Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role

Association of state Medicaid expansion policies with pediatric liver transplant outcomes

Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.

Changes in Health Care-Related Financial Burden for US Families With Children Associated With the Affordable Care Act

IMPORTANCE

The Affordable Care Act (ACA) sought to improve access and affordability of health insurance. Although most ACA policies targeted childless adults, the extent to which these policies also impacted families with children remains unclear.

OBJECTIVE

To examine changes in health care-related financial burden for US families with children before and after the ACA was implemented based on income eligibility for ACA policies.

DESIGN, SETTING, AND PARTICIPANTS

Data used for this cohort study were obtained from the 2000-2017 Medical Expenditure Panel Survey, a nationally representative, population-based survey. Multivariable regression with a difference-in-differences estimator was used to examine changes in family financial burden before and after ACA implementation according to income-based ACA eligibility groups (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The cohort included 92 165 families with 1 or more children (age ≤18 years) and 1 or more adult parents/guardians.

EXPOSURES

Income-based eligibility groups during post-ACA years (calendar years 2014-2017) vs pre-ACA years (calendar years 2000-2013).

MAIN OUTCOMES AND MEASURES

Family annual out-of-pocket (OOP) health care and premium cost burden relative to income. High OOP burden was determined based on a previously validated algorithm with relative cost thresholds that vary across incomes, and extreme OOP burden was defined as costs exceeding 10% of income. Premiums exceeding 9.5% of income were classified as burdensome and premiums relative to median household income defined an unaffordability index.

RESULTS

Compared with high-income families who experienced a lesser change post-ACA implementation (high OOP burden, 1.1% pre-ACA vs 0.9% post-ACA), the lowest-income families saw the greatest reduction in high OOP burden (35.6% pre-ACA vs 23.7% post-ACA; difference-in-differences: -11.4%; 95% CI, -13.2% to -9.5%) followed by low-income families (24.6% pre-ACA vs 17.3% post-ACA, difference-in-differences: -6.8%; 95% CI, -8.7% to -4.9%) and middle-income families (6.1% pre-ACA vs 4.6% post-ACA, difference-in-differences: -1.2%; 95% CI, -2.3% to -0.01%). Although premiums rose for all groups, premium unaffordability was the least exacerbated for the lowest-, low-, and middle-income families compared with higher-income families.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that low- and middle-income families with children who were eligible for ACA Medicaid expansions and Marketplace subsidies experienced greater reductions in health care-related financial burden after the ACA was implemented compared with families with higher incomes. However, despite ACA policies, many low- and middle-income families with children appear to continue to face considerable financial burden from premiums and OOP costs.

Association of Medicaid Expansion With Insurance Coverage Among Children With Cancer

IMPORTANCE

Despite evidence of improved insurance coverage under the Affordable Care Act and Medicaid expansion among adults with cancer, little is known regarding the association of these policies with coverage among children with cancer.

OBJECTIVE

To assess the association of early Medicaid expansion with rates of Medicaid coverage, private coverage, and no uninsurance among children with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2007, to December 31, 2015, to identify children diagnosed with cancer at ages 0 to 14 years in the United States. Data were analyzed from July 27, 2017, to October 7, 2019.

EXPOSURES

Changes in insurance status at diagnosis after early Medicaid expansion in California, Connecticut, Washington, and New Jersey (EXP states) were compared with changes in nonexpansion (NEXP) states (Arkansas, Georgia, Hawaii, Iowa, Kentucky, Louisiana, Michigan, New Mexico, and Utah).

MAIN OUTCOMES AND MEASURES

Difference-in-differences (DID) analyses were used to compare absolute changes in insurance status (uninsured, Medicaid, private/other) at diagnosis before (2007 to 2009) and after (2011 to 2015) expansion in EXP relative to NEXP states.

RESULTS

A total of 21 069 children (11 265 [53.5%] male; mean [SD] age, 6.18 [4.57] years) were included. A 5.25% increase (95% CI, 2.61%-7.89%; P < .001) in Medicaid coverage in children with cancer was observed in EXP vs NEXP states, with larger increases among children of counties with middle to high (adjusted DID estimates, 10.18%; 95% CI, 4.22%-16.14%; P = .005) and high (adjusted DID estimates, 6.13%; 95% CI, 1.10%-11.15%; P = .05) poverty levels (P = .04 for interaction). Expansion-associated reductions of children reported as uninsured (-0.73%; 95% CI, -1.49% to 0.03%; P = .06) and with private or other insurance (-4.52%; 95% CI, -7.16% to -1.88%; P < .001) were observed. For the latter, the decrease was greater for children from counties with middle to high poverty (-9.00%; 95% CI, -14.98% to -3.02%) and high poverty (-6.38%; 95% CI, -11.36% to -1.40%) (P = .04 for interaction).

CONCLUSIONS AND RELEVANCE

In this study, state Medicaid expansions were associated with increased Medicaid coverage in children with cancer overall and in some subgroups primarily owing to switching from private coverage, particularly in counties with higher levels of poverty but also through reductions in the uninsured.

Where Do Oregon Medicaid Enrollees Seek Outpatient Care Post-affordable Care Act Medicaid Expansion?

BACKGROUND

Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care.

OBJECTIVES

To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization.

RESEARCH DESIGN

A retrospective cohort study.

SUBJECTS

Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA.

MEASURES

Site of first and last outpatient visit, established with primary care status, and outpatient care utilization.

RESULTS

The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18-0.19] and returning insured (OR, 0.22; 95% CI, 0.22-0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01-2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates.

CONCLUSIONS

Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.

Adult-Oriented Health Reform and Children's Insurance and Access to Care: Evidence from Massachusetts Health Reform

Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)-the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0-17 years in Massachusetts compared to children in other New England states. The National Survey of Children's Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts's enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = - 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.

Spillover Effects of Adult Medicaid Expansions on Children's Use of Preventive Services

BACKGROUND

Since the passage of the Affordable Care Act, Medicaid enrollment has increased by ∼17 million adults, including many low-income parents. One potentially important, but little studied, consequence of expanding health insurance for parents is its effect on children's receipt of preventive services.

METHODS

By using state Medicaid eligibility thresholds linked to the 2001-2013 Medical Expenditure Panel Surveys, we assessed the relationship between changes in adult Medicaid eligibility and children's likelihood of receiving annual well-child visits (WCVs). In instrumental variable analyses, we used these changes in Medicaid eligibility to estimate the relationship between parental enrollment in Medicaid and children's receipt of WCVs.

RESULTS

Our analytic sample consisted of 50 622 parent-child dyads in families with incomes <200% of the federal poverty level, surveyed from 2001 to 2013. On average, a 10-point increase in a state's parental Medicaid eligibility (measured relative to the federal poverty level) was associated with a 0.27 percentage point higher probability that a child received an annual WCV (95% confidence interval: 0.058 to 0.48 percentage points, P = .012). Instrumental variable analyses revealed that parental enrollment in Medicaid was associated with a 29 percentage point higher probability that their child received an annual WCV (95% confidence interval: 11 to 47 percentage points, P = .002).

CONCLUSIONS

In our study, we demonstrate that Medicaid expansions targeted at low-income adults are associated with increased receipt of recommended pediatric preventive care for their children. This finding reveals an important spillover effect of parental insurance coverage that should be considered in future policy decisions surrounding adult Medicaid eligibility.

Parental Consent and Access to Oral Health Care for Adolescents

While most states allow minors 12 years and older to consent to services for contraception, prenatal care, or sexually transmitted infections, the same adolescents are required to have parental consent for even preventive oral health care. Many adolescents are denied access to preventive oral health care because of the challenge of securing parental consent for care when parents are unwilling, unable, or unavailable to consent. Our purpose is to examine the barriers to preventive oral health care for U.S. adolescents related to parental consent laws, explore the issues surrounding these laws, and recommend policy changes. We explain the current range and status of consent laws across the country and arguments for parental consent law as it now stands. We discuss the difficulty of applying general medical consent law to preventive oral health care, neuroscience research on cognitive capacity among adolescents, and the distinction between parental consent and adolescent assent. We recommend replacing required "opt-in" consent with simpler "opt-out" consent; developing a tool for assessing adolescent decision-making capacity; advocating for consent laws that apply specifically to preventive oral health care; and empowering school nurses to lead local, state, and nationwide policy and legislation efforts.

Trends in Type of Health Insurance Coverage for US Children and Their Parents, 1998-2011

OBJECTIVE

To examine trends in health insurance type among US children and their parents.

METHODS

Using the Medical Expenditure Panel Survey (1998-2011), we linked each child (n = 120,521; weighted n ≈ 70 million) with his or her parent or parents and assessed patterns of full-year health insurance type, stratified by income. We examined longitudinal insurance trends using joinpoint regression and further explored these trends with adjusted regression models.

RESULTS

When comparing 1998 to 2011, the percentage of low-income families with both child and parent or parents privately insured decreased from 29.2% to 19.1%, with an estimated decline of -0.86 (95% confidence interval, -1.10, -0.63) unadjusted percentage points per year; middle-income families experienced a drop from 74.5% to 66.3%, a yearly unadjusted percentage point decrease of -0.73 (95% confidence interval, -0.98, -0.48). The discordant pattern of publicly insured children with uninsured parents increased from 10.4% to 27.2% among low-income families and from 1.4% to 6.7% among middle-income families. Results from adjusted models were similar to joinpoint regression findings.

CONCLUSIONS

During the past decade, low- and middle-income US families experienced a decrease in the percentage of child-parent pairs with private health insurance and pairs without insurance. Concurrently, there was a rise in discordant coverage patterns-mainly publicly insured children with uninsured parents.