands now, however, these measures are not in wide use.

I don't want to make it sound like until this point medical specialists have been completely left out of the equation. For years CMS, HHS, and other administrative bodies have expressed an interest in specialist participation. For example, in 2010 Congress enacted health care reform legislation in the form of the aforementioned Patient Protection and Affordable Care Act, or ACA (better known as Obamacare).

This act of Congress involved the creation of an agency called the Center for Medicare and Medicaid Innovation (CMMI), which is also known as the CMS Innovation Center. This division of CMS develops and tests alternative payment models (APMs) that strive to ensure coordinated care delivery.

The promise of CMMI specifically, and APMs in general, is that innovative models can be designed that align incentives among PCPs and specialists to deliver cost-effective, high-quality care. This is often done through risk-sharing with the federal government, where the physicians involved in an APM have a share in the model's financial performance.

In one-sided or upside risk, the participating providers share in savings if the care they provided over a certain length of time comes in under a predetermined cost threshold. If, on the other hand, the care they provide exceeds their allotted budget, they aren't penalized. In addition to cost targets, CMS will also usually set up quality benchmarks for physicians to meet.

In downside risk models, on the other hand, providers are financially penalized if they don't provide cost-effective care. As in upside risk models, quality benchmarks also play an important role in downside risk models. When upside and downside risk is incorporated into the same reimbursement model, it's called a two-sided risk model. Gainsharing is a similar concept in which physicians are rewarded for keeping costs low (as opposed to making the entity profitable).

Also of note, some private insurers have taken CMS' lead and set up APM arrangements with the healthcare entities with which they contract.

The upshot is that instead of treating patients as a series of unrelated illnesses, this kind of value-based, innovative care delivery model can save money while taking the whole patient into account. This approach works optimally when both PCPs and specialists closely coordinate care. To incentivize this collaboration, CMS has introduced some ambitious goals around their reimbursement models.

One of these goals, announced as part of CMMI's strategic refresh in 2021, is to bring 100% of Original Medicare beneficiaries and most Medicaid beneficiaries into accountable care relationships by 2030. In CMS' words, "beneficiaries should experience longitudinal, accountable care with providers that are responsible for the quality and total cost of their care. Accountable care requires access to and coordination of primary care and specialty care to meet the full range of patient needs."

Some of the groundwork for this was laid a decade ago when Congress created the Physician-Focused Payment Model Technical Advisory Committee (PTAC). PTAC was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). One of the reasons it was enacted was to "improve how the federal Medicare program pays physicians for the care they provide to Medicare beneficiaries."

As the above linked article states, "The statutory mission of PTAC is to make comments and recommendations to the Secretary of Health and Human Services (the Secretary, HHS) on proposals for PFPMs (Physician-Focused Payment Models, my note) submitted to PTAC by individuals and stakeholder entities. MACRA requires the Secretary to review PTAC’s comments and recommendations on submitted proposals and post a detailed response on the Centers for Medicare & Medicaid Services (CMS) website."

One would think that the establishment of a group like PTAC would spur a flood of specialist-focused APMs into the market – but it just hasn't been the case. Models like ACO REACH remain the exception. That said, there have been many attempts to create APMs that encourage cooperation across service lines. Recent examples include the TEAM payment model built specifically for surgeons, along with the Bundled Payments for Care Improvement (BPCI) Advanced model.

The fact remains that specialists aren't clamoring to be involved in these care delivery schemes. Evidence for why specialists have participated in smaller numbers was presented in a 2024 cross-sectional analysis of 2023 ACO survey data where a team of researchers led by Robert E. Mechanic, MBA, attempted to ascertain the level of specialist involvement in ACOs.

To do this, the authors examined data from "101 respondents representing 174 ACOs participating in the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health ACO model in 2023." They found that while primary care physicians (PCPs) valued specialist participation in coordinating care to optimize patient outcomes, "Only 11% reported that employed specialists were highly aligned and 7% reported that contracted specialists were highly aligned."

The ACO REACH model strives to transcend the barriers that have always existed to coordinated care. It is a "voluntary model that aims to improve quality of care and health outcomes for Medicare beneficiaries through the alignment of financial incentives, emphasis on patient choice, strong monitoring to ensure that beneficiaries maintain access to care, and an emphasis on care delivery." Its defining features are that it provides incentives for PCPs and specialists to work in tighter coordination, and that it requires more transparent reporting on progress toward meeting or surpassing quality benchmarks than previous iterations.

In the service of these aims, "ACO REACH provides novel tools and resources for healthcare providers to work together in an ACO to improve the quality of care for people with traditional Medicare." It makes important changes to the previous Global and Professional Direct Contracting (GPDC) Model (the reason behind the shift from the GPDC model to ACO REACH is a story for another time).

While the ACO REACH Model does interesting things like provide "greater transparency into the model’s progress during implementation," allowing for "stronger protections against inappropriate coding," and going "beyond prior ACO initiatives by requiring at least two beneficiary advocates on the governing board (at least one Medicare beneficiary and at least one consumer advocate), both of whom must hold voting rights," to me, the most important aspect is the emphasis it places on the involvement of specialists.

The fact that specialty care physicians are included isn't what's novel about this — as I noted before, there has been specialist involvement in a range of payment models before. What's new is the degree to which their voices matter. An AJMC article from 2022 highlights the shift:

"ACO REACH makes a return to more traditional ACO models by mandating that 75% of governing bodies—the boards that set the broad, strategic vision of the ACOs’ work—be made up of participating providers. Under GPDC, it was just 25%. Also under REACH, an ACO’s beneficiary representative and consumer advocate must be separate individuals, and each must hold full voting rights. All these recent changes enhance both the provider and patient voices."

What is an ACO governing body? Check out the definition in the Code of Federal Regulations.

It's tricky to convince many specialists to join ACO configurations like the REACH model because they are often still paid on a fee-for-service basis, and thus have no natural inclination towards improving patient care in the name of saving money. Because of this, Robert E. Mechanic suggests that ACOs stand a better chance enticing specialists to join their efforts by shifting their focus to quality patient outcomes.

The reason for this comes down to money, but probably not in the way you think. When Healthcare Finance interviewed Mechanic on his team's research, he noted the following: "Financial incentives probably carry more weight for independent specialists. But referrals are even more important," noting that independent specialists may be spurred to more closely coordinate care if they're at risk for losing referrals.

Mechanic went on to say, "It is important to compensate specialists for their time" because "Medicare only pays specialists about $50 for an e-consult with primary care so ACOs may need to supplement this."

With its growing success in saving CMS money and thus garnering higher reimbursements for many of its participants, it'll come as no surprise that the program has seen steady growth over the past few years. Using data last updated in April of 2025 on data.cms.gov, I tracked the rate at which the model has been adopted. Data for 103 sites are included. Between 2021 and 2023, the numbers have fluctuated somewhat, but overall have grown.

Data courtesy of data.cms.gov

In terms of model type, three varieties of ACO REACH model were captured in the data: Standard ACO, High Needs Population ACO, and New Entrant ACO. For PY 2025, most participants by far are Standard ACOs, followed by High Needs Population ACOs and New Entrant ACOs.

Data courtesy of data.cms.gov

CMS said it is making changes to the model based on preliminary data on 2023 performance. They found that "standard accountable care organizations saved $197.5 million in aggregate that year. New entrant ACOs, meanwhile, generated $36.8 million in aggregate savings, reducing gross spending at higher rates than standard organizations."

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The past few weeks have been monumental in terms of proposed changes to federal healthcare legislation. In an attempt to stay current with how things could change on that front, I've put together some thoughts on the fiscal year 2025 budget reconciliation bill, otherwise known as the "Big Beautiful Bill." The bill itself is broad and sweeping, so I've chosen to focus on the healthcare implications of the bill's provisions.

Before you run away with your hands in the air yelling, "No more politics!" I've tried to turn down the political temperature and focus on facts and figures; specifically, we'll zoom in on how the bill would affect rural healthcare providers.

As I alluded to off the top, on May 22 the House of Representatives passed the fiscal year 2025 budget reconciliation bill. I'm going to resist calling the bill by its more marketing-friendly name, the "Big Beautiful Bill," and will instead refer to it as the "BBB."

In its current form, the BBB enacts deep cuts to several programs including Medicaid. According to a recent report by the Georgetown University Center for Children and Families (CCF), the bill cuts federal support for Medicaid by $800 billion over 10 years.

That's concerning enough, but aspects of Medicare, the Affordable Care Act (ACA), and Health Savings Accounts are also in the crosshairs. For starters, the bill doesn't extend the enhanced premium tax credits, also known as ACA marketplace subsidies, past 2025. According to the Center on Budget and Policy Priorities, these tax credits help "more than 22 million people buy insurance on the marketplace."

At the end of the day, millions of people would likely lose their health insurance.

In a recent opinion piece on MSNBC, the authors noted that if significant cuts are made to Medicaid, it would create a "domino effect, leading to inferior, more expensive health care — and, therefore, worse health — for virtually all Americans, including those with insurance provided by their employers."

It's important to note that the BBB, which passed the House narrowly and now faces opposition by deficit hawks in the Senate, is due to be voted on this week by the upper chamber. If only a few conservative senators break ranks with their party, there's a chance this legislative process will temper the proposed cuts to healthcare. But in the unlikely event that all provisions are kept intact, we're looking at a very different federal insurance environment from the one we've known for many years.

The impact of such a bill, says the MSNBC article, wouldn’t just be felt by individuals: state governments, hospitals, and health workers would also feel the pinch. In other words, healthcare would be asked to do more with fewer resources. And if people start losing their insurance, it will l likely have a cascading effect across all of medicine.

This idea of a domino effect is one I've seen discussed often: reducing federal matching funds for the ACA Medicaid expansion, for instance, or instituting work requirements make it harder for people to qualify for insurance. The uninsured become sicker and seek care in emergency departments, hospitals can't collect money from low income patients, and healthcare gets more expensive for everyone.

Among the biggest potential losers in the scenario outlined above are rural healthcare providers. That's because there is a very real possibility that, if the House bill passes the Senate and is signed into law by the president, many rural hospitals and health clinics across the country will he forced to curtail services.

A recent article in The Hill made the stakes clear:

"Nineteen percent of Americans, or over 72 million, are insured by Medicaid and the share of the 66 million rural Americans on Medicaid is even higher at 23 percent."

The article goes on to cite a June 2025 study by the Center for Healthcare Quality and Payment Reform that estimates that over 300 rural hospitals face an “immediate risk” of closure – and this after nearly 200 rural hospitals have already closed in the last twenty years. The majority of these hospitals are in states that didn't expand Medicaid under the Affordable Care Act.

Now that we have a solid background on what the BBB is all about, let's look at rural health data from Data.gov to examine trends in what are called Rural Health Clinics (RHCs). While these clinics primarily care for Medicare patients, given the instability that the BBB could cause no matter what type of insurance a given person may have, these entities might feel the reverberations.

It's helpful to get a baseline for how many entities have enrolled as RHCs over the past few years so that, if some form of the BBB should become law, we can track how many of them remain in the program going forward.

Since we're looking at CMS data, that organization defines RHCs as follows:

"For RHC purposes, any area that is not defined by the U.S. Census Bureau as urbanized is considered non-urbanized. RHCs are located in areas that are designated or certified by the Secretary of the Department of Health and Human Services as Health Professional Shortage Areas (HPSA) or Medically Underserved Areas (MUA). A Clinic cannot be Medicare approved concurrently as a RHC and a Federally Qualified Health Center."

Federally Qualified Health Centers are distinct from RHCs in the following ways:

"Medicare-certified rural health clinics (RHC) are located in a rural areas (sic) designated as a shortage area, is not a rehabilitation agency or a facility primarily for the care or treatment of mental diseases. Federally qualified health centers (FQHC) are located in both rural/urban areas designated as a shortage area."

It may be worthwhile charting state-level changes in FQHCs as well, but for now we'll confine our exploration to RHCs. Let's first look at the top five states in which RHCs operate. These states include Kentucky, Texas, Missouri, Tennessee, and Illinois, respectively. In the graph below I've tracked the number of RHCs registered in each of these states between 2023 and 2025.

Data courtesy of Data.gov

To make it easier to see how these top five states stack up, I've put their numbers together in table form:

Data courtesy of Data.gov

There isn't much surprising about these numbers, aside from the fact that besides Missouri, every state has gained more RHCs each year. For a look at the states with the largest changes in enrollment, I made a chart showing the five states with the biggest changes in terms of percentage (North Carolina, Indiana, Arkansas, New Hampshire, and Utah). The chart also shows the five states with the largest percentage drop in the number of RHCs. It will be interesting to track this as the BBB makes its way through Congress and, possibly, to the president's desk.

Data courtesy of Data.gov

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We're back in action, folks! Well, at least when it comes to analyzing the State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. This dataset went dark for a few months earlier this year, but I'm happy to report that, as of March, it's back!

I've written about the CHIP enrollment numbers in a few states in previous blog posts here and here. Many observers are watching what happens to Medicaid closely due to factors I'll discuss below, but suffice it to say that if the Medicaid budget is reduced over the coming year, I have no doubt that CHIP enrollment will also be affected.

As a reminder, in past posts I've chosen five states to highlight – Maine, Arizona, North Dakota, Kansas, and Colorado. I've done so because, to some degree, they represent the U.S. political spectrum: one of these states is reliably liberal (Maine), one is a swing state (Arizona), and two are reliably conservative states (North Dakota and Kansas). I also included Colorado because it's been in the news lately because a large number of people there have recently lost their Medicaid coverage.

We'll come to this in a minute, but Kansas is an interesting state because although the population tends to vote conservative in national elections, they have been known to vote more liberal on things like state constitutional amendments.

As I've mentioned before, examining these states' approach to expanding Medicaid (or not, as with Kansas) should give us a good sense of the varieties of options on offer as they relate to children, and to what degree they're proving successful.

This post can be thought of as an adjunct to my last post about enhanced premium tax credits related to Obamacare. What once seemed a foregone conclusion to extend the tax credits beyond 2025 (given that most people who benefit from these tax credits live in conservative states) has now become a hotly-debated question given how focused Congress has become on trimming the Medicaid budget by around $880 billion.

As part of this effort, lawmakers are considering a reduction in the federal government’s share of Medicaid expansion; doing so would shift more of the financial responsibility for expansion to the states. Also on the chopping block could be the Affordable Care Act expansion group, many of whom benefit from the enhanced premium tax credits. So the fate of Obamacare and the CHIP program are loosely related insofar as they're both largely dependent on federal government funds.

Quick note: with respect to the State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data, i.e. the data set from which I've pulled the numbers you'll see below, there was already a big lag between reporting dates and the actual dates when the reports come available. Now, because there weren't any updates provided for several months in early 2025, that time lag has only increased. So today we'll be looking at how CHIP enrollment changed in November of 2024, and see if the trend lines have changed.

Since these numbers are tied up in states' decision whether or not to expand Medicaid, it's worth noting that the federal insurance program may undergo some major changes in the coming months. As I alluded to above, right now the U.S. Congress is considering cutting around $880 billion from the program over the next 10 years, which would undoubtedly affect CHIP enrollment numbers (or, indeed, the very existence of the program).

Depending on who you ask, Medicaid has either been a major success, or it's too wasteful and needs to be constrained. It should also be said that for two years now, nationwide CHIP enrollment has declined. Here is a report from the official Medicaid website:

"Since March 2023, total enrollment across Medicaid, CHIP, BHP, and the Marketplace has declined by 7.8 million individuals (7 percent). This is a 14.6 million individual decrease for Medicaid and CHIP and a 6.4 million individual increase for the Marketplace."

With that in mind, let's see how CHIP enrollment numbers were doing as of November of 2024 in five U.S. states which, again, is the latest date for which we have data.

To get us started, let's look at enrollment numbers in Arizona. As a reminder, I discussed the circumstances surrounding Arizona's CHIP expansion in an earlier post. As I mentioned in that post, as part of the state budget approval process in 2023, Governor Katie Hobbs and the state legislature agreed on an expansion of KidsCare, which is the name of Arizona's CHIP program. The decision allowed KidsCare to expand eligibility to cover more children by increasing family income limits.

Since the expansion took effect on March 1, 2024 and data started being collected in May, we'll look at enrollment rates between May and November of 2024.

Data courtesy of Data.Medicaid.gov

As will become a common refrain in this post, enrollment numbers have been on a more or less constant descent ever since the program expanded. This trend stands in stark contrast to Obamacare enrollment rates overall, which shows that Medicaid expansion has achieved uneven results for different cohorts of people in different states. But maybe the fact that Arizona is a Republican-leaning state has something to do with this? Let's now look at a more liberal state to test that theory.

Calling Maine a liberal state is a little but like calling an SUV a truck: it is, and it isn't.

Maine is in some ways the inverse of Kansas, another state we'll be looking at. This is true in the sense that in national politics the state generally votes for the Democrats and they currently have a Democrat as a governor, whereas the state's Senate and important state-level seats are often held by Republicans.

As noted in my previous blog post, the CHIP expansion didn't take effect until August of 2024. Oddly, it just so happens that in that same month, enrollment numbers started to take a nosedive, matching the national trend. It's not apparent to me why an expansion of CHIP would be met with a near collapse in the numbers of those receiving the benefit, and this warrants further investigation.

Data courtesy of Data.Medicaid.gov

Like a few of the cases we'll be discussing, CHIP enrollment numbers in Colorado started to decline after the Consolidated Appropriations Act of 2023 decoupled the Medicaid continuous enrollment provision from the Covid-19 public health emergency (PHE) on March 31, 2023. This allowed the government to resume Medicaid disenrollments. (Read more about the disenrollments here.)

But the news isn't all bad in Colorado. Ever since around June of 2024, CHIP enrollment numbers have leveled out and, in some months, even slightly improved. It's nothing to shout from the rooftops, but at least state lawmakers have a steady base from which to work.

I'm not sure why numbers in Colorado have stabilized, but as I noted in the above-referenced blog post, to combat the state's declining numbers, Colorado's Department of Health Care Policy & Financing (HCPF) announced a policy that will "support continuous coverage for children from birth to age three who are eligible for Health First Colorado (Colorado’s Medicaid program) or Children’s Health Insurance program (CHP+)."

Although the program doesn't go into operation until January 1, 2026, it's possible that this announcement has instilled confidence in the people of Colorado that this program will be around for some time to come. Maybe this is why the enrollment numbers are slowly climbing? I'm not sure, but I'll keep watching.

Data courtesy of Data.Medicaid.gov

Medicaid expansion was first enacted in North Dakota in 2014 as a result of the Affordable Care Act, and then was expanded again on April 1, 2024. This makes it one of the earlier states in our field to expand Medicaid. But despite being on the vanguard of expansion, ever since early 2023 (around the time when the Consolidated Appropriations Act of 2023 went into effect), North Dakotans have mostly kept pace with the national downward trend of enrolling their children in the CHIP program.

Data courtesy of Data.Medicaid.gov

Kansas is an interesting case. Like Maine, the state is run by a Democratic governor, but unlike Maine, national-level politics in the state lean more Republican. The state's governor, Laura Kelly, has been trying to expand Medicaid to her constituents and, as a consequence, open up access for more children to be enrolled in the CHIP program.

But in a story published a few days ago on a local news website, it was revealed that state leaders, including Kelly, are fighting hard to help her state avoid cuts to Medicaid. Kansas is potentially facing around $1 billion in cuts, which would probably affect CHIP enrollees. We likely won't know for several months whether this news will have a destabilizing effect on enrollment numbers.

What we can say with confidence is that through November of 2024, numbers of enrollees had steadied after a drop starting in early 2023 (the likely cause being, again, the Consolidated Appropriations Act of 2023 going into effect in March of 2023). While there are now fewer enrollees than in early 2023, the fact that the numbers have stabilized could be seen as a positive sign.

Data courtesy of Data.Medicaid.gov

It's not totally clear why, at a time when Obamacare enrollment numbers are up (check out this post for more on Obamacare), CHIP enrollment is down. It's possible that, due to the availability of premium tax credits, parents who would otherwise have enrolled their children in CHIP have found it more advantageous to enroll as a family in the insurance exchange.

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In most articles about the looming expiration of the enhanced premium tax credit (EPTC) associated with the Affordable Care Act (ACA), the authors tend to focus on how many people are at risk of losing their insurance. While a central feature of the debate over whether or not to keep these tax credits, it only tells part of the story.

I've seen this information sliced and diced and repackaged lots of ways. But in a recent Commonwealth Fund issue brief, the authors go farther than most, analyzing the broader impact on hospitals, care providers, insurers, health workers, and so on. They even look at the impact on businesses on the periphery of healthcare that will be affected when, for instance, rural hospitals have to shut down due to a lack of funding as a direct result of dipping Obamacare enrollment numbers.

Going even further, the authors of the data brief also forecast the impact of these potential changes on economies, employment, and tax revenue on every state plus the District of Columbia. It's a holistic approach that foregrounds the danger to everyone within shouting distance of the healthcare industry of a collapse of the EPTC, and even those outside of the industry.

The EPTC is one of two existing Obamacare subsidies, and it helps low- and middle-income individuals and families who meet certain criteria to buy insurance through the ACA health insurance marketplaces at an affordable rate.

The ball is now in Congress' court to reauthorize EPTC legislation. Needless to say, if these tax credits are allowed to expire later this year, as they are scheduled to do, costs will rise sharply and fewer people will be able to afford to stay on their plan. This will lead to millions of people losing health coverage.

To set a baseline for the discussion, I'll post six graphs that tell the story of the progress that Obamacare has made in the past five years in enrolling steadily (and then drastically!) more people.

For those uninitiated in things like insurance exchanges and tax credits, I only ask that you look at the trend lines for now, which I've provided to give you a sense of how literally everything is moving in the right direction. The charts are broken down by so-called "metal level," which is just another way of saying "insurance plan type." The "metal" comes from their naming convention, such as gold, silver, bronze, and platinum.

Please note that this data comes only from the 31 states that are considered "inside the ACA exchanges." These are states that either have Federally Facilitated Exchanges (FFE) – including states performing plan management functions – and states whose State-based Exchanges rely on the federal information technology platform for QHP eligibility and enrollment (SBE-FP). Put another way, these 31 states use Healthcare.gov as the underlying infrastructure of their plans.

Don't worry about the particulars of this right now, as I'll get into these distinctions a little further down. Just know that this data doesn't represent the entirety of the performance of ACA insurance exchanges. That said, to me it's a good indicator of broader trends at work.

First up, the data for gold plan enrollees:

This is a good graph to start with, because you can very clearly see where enrollment numbers drastically increased in 2024. There are reasons for this, which I'll detail in a minute. Next up, let's look at silver plan enrollees:

You might have noticed a significant jump in the total numbers of enrollees for the silver plan in the year 2024, and there's a good reason for that. That's because incentives have tipped over time toward driving people toward this plan. We'll investigate why in a little bit. Next we have bronze plan enrollees, followed by platinum, catastrophic, and expanded bronze enrollees:

Look at those trend lines! They're all ramping up, no matter the metal level. Keep this in mind as we explore the consequences of making it more challenging for people to enroll in Obamacare.

Before we get started, I think it's important to keep in mind that these enrollees are human beings we're talking about, and their lives will drastically change if these measures aren't extended. It's important to ground the numbers I'll be pointing to in this reality, because this sort of blog post can rapidly become an intellectual exercise if we're not careful. There's a lot on the line here.

Of particular note, the previously-mentioned Commonwealth Fund issue brief notes that consequences of not extending the tax credits would fall most squarely on Black and Latino Americans. In addition, residents of states that haven't expanded Medicaid under the ACA will be disproportionately affected. These two groups – African American/Latino populations and residents of non-Medicaid expansion states – overlap significantly.

Indeed, according to the Center on Budget and Policy Priorities, as of 2024, the following was true:

"Some 38 and 33 percent of Black and Latino people, respectively, reside in non-expansion states, compared to 26 percent of the overall U.S. population…Texas alone, where roughly 1 in 5 Latino people in the U.S. live, is home to 74 percent of Latino people in the coverage gap."

What is this so-called "Medicaid coverage gap"? People facing this issue earn incomes below the federal poverty level, and their income level makes them ineligible for financial assistance through the ACA marketplaces; at the same time, they don’t qualify for Medicaid because they live in one of the states that have not adopted the ACA Medicaid expansion. A total of 1.6 million uninsured adults are stuck in the coverage gap, and African Americans and Hispanics make up a disproportionate percentage of this population.

We'll look at these trends in more depth a little further down, but briefly, in 2024 the Urban Institute found that "Black and Hispanic people will see greater reductions in the percent of uninsured people relative to White people because of enhanced PTCs." The inverse of this is true as well: if the EPTCs go away, an outsized number of these minority groups will feel the negative effects.

It's also worth noting at the outset that any changes to Medicare, no matter their specific target, are deeply unpopular with the American public. While not mentioning the EPTC directly, a recent KFF survey found the following:

"...fewer than one in five (17%) say they want to see Medicaid funding decreased. In fact, most people say funding for Medicaid should either increase (42%) or stay about the same (40%)."

When it comes to Medicaid funding, it should be no surprise that a strong majority (64%) of Democrats favor increasing spending, as do four in ten independents. Sentiment for increasing Medicaid funding also holds true broadly across Republican ranks, and interestingly, about three in four total rural residents and two-thirds of rural Republicans say funding should increase or stay the same.

No matter how you frame it, cutting Medicare and Medicaid benefits are not broadly popular prospects. Before we go any further and start digging into the data, a quick primer on the EPTC is in order.

The EPTCs, which started out as just PTCs (more on that evolution below), are available only to people residing in states that have accepted extended Medicaid benefits. As stated before, the PTCs were established under the ACA, and it helped people previously unable to afford insurance to gain coverage. The tax credits have evolved over the years, most significantly in 2020 and 2022.

The enhanced (sometimes also called "advanced") premium tax credit is based on an individual's estimated income and household size, and it takes into account how much health coverage costs in a given state.

As the Commonwealth Fund notes, "As part of the American Rescue Plan Act of 2020, Congress increased the ACA marketplace premium tax credits (PTCs) to ensure that Americans had access to affordable health insurance during the pandemic. In 2022, Congress extended these enhanced tax credits through 2025 as part of the Inflation Reduction Act."

As the Congressional Budget Office (CBO) puts it, "ARPA reduced the maximum amount eligible enrollees must contribute toward premiums for health insurance purchased through the marketplaces established by the Affordable Care Act, and it extended eligibility to people whose income is above 400 percent of the federal poverty level (FPL)." The Inflation Reduction Act (IRA) extended the ARPA provision for three additional tax years, 2023 to 2025.

Remember how my graphs all showed a significant uptick in enrollment numbers in 2024? This is likely because of the IRA extending ARPA provisions. As the CBPP puts it, "...a record-breaking 21.4 million people had selected a marketplace health insurance plan for 2024. This is a 30 percent increase over last year and is the fourth consecutive year of record ACA marketplace enrollment."

Referencing the IRA and ARPA, the CBPP goes on to say the following:

"Those laws also removed the income cap on premium tax credit (PTC) eligibility (previously set at four times the federal poverty level, or about $58,000 a year for an individual), ensuring that no one pays more than 8.5 percent of their income for the silver-level benchmark plan. These enhancements have driven consistent enrollment growth since 2021."

If you recall the graph at the beginning of this post showing how enrollment in the silver plan has shot through the stratosphere in the ensuing years, this is the likely reason behind it. Now that we're in the final year of that expansion, Congress has to revisit this issue and decide whether or not to extend the tax credits yet again.

Offering these progressively more generous premium tax credits spurred ever-increasing enrollment in ACA marketplace insurance, which contributed to record low uninsured rates. As of 2024, 93 percent of marketplace enrollees – which equates to 19.3 million people – receive premium tax credits, which is a record level of enrollees.

As part of the Affordable Care Act, the framers stipulated two different approaches for lowering monthly insurance premiums. You might have heard them referred to as Obamacare subsidies. The first of these we've already talked about: EPTCs. The second is what is known as Cost-Sharing Reductions, or CSRs.

Similar to EPTCs, CSRs provide extra savings that reduce beneficiaries' out-of-pocket costs. A person must fill out an application online to see if their income level qualifies them to receive out-of-pocket cost savings, and they must enroll in a silver plan (more on the tiered plan structure below). If you cast your mind back to the graphs at the beginning of the post, you'll see mounting evidence for why most enrollees elect for the silver plan.

These savings are achieved by lowering an enrollee's deductible, coinsurance rate, or copays. The out-of-pocket maximum is also limited by this subsidy. Some potential enrollees may be eligible for both the EPTC and CSRs, and this can help them save on annual health plan costs.

I think it's worthwhile to give a very brief overview of how the APA insurance exchanges work, and also to take a general look at the flavors of insurance plans nationwide. It will help to keep in mind the various types of plans when we look at trends a little further down, and how all of this will likely reverse if the tax credits aren't renewed.

When looking at data from the health insurance exchanges, it's important to understand that they fall into three broad categories:

A total of 31 states fit into the first two categories listed above (FFE + SBE-FP) – these are sometimes referred to as being "inside the ACA exchanges." It's data from these exchanges that I used to inform my graphs at the top of this post. On the other hand, 20 states plus the District of Columbia fit into the third category and don't use the federal government platform ​to determine plan eligibility or enact enrollment. These latter states are referred to as being "outside of the ACA exchanges."

I'm not 100% sure about this, but it seems that for the plans inside the ACA marketplace, enrollees must pick one of the four so-called "metal tiers," or gold, silver, bronze, or platinum. In other words, the other two categories aren't available to them. The defining features of these tiers is something called "actuarial value."

Put simply, actuarial value – or actuarial value percentages – represent how much of a typical population’s medical spending is covered by a health insurance plan.

I like the following definition of actuarial value provided by a website called Beyond the Basics:

"The actuarial value is 60 percent for bronze plans, 70 percent for silver plans, 80 percent for gold plans, and 90 percent for platinum plans. The higher the actuarial value, the more the plan covers of a typical population’s costs (and thus the typical population would pay less out-of-pocket). A lower actuarial value means the plan covers less of the costs (and the population pays more). The actuarial value calculation focuses mainly on cost-sharing charges. This means that a bronze plan generally would have higher overall enrollee cost sharing than a gold plan would."

It's worth stopping for a minute and asking why residents of states that haven't expanded Medicaid will be most affected if the tax credits aren't renewed. Earlier we examined how certain minority groups, which are disproportionately represented in non-Medicaid expansion states, would fare worse than other groups if the EPTCs weren't extended. But what's so special about Medicaid that states with less robust versions come out on the short end of the stick? The Commonwealth Fund article provides us with some insight:

"Residents of these states are more reliant on enhanced PTCs, because their legislatures and governors have not taken up the ACA’s Medicaid expansion and there are no other affordable health insurance options."

These states include Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. In addition to many people in these states and others losing their insurance, it's also worth pointing out that the CBO predicts "that not extending the credit will increase the number of people without health insurance and raise the average gross benchmark premiums for plans purchased through the marketplaces."

What are these benchmark premiums that are likely to rise? The Paragon Health Institute tells us that "a benchmark plan is the second lowest-cost silver plan premium in the consumer’s region. The Premium Tax Credit (PTC) related to Affordable Care Act plans is based on the cost of the benchmark plan as it relates to the household income of the insurance enrollee. The higher the benchmark plan premium, the larger the PTC."

The American Hospital Association adds numbers to the mix, stating that "The lack of an extension would also increase gross benchmark premiums by 4.3% in 2026 and by 7.9% on average from 2026-2034." So not only will people lose their insurance, but for everyone else obtaining insurance through the insurance exchange, their premiums will likely rise significantly.

While the knock-on effects of stopping the EPTC are fairly straightforward, it's worth reviewing how the authors of the Commonweath Fund issue brief conceive of them:

"The dynamics of this ripple effect work as follows. As the enhanced PTCs disappear, former recipients will likely either become uninsured or shift to another form of health insurance. Health insurers, in turn, will no longer collect the PTCs (and other insurance payments), causing them to cut payments for patient care to hospitals, doctors’ offices, pharmacies, and other health providers. For their part, health providers will need to cut jobs — some could even close due to loss of revenue. This would lower access to health care overall, even for people who remain insured."

Wait, there's more!

"Providers will also need to reduce payments to businesses in their supply chains, and, in response, those firms will be forced to cut labor and other costs. As employees lose income, they must reduce spending on consumer goods and services. Finally, the loss of individual and business income results in less state and local tax revenue collected."

It's on these last two items – a reduction in consumer spending and loss of state and local tax revenue – that every American should be focused. For me, these concerns represent a wider picture of the repercussions of Congressional inaction. These two eventualities could affect all of us, no matter our medical status. They throw into stark relief the deep consequences of ending these tax credits, particularly in states that haven't expanded Medicaid coverage.

So, telehealth. Over the past couple of decades, it's been a subject of much interest and some controversy in the United States. Before the COVID-19 pandemic, telehealth – or telemedicine, as some call it – was underused and underappreciated. While patients who actually used the technology tended to look favorably on it, many physicians either couldn't bear the red tape associated with it, or flat-out thought it was the catalyst for a race to the bottom when it came to quality.

But then COVID-19 changed everything. The pandemic served as the impetus for passage of the CARES Act and CMS 1135 Waiver, which in turn led to the federal government dropping licensing requirements and other barriers to utilizing telehealth. Patients with routine appointments could now be seen virtually, freeing up hospital space for emergent cases of COVID and avoiding relatively healthy people being exposed to the virus in a clinical setting.

This set of circumstances led to an ever-increasing acceptance of telehealth by the mainstream. In fact, in a 2022 survey administered by the American Medical Association, "74.4% of physicians surveyed reported that telehealth was used in their medical practices—nearly three times the share in 2018."

When any technology is adopted relatively overnight, there are bound to be bumps along the way. This is borne out by a 2024 JD Power telehealth satisfaction survey which found that telehealth user experience has varied significantly across various demographics. Despite this somewhat spotty record, however, most respondents praised the relative convenience of the technology.

This dynamic squares with most other articles I've read about the subject: although barriers persist, most people can at least agree that it's easier to hop on a telehealth call than taking the time to travel to a doctor's office.

Because I keep hearing about the ascendancy of telehealth, I wanted to get a better sense of who exactly is using it. The best data set I have access to is the Medicare Telehealth Trends data, so I'll be relying on it in this post as a proxy for how much telehealth has caught on among different demographic groups. The data set contains numbers for Medicare enrollees between 2020 and the second quarter of 2024.

But first, a few caveats.

Caveat #1: Because this is Medicare data, it has limited utility for this question. For instance, since Medicare is intended to insure mostly older Americans, we won't be able to get a feel for how most younger folks are using telehealth.

Caveat #2: Although the majority of Medicare beneficiaries are ages 65 and older (86%), 14% are younger and qualify for Medicare enrollment because of a long-term disability. Among this group, "(l)arger shares of Black (25%) and Hispanic (19%) beneficiaries are under age 65 compared to White beneficiaries (12%)" which makes comparing the general population to Medicare beneficiaries challenging.

Caveat #3: Medicare Part B and some Medicare Part A enrollees are eligible for telehealth services, but of those Part A beneficiaries who are permitted to use telehealth, most are enrolled in Medicare Advantage plans. For this reason, I'll be focusing only on Medicare Part B beneficiaries in this post.

Caveat #4: Since the latest data available in this data set only runs through Q2 of 2024, we can't get a full picture of current telehealth use.

With all that said, we'll look at trends over the past four years for how Medicare Part B enrollees have been utilizing telehealth services. Let's dive in.

Let's start at what might seem like an obvious place: age. As stated above, keeping in mind that there are some exceptions, the data for Part B beneficiaries necessarily skews to the older crowd. It's fair to assume that the older you get, the more touch points there would be with healthcare services and, thus, more telehealth consumption.

But surprisingly, this assumption is incorrect. As it turns out, Medicare Part B enrollees between 2020 and 2024 tended to use more telehealth services as they aged, but then the trend reversed when with the 75-84 year old cohort. Let's take a look at the data to see what I'm talking about here.

*Important note: all numbers are reflective of the years 2020 - Q2 of 2024

When graphed, it looks like this:

I may go into the reasons for this dropoff as age increases in another blog post, but my initial guess is that older folks tend to have more issues with technology and likely prefer to see doctors in person.

Now let's turn to differences by gender, again keeping in mind that these numbers are reflective of total telehealth use between 2020 and Q2 of 2024.

Between 2020 and Q2 of 2024, 2,424,715 more female than male Medicare Part B beneficiaries used telehealth. Personally, I don't find this very surprising given that, according to the Harvard Business School website, "At an individual level, studies have shown that women utilize more healthcare services" and are "76% more likely than men to have visited a doctor within the past year. At the family level, women control 80% of healthcare decisions…in the home."

Now here's where things get interesting. I've done a few things differently here to try to provide better context for what's going on: I've averaged telehealth use by race for the years 2020 - 2024, and added two additional new columns – one for numbers of each racial group enrolled in Medicare as of 2023, and then I averaged the mean number of enrollees in each racial category and the number enrolled in Medicare Part A and B as of 2023.

As it turns out, American Indian/Alaska Native enrollees top the list of average use of telehealth. Given all of the challenges facing that community, including lower overall access to high-speed internet, I was pleasantly surprised to find that they are relatively comfortable with using telehealth.

This is in keeping with research that shows that as of 2021, "Non-Hispanic White (39.2%) and non-Hispanic American Indian or Alaska Native (40.6%) adults were more likely to use telemedicine compared with Hispanic (32.8%), non-Hispanic Black (33.1%), and non-Hispanic Asian (33.0%) adults."

Happy New Year! For my first post of 2025, I'd like to talk about an innovative approach to healthcare delivery that recently appeared on my radar. Toward the end of 2024 I attended several events on Capitol Hill related to healthcare. The days before and immediately after the U.S. presidential election were an exciting yet exhausting time filled with snap reflections and bold predictions.

In other words, the boundless optimism of the healthcare policy crowd wasn't in short supply.

On "team optimism" I ran across a group of healthcare providers-turned-policy-advocates from the appropriately-named Advocate Health, a nationwide healthcare system, who'd traveled to the Hill from Charlotte, North Carolina to advocate for the continuation of a program called the Acute Hospital Care at Home (AHCAH) initiative.

Featured prominently among the speakers on Capitol Hill was Colleen Hole, a Person-Centered Healthcare Advisor working on the front lines of delivering value-based healthcare. The Advocate Health team was advocating for the continuation of CMS waivers (which I'll explain in more detail below) beyond the end of 2024. I subsequently interviewed Colleen for a forthcoming episode of the Dragon Tree Podcast, so I'll update this post when the video is available.

Spoiler alert: the aforementioned waivers were extended by the American Relief Act, 2024, through March 31, 2025; however, without action by Congress to extend the initiative further, CMS will no longer accept waiver requests for participation in the initiative.

But I'm getting ahead of myself.

When I first read the advertisement for the Capitol Hill briefing, the whole concept of acute care patients receiving equivalent medical care at home seemed alien to me. I suppose I'd heard of Hospital at Home (HaH) care before, but the event announcement made it seem like, at least for certain patients who would under most circumstances have to seek care in a brick-and-mortar hospital, they could now receive care in the friendly confines of their homes.

According to a recently-released report (PDF file) on the AHCAH, the concept has its roots in the UK: "The first trials, held in the United Kingdom (UK) in the late 1970s for patients experiencing acute myocardial infarctions, found that hospitalizations conferred no benefits over home-based acute care. Since then, HaH programs have been established in the UK, Italy, Australia, Canada, Israel, and other countries with government-run health systems."

The report goes on to say that similar studies were made in the U.S. in the 1990s, but the approach doesn't seem to have been adopted to any significant extent here. So it stands to reason that, while HaH has been used to good effect elsewhere, I was new to the AHCAH, a CMS-sanctioned care delivery approach that takes this brand of home care to the next level.

The initiative, which was authorized by CMS in the Acute Hospital Care at Home Individual Waiver in the opening days of the COVID-19 pandemic, served as a way to relieve pressure on overstretched care facilities. It allowed certain hospitals to begin treating patients with inpatient-level care at home, with a goal of improving their outcomes and experience, while at the same time reducing hospital costs.

This waiver covers Medicare patients at Atrium who are eligible for enrollment into the AHCAH. Regarding Medicaid patients, however, an AMA Future of Health Case Study (PDF file) spotlighting Advocate's HaH program notes that, "as of November 1, 2023, North Carolina Medicaid covers this program under the existing diagnosis-related group (DRG) methodology."

The case study notes that coverage for Medicaid patients was meant to run through the end of 2024, and I was unable to find out if, like the plan covering Medicare patients, this, too was extended. I'll update this post if I find further information. But whatever the case may be, AHCAH proved a revolutionary approach to care delivery during the pandemic, when brick-and-mortar hospitals were becoming overrun by COVID patients. Many will remember that especially during 2020, the prospect of someone with non-emergent issues stepping foot inside a care facility was met with serious skepticism.

Despite a short runway for takeoff, the AHCAH initiative proved a big success in places like Charlotte. In that city, Atrium Health – which is part of Advocate Health and is an integrated nonprofit health system operating the Atrium Health Hospital at Home (AH-HaH) program, a version of the AHCAH – has achieved impressive results (PDF file). To date, they've enrolled over 8,400 patients across 10 counties in the Charlotte region. This has resulted in nearly 30,000 bed days saved since March 2020.

The goal of Advocate Health's AHHaH program, which is a strategic partnership between a traditional brick-and-mortar health system and a technology company, is to "build and scale a program that enables patients to continue their care and recovery at home." There was good reason at the outset to think the program would prove useful in stemming the flow of patients flooding hospitals in 2020, and that, if properly implemented, it could continue once COVID rates started falling.

And Advocate Health's optimistic outlook is shared by other HaH participants, including Mt. Sinai. The New York-based healthcare system recently reported that it has doubled the number of providers involved in its program. Part of the reason for their success is that they began providing home-based care a decade ago. From the article:

"The health system already has one of the oldest hospital-at-home offerings in the country, starting in 2015, before the CMS waiver that propelled many health systems to launch the care model. So Mount Sinai has learned to provide acute inpatient care at home in the face of regulatory uncertainties."

These "regulatory uncertainties" have likely put a damper on wider, nationwide uptake of the AHCAH programs, along with, as Ania Wajnberg, MD, president of Mount Sinai at Home, puts it in the article, "people-heavy" aspect of the business. New York requires that HaH patients receive two in-person visits per day, and that these visits be made by nurses, the latter of whom seem to be in relatively short supply in relation to the demands of the program.

Dr. Wajnberg and her team have mitigated this challenge by opening the program up to a wider array of patients, including "patients who need dialysis, post-surgical care, or monitoring for complex cardiac conditions." The fact that they've managed to double their HaH staff speaks to the confidence Mt. Sinai leadership has in the program.

Reminiscent of the UK study I quoted earlier, the previously-mentioned CMS report on the AHCAH provides evidence for the efficiency of this care approach: "A variety of studies and systematic evidence reviews have demonstrated that HaH is similar to or better than in-hospital stays across a variety of measures, including costs, mortality, length of treatment, health care usage, readmissions, long-term care admissions, anxiety and depression, and patient and caregiver satisfaction."

This success can, at least in part, be attributed to the fact that, to ensure that the initiative carries out its intended purpose, AHCAH sites have to be selective when choosing which patients to enroll. As a fact sheet on the previously-quoted report attests, although hospitals were given some latitude to decide on inclusion criteria for participating patients, "Participating hospitals indicated that these criteria were developed and utilized with the intent to ensure that eligible patients were willing and able to participate in a HaH program, that such patients were clinically and psychosocially appropriate to safely receive care in the home, and that patients’ home and community environments were conducive to the safe and effective provision of acute inpatient care at home."

It's temping to think about home care purely in terms of a CMS-funded initiative, since it was the AHCAH waiver that triggered outfits like Atrium Health to go all in on home care. But in the intervening years the program has grown, and, like Atrium, participant sites have begun accepting a diverse mix of payers for their program.

As the AMA case study attests, Atrium (through Advocate Health) accepts patients who are enrolled in Traditional Medicare, select Medicare Advantage plans, North Carolina Medicaid, and "select commercial payers." As the same case study makes clear, however, "Coverage by commercial payers is inconsistent."

Similarly, Mt. Sinai has incorporated a dynamic payer mix into its program. According to the Becker's article, "Mount Sinai has been at this so long it has contracts with payers outside of Medicare." This seems to be a key way to hedge against the uncertainty of whether or not, at some point, Medicare patients may be dis-enrolled from the initiative.

Keeping in mind that patients other than those strictly on Medicare or Medicaid participate in acute care at home programs, it's instructive to look at the skew of Medicare versus Medicaid enrollee participation. In the previously-mentioned report, CMS found that, when compared to patients receiving comparable services in brick-and-mortar hospitals, the demographics of those enrolled in the AHCAH initiative were, on average, skewed toward Medicare beneficiaries. As the report states, "In general, AHCAH patients were more likely to be white and live in an urban location and less likely to receive Medicaid or low-income subsidies."

This care delivery approach lasted for the duration of the pandemic and has only gained traction in the intervening years. As a sign of its enduring value, at the end of the public health emergency, the Consolidated Appropriations Act, 2023 extended the waivers and flexibilities associated with the AHCAH initiative until December 31, 2024. And, as mentioned earlier, it was recently extended again through March of 2025.

In addition to expanding its insurance payer mix, teams like Advocate Health have found innovative ways to improve the program and help more people. For instance, in 2023, Atrium partnered with Best Buy Health to diversify its technological toolkit. Best Buy Health offers its own care at home platform called Current Health, which debuted in 2021 and "brings together remote patient monitoring, telehealth and patient engagement into a single solution for healthcare providers."

Through this partnership, Atrium is able to enhance its patient education along with enabling in-home technology offerings with the assistance of Geek Squad Agents, Best Buy's 24/7 support agents who are available to provide logistics and technical help.

For part two of an ongoing series, we're once again looking at the numbers of U.S. children enrolled in the federal government's Children's Health Insurance Program (CHIP). As I discussed in my last blog post, several U.S. states have either widened eligibility for CHIP, or are considering doing so now that the federal Covid emergency has ended.

As a recap, in the spring of 2023, a process called "Medicaid unwinding" took place where people were once again eligible to lose their Medicaid coverage based on changes in their life circumstances. To soften the blow of that unwinding, several states agreed to expand Medicaid eligibility to include more children.

Despite this, however, the unwinding has led to millions of people losing Medicaid coverage. This issue has drawn national headlines, such as this recent NBC News story that focused on large numbers of people losing their Medicaid coverage in Colorado. What the story leaves out is that Colorado has taken steps to correct this, which we'll get to in a minute.

According to Medicaid data, the numbers of children enrolled in Medicaid through Colorado's CHIP program have been on a steady decline ever since they hit a high of 652,517 enrollees in February of 2023. This is the month before the Consolidated Appropriations Act of 2023 decoupled the Medicaid continuous enrollment provision from the Covid-19 public health emergency (PHE) on March 31, 2023 and resumed Medicaid disenrollments.

Currently, CHIP enrollments in Colorado are at 520,641. Here is a graph that shows the overall decline in the state up until August of 2024, the last month for which data is available:

Data courtesy of Data.Medicaid.gov

To combat these declining numbers, Colorado's Department of Health Care Policy & Financing (HCPF) recently announced that it will be extending its CHP+ coverage eligibility for children. According to the department's press release detailing the particulars of the expansion, "The policy will support continuous coverage for children from birth to age three who are eligible for Health First Colorado (Colorado’s Medicaid program) or Children’s Health Insurance program (CHP+). This expands continuous coverage for young children to 36 months, rather than the current continuous coverage of 12 months."

The change was made possible by an amendment to a Medicaid section 1115 demonstration waiver. "Through this amendment," the press release states, "HCPF expects to prevent coverage gaps for an average of 31,000 children over a 5-year demonstration period." The program goes into operation on January 1, 2026, so it will likely be a while before we see CHIP enrollment numbers start improving in the state.

Colorado is one of 41 states and the District of Columbia that have expanded Medicaid. While 10 states have elected not to increase access to this safety net program, some (like Kansas) are still debating expansion. In our last blog post, we highlighted enrollment numbers in the expansion states of Maine and Arizona, a blue and swing state, respectively; for the remainder of this post, we'll zoom in on expanded enrollment in two reliably conservative states, namely North Dakota and Kansas.

Updated numbers from CMS for August 2024 CHIP enrollment were released at the end of November, so those are the numbers we'll use. As a quick reminder, there is a lag of several months in the data, so we won't be able to get up-to-the-minute numbers. That being said, let's dive in and look at the circumstances surrounding North Dakota's Medicaid expansion, how it stacks up against those of Maine and Arizona, and how the state's enrollment numbers performed through August of 2024.

As stated in our previous blog post, we chose to include North Dakota and Kansas in the mix because North Dakota is a solidly conservative state while Kansas, which is overall a conservative state, is still home to an interesting combination of conservative and liberal tendencies. Together with Maine (liberal) and Arizona (swing state), these four states constitute a spectrum of political leanings.

According to the North Dakota Health & Human Services website, "CHIP is intended to meet the needs of working families, who cannot afford health care coverage for their children, yet earn too much to qualify for Medicaid."

"To qualify," the website continues, "a family's Modified Adjusted Gross income (MAGI) must be greater than the Medicaid level, but cannot exceed 205% of the federal poverty level." This seems to be a stable benchmark that hasn't changed much in recent years.

Medicaid expansion was first enacted in North Dakota in 2014 as a result of the Affordable Care Act. While Medicaid expanded again in North Dakota as of April 1, 2024 for "individuals between 19-64 with household incomes up to 138% of the federal poverty level (FPL)," the CHIP component of the state's Medicaid program doesn't seem to have been affected.

So although North Dakota qualifies as a Medicaid expansion state, not much work seems to have been done in opening up healthcare access to more children in the state. But it's still worth asking: now that more adults are eligible for Medicaid there, might that also mean that increased awareness around enhanced Medicaid availability will prompt those adults who earn too much to qualify for Medicaid but who also still need help insuring their children to seek out insurance under the state's CHIP program?

I'm not sure how many residents fall into this category, so the premise of the question might be a long shot. But we're all about long shots here at Dragon Tree, so let's dig into the numbers and find out. First, here is a graph that looks at CHIP enrollment numbers between early 2023 and August of 2024.

Data courtesy of Data.Medicaid.gov

As you can see, CHIP enrollment is down year-over-year in the state, having declined 17.2% since the unwinding began in April of 2023. An interesting data point reported by the Kaiser Family Foundation that undercuts my premise stated above is that​, "During the unwinding of the Medicaid continuous enrollment provision, over 25 million people were disenrolled and over 56 million had their coverage renewed. Overall, 31% of people whose coverage was redetermined during the unwinding were disenrolled, but that share ranged widely across states."

Given that 45% of people were disenrolled from the state-run Medicaid program during the unwinding, that puts North Dakota in the upper fourth of states. So, although Medicaid eligibility criteria have become marginally more generous in North Dakota since the spring of 2023, not only have overall Medicaid enrollment numbers gone down, but there's also been a similar – although less drastic – downward trend of children enrolling in the CHIP program in the state.

Expansion of Medicaid is still only an aspiration of some lawmakers in Kansas. Still, it's worth establishing a baseline understanding of where CHIP enrollments stand so that, in the event the state does expand Medicaid eligibility in the near future, we can track its progress more effectively.

Let's start by looking at current qualifications for CHIP enrollment in Kansas. The Division of Health Care Finance (DHCF) is responsible for purchasing health services for children through CHIP. According to the DHCF website, "Kansas provides low-cost health insurance coverage to children who are under the age of 19, do not qualify for Medicaid, have family incomes under 232% of the federal poverty level, and are not covered by private health insurance."

That means that CHIP enrollment eligibility in Kansas is more generous than in North Dakota and is on par with Arizona, where annual family income limits will soon be 225% of the federal poverty level (FPL). It isn't, however, as generous as Maine, which sets limits on household income at 300% of the FPL.

Next, let's look at CHIP enrollment numbers over the past couple of years in Kansas. Like the other states on our list, there was a drop in enrollment in March of 2023 from which the state hasn't yet bounced back:

Data courtesy of Data.Medicaid.gov