With nearly half the states planning to expand Medicaid eligibility in 2014, Health AffairsJuly issue, released today, includes several articles that reflect, in the words of founding editor John Iglehart, “various cross currents of federalism.”

Medicaid, as seen in this issue, says Iglehart, “is not the uniform national health program envisioned by Democrats, but one that reflects the heterogeneity of the United States and the Republican imperative for decentralized policy making.”

This variety issue also addresses health care workforce concerns, an increase in e-prescribing by providers responding to a federal incentive program, and the lessons for state legislatures when school immunization exemption laws are relaxed.

Selected content in the issue is supported by a grant from Blue Shield of California Foundation.

Noteworthy articles include:

Existing Medicaid Beneficiaries May Be Denied Preventative Care. The Affordable Care Act promotes access to preventive care as outlined by the US Preventive Services Task Force. However, because the law treats new and existing Medicaid beneficiaries differently, the two groups may not be eligible for the same preventive services. A study by Sara Wilensky and Elizabeth Gray of the George Washington University reviewed Medicaid policies across the country between June and November 2012. They found that most states do not offer existing beneficiaries all the services rated “A” and “B” by the US Preventive Services. In contrast, states expanding their Medicaid eligibility must offer these benefits to new participants without cost sharing.

A related article looks at how, under the Affordable Care Act, primary care physicians accepting Medicaid patients will receive higher payments than in the past. Sandra L. Decker of the National Center for Health Statistics established 2011 and 2012 baseline Medicaid acceptance rates by state. Using data from the National Ambulatory Medical Care Survey Electronic Medical Records Supplement, Decker reported that about 33 percent of primary care physicians did not accept new Medicaid patients in 2011–12. The nonacceptance rate ranged from a low of 8.9 percent in Minnesota to a high of 54.0 in New Jersey. These data will provide a starting point with which to compare Medicaid acceptance rates after the Affordable Care Act’s implementation.

A final Medicaid article looked at how quickly state programs shifted their drug payments in response to the availability of generic alternatives. Christina M.L. Kelton of the University of Cincinnati and coauthors examined one such case: when the patent for Prozac, a widely prescribed antidepressant, expired in 2001. Overall, they found that state Medicaid programs could have saved $220 million had they adjusted their reimbursement rates more quickly. They also found that states differed considerably in the speed with which they shifted to 90 percent use of the generic equivalent. The authors recommend more coordination of cost lists between states and a federal role obtaining and disseminating price data on generic drugs.

With E-Prescribing, Federal Financial Incentives Led To Increased Adoption And Usage. Although most US pharmacies had the software to effectively receive electronic prescriptions from providers by the mid-2000s, only 6 percent of office-based providers were e-prescribing. Congress stepped in, and beginning in 2009, the Medicare Improvements for Patients and Providers Act authorized a 2 percent bonus payment for e-prescribing. According to a study by Seth B. Joseph of Surescripts, Michael F. Furukawa of the US Department of Health and Human Services, and colleagues, almost 40 percent of e-prescribers adopted the technology between July 2008 and December 2010 in response to the federal incentive program. The authors believe that this is the first case in which researchers used transactional data from a health information network to study the impact of federal intervention on providers’ adoption of health information technology.

Why Do Low-Income Patients Prefer Hospitals To The Doctor’s Office? Patients with low socioeconomic status (SES) use emergency and hospital-based care more often than primary care, a care pattern that leads to poor health outcomes and, according to government data, costs $30.8 billion annually. To better understand this phenomenon, Shreya Kangovi of the Philadelphia Veterans Affairs Medical Center and colleagues from the Perelman School of Medicine at the University of Pennsylvania conducted a qualitative study of hospitalized patients identified as having low socioeconomic status while they were being hospitalized. Study participants described the hospital as: having better access and technical quality; being more affordable; and, in some cases, providing an oasis to heal. Concluded the authors, “The patients in our study articulated clear, logical reasons for preferring hospital to ambulatory care.” Kangovi and colleagues urge policy makers to review these findings as they strive to increase ambulatory care use by low-SES patients.

Also of interest in the July issue: two studies comparing the overall impact of state-by-state variation in key regulations: