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Original Investigation
June 27, 2017

Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014

Author Affiliations
  • 1Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
  • 2Department of Health Services Policy and Practice, Brown School of Public Health, Providence, Rhode Island
  • 3Providence VA Medical Center, Providence, Rhode Island
JAMA. 2017;317(24):2524-2531. doi:10.1001/jama.2017.7118
Key Points

Question  When insurers (and their plans) stop providing coverage for Medicaid enrollees (ie, “exit” Medicaid managed care), are there associated changes in market-level performance in quality of care?

Findings  In this retrospective cohort study of 366 Medicaid managed care plans, 106 plans exited the Medicaid program from 2006 through 2014. Exit was not associated with significant changes in market-level quality or self-reported patient experience.

Meaning  Health plan exit from the US Medicaid program was frequent, but was not associated with a significant change in health care market performance.


Importance  State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences.

Objective  To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality.

Design, Setting, and Participants  Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014.

Exposures  Plan exit, defined as the withdrawal of a managed care plan from a state’s Medicaid program.

Main Outcomes and Measures  Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10–point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries).

Results  Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state’s Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, −2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7–percentage point improvement in preventive care quality (95% CI, −4.9 to 6.3); 0.2–percentage point improvement in chronic disease care management quality (95% CI, −5.8 to 6.2); 0.7–percentage point decrease in maternity care quality (95% CI, −6.4 to 5.0]); and a 0.6–percentage point improvement in patient experience ratings (95% CI, −3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience.

Conclusions and Relevance  Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.