The medicaid windfall: Medicaid expansions and the target efficiency of hospital safety-net subsidies
中文摘要
联邦医院安全网补贴计划旨在弥补医院无偿照护的成本，但其资格标准却以医疗补助服务量为依据。因此，补贴的“目标效率”较差：提供大量无偿照护的医院可能得不到补贴（排除错误），而提供很少无偿照护的医院却可能获得补贴（纳入错误）。医疗补助扩围可能通过增加医疗补助患者服务量、同时减少无偿照护，而加剧目标定位的偏差。我利用2003年至2019年的医院行政数据，量化了联邦医疗保险和医疗补助不成比例份额医院（DSH）支付以及340B药品折扣计划的目标效率，并量化了医疗补助资格变化如何影响安全网补贴的获得与目标效率。我发现，《平价医疗法案》（ACA）的医疗补助扩围提高了医院对联邦医疗保险DSH和340B的参与，尤其是在非安全网医院中（纳入错误），导致约50亿美元从安全网医院转移至非安全网医院。对于2005年田纳西州的医疗补助缩减，我发现结果相反。我的结果表明了以医疗补助为依据的资格标准的一个意外后果：医疗补助覆盖范围的变化会影响面向安全网患者的公共补贴的分配。
Abstract
Federal hospital safety-net subsidy programs seek to defray costs of uncompensated hospital care, but eligibility criteria are based on Medicaid volume. Therefore, subsidies have poor “target efficiency”: hospitals that provide large amounts of uncompensated care may not receive subsidies (exclusion error), while hospitals that provide little uncompensated care may receive subsidies (inclusion error). Medicaid expansions may exacerbate poor targeting by increasing Medicaid patient volume while reducing uncompensated care. Using hospital administrative data from 2003 to 2019, I quantify the target efficiency of Medicare and Medicaid Disproportionate Share Hospital payments and the 340B drug discount program and quantify how changes in Medicaid eligibility affect safety-net subsidy receipt and target efficiency. I find that the ACA Medicaid expansion increased participation in Medicare DSH and 340B, especially among non-safety-net hospitals (inclusion errors) resulting in a shift of approximately $5B from safety-net to non-safety-net hospitals. I find the opposite for a Medicaid contraction in Tennessee in 2005. My results demonstrate an unintended consequence of Medicaid-based eligibility criteria: changes in Medicaid coverage affect the allocation of public subsidies for safety-net patients.