Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan

"I probably have access, but I can't afford it": expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA

BACKGROUND

Disparities in rates of contraceptive use are frequently attributed to unequal access to and affordability of care. There is a need to better understand whether common definitions of affordability that solely relate to cost or to insurance status capture the reality of individuals' lived experiences. We sought to better understand how individuals with low incomes and the capacity for pregnancy conceptualized one domain of contraceptive access-affordability --in terms of health system and individual access and how both shaped contraceptive care-seeking in the US South.

METHOD

Between January 2019 to February 2020, we conducted twenty-five life-history interviews with low-income individuals who may become pregnant living in suburban counties in Georgia, USA. Interviews covered the ways individual and health system access factors influenced care-seeking for family planning over the life course. Interview transcripts were analyzed using a thematic analysis approach to identify experiences associated with individual and health system access.

RESULTS

Affordability was identified as a major determinant of access, one tied to unique combinations of individual factors (e.g., financial status) and health system characteristics (e.g., cost of methods) that fluctuated over time. Navigating the process to attain affordable care was unpredictable and had important implications for care-seeking. A "poor fit" between individual and health system factors could lead to inequities in access and gaps in, or non-use of contraception. Participants also reported high levels of shame and stigma associated with being uninsured or on publicly funded insurance.

CONCLUSIONS

Affordability is one domain of contraceptive access that is shaped by the interplay between individual factors and health system characteristics as well as by larger structural factors such as health and economic policies that influence both. Assessments of the affordability of contraceptive care must account for the dynamic interplay among multilevel influences. Despite the expansion of contraceptive coverage through the Affordable Care Act, low-income individuals still struggle with affordability and disparities persist.

Racial and Ethnic Disparities in Access to and Outcomes of Infertility Treatment and Assisted Reproductive Technology in the United States

Infertility disproportionately affects the minority, non-White populace, with Black women having twofold higher odds than White women. Despite higher infertility rates, minority racial and ethnic groups access and utilize fertility care less frequently. Even once care is accessed, racial and ethnic disparities exist in infertility treatment and ART outcomes. Preliminary studies indicate that Asian and American Indian women have lower intrauterine insemination pregnancy rates. Many robust studies indicate significant racial and ethnic disparities in rates of clinical pregnancy, live birth, pregnancy loss, and obstetrical complications following in vitro fertilization, with lower favorable outcomes in Black, Asian, and Hispanic women.

Voting restrictions associated with health inequities in teenage birth rates

OBJECTIVES

Since the Landmark Shelby V. Holder Supreme Court Ruling, the number of laws in the United States that make it difficult to vote has increased dramatically. This may lead to legislation that limits access to health care, including options for family planning services. We determine whether voting restrictions are associated with county-level teenage birth rates.

STUDY DESIGN

This is an ecological study.

METHODS

The Cost of Voting Index, a state-level measure of barriers to voting during US elections from 1996 to 2016, was used as a proxy for access to voting. County-level teenage birth rates were obtained from the County Health Rankings data. We used multilevel modeling to determine whether restrictive voting laws were associated with county-level teenage birth rates. We tested whether associations varied across racial and socio-economic groups.

RESULTS

When confounders were included, a significant association was observed between increasing voting restrictions and teenage birth rates (β = 1.72, 95% confidence interval: 0.54, 2.89). A Cost of Voting Index-median income interaction term was tested and was statistically significant (β = -1.00, 95% confidence interval: -1.36, -0.64), indicating that the observed relationship was particularly strong among lower-income counties. The number of reproductive health clinics per capita within each state is a potential mediator.

CONCLUSION

Restrictive voting laws were associated with higher teenage birth rates, particularly for low-income counties. Future work should use methods in which a causal relation can be identified.

Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion

Objectives: We compared the use of sexual and reproductive health (SRH) services for Medicaid-enrolled women of reproductive age (WRA) living in Oregon by urban/rural status and examined the effect of the Affordable Care Act (ACA) Medicaid expansion on the use of SRH services for these women. Methods: We linked Oregon Medicaid enrollment files and claims for the years 2008-2016 to identify 392,111 WRA. Outcome measures included receipt of five key SRH services. The main independent variables were urban/rural status (urban, large rural cities, and small rural towns) and an indicator for the post-Medicaid expansion time period (2014-2016). We performed (conditional) fixed-effects logistic regression and multiple-group interrupted time-series analyses. Results: Women living in small rural towns were less likely than women living in urban areas to receive well-woman visits (odds ratio [OR] = 0.87; 95% confidence interval [95% CI] [0.80-0.94]), sexually transmitted infection (STI) screening (OR = 0.81; 95% CI [0.72-0.90]), and pap tests (OR = 0.91; 95% CI [0.84-0.99]). Women living in large rural cities were less likely than women living in urban areas to receive STI screening (OR = 0.91; 95% CI [0.84-0.98]). Following the implementation of ACA Medicaid expansion, the average number of all five SRH services increased for all women. With the exception of contraceptive services, the average number of SRH services examined increased more for urban women than for women living in small rural towns. Conclusions: Although Medicaid expansion contributed to increased use of SRH services for all WRA, the policy was unsuccessful in reducing disparities in access to SRH services for WRA living in rural areas compared with urban areas.

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Trends in Postpartum Contraceptive Use in 20 U.S. States and Jurisdictions: The Pregnancy Risk Assessment Monitoring System, 2015-2018

INTRODUCTION

In the last decade, state and national programs and policies aimed to increase access to postpartum contraception; however, recent data on population-based estimates of postpartum contraception is limited.

METHODS

Using Pregnancy Risk Assessment Monitoring System data from 20 sites, we conducted multivariable-adjusted weighted multinomial regression to assess variation in method use by insurance status and geographic setting (urban/rural) among people with a recent live birth in 2018. We analyzed trends in contraceptive method use from 2015 to 2018 overall and within subgroups using weighted multinomial logistic regression.

RESULTS

In 2018, those without insurance had lower odds of using permanent methods (adjusted odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.53-0.98), long-acting reversible contraception (LARC) (AOR, 0.67; 95% CI, 0.51-0.89), and short-acting reversible contraception (SARC) (AOR, 0.61; 95% CI, 0.47-0.81) than those with private insurance. There were no significant differences in these method categories between public and private insurance. Rural respondents had greater odds than urban respondents of using all method categories: permanent (AOR, 2.15; 95% CI, 1.67-2.77), LARC (AOR, 1.31; 95% CI, 1.04-1.65), SARC (AOR, 1.42; 95% CI, 1.15-1.76), and less effective methods (AOR, 1.38; 95% CI, 1.11-1.72). From 2015 to 2018, there was an increase in LARC use (odds ratio [OR], 1.03; 95% CI, 1.01-1.05) and use of no method (OR, 1.05; 95% CI, 1.02-1.07) and a decrease in SARC use (OR, 0.97; 95% CI, 0.95-0.99). LARC use increased among those with private insurance (OR, 1.05; 95% CI, 1.02-1.08) and in urban settings (OR, 1.04; 95% CI, 1.02-1.07), but not in other subgroups.

CONCLUSIONS

We found that those without insurance had lower odds of using effective contraception and that LARC use increased among those who had private insurance and lived in urban areas. Strategies to increase access to contraception, including increasing insurance coverage and investigating whether effectiveness of existing initiatives varies by geographic setting, may increase postpartum contraceptive use and address these differences.

Recap of the sixth international symposium on intrauterine devices and systems for women's health

Due to the COVID-19 pandemic, the Sixth International Symposium on Intrauterine Devices and Systems for Women's Health was held as a series of seven 2-hour webinars between May 28, 2020, and June 22, 2021. This Symposium featured 48 different presenters and moderators covering a wide range of topics to highlight new IUD issues and update general IUD knowledge, just as it was done in previous symposia dating back to 1962 [1-5]. A total of 1346 people attended remotely to observe the events live. In this article, we share summaries of the presentations from the sixth symposium. These summaries, provided by the presenters, are meant to archive the symposium. This article gives the reader an overview of the topics and identifies the sessions' moderators and speakers charged with providing the content. Those interested in further detail, references, and information about the speakers can find more information on the conference website: www.iud2020.com. After the summaries, we share ideas for future IUD research and programmatic needs, as provided by Symposium's presenters and organizers. The authors' summaries are personal opinions and do not necessarily reflect the perspectives of the Symposium's organizers or the medical community at large. The Symposium was recorded and the sessions are available for viewing free of charge at the website, www.iud2020.comor on YouTube. As of July 2022, approximately 1700 visitors have viewed the recordings.

Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery

The American Rescue Plan provides a pathway for states to expand postpartum Medicaid coverage for low-income mothers through 12 months after delivery. Data suggests that extension of post-partum Medicaid coverage should improve access to outpatient health care services, increase healthcare utilization, improve chronic disease management for at-risk mothers, and reduce disparities in care for racial/ethnic groups over-represented in Medicaid. Opportunities to provide increased preventive care for perinatal mood disorders and smoking cessation also exist. Further, this policy may reduce the burden of late maternal mortality. While improved access to contraceptive service postpartum provides a potential mechanism by which birth outcomes may improve, the effect of this policy on NICU admission, low birth weight (LBW) infants, and preterm birth is unknown. We discuss possible birth, infant and maternal health outcomes which may result from this expansion, drawing on data from the 2010 Medicaid Expansion via the Affordable Care Act.

Racial disparities in access to reproductive health and fertility care in the United States

PURPOSE OF REVIEW

To examine the status of racial and ethnic inequalities in fertility care in the United States (U.S.) at inception of 2022. This review highlights addressable underpinnings for the prevalent differentials in access to and utilization of infertility treatments and underscores gaps in preventive care as key contributors to racial and ethnic disparities in risk burden for subfertility and infertility.

RECENT FINDINGS

Significant gaps in access to and utilization of fertility care are consistently reported among racial and ethnic minorities, particularly Black and Hispanic women. Access to and utilization of contraceptives, human papilloma virus vaccination rates, preexposure prophylaxis use, and differentials in treatment of common gynecologic disorders are relevant to the prevalent racial and ethnic disparities in reproductive health. The spectrum of differential in reproductive wellness and the magnitude of reproductive health burden afflicting racial minorities in the U.S. raise concerns regarding systemic and structural racism as plausible contributors to the prevalent state of affairs.

SUMMARY

Despite efforts to reform unequal reproductive health practices and policies, racial and ethnic disparities in fertility care are pervasive and persistent. In addition to measures aimed at reducing barriers to care, societal efforts must prioritize health disparity research to systematically examine underpinnings, and addressing structural racism and interpersonal biases, to correct the prevalent racial inequities and mitigate disparities.

Health care access and contraceptive use among adult women in the United States in 2017

OBJECTIVE

To examine the relationship between insurance status and contraceptive use, with health care access as a mediating variable.

STUDY DESIGN

This study uses data from the 2017 Behavioral Risk Factor Surveillance Survey to determine whether having a personal healthcare provider and experiencing cost as a barrier to care mediate the relationship between health insurance status and contraceptive use among women at risk of unintended pregnancy. Contraceptive use is measured 3 ways: as a binary variable (use vs non-use), by prescription status, and by tiered effectiveness.

RESULTS

Having insurance increases the odds of using all categories of contraception. Having a personal health care provider mediates this relationship, with having a personal health care provider increasing the odds of using any contraceptive, using a prescription method, and using a tier I or tier II method. Experiencing cost as a barrier to care is not associated with contraceptive use in weighted multivariable models but does mediate the relationship between having insurance and using tier-II methods.

CONCLUSIONS

These findings suggest that having health insurance and an ongoing relationship with a health care provider are key to ensuring consistent access to the full range of contraceptive options. This is particularly relevant in light of the ongoing policy debates regarding laws intended to increase health insurance access and decrease barriers to contraceptive use.

IMPLICATIONS

This paper updates and extends previous findings to show that the relationship between healthcare access and contraceptive use persists after the implementation of the Affordable Care Act and that having a personal provider partially explains this relationship.

Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age

Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.

Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine

BACKGROUND

Availability of long-acting reversible contraception (LARC) is an important indicator of high-quality women's health care. There are limited data on the impact of state-level Medicaid eligibility changes on LARC use.

STUDY DESIGN

We used All-Payers Claims Databases to examine LARC insertions among women enrolled in Medicaid in Massachusetts, which expanded Medicaid in 2014, and Maine, which restricted Medicaid eligibility in 2013. We used interrupted time series (ITS) analyses to determine the impact of Medicaid eligibility changes on level and trends in LARC insertions in these states.

RESULTS

In Massachusetts, graphical evidence demonstrates that after Medicaid expansion, there was an immediate increase in mean monthly LARC insertions and insertions per 1000 enrollees. In ITS regression adjusting for age, LARC insertions per enrollee increased immediately after Medicaid expansion by 32% (P<0.001). After expansion, as the number of enrollees continued to rise, mean monthly LARC insertions rose, but there was a slightly decreasing trend in insertions per enrollee by 1% per month (P<0.001). In Maine, graphical evidence shows that initial reductions in Medicaid eligibility were associated with an immediate drop in LARC insertion numbers and rates per 1000, with ITS regression demonstrating an immediate 17% drop in insertions per enrollee (P<0.001). As Maine's Medicaid enrollment declined from 2013 to 2015, the number of LARC insertions remained flat, leading to an increasing trend in insertions per enrollee, similar to pre-2013 trends (P=0.17).

CONCLUSIONS

Medicaid eligibility changes were associated with immediate changes in LARC uptake. Medicaid expansion may help ensure access to this effective contraceptive method.

Medicaid expansion and neonatal outcomes in Oregon

RATIONALE, AIMS AND OBJECTIVES

Low-income women disproportionately experience preventable, adverse neonatal outcomes. Prior to the Affordable Care Act (ACA) Medicaid expansion, many low-income women became eligible for coverage only after becoming pregnant, reducing their access to healthcare before pregnancy and creating discontinuities in care that may delay Medicaid enrollment. The objective of this study was to examine the impact of the ACA Medicaid expansion on neonatal outcomes among low-income populations in Oregon.

METHOD

We used linked Oregon birth certificate and Medicaid data from 2008-2016 to identify control and policy groups of women who gave birth both before and after implementation of the ACA Medicaid expansion (n = 21 204 births to N = 10 602 women). We conducted a difference-in-differences analysis of the effect of Medicaid expansion on preterm birth, low birthweight (LBW), neonatal intensive care unit (NICU) admissions, and neonatal mortality.

RESULTS

We found policy effects on reducing LBW (interaction aOR = 0.71, 95% CI: 0.57-0.90) and preterm birth (interaction aOR 0.77, 95% CI: 0.62 = 0.96) but not on NICU admissions or neonatal mortality.

CONCLUSIONS

This study provides evidence that expanding Medicaid coverage may have positive effects on LBW and preterm birth, which could lead to important long-term impacts on childhood and later-life health outcomes. States that have not expanded their Medicaid programs might improve neonatal outcomes among low-income populations by extending insurance coverage to low-income adults.

Influence of Medicaid expansion on short interpregnancy interval rates in the United States

BACKGROUND

Short interpregnancy intervals have been associated with poor maternal and infant outcomes. Contraception access could affect the short interpregnancy interval rates.

OBJECTIVE

To assess the influence of Medicaid on short interpregnancy intervals. We tested the hypothesis that Medicaid expansion and subsequent access to birth control would be associated with decreased short interpregnancy intervals.

STUDY DESIGN

Using the United States birth certificate data, we performed a population-based retrospective cohort study including multiparous women who had live births in 2012 and 2016, which is before and after Medicaid expansion had been implemented in 2014. Multivariate logistic regression estimated the influence of Medicaid expansion on short interpregnancy intervals (<12 months). The rate differences of short interpregnancy intervals in 2012 and 2016 were compared between Medicaid expansion vs non-Medicaid expansion states.

RESULTS

There were a total of 7,916,908 live births in 2012 and 2016 in the United States, of which 3,362,904 (42.5%) were in multiparous women with data on interpregnancy intervals (n=1,961,683 [58.3%]) in Medicaid expansion states and in non-Medicaid expansion states (n=1,401,221 [41.7%]). The rate of short interpregnancy intervals in the United States was slightly lower in 2016 (17.3%) than in 2012 (17.4%), P=.0006; rate difference 0.13% (95% confidence interval, 0.05-0.20). Short interpregnancy intervals occurred more frequently in non-Medicaid expansion states than in Medicaid expansion states in both 2012 (18.1% vs 16.6%, respectively; P<.001) and 2016 (18.1% vs 16.4%, respectively; P<.001). The rate of short interpregnancy intervals decreased by 0.11% (95% confidence interval, 0.01-0.22) in Medicaid expansion states and increased by 0.04% (95% confidence interval, 0.09-0.17) in non-Medicaid expansion states. In 2016, living in a Medicaid expansion state was associated with a modestly decreased risk of short interpregnancy intervals (adjusted relative risk, 0.97; 95% confidence interval, 0.97-0.98), even after adjustment for coexisting risks.

CONCLUSION

The risk of short interpregnancy intervals decreased in the Medicaid expansion states even after adjusting for risk factors. Moreover, the short interpregnancy interval rates increased in nonexpansion states but decreased in Medicaid expansion states. If non-Medicaid expansion states had experienced the same rate of decrease in short interpregnancy intervals as Medicaid expansion states, 1122 fewer women would have had a short interpregnancy interval in 2016. Considering the known association between short interpregnancy intervals and adverse maternal and infant outcomes, these findings indicate that Medicaid expansion could improve perinatal outcomes.

Medicaid expansions, preconception insurance, and unintended pregnancy among new parents

OBJECTIVE

To assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first-time parents.

DATA SOURCE

This study used individual-level data from the national Pregnancy Risk Assessment Monitoring System (2006-2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.

STUDY DESIGN

Outcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female-identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.

DATA COLLECTION/EXTRACTION METHODS

The sample included all individuals aged 20-44 with a first live birth in 2009-2017.

PRINCIPAL FINDINGS

Among all first-time parents, a 10-percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high-school degree or less.

CONCLUSIONS

Increasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first-time parents.

Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US

Importance

Contemporary data directly comparing experiences between individuals with public and private health insurance among the 5 major forms of coverage in the US are limited.

Objective

To compare individual experiences related to access to care, costs of care, and reported satisfaction with care among the 5 major forms of health insurance coverage in the US.

Design, Setting, and Participants

This survey study used data from the 2016-2018 Behavioral Risk Factor Surveillance System on 149 290 individuals residing in 17 states and the District of Columbia, representing the experiences of more than 61 million US adults.

Exposure

Private (individually purchased and employer-sponsored coverage) or public health insurance (Medicare, Medicaid, and Veterans Health Administration [VHA] or military coverage).

Main Outcomes and Measures

A pairwise multivariable analysis was performed, controlling for underlying health status of US adults covered by private and public health insurance plans, and responses to survey questions on access to care, costs of care, and reported satisfaction with care were compared. Estimates are weighted.

Results

A total of 149 290 individuals responded to the survey (mean [SD] age, 50.7 [0.2] years; 52.8% female). Among the respondents, most were covered by private insurance (95 396 [63.9%]), followed by Medicare (35 531 [23.8%]), Medicaid (13 286 [8.9%]), and VHA or military (5074 [3.4%]) coverage. Among those with private insurance, most (117 939 [79.0%]) had employer-sponsored coverage. Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57) and were more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17). Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64). Compared with individuals covered by Medicaid, those with employer-sponsored insurance were more likely to report having medical debt (OR, 2.06; 95% CI, 1.83-2.32) and were less likely to report difficulty seeing a physician because of costs (OR, 0.83; 95% CI, 0.73-0.95) and not taking medications because of costs (OR, 0.78; 95% CI, 0.66-0.92). No difference in satisfaction with care (OR, 0.96; 95% CI, 0.87-1.06) was found between individuals with employer-sponsored private health insurance and those with Medicaid coverage.

Conclusions and Relevance

In this survey study, individuals with private insurance were more likely to report poor access to care, higher costs of care, and less satisfaction with care compared with individuals covered by publicly sponsored insurance programs. These findings suggest that public health insurance options may provide more cost-effective care than private options.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.

Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020

Racial and ethnic disparities in women's health have existed for decades, despite efforts to strengthen women's reproductive health access and utilization. Recent guidance by the American College of Obstetricians and Gynecologists (ACOG) underscores the often unacknowledged and unmeasured role of racial bias and systemic racial injustice in reproductive health disparities and highlights a renewed commitment to eliminating them. Reaching health equity requires an understanding of current racial-ethnic gaps in reproductive health and a concerted effort to develop and implement strategies to close gaps. We summarized national data for several reproductive health measures, such as contraceptive use, Pap tests, mammograms, maternal mortality, and unintended pregnancies, by race-ethnicity to inform health-equity strategies. Studies were retrieved by systematically searching the PubMed (2010-2020) electronic database to identify most recently published national estimates by race-ethnicity (non-Hispanic Black or African American, Hispanic or Latinx, and non-Hispanic White women). Disparities were found in each reproductive health category. We describe relevant components of the Affordable Care Act (ACA) and the Preventing Maternal Deaths Act, which can help to further strengthen reproductive health care, close gaps in services and outcomes, and decrease racial-ethnic reproductive health disparities. Owing to continued diminishment of certain components of the ACA, to optimally reach reproductive health equity, comprehensive health insurance coverage is vital. Strengthening policy-level strategies, along with ACOG's heightened commitment to eliminating racial disparities in women's health by confronting bias and racism, can strengthen actions toward reproductive health equity.

Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon

BACKGROUND

The Affordable Care Act allowed states to expand Medicaid eligibility for women with low incomes before pregnancy. Women who experience an unintended pregnancy may encounter fewer delays in accessing abortion services if they are already enrolled in Medicaid. In states where the Medicaid program includes coverage for abortion services, Medicaid expansion may increase timely access to abortion services. Oregon has expanded Medicaid and is 1 of 16 states in which the Medicaid program covers abortion services. We explored how Medicaid expansion in Oregon was associated with Medicaid-financed abortion rates and receipt of medication abortion relative to surgical abortion.

METHODS

Using Medicaid claims and eligibility data we identified women ages 19 to 43 (n = 30,367) who had abortions before the expansion period (2008-2013) and after the expansion period (2014-2016). We used American Community Survey data to estimate the annual number of Oregon women aged 19 to 43 with incomes below 185% of the federal poverty level who would be eligible for a Medicaid-financed abortion. We conducted interrupted time series analyses using negative binomial and logistic regression models.

RESULTS

Incidence of Medicaid-financed abortion increased from 13.4 in 1,000 women in 2008 to 16.3 in 2016. Medication abortion receipt increased from 11.5% of abortions in 2008 to 31.7% in 2016. For both outcomes, we identified an increasing time trend after Medicaid expansion, followed by a subsequent leveling off of the trend. By the end of 2016, incidence of Medicaid-financed abortion was 4.5 abortions per 1,000 women-years (95% confidence interval, 3.3-5.7) higher than it would have been without expansion and medication abortions comprised a 7.4 percentage point (95% confidence interval, 4.4-10.4) greater share of all abortions.

CONCLUSIONS

Medicaid expansion was associated with increased receipt of Medicaid-financed abortions and may have reduced out-of-pocket payment among women with low incomes. Increased receipt of medication abortion may indicate that expansion enhanced earlier access to services, possibly as a result of increased prepregnancy Medicaid enrollment, and this earlier access may increase reproductive autonomy and safety.

Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program

Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

Use of a rapid electronic survey methodology to estimate blood donors' potential exposure to emerging infectious diseases: Application of a statistically representative sampling methodology to assess risk in US blood centers

Risk assessments of transfusion-transmitted emerging infectious diseases (EIDs) are complicated by the fact that blood donors' demographics and behaviors can be different from the general population. Therefore, when assessing potential blood donor exposure to EIDs, the use of general population characteristics, such as U.S. travel statistics, may invoke uncertainties that result in inaccurate estimates of blood donor exposure. This may, in turn, lead to the creation of donor deferral policies that do not match actual risk.

STUDY DESIGN AND METHODS

This article reports on the development of a system to rapidly assess EID risks for a nationally representative portion of the U.S. blood donor population. To assess the effectiveness of this system, a test survey was developed and deployed to a statistically representative sample frame of blood donors from five blood collecting organizations. Donors were directed to an online survey to ascertain their recent travel and potential exposure to Middle East respiratory syndrome coronavirus (MERS-CoV).

RESULTS

A total of 7128 responses were received from 54 256 invitations. The age-adjusted estimated total number of blood donors potentially exposed to MERS-CoV was approximately 15 640 blood donors compared to a lower U.S. general population-based estimate of 9610 blood donors.

CONCLUSION

The structured donor demographic sample-based data provided an assessment of blood donors' potential exposure to an emerging pathogen that was 63% larger than the U.S. population-based estimate. This illustrates the need for tailored blood donor-based EID risk assessments that provide more specific demographic risk intelligence and can inform appropriate regulatory decision making.

Examination of Changes in Health Status Among Michigan Medicaid Expansion Enrollees From 2016 to 2017

IMPORTANCE

Evidence about the health benefits of Medicaid expansion has been mixed and has largely come from comparing expansion and nonexpansion states.

OBJECTIVE

To examine the self-reported health of enrollees in Michigan's Medicaid expansion, the Healthy Michigan Plan (HMP), over time.

DESIGN, SETTING, AND PARTICIPANTS

A telephone survey from January 1 to October 31, 2016 (response rate, 53.7%), and a follow-up survey from March 1, 2017, to January 31, 2018 (response rate, 83.4%), were conducted in Michigan, which expanded Medicaid in 2014 through a Section 1115 waiver permitting state-specific modifications. Four thousand ninety HMP beneficiaries aged 19 to 64 years with at least 12 months of HMP coverage and at least 9 months in a Medicaid health plan were eligible to participate. Data were analyzed from April 1 to November 30, 2018.

MAIN OUTCOMES AND MEASURES

Surveys measured demographic characteristics and health status. Analyses included weights for sampling probability and nonresponse. Comparisons between 2016 and 2017 included those who responded to both surveys (n = 3097).

RESULTS

Of the 3097 respondents to the 2017 follow-up survey, 2388 (77.1%) were still enrolled in HMP (current enrollees) and 709 (22.9%) were no longer enrolled when surveyed (former enrollees). Among all follow-up respondents, a weighted 37.5% (95% CI, 35.3%-39.9%) were aged 19 to 34 years, 34.0% (95% CI, 31.8%-36.2%) were aged 35 to 50 years, and 28.5% (95% CI, 26.7%-30.3%) were aged 51 to 64 years; 53.0% (95% CI, 50.8%-55.3%) were female. Respondents who reported fair or poor health decreased from 30.7% (95% CI, 28.7%-32.8%) in 2016 to 27.0% (95% CI, 25.1%-29.0%) in 2017 (adjusted odds ratio [AOR], 0.66 [95% CI, 0.53-0.81]; P < .001), with the largest decreases observed in respondents who were non-Hispanic black (from 31.5% [95% CI, 27.1%-35.9%] in 2016 to 26.0% [95% CI, 21.9%-30.1%] in 2017; P = .009), from the Detroit metropolitan area (from 30.7% [95% CI, 27.0%-34.4%] in 2016 to 24.9% [95% CI, 21.6%-28.3%] in 2017; P = .001), and with an income of 0% to 35% of the federal poverty level (from 37.6% [95% CI, 34.2%-40.9%] in 2016 to 32.3% [95% CI, 29.1%-35.5%] in 2017; P < .001). From 2016 to 2017, the mean number of days of poor physical health in the past month decreased significantly from 6.9 (95% CI, 6.5-7.4) to 5.7 (95% CI, 5.3-6.0) (coefficient, -6.10; P < .001), including among current (from 7.0 [95% CI, 6.5-7.5] to 5.6 [95% CI, 5.1-6.0]; P < .001) and former (from 6.8 [95% CI, 5.9-7.7] to 5.8 [95% CI, 5.0-6.7]; P = .02) enrollees, those with 2 or more chronic conditions (from 9.9 [95% CI, 9.3-10.6] to 8.5 [95% CI, 7.8-9.1]; P < .001), across all age groups (19-34 years, from 4.3 [95% CI, 3.7-4.9] to 3.0 [95% CI, 2.5-3.5]; P < .001; 35-50 years, from 8.2 [95% CI, 7.3-9.0] to 6.9 [95% CI, 6.1-7.7]; P = .002; 51-64 years, from 9.0 [95% CI, 8.2-9.8] to 7.6 [95% CI, 6.9-8.3]; P = .001), and among non-Hispanic white (from 7.5 [95% CI, 7.0-8.1] to 6.1 [95% CI, 5.6-6.6]; P < .001) and black (from 5.9 [95% CI, 5.1-6.8] to 4.4 [95% CI, 3.6-5.1]; P < .001) respondents. No changes in days of poor mental health or usual activities missed owing to poor physical or mental health were observed.

CONCLUSIONS AND RELEVANCE

These findings suggest that HMP enrollees in Michigan have experienced improvements in self-reported health over time, including minority groups with a history of health disparities and enrollees with chronic health conditions.

Payment for Contraceptive Services in Safety Net Clinics: Roles of Affordable Care Act, Title X, and State Programs

OBJECTIVES

We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs.

METHODS

Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities.

RESULTS

We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states.

CONCLUSIONS

Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.

Beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care

In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people's contraceptive needs and support reproductive autonomy.

Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion

BACKGROUND

Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services.

OBJECTIVE

Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services.

DESIGN

Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment.

PARTICIPANTS

4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims.

KEY RESULTS

In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services.

CONCLUSIONS

After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.

Engagement with Health Risk Assessments and Commitment to Healthy Behaviors in Michigan's Medicaid Expansion Program

BACKGROUND

Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees' health.

OBJECTIVE

To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program.

DESIGN

Telephone survey conducted in Michigan January-October 2016.

PARTICIPANTS

A random sample of HMP enrollees aged 19-64 with ≥ 12 months of enrollment, stratified by income and geographic region.

MAIN MEASURES

Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior.

KEY RESULTS

Among respondents (N = 4090), 49.3% (95% CI 47.3-51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5-86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6-92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5-52.8% vs. 36.2%, 95% CI 31.7-41.1%; p < 0.01). Among enrollees completing an HRA, nearly half said they did it because their PCP suggested it (45.9%, 95% CI 43.2-48.7%), and most reported it helped their PCP understand their health needs (89.7%). Awareness of financial incentives was limited (28.1%, 95% CI 26.3-30.0%), and very few reported it as the primary reason for HRA completion (2.5%, 95% CI 1.8-3.4%). Most committed to a healthy behavior (80.7%, 95% CI 78.5-82.8%), and common behaviors chosen were nutrition/diet (57.2%, 95% CI 54.2-60.2%) and exercise/activity (52.6%, 95% CI 49.5-55.7%).

CONCLUSIONS

In the Healthy Michigan Plan, PCPs appeared influential in enrollees' completion of HRAs and healthy behavior engagement, while knowledge of financial incentives was limited. Additional study is needed to understand the relative importance of financial incentives and PCP engagement in impacting healthy behaviors in state Medicaid programs.

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan

IMPORTANCE

Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear.

OBJECTIVE

To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018.

MAIN OUTCOMES AND MEASURES

Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students.

RESULTS

The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status.

CONCLUSIONS AND RELEVANCE

Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.

Association of Expanded Medicaid Coverage With Health and Job-Related Outcomes Among Enrollees With Behavioral Health Disorders

OBJECTIVES

The study objective was to assess the impact of Medicaid expansion on health and employment outcomes among enrollees with and without a behavioral health disorder (either a mental or substance use disorder).

METHODS

Between January and October 2016, the authors conducted a telephone survey of 4,090 enrollees in the Michigan Medicaid expansion program and identified 2,040 respondents (48.3%) with potential behavioral health diagnoses using claims-based diagnoses.

RESULTS

Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work. In adjusted analyses, both enrollees with behavioral health diagnoses and those without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work and made them better able to look for a job. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as those without a behavioral health diagnosis to report improved ability to work and improved job seeking after Medicaid expansion.

CONCLUSIONS

Coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.

Evaluating the effect of Medicaid expansion on access to preventive reproductive care for women in Oregon

We evaluated the effect of the Affordable Care Act (ACA) Medicaid expansion on receipt of preventive reproductive services for women in Oregon. First, we compared service receipt among continuing Medicaid enrollees pre- and post-ACA. We then compared receipt among new post-ACA Medicaid enrollees to receipt by continuing enrollees after ACA implementation. Using Medicaid enrollment and claims data, we identified well-woman visits, contraceptive counseling, contraceptive services, sexually transmitted infection (STI) screening, and cervical cancer screening among women ages 15-44 in years when not pregnant. For pre-ACA enrollees, we assessed pre-ACA receipt in 2011-2013 (n = 83,719) and post-ACA receipt in 2014-2016 (n = 103,225). For post-ACA enrollees we similarly assessed post-ACA service receipt (n = 73,945) and compared this to service receipt by pre-ACA enrollees during 2014-2016. We estimated logistic regression models to compare service receipt over time and between enrollment groups. Among pre-ACA enrollees we found lower receipt of all services post-ACA. Adjusted declines ranged from 7.0 percentage points (95% CI: -7.5, -6.4) for cervical cancer screening to 0.4 percentage points [-0.6, -0.2] for STI screening. In 2014-2016, post-ACA enrollees differed significantly from pre-ACA enrollees in receipt of all services, but all differences were <2 percentage points. Despite small declines in receipt of several preventive reproductive services among prior enrollees, the ACA resulted in Medicaid financing of these services for a large number of newly enrolled low-income women in Oregon, which may eventually lead to population-level improvements in reproductive health. These findings among women in Oregon could inform Medicaid coverage efforts in other states.