The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

Evaluating the health outcomes of aging in place: the role of medicaid aging waiver program on U.S. older adults

The Medicaid Aging Waiver program (MAW) subsidizes the cost of long-term care (LTC) at home or in communities to satisfy older people's increasing desire to age in place. The MAW program might be health improving for older people by allowing them to age at home. However, less quality and quantity of home-based care comparing to nursing home care could offset some of the potential benefits. I use policy expenditure across states over time linked with detailed health information from the Health and Retirement Study (HRS) to identify the associated effects of MAWs on health outcomes of older adults who are at risk of needing LTC and who are resources constrained to be potentially eligible for Medicaid. Overall, the findings suggest that the MAW program is beneficial to health: a $1,000 increase in MAW spending for each older person results is associated with a 1.4 percent improvement in self-reported health status, a 1.5 percent reduction in functional mobility limitations, a 1.6 percent decrease in Instrumental Activities of Daily Living (IADL) limitations, and a 1.7 percent improvement in negative psychological feelings. For older people who are most likely not eligible for MAWs, such as those who are wealthy or in good health and do not require LTC, these health-improving effects have not been observed.

The impact of the 2014 Medicaid expansion on the health, health care access, and financial well-being of low-income young adults

Prior to the 2014 Affordable Care Act (ACA) expansion, 37% of young adults ages 19-25 in the United States were low-income and a third lacked health insurance coverage-both the highest rates for any age group in the population. The ACA's Medicaid eligibility expansion, therefore, would have been significantly beneficial to low-income young adults. This study evaluates the effect of the ACA Medicaid expansion on the health, health care access and utilization, and financial well-being of low-income young adults ages 19-25. Using 2010-2017 National Health Interview Survey data, I estimate policy effects by applying a difference-in-differences design leveraging the variation in state implementation of the expansion policy. I show that Medicaid expansion improved health insurance coverage, health care access, and financial well-being for low-income young adults in expansion states, but had no effect on their health status and health care utilization. I also find that the policy was associated with larger gains in health coverage for racial minorities relative to their Non-Hispanic White counterparts. With the continued health policy reform debates at the state and federal levels, the empirical evidence from this study can help inform policy decisions that aim to improve health care access and utilization among disadvantaged groups.

Inequities in Alcohol Screening of Primary Care Patients with Chronic Conditions

INTRODUCTION

Routine alcohol screening of people with chronic health conditions that are exacerbated by alcohol can help to prevent morbidity and mortality. The U.S. Affordable Care Act and other recent health reforms expanded insurance coverage and supported alcohol screening in primary care. This study assessed increases in alcohol screening following health reform, and insurance-related and racial and ethnic disparities in screening.

METHODS

Data are from the 2013-2019 National Surveys on Drug Use and Health for adults with alcohol-related chronic conditions who received primary care in the past year (N=46,014). The outcome was receipt of alcohol screening (yes/no) in which a health care provider inquired whether, how often, or how much the respondent drank, or about having alcohol-related problems. Multivariable logistic regression models assessed temporal changes in screening overall and by insurance type and race/ethnicity, adjusting for demographics, health conditions, and primary care utilization. Statistical analysis was performed in 2023.

RESULTS

Alcohol screening prevalence rose from 69% to 77% from 2013 through 2019, with a notable increase in 2014-15 for both Medicaid-insured and privately-insured patients. Black and Asian American patients were generally less likely to be screened than White patients. Importantly, racial disparities in screening were found among privately-insured patients, patients with hypertension, patients with heart disease, and patients with diabetes who drink alcohol.

CONCLUSIONS

Alcohol screening of primary care patients with chronic conditions increased following health reform, but persistent disparities among patients with private insurance and specific chronic conditions underscore the need to address drivers of unequal preventive care.

Access to PrEP and other sexual health services for cisgender women in the United States: a review of state policy and Medicaid expansion

Pre-exposure prophylaxis (PrEP) has the potential to prevent new HIV infections, but it is unclear how state policies governing sexual and reproductive health services (SRH) impact access for cisgender women. The objective of this review is to identify barriers to PrEP access for cisgender women in the United States. Using the CDC Atlas Program, 20 states with the highest HIV incidence among cisgender women were included in this analysis. Through a search conducted in May-July 2022 of CDC, PrEPWatch.org, and other State Department and Insurance websites, Medicaid expansion status, pharmacist PrEP prescribing laws, financial support programs, and Traditional Medicaid coverage of PrEP, HIV testing, and emergency contraception were reviewed. Of the included states, nearly half did not expand Medicaid at the state level. Emergency contraception and HIV testing was covered under Traditional Medicaid for almost all included states, but insurance stipulations and eligibility requirements remain. Although PrEP is covered under all Traditional Medicaid plans, six states require pre-authorization. Three states have HIV testing mandates, four allow pharmacists to prescribe PrEP and six have financial support programs to cover the cost of PrEP. Medicaid expansion, pre-authorization requirements for PrEP prescriptions and emergency contraception, and limitations on pharmacist prescribing abilities were identified as barriers to SRH access for cisgender women. Medicaid expansion should be prioritized as an approach to expanding access to HIV prevention services at the state level.

Association of Medicaid coverage with emergency department utilization after self-harm in Korea: A nationwide registry-based study

BACKGROUND

Self-harm presents an important public health challenge. It imposes a notable burden on the utilization of emergency department (ED) services and medical expenses from patients and family. The Medicaid system is vital in providing financial support for individuals who struggle with medical expenses. This study explored the association of Medicaid coverage with ED visits following incidents of self-harm, utilizing nationwide ED surveillance data in Korea.

METHODS

Data of all patients older than 14 years who presented to EDs following incidents of self-harm irrespective of intention to end their life, including cases of self-poisoning, were gathered from the National ED Information System (NEDIS). The annual self-harm visit rate (SHVR) per 100,000 people was calculated for each province and a generalized linear model analysis was conducted, with SHVR as a dependent variable and factors related to Medicaid coverage as independent variables.

RESULTS

A 1% increase in Medicaid enrollment rate was linked to a significant decrease of 14% in SHVR. Each additional 1,000 Korean Won of Medicaid spending per enrollee was correlated with a 1% reduction in SHVR. However, an increase in Medicaid visits per enrollee and an extension of Medicaid coverage days were associated with an increase in SHVR. SHVR exhibited a stronger associated with parameters of Medicaid coverage in adolescents and young adults than in older adult population.

CONCLUSION

Expansion of Medicaid coverage coupled with careful monitoring of shifts in Medicaid utilization patterns can mitigate ED overloading by reducing visits related to self-harm.

The effects of Medicaid expansion on the racial/ethnic composition within nursing home residents

BACKGROUND

The Affordable Care Act (ACA), enacted in 2010, aimed to improve healthcare coverage for American citizens. This study investigates the impact of Medicaid expansion (ME) under the ACA on the racial and ethnic composition of nursing home admissions in the U.S., focusing on whether ME has led to increased representation of racial/ethnic minorities in nursing homes.

METHODS

A difference-in-differences estimation methodology was employed, using U.S. county-level aggregate data from 2000 to 2019. This approach accounted for multiple time periods and variations in treatment timing to analyze changes in the racial and ethnic composition of nursing home admissions post-ME. Additionally, two-way fixed effects (TWFE) regression was utilized to enhance robustness and validate the findings.

RESULTS

The analysis revealed that the racial and ethnic composition of nursing home admissions has become more homogeneous following Medicaid expansion. Specifically, there was a decline in Black residents and an increase in White residents in nursing homes. Additionally, significant differences were found when categorizing states by income inequality, and poverty rate levels. These findings remain statistically significant even after controlling for additional variables, indicating that ME influences the racial makeup of nursing home admissions.

CONCLUSIONS

Medicaid expansion has not diversified nursing home demographics as hypothesized; instead, it has led to a more uniform racial composition, favoring White residents. This trend may be driven by nursing home preferences and financial incentives, which could favor residents with private insurance or higher personal funds. Mechanisms such as payment preferences and local cost variations likely contribute to these shifts, potentially disadvantaging Medicaid-reliant minority residents. These findings highlight the complex interplay between healthcare policy implementation and racial disparities in access to long-term care, suggesting a need for further research on the underlying mechanisms and implications for policy refinement.

Examining the impact of Medicaid payments for immediate postpartum long-acting reversible contraception on the mental health of low-income mothers

OBJECTIVE

To examine the effect of Medicaid immediate postpartum long-acting reversible contraception (IPP LARC) reforms on self-reported mental health among low-income mothers aged 18-44 years.

DATA SOURCES AND STUDY SETTING

We used national secondary data on self-reported mental health status in the past 30 days from the core component (2014-2019) of the Behavioral Risk Factor Surveillance System (BRFSS).

STUDY DESIGN

We estimated linear probability models for reporting any days of not good mental health in the past 30 days. We adjusted for individual-level factors, state-level factors, and state and year fixed effects. Our primary independent variable was an indicator for IPP LARC payment reform. We examined the effect of the Medicaid payment reforms on self-reported mental health status in the past 30 days using difference-in-differences and event-study designs.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

State adoption of Medicaid IPP LARC reforms was associated with significant reductions (between 5.7% and 11.5%) in the predicted probability of reporting any days of not good mental health among low-income mothers. Treatment effects appeared to be driven by respondents reporting two or more children (less than 18 years of age) in the household (ATT = -0.028, p = 0.04). Results are robust to a series of sensitivity tests and alternative estimation strategies.

CONCLUSIONS

Our findings suggest that contemporary efforts to improve access to contraceptive methods may have important benefits beyond reproductive autonomy. These findings have implications for policymakers as the landscape related to family planning services continues to shift.

Utilization and Outcomes of Roux-en-Y Gastric Bypass Surgery Following the Affordable Care Act in the United States

BACKGROUND

The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery.

METHODS

Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type.

RESULTS

In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period.

DISCUSSION

Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.

The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion

BACKGROUND

Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods.

MAIN OUTCOMES AND MEASURES

The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64.

RESULTS

Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries.

CONCLUSIONS

Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

The impact of Medicaid expansion and travel distance on access to transplantation

Most transplant centers require candidates be insured before they can join the waitlist for a deceased donor organ. After the Affordable Care Act, many uninsured Americans gained improved access to Medicaid. I examine the effect of this increase in access to insurance and find that Medicaid expansions significantly increase Medicaid-insured waitlist registrations by 39% and deceased donor transplants received by 44%, but the increase in registrations is larger for candidates who live closer to a transplant center. Additionally I show that most of these registrations would have been privately insured otherwise but provide suggestive evidence that this is better explained by improved access to subsidized private coverage due to other ACA reforms than from candidates with private coverage before the ACA switching to Medicaid coverage after expansion. This suggests that although the ACA improved access to the transplantation system, access is still limited for candidates who live far from centers.

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states

BACKGROUND AND AIMS

Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line.

DESIGN

A two-way fixed-effects model was used to analyze serial cross-sectional observational data.

SETTING

Seventeen metro areas in 13 US states took part in the study.

PARTICIPANTS

Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD.

MEASUREMENTS

State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation).

FINDINGS

The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584).

CONCLUSIONS

US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Unmet needs and the effect of healthcare system generosity on prevention activity - A multilevel analysis

INTRODUCTION

Maintaining a healthy lifestyle and obtaining preventive care (hereafter, prevention-activity) usually have an inverse association with poverty status and unmet needs. We seek to estimate the extent to which the effect of individual unmet needs status on prevention-activity is moderated by the generosity of the healthcare system.

MATERIALS AND METHODS

Two datasets were combined: Pre-Covid Wave-8 (2019-2020) of the Survey of Health, Ageing and Retirement in Europe (SHARE, Release 8.0.0), with 46,500 individuals aged 50+ from 27 countries (26 European countries and Israel) and 12 healthcare generosity variables obtained from the OECD Health Statistics Library. An econometric two-level model was used in three sequentially models. Outcome variables included five prevention-activities align over a continuum (sports, smoking, flu vaccinations, mammography, and colon cancer screening) and unmet needs status, defined as the lack of resources necessary to meet basic human and medical needs.

RESULTS

We found that unmet needs at the individual level had a significant negative fixed effect in all of the prevention-activity models including a healthy lifestyle, primary prevention and secondary prevention. Sources of intra-country variation were social/public insurance, health expenditure and number of nurses, which have had a significant and positive effect on an individual's prevention-activities (except years of smoking). Nonetheless, the gaps in generous countries between people reporting on unmet need and others were larger or similar to those in less generous countries, suggesting that disparities increase with the generosity of the health system.

CONCLUSIONS

The study provides insight into the effect of health system generosity on socioeconomic inequalities in healthy lifestyle and prevention care. Our findings suggest that the state has an important and decisive role to play in ensuring that prevention services are accessible to the entire population, particularly those reporting unmet needs.

Health insurance and fertility among low-income, childless, single women: evidence from the ACA Medicaid expansions

Expansions of Medicaid family planning services have been associated with decreases in pregnancy rates. Access to a broader range of medical, non-family planning services may influence pregnancy rates as well if the increased exposure to medical services spills over to other kinds of behaviour. Using a difference-in-difference approach, I examine the impact of the Affordable Care Act (ACA) Medicaid expansions on the propensity of low-income, single women to become single mothers. Previous expansions of Medicaid family planning services allow us to also investigate the influence of access to other medical services (i.e. non-family planning). I find that although access to contraceptives is associated with a reduction in the propensity of becoming a single mother among adult, low-income women, medical services beyond access to contraceptives can provide additional impacts.

Cancer pain and alcohol self-medication

BACKGROUND

Cancer survivors are at increased risk of pain due to their either cancer and/or treatments. Substances like alcohol may be used to self-medicate cancer pain; however, these substances pose their own health risks that may be more pronounced for cancer survivors.

METHODS

We used cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) 2012-2019 to quantify the association between cancer pain and alcohol use. We used negative binomial regression, with interaction terms added to examine variations across age, sex, and race. We also examined whether alcohol use relates to cancer pain control status.

RESULTS

Cancer survivors with cancer pain were more likely to be younger, female, Black, and to have been diagnosed with breast cancer. Cancer pain was associated with lower alcohol consumption (incidence rate ratio (IRR): 0.88, confidence interval (CI): 0.77, 0.99). This association was primarily among people 65 and older, women, and white and Hispanic people. Cancer pain control status was not related to alcohol use.

CONCLUSIONS

Lower alcohol use among cancer survivors with pain has many possible explanations, including several alternative pain management strategies or a decrease in social engagement. Our findings of racial and gender disparities in cancer pain are consistent with the broader evidence on disparities in pain.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer pain management for marginalized groups should be improved. Healthcare providers should screen cancer survivors for both pain and substance use, to prevent unhealthy self-medication behaviors.

Effects of private health insurance on healthcare services during the MERS Pandemic: Evidence from Korea

This study investigates how private health insurance impacted healthcare services during the MERS pandemic in Korea. Using the Korea Health Panel Study (KHPS), this study examines the difference in healthcare utilization between insured and uninsured individuals during the pandemic. If insured individuals use fewer healthcare services than the uninsured during the MERS pandemic, it could be evidence of moral hazard. During the MERS outbreak, the probability of outpatient medical services utilization was lower by 19 % than during non-pandemic periods. All individuals decreased the number of outpatient visits by 7 %. Insured individuals reduced outpatient visits more than the uninsured in response to the MERS pandemic. The increased outpatient utilization by private health insurance could be attributed to both moral hazard and adverse selection. However, given that people with poor health cannot enroll in private health insurance due to the insurance company's screening process, moral hazard leads to increase healthcare utilization rather than adverse selection.

Trends in Preventive Care Services Among U.S. Adults With Diagnosed Diabetes, 2008-2020

OBJECTIVE

Preventive care services are important to prevent or delay complications associated with diabetes. We report trends in receipt of six American Diabetes Association-recommended preventive care services during 2008-2020.

RESEARCH DESIGN AND METHODS

We used 2008-2020 data from the cross-sectional Medical Expenditures Panel Survey to calculate the proportion of U.S. adults ≥18 years of age with diagnosed diabetes who reported receiving preventive care services, overall and by subpopulation (n = 25,616). We used joinpoint regression to identify trends during 2008-2019. The six services completed in the past year included at least one dental examination, dilated-eye examination, foot examination, and cholesterol test; at least two A1C tests, and an influenza vaccine.

RESULTS

From 2008 to 2020, proportions of U.S. adults with diabetes receiving any individual preventive care service ranged from 32.6% to 89.9%. From 2008 to 2019, overall trends in preventive services among these adults were flat except for an increase in influenza vaccination (average annual percent change: 2.6% [95% CI 1.1%, 4.2%]). Trend analysis of subgroups was heterogeneous: influenza vaccination and A1C testing showed improvements among several subgroups, whereas cholesterol testing (patients aged 45-64 years; less than a high school education; Medicaid insurance) and dental visits (uninsured) declined. In 2020, 8.2% (95% CI 4.5%, 11.9%) of those with diabetes received none of the recommended preventive care services.

CONCLUSIONS

Other than influenza vaccination, we observed no improvement in preventive care service use among U.S. adults with diabetes. These data highlight services and specific subgroups that could be targeted to improve preventive care among adults with diabetes.

Changes in emergency department use associated with Medicaid expansion under the Affordable Care Act: A comparison of waiver and traditional expansion states

Objective

To determine whether changes in emergency department use associated with Medicaid expansions differed between states undergoing waiver and traditional expansions.

Methods

Design: This study was a cross-sectional difference-in-difference and event studies of Medicaid Expansion among states that expanded during or after 2014. Setting: We used a nationally representative cross-sectional survey from all 50 United States and the District of Columbia from 2010 to 2016. Participants: Adults aged 19-65 years with incomes <138% of the federal poverty level were included. Main Outcomes and Measures: Main outcomes were self-reported emergency department (ED) utilization in the last 12 months.

Results

Individuals in states across all expansion types were not more likely to report any ED use in the previous year (2.8 percentage point increase [0.0-5.5], P = 0.052) but were more likely to report visiting an ED 2 times or more in the previous year (2.0 [0.0-4.1], P = 0.049) than those in non-expansion states. Individuals in states undergoing traditional expansions likewise were not more likely to report any ED use (2.2 [-0.7 to 1.5], P = 0.136) but were more likely to report visiting an ED 2 times or more in the previous year (2.3 [0.1-4.4], P = 0.038). Conversely, individuals in waiver states were more likely to report increase in any ED use (5.6 [0.3-11.0], P = 0.038), but were not more likely to report use of EDs 2 times or more in the previous year (0.8 [-3.2-4.9], P = 0.688). The differences between traditional and waiver states in any ED use and ED use 2 times or more in the previous 12 months were not statistically significant (P = 0.215 and P = 0.501, respectively).

Conclusions

Three years after expanding Medicaid under the Affordable Care Act, there is little evidence of differences between traditional and waiver expansion states in changes in any ED use or intensive ED use. Future studies should investigate longer term changes in ED use.

The effect of hurricanes on mental health over the long term

Existing causal studies examining the impact of hurricanes on health and health-related outcomes typically focus on short-run impacts and specific outcomes associated with physical health. In this paper, I explore the long-term effects of Hurricanes Katrina and Rita on the mental health of adults using two individual-level datasets from the Behavioral Risk Factor Surveillance System and the Panel Survey of Income Dynamics. Difference-in-differences models are used to estimate the long-run causal impact of hurricanes. I compare the mental health of adults living in Katrina and Rita affected counties to those in other counties before and after the hurricanes. My findings suggest that the hurricanes increased the number of poor mental health days by 0.49 days per 30 days (14.5 %) during a seven-year post period (2006-2012) and psychological distress by 0.46 K-6 points (15.2 %) during a six-year post period. I also find that the estimated effects were notably larger among specific sub-groups, such as single mothers and black respondents. These results are robust to different sample and functional form specifications. From a policy perspective, these findings suggest that long-lasting effects need to be included in any analysis of the impact of hurricanes in order to capture their full effect.

Ex-ante moral hazard and health insurance: Evidence from China's urban residence basic medical insurance scheme

This study examines whether implementing Urban Residents Medical Insurance Scheme decreased an individual's risky lifestyle behavior before illness, termed ex-ante moral hazard. Ex-ante moral hazard is predicted by the classical economic theory suggesting that health insurance coverage reduces an individual's incentive to take preventive efforts to remain healthy. Studies have provided mixed evidence for this prediction. China's 2006 nationwide social experiment of implementing the Urban Residents Basic Medical Insurance Scheme offers an excellent opportunity for examining the effect of the transition from uninsured to insured on an individual's health behaviors. We exploit the longitudinal dimension of a representative survey data for 2007-2010 and employ the instrumental variable technique, thereby addressing the issue of self-selection into voluntary health insurance schemes. The results do not provide evidence for and contrast the prediction of the ex-ante moral hazard. Significant differences exist between insured and uninsured groups with respect to smoking, drinking habits, and being overweight. People with insurance care more about their health than people without insurance do. The main results still hold if we use alternative estimation methods and other robustness tests.

Associations Between Medicaid Expansion and Mental Health Among U.S. Racial and Ethnic Groups

OBJECTIVE

The authors examined associations between Medicaid expansion and self-reported mental health by race-ethnicity, focusing on lagged associations.

METHODS

This retrospective, cross-sectional study used 2011-2019 data from the Behavioral Risk Factor Surveillance System. The sample included low-income, childless adults ages 25-64 years. Difference-in-differences (DID) analysis was used to estimate associations between Medicaid expansion and self-reported mental health. Lagged associations were examined by separating the postexpansion period into proximal (2014-2016) and distal (2017-2019) periods.

RESULTS

In the overall sample (N=327,248), Medicaid expansion was associated with a reduction in the mean number of self-reported past-month poor mental health days (DID=-0.12, 95% CI=-0.21 to -0.03), after adjustment for covariates. The expansion was associated with significant reductions in past-month poor mental health days for the following groups: non-Hispanic White (DID=-0.18, 95% CI=-0.29 to -0.07), non-Hispanic Asian (DID=-1.15, 95% CI=-1.37 to -0.93), non-Hispanic other (DID=-0.62, 95% CI=-1.03 to -0.21), and Hispanic (DID=-0.48, 95% CI=-0.73 to -0.23). The non-Hispanic Black group had a significant increase in past-month poor mental health days (DID=0.27, 95% CI=0.06 to 0.49), and no significant change was noted for the American Indian or Alaska Native (AIAN) group. Improvements in mental health observed at the beginning of the policy implementation (proximal period) were not sustained over time for some racial-ethnic minority groups.

CONCLUSIONS

Although Medicaid expansion improved mental health for the overall sample, some racial-ethnic disparities were detected. The negative and insignificant associations for the non-Hispanic Black and AIAN groups, respectively, highlight the need to better understand why the Medicaid expansion affected racial-ethnic groups differently.

Proportion Of Preventive Primary Care Visits Nearly Doubled, Especially Among Medicare Beneficiaries, 2001-19

There is debate about the value of preventive visits in primary care, and multiple policy trends during the past fifteen years may have influenced the likelihood of US adults undergoing preventive primary care visits. Using nationally representative, serial cross-sectional data on adult visits to primary care physicians from the 2001-19 National Ambulatory Medical Care Survey, we characterized temporal trends in the proportion of primary care visits with a preventive focus and the differential characteristics of these visits. Based on a sample of 139,783 unweighted (5,902,144,258 weighted) US primary care visits, we found that the proportion of primary care visits with a preventive focus increased between 2001 and 2019 (12.8 percent of visits in 2001-02 versus 24.6 percent in 2018-19; [Formula: see text]), with the greatest rate of increase seen for people with Medicare. Primary care visits with a preventive focus involved more time spent with the physician and addressed fewer reasons for the visit compared with problem-based visits. At least one of the following was significantly more likely to occur during a preventive visit than a problem-based visit: counseling provision, ordering of preventive labs, or ordering of a preventive image or procedure. Our findings demonstrate a relative increase in preventive versus problem-based visits in primary care and suggest the importance of enhanced insurance coverage in influencing preventive care delivery trends.

The validity of causal claims with repeated measures designs: A within-study comparison evaluation of differences-in-differences and the comparative interrupted time series

Modern policies are commonly evaluated not with randomized experiments but with repeated measures designs like difference-in-differences (DID) and the comparative interrupted time series (CITS). The key benefit of these designs is that they control for unobserved confounders that are fixed over time. However, DID and CITS designs only result in unbiased impact estimates when the model assumptions are consistent with the data at hand. In this paper, we empirically test whether the assumptions of repeated measures designs are met in field settings. Using a within-study comparison design, we compare experimental estimates of the impact of patient-directed care on medical expenditures to non-experimental DID and CITS estimates for the same target population and outcome. Our data come from a multi-site experiment that includes participants receiving Medicaid in Arkansas, Florida, and New Jersey. We present summary measures of repeated measures bias across three states, four comparison groups, two model specifications, and two outcomes. We find that, on average, bias resulting from repeated measures designs are very close to zero (less than 0.01 standard deviations; SDs). Further, we find that comparison groups which have pre-treatment trends that are visibly parallel to the treatment group result in less bias than those with visibly divergent trends. However, CITS models that control for baseline trends produced slightly more bias and were less precise than DID models that only control for baseline means. Overall, we offer optimistic evidence in favor of repeated measures designs when randomization is not feasible.

Differences in use of high- and low-value health care between immigrant and US-born adults

OBJECTIVE

To examine differences in the use of high- and low-value health care between immigrant and US-born adults.

DATA SOURCE

The 2007-2019 Medical Expenditure Panel Survey.

STUDY DESIGN

We split the sample into younger (ages 18-64 years) and older adults (ages 65 years and over). Our outcome measures included the use of high-value care (eight services) and low-value care (seven services). Our key independent variable was immigration status. For each outcome, we ran regressions with and without individual-level characteristics.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Before accounting for individual-level characteristics, the use of high- and low-value care was lower among immigrant adults than US-born adults. After accounting for individual-level characteristics, this difference decreased in both groups of younger and older adults. For high-value care, significant differences were observed in five services and the direction of the differences was mixed. The use of breast cancer screening was lower among immigrant than US-born younger and older adults (-5.7 [95% CI: -7.4 to -3.9] and -2.9 percentage points [95% CI: -5.6 to -0.2]) while the use of colorectal cancer screening was higher among immigrant than US-born younger and older adults (2.6 [95% CI: 0.5 to 4.8] and 3.6 [95% CI: 0.2 to 7.0] percentage points). For low-value care, we did not identify significant differences except for antibiotics for acute upper respiratory infection among younger adults and opioids for back pain among older adults (-3.5 [95% CI: -5.5 to -1.5] and -3.8[95% CI: -7.3 to -0.2] percentage points). Particularly, differences in socioeconomic status, health insurance, and care access between immigrant and US-born adults played a key role in accounting for differences in the use of high- and low-value health care. The use of high-value care among immigrant and US-born adults increased over time, but the use of low-value care did not decrease.

CONCLUSION

Differential use of high- and low-value care between immigrant and US-born adults may be partly attributable to differences in individual-level characteristics, especially socioeconomic status, health insurance, and access to care.

Cost of Public Health Insurance for US-Born and Immigrant Adults

Importance

The immigrant population in the US has low health insurance coverage. Surveys find that approximately one-half of the US population is opposed to public health insurance of immigrants, and there is a widely held belief that immigrants are a state fiscal liability.

Objective

To estimate the cost of providing public health insurance to immigrants in the US.

Design, Setting, and Participants

This serial cross-sectional study used restricted data from the 2011 to 2019 Medical Expenditure Panel Survey (and data from 2011-2020 in supplemental analyses). The data are nationally representative of the US civilian noninstitutionalized population. Participants included adults aged 19 to 64 years with family incomes below 138% of the Federal Poverty Level, the population that benefited from the Medicaid expansions. Data analysis was performed from November 2022 to August 2023.

Exposures

State Medicaid expansion.

Main Outcomes and Measures

The primary outcomes were insurance coverage, total health care expenditures, expenditures categorized by payment source (paid by self or family and paid by others), expenditures by major health care type (office based, inpatient, and prescription), and health care utilization (number of office-based visits, outpatient facility visits, emergency department visits, hospital discharges, dental care visits, home health clinician days, and prescription medicine refills). A difference-in-differences method was used to compare the health care cost and utilization by low-income, working-age US-born and immigrant adults in states that adopted the Patient Protection and Affordable Care Act (ACA) Medicaid expansions with the corresponding change in nonexpansion states before and after the policy implementation.

Results

Among the study sample of 44 482 individuals (mean [SD] age, 38.5 [14.0] years; 25 221 female individuals [56.7%]; 34 052 [76.6%] US born), 46% of immigrant adults (1953 participants) and 70% of US-born adults (9396 participants) had insurance coverage in the pre-ACA period. Medicaid expansions increased insurance coverage of both groups by 7 percentage points (95% CI, 3 to 11 percentage points). The resulting change in health care increased total expenditures (self-paid plus insurer paid) by $660 (95% CI, $79 to $1242) and insurer-paid expenditures by $745 (95% CI, $141 to $1350) per US-born adult. For immigrant adults, the corresponding changes in total ($266; 95% CI, -$348 to $880) and insurer-paid ($308; 95% CI, -$352 to $968) expenditures were small and not statistically significant. Estimates suggest that providing insurance to immigrants costs the health care system approximately $3800 per person per year, less than one-half the corresponding cost ($9428 per person per year) for US-born adults.

Conclusions and Relevance

These findings suggest that the direct cost of providing public health insurance to immigrants is less than that for the US born, and immigrants' health care utilization, upon coverage, remains comparatively modest, thus refuting the notion that providing insurance to immigrants imposes a heavy fiscal burden.

Finding fraud: enforcement, detection, and recoveries after the ACA

Medicaid Fraud Control Units investigate and prosecute acts of financial fraud and patient abuse within the program. Prior to the expansion of Medicaid under the Affordable Care Act (ACA), federal government MFCU expenditures totaled half a percent of Medicaid expenditures. Following the enrollment of 12 million adults into the Medicaid program under the ACA, expenditures for these units are now less than pre-ACA levels, as a share of program expenses. We use data for states' fraud enforcement efforts in the period 2010-2018 and a difference-in-differences design that exploits states' decision to expand Medicaid under the ACA. States that did expand Medicaid increased their fraud investigations, compared to states that did not expand. Further, civil recoveries and excluded individuals increased after the Medicaid expansion. We find evidence that increases in program scale, in terms of enrollment and utilization, reverted to the mean, facilitating the identification of outlier provider behavior.

Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multistate Evaluation

BACKGROUND

Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act's Medicaid expansion increased screening of colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown.

OBJECTIVE

This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income.

DESIGN

Using the 2012 to 2015 State Inpatient Databases, a retrospective cohort study was conducted.

SETTINGS

State Inpatient Databases from 3 expansion states (Maryland, New Jersey, and Kentucky) and 2 nonexpansion states (Florida and North Carolina) were used.

PATIENTS

This study examined 22,304 adult patients aged 18 to 64 years who underwent colorectal cancer surgery.

MAIN OUTCOME MEASURES

Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed.

RESULTS

Elective vs nonelective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs nonexpansion states at policy implementation (adjusted OR 1.37; 95% CI, 1.05-1.79; p = 0.02), but it subsequently decreased (combined adjusted OR 0.95; 95% CI, 0.92-0.99; p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs post-trend 0.98) and low-income persons in expansion states (pre-trend 1.03 vs post-trend 0.97) (for all, p > 0.1).

LIMITATIONS

The study was limited to 5 states. Although patients may have increased access to cancer screening services and surgery after expansion, the State Inpatient Databases only provide information on patients who underwent surgery.

CONCLUSIONS

Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities. See Video Abstract at http://links.lww.com/DCR/C217 .

DISPARIDADES PERSISTENTES EN EL ACCESO A LA CIRUGA ELECTIVA DEL CNCER COLORRECTAL DESPUS DE LA EXPANSIN DE MEDICAID EN VIRTUD DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO UNA EVALUACIN MULTIESTATAL

ANTECEDENTES: A pesar de su mayor incidencia de cáncer colorrectal, los pacientes de minorías etnoraciales y de bajos ingresos tienen un acceso reducido a la cirugía electiva de cáncer colorrectal. Aunque la expansión de Medicaid de la Ley del Cuidado de Salud a Bajo Precio aumentó las colonoscopias de detección, aún se desconoce su efecto sobre las disparidades en la cirugía electiva de cáncer colorrectal.OBJETIVO: Este estudio evaluó los efectos de la expansión de Medicaid en las tasas de cirugía electiva de cáncer colorrectal en general y por raza, etnia e ingresos.DISEÑO: Utilizando las bases de datos estatales de pacientes hospitalizados de 2012-2015, se realizó un estudio de cohorte retrospectivo.CONFIGURACIÓN: Se utilizaron bases de datos estatales de pacientes hospitalizados de tres estados en expansión (Maryland, Nueva Jersey, Kentucky) y dos estados sin expansión (Florida, Carolina del Norte).PACIENTES: Este estudio examinó a 22,304 pacientes adultos de 18 a 64 años que se sometieron a cirugía de cáncer colorrectal.RESULTADO PRINCIPAL: Mediante el análisis de series de tiempo interrumpido, se evaluó el efecto de la expansión de Medicaid en las probabilidades de cirugía electiva de cáncer colorrectal.RESULTADOS: Las tasas de cirugía electiva frente a no electiva permanecieron sin cambios en general (70,2% frente a 70,7%, p = 0,63) y en las minorías etnoraciales en los estados de expansión (blancos del 72,8% al 73,8 % antes y después, p = 0,40 y no blancos del 64,0% al 63,1% pre a post, p = 0,67). Hubo un aumento instantáneo en las probabilidades de cirugía electiva en los estados de expansión frente a los de no expansión en la implementación de la política (OR ajustado 1,37, IC del 95%, 1,05-1,79, p = 0,02), pero disminuyó posteriormente (OR ajustado combinado 0,95, 95% IC, 0,92-0,99, p = 0,03). Las tasas de cirugía electiva también se mantuvieron sin cambios entre las minorías etnoraciales (cambios instantáneos en los estados de expansión, efecto combinado 1,06; antes de la tendencia 1,01 frente a la postendencia 0,98) y las personas de bajos ingresos en los estados de expansión (antes de la tendencia 1,03 frente a la postendencia 0,97; para todos, p > 0,1).LIMITACIONES: El estudio se limitó a cinco estados. Si bien los pacientes pueden tener un mayor acceso a los servicios de detección de cáncer y la expansión posterior a la cirugía, la base de datos de pacientes hospitalizados del estado solo brinda información sobre los pacientes que se sometieron a cirugía.CONCLUSIONES: A pesar de los avances en la detección, la expansión de Medicaid no se asoció con reducciones en las disparidades etnoraciales o basadas en los ingresos conocidas en las tasas de cirugía electiva de cáncer colorrectal. Ampliar el acceso a la cirugía del cáncer colorrectal para las poblaciones desatendidas probablemente requiera atención a los factores del proveedor y del sistema de salud que contribuyen a las disparidades persistentes. Consulte el Video Resumen en http://links.lww.com/DCR/C217 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

The Impact of Medicaid Expansion on Patients with Cancer in the United States: A Review

Since 2014, American states have had the option to expand their Medicaid programs as part of the Affordable Care Act (ACA), which was signed into law by former President Barack H. Obama in 2010. Emerging research has found that Medicaid expansion has had a significant impact on patients with cancer, who often face significant financial barriers to receiving the care they need. In this review, we aim to provide a comprehensive examination of the research conducted thus far on the impact of Medicaid expansion on patients with cancer. We begin with a discussion of the history of Medicaid expansion and the key features of the ACA that facilitated it. We then review the literature, analyzing studies that have investigated the impact of Medicaid expansion on cancer patients in terms of access to care, quality of care, and health outcomes. Our findings suggest that Medicaid expansion has had a positive impact on patients with cancer in a number of ways. Patients in expansion states are more likely to receive timely cancer screening and diagnoses, and are more likely to receive appropriate cancer-directed treatment. Additionally, Medicaid expansion has been associated with improvements in cancer-related health outcomes, including improved survival rates. However, limitations and gaps in the current research on the impact of Medicaid expansion on patients with cancer exist, including a lack of long-term data on health outcomes. Additionally, further research is needed to better understand the mechanisms through which Medicaid expansion impacts cancer care.

Residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling by adults with lower incomes: Is increased access to primary care enough?

BACKGROUND

We investigate whether living in a state that expanded Medicaid eligibility is associated with receiving alcohol screening and brief counseling among nonelderly, low-income adults and a subgroup with chronic health conditions caused or exacerbated by alcohol use.

METHOD

Data are from the 2017 and 2019 Behavioral Risk Factor Surveillance System (N = 15,743 low-income adults; n = 7062 with a chronic condition). We used propensity score-weighted, covariate-adjusted, modified Poisson regression to estimate associations between residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling. Models estimated associations in the overall sample and chronic conditions subsample, as well as differential associations across sex, race, and ethnicity using interaction terms.

RESULTS

Living in a state that expanded Medicaid eligibility was associated with being asked whether one drank (prevalence ratio (PR) = 1.15, 95% confidence interval (CI) = 1.08, 1.22), but not with further alcohol screening, guidance about harmful drinking, or advice to reduce drinking. Among individuals with alcohol-related chronic conditions, expansion state residence was associated with being asked about drinking (PR = 1.13, 95% CI = 1.05, 1.20) and, among past 30-day drinkers with chronic conditions, being asked how much one drank (PR = 1.28, 95% CI = 1.04, 1.59) and about binge drinking (PR = 1.43, 95% CI = 1.03, 1.99). Interaction terms suggest that some associations differ by race and ethnicity.

CONCLUSIONS

Living in a state that expanded Medicaid is associated with a higher prevalence of receiving some alcohol screening at a check-up in the past 2 years among low-income residents, particularly among individuals with alcohol-related chronic conditions, but not with the receipt of high-quality screening and brief counseling. Policies may have to address provider barriers to delivery of these services in addition to access to care.

Who did the ACA Medicaid expansion impact? Estimating the probability of being a complier

Who enrolled in Medicaid as a consequence of the Affordable Care Act (ACA)? Using the 2010-2017 American Community Survey, I estimate how characteristics relating to work status and race/ethnicity affect the probability that an individual will be a complier, defined as those induced by the ACA Medicaid expansion to obtain Medicaid coverage. Across all states, I find that part-time workers, not non-workers, are the most likely to be compliers. This finding is not consistent with certain notions that Medicaid participants are the "undeserving poor" - a sentiment that may have hindered efforts to expand Medicaid in certain states. Additionally, I find that in non-expansion states, many of which have high Black populations, the probability of being a complier is higher for Blacks than for other racial/ethnic groups, suggesting that Black people in non-expansion states would be the largest beneficiaries of any new expansions. This paper not only identifies the types of individuals who were already impacted by the expansion but also identifies which populations would benefit the most from subsequent expansions.

Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act

This study uses a difference-in-differences design within an event-study framework to examine how state decisions to expand Medicaid following the passage of the Affordable Care Act (ACA) affected mental health treatment. The findings suggest that expansion states experienced increased admissions to mental health treatment facilities and Medicaid-reimbursed prescriptions for medications used to treat common forms of mental illness. The results also indicate an increase in admissions with trauma, anxiety, conduct, and depression disorders. There is also suggestive evidence of an increase in the number of mental health treatment facilities accepting Medicaid as a form of payment. Lastly, as with previous studies, I find weak evidence of a decrease in suicides in Medicaid expansion states. These findings highlight the vital role of the ACA in providing access to mental health treatment for low-income Americans.

The Impact of the Medical Insurance System on the Health of Older Adults in Urban China: Analysis Based on Three-Period Panel Data

The impact of the medical insurance system (MIS) on the health of older adults is a key element of research in the field of social security. Because China's MIS consists of different types of insurance, and the benefits and levels of coverage received by participating in different medical insurance vary, different medical insurance may have a differential impact on the health of older adults. This has rarely been studied before. In this paper, the panel data of the third phase of the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2013, 2015 and 2018 were used to investigate the impact of participation in social medical insurance (SMI) and commercial medical insurance (CMI) on the health of urban older adults and its mechanism relationship. The study found that SMI had a positive impact on the mental health of older adults, but only in the eastern region. Participation in CMI was positively correlated with the health of older adults, but this association was relatively small and was only observed in the sample of older adults aged 75 years and above. In addition, future life security plays an important role in the process of improving the health of older adults through medical insurance. Both research hypothesis 1 and research hypothesis 2 were verified. The results of this paper show that the evidence of the positive effect of medical insurance on the health of older adults in urban areas proposed by scholars is not convincing enough. Therefore, the medical insurance scheme should be reformed, focusing not only on coverage, but on enhancing the benefits and level of insurance, so as to enhance its positive impact on the health of older adults.

The Role of Government-Funded Assistance Programs on HIV Testing Among Poor U.S. Adults

Government-funded assistance program enrollment may play an important role in the overall increase of HIV testing among low-income U.S. adults. We pooled data from the 2016-2018 National Health Interview Survey and limited analyses to respondents aged 18 to 64 years with incomes less than 100% of the U.S. poverty threshold (N = 9,497). The outcome of interest was ever testing for HIV. Prevalence ratios were used to assess the likelihood of ever testing for HIV and were adjusted for sociodemographic covariates including whether the respondent was a beneficiary of any government-funded assistance programs (e.g., Medicaid; job-placement/training/human services; or Temporary Assistance for Needy Families). After adjusting for significant sociodemographic covariates, government-funded assistance beneficiaries were significantly more likely to ever test for HIV (adjusted prevalence ratio = 1.3; 95% CI = [1.2, 1.4], p < .0001) than adults with incomes less than 100% of the U.S. poverty threshold who did not receive government assistance. Beneficiaries of government-funded assistance programs are more likely to test for HIV.

Factors associated with the adoption of evidence-based innovations by substance use disorder treatment organizations: A study of HIV testing

INTRODUCTION

Though prior research shows that a range of important regulatory, market, community, and organizational factors influence the adoption of evidence-based practices (EBPs) among health care organizations, we have little understanding of how these factors relate to each other. To address this gap, we test a conceptual model that emphasizes indirect, mediated effects among key factors related to HIV testing in substance use disorder treatment organizations (SUTs), a critical EBP during the US opioid epidemic.

METHODS

We draw on nationally representative data from the 2014 (n = 697) and 2017 (n = 657) National Drug Abuse Treatment System Survey (NDATSS) to measure the adoption of HIV testing among the nation's SUTs and their key organizational characteristics; we also draw on data from the US Census Bureau; Centers for Disease Control; and legislative sources to measure regulatory and community environments. We estimate cross-sectional and longitudinal structural equation models (SEM) to test the proposed model.

RESULTS

Our longitudinal model of the adoption of HIV testing by SUTs in the United States identifies a pathway by which community and market characteristics (rurality and the number of other SUTs in the area) are related to key sociotechnical characteristics of these organizations (alignment of clients, staff, and harm-reduction culture) that, in turn, are related to the adoption of this EBP.

CONCLUSIONS

Results also show the importance of developing conceptual models that include indirect effects to account for organizational adoption of EBPs.

Expanding Medicaid to Reduce Human Immunodeficiency Virus Transmission in Houston, Texas: Insights From a Modeling Study

CONTEXT

Medicaid expansion has been nationally shown to improve engagement in the human immunodeficiency virus (HIV) treatment and prevention continua, which are vital steps to stopping the HIV epidemic. New HIV infections in the United States are disproportionately concentrated among young Black men who have sex with men (YBMSM). Houston, TX, is the most populous city in the Southern United States with a racially/ethnically diverse population that is located in 1 of 11 US states that have not yet expanded Medicaid coverage as of 2021.

METHODS

An agent-based model that incorporated the sexual networks of YBMSM was used to simulate improved antiretroviral treatment and pre-exposure prophylaxis (PrEP) engagement through Medicaid expansion in Houston, TX. Analyses considered the HIV incidence (number of new infections and as a rate metric) among YBMSM over the next 10 years under Medicaid expansion as the primary outcome. Additional scenarios, involving viral suppression and PrEP uptake above the projected levels achieved under Medicaid expansion, were also simulated.

RESULTS

The baseline model projected an HIV incidence rate of 4.96 per 100 person years (py) and about 368 new annual HIV infections in the 10th year. Improved HIV treatment and prevention continua engagement under Medicaid expansion resulted in a 14.9% decline in the number of annual new HIV infections in the 10th year. Increasing viral suppression by an additional 15% and PrEP uptake by 30% resulted in a 44.0% decline in new HIV infections in the 10th year, and a 27.1% decline in cumulative infections across the 10 years of the simulated intervention.

FINDINGS

Simulation results indicate that Medicaid expansion has the potential to reduce HIV incidence among YBMSM in Houston. Achieving HIV elimination objectives, however, might require additional effective measures to increase antiretroviral treatment and PrEP uptake beyond the projected improvements under expanded Medicaid.

Effect of Eased Restrictions for Aca-Exempt Short-Term Health Plans on Marketplace Premiums and Uninsured Rate: A Difference in Differences Analysis

The Affordable Care Act (ACA) established broad standards for private health insurance in the United States including requiring minimum essential benefits and prohibiting medical underwriting, but the law also permitted some exceptions. This paper examines one type of exempt plan option, Short-Term, Limited Duration Insurance (STLDI) that is not required to fully meet ACA benefit and underwriting standards. Federal rules governing STLDI plans have changed over time, with more permissive rules in the Trump administration allowing individuals to remain covered for longer durations of time relative to the original Obama regulations. Within applicable federal guidelines, states have also varied STLDI rules. Using publicly available data measuring state-level variations in STLDI regulations, ACA benchmark premiums, uninsured rates, and population characteristics for 2014 to 2021, we estimate difference-in-differences models to examine if more permissible STLDI policies are associated with higher premiums in the fully regulated non-group market and, also, lower uninsured rates. We find that longer duration, more permissible STLDI is associated with higher benchmark premiums in ACA exchanges and no difference in state-level uninsured rates. Trump administration regulations permitting longer duration STLDI plans to make available more affordable ACA-exempt health insurance were associated with higher premium costs in the ACA-regulated non-group market but we did not observe measurable impact on state uninsured rates. While longer-duration STLDI plans may result in lower costs for some, they have negative consequences for others requiring comprehensive coverage with no discernible benefit in overall coverage rates. Understanding these tradeoffs can help guide future policies regarding exceptions to ACA plan requirements.

Impacts of Publicly Funded Health Insurance for Adults on Children's Academic Achievement. SOUTHERN ECONOMIC JOURNAL 2023;89:860-884. [PMID: 38845841 PMCID: PMC11156232 DOI: 10.1002/soej.12614]

Empirical evidence demonstrates that publicly funded adult health insurance through the Affordable Care Act (ACA) has had positive effects on low-income adults. We examine whether the ACA's Medicaid expansions influenced child development and family functioning in low-income households. We use a difference-in-differences framework exploiting cross-state policy variation and focusing on children in low-income families from a nationally representative, longitudinal sample followed from kindergarten to fifth grade. The ACA Medicaid expansions improved children's reading test scores by approximately 2 percent (0.04 SD). Potential mechanisms for these effects within families are more time spent reading at home, less parental help with homework, and eating dinner together. We find no effects on children's math test scores or socioemotional skills.

Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

Effects of marriage equality legislation on sexual health of the US population

Even though prior research has investigated the relationship between same-sex partnership recognition policies and health outcomes, the impact of same-sex marriage laws on sexually transmitted infections has not received much attention. Using state-level panel data from 2000 to 2019, I show that marriage equality legislation decreases the spread of (shorter-term) syphilis infections and of (longer-term) human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) infections among the general population. Event study analyses correcting for non-staggered treatment implementation confirm these negative effects, but also suggest that standard difference-in-differences models understate the impact of the legislation by up to 8% points. Further analysis supports that these legislation effects operate through three mechanisms: increasing social tolerance, strengthening relationship commitment, and expanding health care access and coverage for HIV/AIDS prevention and treatment. Disaggregating the results by sexual behavior reveals that legal access to same-sex marriage leads to sizable decreases in AIDS rates among men who have sex with men (MSM) (the most at-risk population for an infection). Even though there is economically significant evidence that the legislation improves sexual health of the heterosexual population due to increased utilization of preventive sexual health care, the legislation does not have a direct impact on infection rates for the non-MSM population.

Racial And Ethnic Disparities In Preventable Hospitalizations And ED Visits Five Years After ACA Medicaid Expansions

Medicaid expansions under the Affordable Care Act (ACA) dramatically increased access to insurance coverage. We examined whether the 2014 ACA Medicaid expansions also mitigated existing racial or ethnic disparities in preventable hospitalizations and emergency department (ED) visits. Using inpatient data from twenty-nine states and ED data from twenty-six states for the period 2011-18, we found that Medicaid expansions decreased disparities in preventable hospitalizations and ED visits between non-Hispanic Black and White nonelderly adults by 10 percent or more. There were no significant effects on disparities between Hispanic and non-Hispanic White nonelderly adults, possibly reflecting lower baseline differences and, separately, persisting coverage disparities. These findings highlight sustained improvements in community-level care for non-Hispanic Black populations, who historically lack access to care. Our findings also suggest access barriers experienced by Hispanic adults that need to be addressed beyond Medicaid eligibility expansion.

The Role of Health Education, Policies, and Services on College Students' Health Behavior

Objective: In this study, we aimed to define the role of health education, health policies, and health service as factors in the health behavior of Chinese college students. It is critical to understand that there is an important role of health behavior in the life of college students in any society because the survival of society is dependent on better health status. Methods: We used SPSS software for analysis to test our hypotheses.Results: We found an important role for health education, health policies, and health services as determinants of health behavior. Conclusion: The focus of healthcare organizations must be to focus on health education, health policies, and health services by creating awareness in college students that ensures they are provided with the appropriate health sector solutions. Additionally, we found theoretical and practical implications to improve the health behavior of Chinese college students via a moderating role of information technology, because, in modern times, the role of information technology is critical to convey information productively.

Is there an ex-ante moral hazard on Indonesia's health insurance? An impact analysis on household waste management behavior

The presence of ex-ante moral hazard could undermine the potential gain from expanding health insurance coverage in developing nations. To test the proposition, this study utilizes a nationally representative longitudinal survey with Indonesia's health insurance for poor policy in 2014 as the quasi-experimental case study. The country represents developing nations that undergo a massive and rapid expansion of health insurance coverage. The empirical approach combines a matching and difference-in-differences method to obviate potential bias of the selectivity nature of health insurance provision and time-invariant unobserved factors. The findings suggest the presence of ex-ante moral hazard in the form of the less people using trash cans associated with the introduction of the subsidized health insurance premium. The results add empirical findings of a negative side effect of expanding health insurance coverage in developing nations.

Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid

OBJECTIVE

To estimate the effects of Affordable Care Act (ACA) Medicaid expansion on insurance and health services use for adults with disabilities who were newly eligible for Medicaid.

DATA SOURCES

2008-2018 Medical Expenditure Panel Survey data.

STUDY DESIGN

We used the Agency for Healthcare Research and Quality (AHRQ) PUBSIM model to identify adults aged 26-64 years with disabilities who were newly Medicaid-eligible in expansion states or would have been eligible in non-expansion states had those states opted to expand. Outcomes included insurance coverage; access to care; receipt of primary care, outpatient specialty physician services, and preventive services; and out-of-pocket health care spending. To estimate the effects of Medicaid expansion, we used two-way fixed effects models and a triple differences framework to compare pre-post changes in each outcome in expansion and non-expansion states for adults with and without disabilities.

EXTRACTION METHODS

We simulated Medicaid eligibility with the AHRQ PUBSIM model, which uses state-specific Medicaid rules and MEPS data on family relationships, state of residence, and income.

PRINCIPAL FINDINGS

Among adults with disabilities who were newly eligible for Medicaid, Medicaid expansion was associated with significant increases in full-year Medicaid coverage (35.9 percentage points [pp], p < 0.001), receipt of primary care (15.5 pp, p < 0.01), and receipt of flu shots (19.2 pp, p < 0.01), and a significant decrease in out-of-pocket spending (-$457, p < 0.01). There were larger improvements for adults with disabilities compared to those without disabilities in full-year Medicaid coverage (11.0 pp, p < 0.01) and receipt of flu shots (18.0 pp, p < 0.05).

CONCLUSIONS

Medicaid expansion was associated with improvements in full-year insurance coverage, receipt of primary and preventive care, and out-of-pocket spending for adults with disabilities who were newly eligible for Medicaid. For insurance coverage, preventive care, and some primary care measures, there were differentially larger improvements for adults with disabilities than for those without disabilities.

Association between state Medicaid expansion status and health outcomes during the COVID-19 pandemic

OBJECTIVE

To assess post-COVID-19 changes in insurance coverage, health behaviors, and self-assessed health among low-income, non-elderly adults by state Medicaid expansion status.

DATA SOURCES

We used nationally representative survey data from the 2016 through 2020 Behavioral Risk Factor Surveillance System (BRFSS). The sample was restricted to adults aged 19-64 with household income below 138 percent of the federal poverty level (N = 179,135).

STUDY DESIGN

We examined a broad set of outcomes related to coverage, health behaviors, and self-assessed health available in the BRFSS. We used a difference-in-differences model to compare changes in outcomes for individuals living in the 35 states and DC that expanded Medicaid under the Affordable Care Act to those in the 15 non-expansion states before and after the COVID-19 pandemic commenced in March 2020.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

We found that the expansions provided some protection for low-income people during the pandemic. In 2020, relative to earlier years, people in expansion states were more likely to report very good or excellent health (4.9 percentage points, 95%CI = 0.022, 0.076; p < 0.01) and physical health (-0.393 days of poor physical health in the past month, 95%CI = -0.714, -0.072; p < 0.05), lower rates of smoking (-1.9 percentage points, 95%CI = -0.041, 0.004; p < 0.10) and heavy drinking (-1.4 percentage points, 95%CI = -0.025, -0.004; p < 0.01), and higher flu vaccination rates (2.8 percentage points, 95%CI = 0.005, 0.051; p < 0.05) than those in non-expansion states. These benefits were particularly salient for Black and Hispanic individuals. We found no significant differences in insurance coverage, exercise, obesity, and self-assessed mental health between expansion and non-expansion states for the overall low-income sample. However, the expansion was associated with greater insurance coverage for Hispanic adults during the pandemic.

CONCLUSIONS

Investments in public health through expanding Medicaid may shield low-income populations from some of the health ramifications of public health emergencies.

The Impact of Payment Reforms on the Safety Net: Examining Effects of the New Jersey Delivery System Reform Incentive Payment Program on Quality of Care Among Medicaid Beneficiaries

The Medicaid Delivery System Reform Incentive Payment (DSRIP) program has been among the most widely adopted value-based payment strategies to drive improved population health management among safety net populations. Using comprehensive claims data from New Jersey and difference-in-differences modeling, the authors examine the impact of DSRIP pay-for-performance disease management programs on outcomes related to targeted chronic conditions. The authors find DSRIP reduced asthma hospitalizations and emergency department visits, pneumonia readmissions, and improved alcohol and drug treatment. Positive program-specific findings are encouraging for future DSRIP-like initiatives and demonstrate provider ability to successfully adapt to payment reforms.

Cloudy with a chance of munchies: Assessing the impact of recreational marijuana legalization on obesity

Obesity in the US arguably constitutes the most significant health epidemic over the past century. Recent legislative changes allowing for recreational marijuana use further create a need to better understand the relationship between marijuana use and health choices, leading to obesity. We examine this relationship by using a synthetic control approach to examine the impact of legalized recreational marijuana access on obesity rates by comparing Washington State to a synthetically constructed counterfactual. We find that recreational marijuana's introduction did not lead to increased obesity rates and may have led to decreases in obesity.

The Affordable Care Act and regulation: Coverage effects of guaranteed issue and ratings reform

An important part of the Affordable Care Act (ACA) that has received relatively little research attention is regulatory reform in the small and non-group markets, particularly guaranteed issue and rating restrictions. In order to identify the effect of this part of the ACA, I use states that already had these policies before 2014 as a control group for states newly exposed to them under the ACA. Overall, the reforms do not have any effect in states that expanded Medicaid but are associated with a 1.64 percentage point (or 2.16%) increase in the probability of having health insurance coverage in states that did not expand Medicaid. Effects are seen across broad age range, and are strongest for those whose incomes are slightly above the Medicaid threshold and qualify them for the highest Marketplace subsidy levels.

Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).

Characteristics of Cancer Survivors Living in Poverty in the United States: Results From the 2020 Behavioral Risk Factor Surveillance System Survey

PURPOSE

There has been increasing concern over the high cost of oncology care and its long-lasting impact on the well-being of cancer survivors.

METHODS

We examined characteristics of impoverished cancer survivors in the United States, including their physical and mental health, using data from the 2020 Behavioral Risk Factor Surveillance System. We used binomial logistic regressions for binary outcome variables, and negative binomial regressions for count variables, to estimate the odds ratios (ORs) and incident rate ratios (IRRs) of the physical, mental, and socioeconomic-related health factors for low-income cancer survivors versus higher-income survivors. We compared the ORs and IRRs for low-income cancer survivors with those of higher income cancer survivors.

RESULTS

There was a two-fold increased odds (adjusted OR, 2.33; 95% CI, 1.86 to 2.91) of having fair/poor health for low-income cancer survivors compared with higher-income cancer survivors. There was an almost two-fold increased odds (adjusted OR, 1.97; 95% CI, 1.50 to 2.59) of not being able to see a doctor among low-income cancer survivors, and a 42% lower odds (adjusted OR, 0.58; 95% CI, 0.39 to 0.86) of having health insurance coverage for low-income cancer survivors compared with higher-income survivors. Incidence rate ratios for physical (IRR, 1.52; 95% CI, 1.31 to 1.75) and mental (IRR, 1.53; 95% CI, 1.26 to 1.86) unhealthy days were significantly higher among low-income cancer survivors compared with nonpoor cancer survivors.

CONCLUSION

Strategies are available to ameliorate financial hardship at multiple levels. Implementation of these strategies is urgently needed.

The Association Between Medicaid Expansion and Diabetic Ketoacidosis Hospitalizations

Background and objective Diabetic ketoacidosis (DKA) is a potentially fatal complication of uncontrolled diabetes and remains a significant source of morbidity and mortality even though it is considered preventable. Diabetes is a chronic illness that requires constant monitoring and regular check-ups. Delaying or foregoing necessary diabetes care due to a lack of health insurance can result in severe complications. The Affordable Care Act (ACA) Medicaid expansion is intended to increase access to healthcare and improve health outcomes. This study aimed to examine the relationship between the ACA Medicaid expansion and hospitalizations with DKA. Methods This retrospective cross-sectional study used discharge records from 2010 to 2017 for hospitals in Texarkana, located on the border of Texas and Arkansas. The study employed a difference-in-differences method. Patients from Arkansas, which expanded Medicaid in 2014, constituted the treatment group, while those from Texas, which did not adopt the expansion, were the control group. A triple difference methodology was used to compare the impact of the expansion on patients with different socioeconomic backgrounds. The main outcome measure was DKA per 1000 discharges. Results A total of 89,184 inpatient discharges from Texarkana hospitals were analyzed; 43,286 patients were from Arkansas (48.54%) and 45,898 (51.46%) were from Texas. Even though DKA cases increased from pre-expansion (2010-2013) to post-expansion (2014-2017) period among patients from Arkansas (by a mean of 4.33) and Texas (by a mean of 8.28), the increase was milder among Arkansas patients with an adjusted decrease of 4.17 per 1000 discharges (95% CI: -5.04 to -3.31; p<0.001), implying a 42% lower risk of hospitalizations with DKA compared to the baseline averages. The triple difference analysis suggested that the decrease in incidences was more pronounced for patients from low-income areas with an adjusted decrease of 13.47 per 1000 discharges (95% CI: -22.45 to -4.49; p=0.003). Conclusions Based on our findings, Medicaid expansion decreases hospitalizations with DKA, presumably due to better monitoring and care of diabetes made possible by increasing access to healthcare among individuals with low incomes.

Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania

Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.