Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
JAMA Health Forum. 2023 Jun 2;4(6):e231744. doi: 10.1001/jamahealthforum.2023.1744.
Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program.
To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study examined the MA market before and after the ACA, which mandated cuts to MA benchmark payment rates. Using 2008 to 2019 county-level enrollment and payment data, a difference-in-differences analysis was conducted comparing MA enrollment changes between counties with larger vs smaller benchmark reductions, before vs after the ACA.
The primary outcome was the MA enrollment rate, defined as the proportion of a county's Medicare beneficiaries enrolled in MA. A secondary analysis examined MA plan payments per member per month.
Among 3138 counties with 37 639 county-year observations, ACA-induced benchmark cuts were sizeable and varied, ranging from 0% to 42.9% (mean [SD], 5.9% [6.6%]). Counties with benchmark cuts above the 75th percentile had population-weighted average benchmark cuts of 14.9% compared with 4.4% in other counties. In the 8 years following the ACA, there was no differential change in MA enrollment between counties with larger vs smaller benchmark cuts (difference-in-differences estimate, 0.02 [95% CI, -1.18 to 1.21] percentage points; P = .98). Plan payments differentially fell in counties with larger benchmark cuts by $78.35 (95% CI, $62.21-$94.48) per member per month (P < .001).
This cohort study found no evidence that the MA benchmark and ensuing payment cuts imposed by the ACA were associated with reduced MA enrollment, compromising access to MA. This evidence can inform ongoing policy debates regarding the growth of MA, concerns about excess payments to MA plans, and proposed Medicare reforms, including further reductions in MA payments.
各种政策提案将减少联邦医疗保险优势计划（MA）的支付。然而，目前尚不清楚支付减少是否会影响受益人获得 MA 计划的机会。
量化《平价医疗法案》（ACA）下 MA 支付减少与 MA 参保人数增长之间的关系。
设计、环境和参与者：本回顾性队列研究考察了 ACA 之前和之后的 MA 市场，该法案规定降低 MA 基准支付率。使用 2008 年至 2019 年的县一级参保和支付数据，采用差异中的差异分析方法，比较了 ACA 前后基准降幅较大与较小的县之间 MA 参保人数的变化。
主要结果是 MA 参保率，定义为该县 Medicare 受益人参保 MA 的比例。二次分析检查了每位会员每月的 MA 计划支付。
在 3138 个县（37639 个县年观测）中，ACA 引发的基准削减规模较大且各不相同，从 0%到 42.9%（平均值[标准差]，5.9%[6.6%]）。基准削减超过第 75 百分位数的县的加权平均基准削减为 14.9%，而其他县的基准削减为 4.4%。在 ACA 后的 8 年中，基准削减较大与较小的县之间的 MA 参保人数没有差异变化（差异中的差异估计值为 0.02[95%CI，-1.18 至 1.21]个百分点；P = .98）。在基准削减较大的县，计划支付每月分别下降 78.35 美元（95%CI，62.21 美元至 94.48 美元）（P < .001）。
本队列研究没有发现证据表明 ACA 实施的 MA 基准和随之而来的付款削减与 MA 参保人数减少有关，从而影响了 MA 的可及性。这一证据可以为正在进行的关于 MA 增长、对 MA 计划过度支付的担忧以及拟议的 Medicare 改革的政策辩论提供信息，包括进一步削减 MA 支付。
