Publications by Teresa A. Coughlin for Health Policy Center

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More about Teresa A. Coughlin's areas of expertise can be found on this Urban Institute expert's page.

Florida is among the first states to implement Medicaid reform using a competitive consumer choice model. Using data from a 2006-07 survey of Medicaid beneficiaries newly enrolled in Florida’s reform program, in an October volume of Health Affairs, Terri Coughlin, Sharon Long and Tim Triplett and colleagues examine how well Florida Medicaid beneficiaries understood the many changes taking place in Medicaid and their experiences in selecting a health plan. They found significant gaps in beneficiaries’ understanding of major components of the reform. Among others, about 30 percent were not aware they were enrolled in reform and more than half had trouble understanding plan information. Additionally, they found that these problems were not particular to any group but instead were experienced broadly across the full Medicaid population.

People uninsured for any part of 2008 spend about $30 billion out of pocket and receive approximately $56 billion in uncompensated care while uninsured. Government programs finance about 75 percent of uncompensated care. If all uninsured people were fully covered, their medical spending would increase by $122.6 billion. The increase represents 5 percent of current national health spending and 0.8 percent of gross domestic product. However, it is neither the cost of a specific plan nor necessarily the same as the government's costs, which could be higher, depending on plans' financing structures and the extent of crowd-out.

Since 2001, more than half the states have changed their Medicaid programs, through either Medicaid waivers or provisions included in the Deficit Reduction Act of 2005. These changes are in benefit flexibility, cost sharing, enrollment expansions and caps, privatization, and structure of program financing. With a few important exceptions, the changes have been fairly circumscribed. However, states may exercise this new flexibility if, for example, national health care reforms do not occur or an economic downturn creates state fiscal pressures. If that happens, new policies could lead to profound changes in Medicaid and could be carried out relatively easily.

Using state survey data, researchers examined Medicaid supplemental payments, including disproportionate share hospital and upper payment limit payments in 2005 and changes in these payments between 2001 and 2005. The researchers found that states increased their use of general funds in financing Medicaid DSH payments while expanding the size and scope of other supplemental payments considerably. Although the federal government has made some headway in reforming state Medicaid financing in recent years, the paper concludes that problems persist and more work remains.

This paper reports on an examination of ten Health Insurance Flexibility and Accountability (HIFA) waiver demonstrations, a major Medicaid initiative of the Bush administration. Among other things, the study finds that the principal motivation for the HIFA waivers was to expand coverage, and not, as some had feared, to control costs. States showed a particular interest in providing coverage to groups that historically have been excluded from publicly-sponsored health programs. Coverage expansion under HIFA, however, has been far short of projections. The biggest obstacle for states in implementing (or maintaining) their demonstrations has been finding state funds. (Health Affairs Web Exclusive, April 25, 2006)

This study uses survey data linked with claims data to examine the consequences of unmet need for future health care use for a sample of disabled Medicaid beneficiaries. The findings show that self-reported unmet need is a strong predictor of future health care use for disabled Medicaid beneficiaries, including a greater reliance on emergency rooms and hospital care for conditions that potentially could be handled in less expensive settings. Addressing the barriers to care that underlie unmet need could generate cost savings to Medicaid and provide better health outcomes for program beneficiaries. (Inquiry, 42, 4, Winter 2005/2006. pp. 413-420)

To assess Medicaid’s importance in improving access to care, in this brief we compare health care access of Medicaid beneficiaries to that of the low-income uninsured population. We focus on low-income parents, the group most likely to be affected by the many recent Medicaid changes. We compare the two groups for the nation as a whole, as well as for selected states. While previous research has documented the significant role Medicaid plays in providing access at the national level, only very limited work has examined how the program performs at the state level.

Hurricane Katrina destroyed much of the New Orleans health care system. The devastation was especially profound for the low-income uninsured, most of whom depend heavily on a handful of providers. Focusing on the low-income population, this essay examines some of the early responses to the many health care issues that surfaced in Katrina's wake, and discusses emerging issues that both private and public decisionmakers will face. One potential strategy for rebuilding is a health care safety net based on a continuum of care to low-income residents, integrating a network of community clinics with a new but smaller Charity Hospital.

In a Health Affairs web exclusive, Terri Coughlin and Stephen Zuckerman examined budget decisions in eight states over the 2003-05 time period when states faced some of their largest budget shortfalls since World War II. Coughlin and Zuckerman report that, on balance, states were reluctant to raise taxes or reduce either benefits or eligibility for Medicaid and SCHIP. Instead, they frequently relied on one-time actions such as shifting money from surplus accounts into general funds, changing accounting rules or delaying payments from one fiscal year into the next. The authors concluded that by taking this approach, however, some states have created structural deficits that will profoundly influence state policy making for many years to come. (Health Affairs Web Exclusive, August 16, 2005)

This study examined how the Medicaid program is providing access to beneficiaries, using the level of access available to low-income privately insured people in the local health care market as the benchmark. The analysis, which focused on ambulatory care measures, was done for the nation as a whole and for thirteen individual states. The researchers concluded that, on balance, Medicaid beneficiaries fared no worse than their low-income privately insured peers in most of the states examined. (Coughlin, Teresa A., Long, Sharon K., Shen, Yu-Chu. July/August 2005. "Assessing Access to Care Under Medicaid: Evidence for the Nation and Thirteen States." Health Affairs 24(4): 1073-1083.)

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