2010-2020 年全国医疗费用增长基准项目及医疗总支出 State Cost Growth Benchmark Programs and Total Medical Expenditures,2010 to 2020

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JAMANetwork

enTM

OriginalInvestigation|HealthPolicy

StateCostGrowthBenchmarkProgramsandTotalMedicalExpenditures,2010to2020

AleenaImran,MD;CarlosOronce,MD,PhD;NicholasJackson,PhD;Ya-ChenTinaShih,PhD;CherylL.Damberg,PhD;CatherineSarkisian,MD,MSPH;JohnN.Mafi,MD,MPH

Abstract

IMPORTANCEUShealthcarespendingcontinuestooutpaceeconomicgrowth,promptingstatestoimplementcost-growthbenchmarkprogramsaimedatconstrainingexpendituregrowth.

However,empiricalevidenceevaluatingtheirassociationswithoverallspendinggrowthremainslimited.

OBJECTIVEToevaluatewhetheradoptionofstatewidecost-growthbenchmarkprogramsisassociatedwithchangesinpercapitatotalmedicalexpenditure(TME)growth.

DESIGN,SETTING,ANDPARTICIPANTSThiscohortstudyusedaquasi-experimental,difference-in-differencesanalysiswith2-wayfixedeffectstoexaminedatafromtheCentersforMedicare&

MedicaidServicesStateHealthExpenditureAccountsfromJanuary1,2010,toDecember31,2020.Atotalof561state-andyear-levelobservationsacross50statesandWashington,DC,wereanalyzed.StatisticalanalysiswasperformedfromJanuary2025toApril2026.

EXPOSURESAdoptionofstatewidecost-growthbenchmarkprogramsinMassachusetts(2013),

Maryland(2014),Vermont(2018),RhodeIsland(2019),andDelaware(2019);allstatespairedtheirbenchmarkprogramswithenforcementmechanismsand/orpaymentreformsexceptforDelaware,whichreliedsolelyonpublicreporting.

MAINOUTCOMESANDMEASURESTheprimaryoutcomewaslog-transformedpercapitaTMEgrowth.Secondaryoutcomesincludedchangesinpayer-specificandspendingcategory–specificexpenditures.

RESULTSAcrossall50statesandWashington,DC,themeanannualpercapitaTMEincreasedby

3.7%duringthestudyperiod.Implementationofcost-growthbenchmarkprogramswasassociatedwitha2.0%reductioninTMEgrowth(95%CI,−3.3%to−0.7%;P=.004).Reductionswere

observedinalltreatmentstatesexceptDelaware.Medicarespendinggrowthdecreasedacrossall

treatmentstates(−2.4%;95%CI,−4.2to−0.6;P=.009),whereasreductionsincommercial

spendinggrowthwereconcentratedinMaryland(−2.2%;95%CI,−3.6to−0.8;P=.003)andRhodeIsland(−18.3%;95%CI,−20.3%to−16.2%;P<.001).Spendingreductionswereprimarilydrivenbydecreasesinhospital(−5.3%;95%CI,−7.3%to−3.3%;P<.001)andskillednursingfacility

expenditures(−7.7%;95%CI,−10.5%to−4.9%;P<.001),alongsideconcomitantspendingincreasesinhomehealthspending(8.9%;95%CI,3.2%to14.8%;P=.002).Findingswererobusttomultiplesensitivityanalyses.

KeyPoints

QuestionArestatewidecost-growthbenchmarkprogramsassociatedwithreductionsinpercapitatotalmedicalexpendituresgrowth?

FindingsInthiscohortstudy,a

difference-in-differencesanalysisof561state-yearobservationsfoundthat

cost-growthbenchmarkadoptionwasassociatedwithastatisticallysignificant2.0%reductioninpercapitaspendinggrowth.Reductionswereconcentratedinhospitalandskillednursingfacility

spending,withcommensuratespendingincreasesinhomehealthcare,andwereobservedinstateswithstronger

regulatoryordeliverysysteminterventions.

MeaningThesefindingssuggestthatstatecost-growthbenchmarkprogramsmayhelpmodestlyslowhealthcare

spendinggrowth,particularlywhenpairedwithstrongeraccountabilityorpaymentreformmechanisms.

+

Supplementalcontent

Authoraffiliationsandarticleinformationarelistedattheendofthisarticle.

CONCLUSIONSANDRELEVANCEThiscohortstudyfoundthatstatecost-growthbenchmark

programswereassociatedwithmodestreductionsinhealthcarespendinggrowth.Thesefindings(continued)

OpenAccess.ThisisanopenaccessarticledistributedunderthetermsoftheCC-BY-NC-NDLicense,whichdoesnotpermitalterationorcommercialuse,includingthosefortextanddatamining,AItraining,andsimilartechnologies.

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JAMANetworkOpen|HealthPolicyStateCostGrowthBenchmarkProgramsandTotalMedicalExpenditures,2010to2020

Abstract(continued)

suggestthatbenchmarkprograms,particularlythosepairedwithenforcementmechanismsorpaymentreforms,maycontributetoslowingexpendituregrowthandshiftingcaretoward

lower-costsettings.

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10.1001/jamanetworkopen.2026.20963

Introduction

Duringthepastdecade,UShealthcarespendinggrowthhasconsistentlyoutpacedeconomic

growth,andpercapitaexpendituresareprojectedtoexceed$24000by2033—totaling$8.6

trillion.1Risingcostscontinuetostrainpatients,payers,andgovernments,2,3promptingrenewedinterestinpoliciesaimedatconstrainingspendinggrowthwhilemaintainingaccessandquality.

Tocurtailspendinggrowthandimproveaffordability,severalstateshaveimplementedcost-

growthbenchmarkprograms,settingannualtargetsforspendinggrowthandestablishingstatewideaccountability.2-4Stateshaveusedarangeofpolicymechanismsforachievingthesetargets;someoperateprimarilythroughprice-basedapproaches(eg,hospitalrateregulation),whereasothersrelyonquantity-basedapproaches(eg,deliverysystemreform).4,5

Between2010and2020,atotalof5statesimplementedcost-growthbenchmarkprograms:Massachusetts(2013),Maryland(2014),Vermont(2018),RhodeIsland(2019),andDelaware(2019).Thedesignandenforcementmechanismsoftheseprogramsvaried.Massachusettsimplemented

publicreporting,performanceimprovementplans,andfinancialpenaltiesforentitiesexceeding

benchmarks,alongsidedeliverysystemreforms,suchasparticipationinaccountablecare

organizations(ACOs).Marylandintegrateditsbenchmarkwithitsall-payerglobalhospitalbudgetmodel,prospectivelycappinghospitalrevenuewhileoperatingunderfederaloversight.Vermont

enteredintoanall-payerACOmodelwiththeCentersforMedicare&MedicaidServices(CMS),tyingstatewideexpendituretargetstobudgetadjustmentsandfederaloversight.RhodeIslandlayeredits2019benchmarkontoearlieraffordabilitystandards(2010)thatcappedannualhospitalprice

growthandrequiredcommercialinsurerstoincreaseprimarycareinvestment,withaccountabilitythroughpublicreporting.Contrastingly,Delawarereliedsolelyonpublicreporting(Table1).4-11

Weconductedaquasi-experimentalanalysistoevaluatewhetheradoptionofstatewidecost-growthbenchmarkprogramswasassociatedwithchangesinpercapitatotalmedicalexpenditures(TME)growth.Giventhepolicyintentoftheseprogramsandlimitedbutsuggestivepriorevidenceonspendinggrowth,wehypothesizedthatadoptionwouldbeassociatedwithmodestchangesinpercapitaTMEgrowth,withoutcomesvaryingbasedonprogramdesignandenforcement.

Methods

StudyDesignandDataSources

Weconductedaquasi-experimentalcohortstudyusingadifference-in-differencesdesignto

evaluatetheassociationbetweenadoptionofstatecost-growthbenchmarkprogramsandchangesinpercapitaTMEgrowth.WeusedpubliclyavailabledatafromtheCMSStateHealthcare

ExpenditureAccounts(SHEA)fromJanuary1,2010,toDecember31,2020,whichincludesstate-

andyear-leveldataontotalpercapitamedicalexpenditures,aswellaspercapitaexpendituresbyspendingcategoryandpayertype(commercial,Medicare,andMedicaid).6Weusedstate-of-

residenceexpenditureestimatestoalignspendingwiththepopulationreceivingcare,avoiding

distortionsfromcross-stateusethatmayoccurwithstate-of-provider(hospitals,physicians,clinics,andnursinghomes)measures.WefollowedtheStrengtheningtheReportingofObservational

StudiesinEpidemiology(

STROBE

)reportingguideline.17Becauseweusedpubliclyavailable,

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deidentifiedaggregatedata,thisstudydeterminedbytheUCLAInstitutionalReviewBoardtobeexemptfromapprovalandinformedconsent.

StudyPopulation

Theanalyticsampleincluded561state-andyear-levelobservationsacross50statesand

Washington,DC,from2010to2020.Fivestatesimplementedcost-growthbenchmarkprogramsindifferentyearsduringthestudyperiod:Massachusetts(2013),Maryland(2014),Vermont(2018),

Table1.DefinitionsofTotalMedicalExpenditures,DataCollectionandReportingAgencies,andEnforcementMechanismsUnderCostGrowthBenchmarkProgramsbyStateasDefinedbytheNationalAcademyforStateHealthPolicy3

Collectingandreporting

State

Payerandproviderascope

Medicalexpenditurefocus

Primarypolicymechanism

agency

Enforcementdetails

Financialpenalties

Massachusetts(2013)

All-payer(commercial,Medicare,Medicaid)andallproviders(hospitals,physicians,andsoon)

Allcategoriesofmedicalexpensesandall

non–claims-related

paymentstoproviders,hospitalinpatientand

outpatientcosts,

includingdirectand

indirectcosts,allpatientcost-sharingamounts

(copayments,

deductibles),andNCPHI

Quantity-oriented:ACO

participation,payer-providercontractingreforms,deliverysystemtransformation,no

hospitalpricecaps

CenterforHealth

InformationandAnalysisandHealthPolicy

Commission

EntityispubliclynamedifitexceedsthebenchmarkandmustsubmitaPIPwithin45daysofreceivingnotice;ifapproved,thePIPmustbeimplementedduring18

months;afineof$500000canbeassessedfor

nonadherence

Federalpartnerships

Maryland(2014)

All-payer(commercial,Medicare,Medicaid

(includingCHIP),

primarilyhospitalundertheall-payermodel

duringourstudyperiodbutexpandedto

nonhospitalprovidersafterexpandingtototalcostofcaremodelin

2019

Hospitalcostgrowthpercapita,MedicarePartAandPartB

Price-andquantity-oriented:useconstraints;global

budgets;enforceshospital

pricecapsthroughitsglobalhospitalbudgetsystem,

whichsetsprospectiveannualrevenuecapsforhospitals

andadjustsunitratesto

ensurehospitalsdonot

exceedthesecaps,

functioningasacore

mechanismtocontrol

hospitalspendingwithinitsbenchmarkprogram4

HSCRC

Federal-stateagreement

withCMS;becausethe

HSCRCsetsglobalbudgetsforhospitals,hospitalsriskrevenuereductionsiftheyexceedrevenuecaps;if$2billionisnotsavedbetween2019and2026,theCMS

canremovewaiverthat

allowsMarylandtoset

Medicarehospitalprices;thestateisrequiredto

provideannualreportsonprogramefficacy;theCMSmaystopmodelifsavingsandqualityrequirementsnotmet

Vermont(2018)

PrimarilyMedicare;alsoMedicaidandcommercialviaACOalignment;

ACO-participating

providers;hospitalsviarevenuetargets

MedicarePartAandB,

healthcareclaimsand

somenonclaimspayment(prospectivepayments,sharedsavingspayments,BlueprintforHealth

payments,andsoon)

Quantity-oriented:all-payerACOmodel;use

management;care

coordination;nodirectpricecaps;annualhospitalrevenuegrowthtargetssetbyGMCB

GMCBinpartnershipwithCMS

Vermonthasaformal

arrangementwithCMS

undertheall-payerACO

model;subjecttopublic

hearings,budget

adjustment,and

terminationofparticipationifspendingexceedstargets,theCMSmaydeclarea

triggeringeventandissuethestateawarningnotice;thestatemustprovidea

planforimprovement;if

planisnotapprovedorif

statefailstoimprovewithin1year,theCMScanimposeitsownprogram

benchmarks

Publicreporting

Delaware(2019)

All-payer(commercial,

Medicare,Medicaid,VA),statewide(nospecific

provider-levelregulation)

Commercial,Medicare

Advantage,MedicareFFS,MedicaidCHIP,MedicaidMCO,MedicaidFFS,VA,

NCPHI,copayments,anddeductibles;this

measurementexcludespaymentonbehalfof

out-of-stateresidents,vision,dental,premiums,andproviderresourcesappliedinthedeliveryofcareforuninsured

individuals

Limitedmonitoringfocused

duringstudyperiod:

transparencyandvalue-basedcareencouragementduringthestudyperiod;hospital

pricegrowthcaps

implementedafter2020

TheDelawareEconomic

andFinancialAdvisory

CommitteeHealthCare

SpendingBenchmark

Subcommitteesetsthe

healthcarespending

benchmark;theDelawareHealthCareCommissionisresponsibleforcollectinginformationandanalyzingperformanceagainstthebenchmark

Performancewillbe

reportedpubliclyonly,aspermemberperyearcosts,andmadeatthestatewidelevelwithdrill-down

analyses;noformal

penaltiesormandatoryimprovementplans

(continued)

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Table1.DefinitionsofTotalMedicalExpenditures,DataCollectionandReportingAgencies,andEnforcementMechanismsUnderCostGrowthBenchmarkProgramsbyStateasDefinedbytheNationalAcademyforStateHealthPolicy3(continued)

Collectingandreporting

State

Payerandproviderascope

Medicalexpenditurefocus

Primarypolicymechanism

agency

Enforcementdetails

RhodeIsland(2019)b

PrimarilycommercialbutalsoMedicare,Medicaidhospitals,insurers,ACOs

Commercial,Medicare

Advantage,MedicareFFS,MedicaidMCO,Rhode

IslandExecutiveOfficeofHealthandHuman

ServicesFFS,NCPHI,

copayments,and

deductibles;this

measurementexcludespaymentonbehalfof

out-of-stateresidents,vision,dental,premiums,andproviderresourcesappliedinthedeliveryofcareforuninsured

individuals

Priceandquantityoriented:mandatedprimarycare

investment;deliverysystemreforms;implementeda

hospitalpricegrowthcapin2010,limitingannualpriceincreasesforinpatientandoutpatienthospitalservicestotheConsumerPriceIndexplus1percentagepoint,

whichcontributedtoslowingspendinggrowthbeforetheformalbenchmarkprogram5

OfficeofHealthInsurance

CommissionerandExecutiveOfficeofHealthandHumanServices

OfficeofHealthInsurance

Commissionerpublicly

reportsonperformance

againstthetargetata

statewidelevel,with

severaldrill-downanalyses;theOHICcombines

benchmarkwithother

regulatorytools,which

mandateminimumprimarycareinvestmentbyinsurers;noformalpenaltiesor

mandatoryimprovementplans;voluntary

compliance

Abbreviations:ACO,accountablecareorganization;CHIP,Children’sHealthInsuranceProgram;CMS,CentersforMedicare&MedicaidServices;FFS,feeforservice;GMCB,GreenMountainCareBoard;HSCRC,HealthServicesCostReviewCommission;MCO,managedcareorganization;NCPHI,netcostofprivatehealthinsurance;OHIC,OfficeoftheHealthInsuranceCommissioner;PIP,performanceimprovementplan;VA,

VeteransAffairs.

aProviderindicateshospitals,physicians,clinics,andnursinghomes.

bWeacknowledgethatRhodeIslandalsoimplementedapricecapprogramin2010;

however,weconsideredthisprogramseparatefromRhodeIsland’scostgrowth

benchmarkprogrambecause(1)thelatterprogramwaslaunched9yearslaterand(2)theNationalAcademyforStateHealthPolicyconsidersthecostgrowthbenchmarkprogramseparatefromthepricecapprogram.Incontrast,Maryland’scostgrowth

benchmarkprogramwaslaunchedintandemwithitshospitalpricecapprogram;thus,weandtheNationalAcademyforStateHealthPolicyconsideredtheseprogramsoneandthesame.Moreover,priorresearchhasalreadyevaluatedtheimpactofRhode

Island’spricecapprogramin2010.5Poststudyperiodupdatesareasfollows:the

MassachusettsprogramcontinueswithongoingmonitoringandenforcementbytheMassachusettsHealthPolicyCommission.TheMarylandmodelevolvedintothetotalcostofcareframeworkin2019,expandingaccountabilitybeyondhospitalspending.TheVermontall-payerACOmodelconcludedinDecember2025.TheRhodeIsland

programcontinuesalongsideaffordabilitystandards;regulatoryframeworkis

ongoing.InDelaware,theDelawareHospitalCostReviewBoardandpriceregulationwereintroducedafter2020,strengtheningenforcement.

RhodeIsland(2019),andDelaware(2019).Treatmentstateswerecomparedbeforeandafter

implementationwith45never-treatedstates.Notyettreatedstatescontributedtothecontrolgroupuntiladoption,allowingforstaggeredimplementationacrossstates.

Exposure

Theexposurewasadoptionofastatewidecost-growthbenchmarkprogram.Stateswereclassifiedastreatedbeginningintheyearofimplementation.Becausedatawereannual,implementationwasmodeledatthecalendar-yearlevel.

OutcomeMeasures

TheprimaryoutcomewasthelogofpercapitaTMEgrowth.Wefocusedontotalhealthcare

expenditure,whichencompassesallpayertypes,includingMedicare,Medicaid,andcommercial

insurance.Thisbroadoutcomemeasureprovidesinsightintotheoverallimpactofcost-growth

benchmarkprogramsonstate-levelhealthcarespending.Logtransformingthedatahelpscaptureproportionalchangesinspendingandallowsinterpretationofcoefficientsaspercentagechanges.Secondaryoutcomesincludedpayer-specificandspendingcategory–specificexpenditures.Theseoutcomeswereincludedtobetterunderstandwhethercost-growthpoliciesinfluencedspecific

payergroupsandspendingcategoriesdifferently.Spendingcategoriesincludedhospitalorinpatient,skillednursingfacility,homehealthcare,physicianservices,prescriptiondrugs,durablemedical

equipment,dental,andprofessionalservices.Expenditureestimatesarereportedininflation-

adjustedterms;therefore,noadditionalinflationadjustmentwasapplied,consistentwiththerealgrowthtargetsusedinstatebenchmarkprograms.

Covariates

Modelswereadjustedforstate-level,self-reporteddemographiccharacteristics,includingage,sex,race,andethnicity,usingdatafromtheAmericanCommunitySurvey.12Thesevariableswere

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includedtoaccountfordifferencesinpopulationcompositionthatmayinfluencehealthcareuseandspending.

StatisticalAnalysis

MainAnalysis

StatisticalanalysiswasperformedfromJanuary2025toApril2026usingStataNow18.5StandardEdition(StataCorp).Weestimateda2.wayfixed.effectsregressionmodel,includingstate.fixed

effectstoaccountfortime.invariantdifferencesacrossstatesandyear.fixedeffectstoaccountfornationalshocks.13Modelswereweightedbystatepopulationusinganalyticweightstogeneratepopulation.representativeestimates.RobustSEswereclusteredatthestateleveltoaccountforserialcorrelationandheteroscedasticity.14Resultswerealsostratifiedbypayerandspending

category.A2.sidedP<.05wasconsideredstatisticallysignificant.

SensitivityAnalyses

Weconductedseveralsensitivityanalysestoevaluatetherobustnessofourfindings.First,we

excluded2020toaccountfordisruptionsinhealthcareuseduringtheCOVlD.19pandemic.Notably,RhodelslandandDelaware—bothadoptingcost.growthbenchmarkprogramsin2019—hadonly1

yearofpostimplementationdataavailable(2020)andwerethusnaturallyexcludedinthis

specification.31Second,wereestimatedallmodels,includingatime.varyingbinaryindicatorforstateMedicaidexpansionstatusunderthePatientProtectionandAffordableCareActtoassesswhetherfindingswererobusttocoverageexpansion–relatedchangesinuseandspending.Third,we

reestimatedmodelsexcludingstateswithpotentialdeviationsfromtheparalleltrendsassumption.Specifically,Rhodelslandexhibitedaminordeviationfromparallelpreimplementationtrendsandwasexcludedinsensitivityanalyses.lnpayer.specificanalyses,Maryland.sMedicaidspendingdidnotmeettheparalleltrendsassumption;therefore,weexcludedMarylandinMedicaid.specific

models.Fourth,weappliedthesespecificationsacrosspayer.andspendingcategory–specific

outcomestoassessrobustnessacrossoutcomedefinitions.Fifth,toassesspotentialconfoundingfromunderlyingpopulationhealthtrends,weexaminedstate.levelBehavioralRiskFactor

SurveillanceSystem(BRFSS)indicators,includingdiabetes,hypertension,cardiovasculardisease,

self.reportedhealthstatus,andfrequentmentaldistress.15AdditionaldetailsonsensitivityanalysesareprovidedintheeMethodsin

Supplement1

.

ParallelTrendsAssumption

Thedifference.in.differencesapproachassumesparallelpretreatmenttrendsbetweentreatment

andcontrolstates.16Weassessedthisassumptionthroughvisualinspectionofpreimplementationtrendsinpercapitahealthcarespendinggrowthforbothtreatmentandcontrolstates(Figure,A.E).Wealsoassessedpretreatmenttrendsacrosspayer.andspendingcategory–specificoutcomes.

Results

Weanalyzed561state.andyear.levelobservations.Acrossallstates,meanannualpercapitaTMEincreasedby3.7%.Cost.growthbenchmarkimplementationwasassociatedwitha2.0%(95%Cl,–3.3%to–0.7%)relativereductioninTMEgrowth(P=.004).State.specificanalysesdemonstratedreductionsinTMEgrowthinMassachusetts,Maryland,Vermont,andRhodelsland,whereas

Delawareshowednosignificantchange(Table2).

Bypayer,significantreductionswereobservedacrossalltreatmentstatesforMedicare(_2.4%;95%Cl,_4.2to_0.6;P=.009),withVermontshowingthelargestreduction(_13.1%;95%Cl,_14.1%to_12.0%;P<.001).ReductionsincommercialspendingwereconcentratedinMaryland(_2.2%;

95%Cl,_3.6%to_0.8%;P=.003)andRhodelsland(_18.3%;95%Cl,_20.3%to_16.2%;P<.001).Medicaidresultswereheterogeneousacrossstates(Table2).

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Byspendingcategory,TMEgrowthreductionswereconcentratedinhospital(−5.3%;95%CI,−7.3to−3.3;P<.001)andskillednursingfacilityspending(−7.7%;95%CI;−10.5%to−4.9%;

P<.001),withconcurrentincreasesinhomehealthcare(8.9%;95%CI,3.2%to14.8%;P=.002)

(Table2).AdditionalexploratoryanalysesstratifiedbypayerandspendingcategoryshowedsimilarpatternswithinMedicare,withreductionsinskillednursingfacilityspending(−13.5%;95%CI,

Figure.LineGraphsofPreimplementationandPostimplementationTrendsinPerCapitaHealthCareSpendingGrowthforTreatmentandControlStates

A

LogpercapitaTME

Massachusetts(2010-2020)

9.6

PreimplementationPostimplementation

9.5

Massachusetts9.4

9.3

Controlstates9.2

9.1

9.0

8.9

8.8

20102011201220132014201520162017201820192020

Year

BMaryland(2011-2020)

LogpercapitaTME

9.6

Preimplementation

Postimplementation

9.5

9.4

Maryland

9.3

9.2

Controlstates

9.1

9.0

8.9

8.8

2011

201220132014

201520162017201820192020

Year

CVermont(2015-2020)

DDelaware(2016-2020)

LogpercapitaTME

9.6

PreimplementationPostimplementation

9.5

Vermont9.4

9.3

9.2

Controlstates9.1

9.0

8.9

8.8

201520162017201820192020

Year

LogpercapitaTME

9.6

PreimplementationPostimplementation

9.5

9.4Delaware9.3

9.2

Controlstates9.1

9.0

8.9

8.8

20162017201820192020

Year

ERhodeIsland(2016-2020)

LogpercapitaTME

9.6

PreimplementationPostimplementation

9.5

9.4RhodeIsland9.3

9.2

Controlstates9.1

9.0

8.9

8.8

20162017201820192020

Year

ThesefiguresplotaveragelogpercapitahealthcarespendinginMassachusetts,

Maryland,Vermont,Delaware,andRhodeIslandcomparedwithmatchedcontrolstates.Theverticallightbluelineindicatestheyearthestateimplementeditscost-growth

benchmarkprogram.Thevisualinspectionofpretreatmenttrendssupportsthevalidity

oftheparalleltrendsassumptionunderlyingdifference-in-differencesanalyses,otherthanaminordeviationinRhodeIsland.SensitivityanalysesrevealedsimilarresultsafterexcludingRhodeIsland(Table2).TMEindicatestotalmedicalexpenditures.

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−20.6%to−5.7%;P=.001)andconcomitantincreasesinhomehealthcare(8.0%;95%CI,0.8%to15.7%;P=.03)(Table3).

Resultswererobustacrossmultiplesensitivityanalyses,includingexclusionof2020toaccountforCOVID-19–relateddisruptions,adjustmentforMedicaidexpansion,andexclusionofany

nonparallelpreimplementiontrendacrossall-payer,payer-specific,andspending-categoryanalysis(Table2).AnalysesofBRFSSindicatorsshowednoevidenceofdifferentialpo