The Effect of Health Insurance on Prescription Drug Use Among Low-Income Adults:Evidence from Recent Medicaid Expansions

The cost of influence: How gifts to physicians shape prescriptions and drug costs

This paper investigates the influence of gifts - monetary and in-kind payments - from drug firms to US physicians on prescription behavior and drug costs. Using causal models and machine learning, we estimate physicians' heterogeneous responses to payments on antidiabetic prescriptions. We find that payments lead to increased prescription of brand drugs, resulting in a cost rise of $23 per dollar value of transfer received. Paid physicians show higher responses when they treat higher proportions of patients receiving a government-funded low-income subsidy that lowers out-of-pocket drug costs. We estimate that introducing a national gift ban would reduce diabetes drug costs by 2%.

Interruptions in Insurance Coverage and Prescription Drug Utilization: Evidence from Kentucky

This study examined how interruptions in insurance coverage affect purchases of prescription drugs for young adults. It used data spanning 2014 to 2018 from Kentucky's prescription drug monitoring program, which tracked the universe of federally-regulated (Schedule II-V) prescription drugs dispensed in the state. The study employed a regression discontinuity design based on the age limit at 26 for dependent insurance coverage for children. At age 26, the probability of purchasing a prescription decreased by 5%, with all subcategories of prescriptions affected. The share of generic prescriptions increased for stimulants (the only category observed with substantial branded prescriptions). By age 27, prescription purchases returned to levels observed at 25, but the share purchased with public insurance and the generic share for stimulants remained higher. The findings suggest that interruptions in insurance coverage decrease prescription drug utilization by young adults and that public insurance programs such as Medicaid are important for resuming treatment.

Patient-Centered Practice Guidelines: GRADEing Evidence to Incorporate Certainty, Balance Between Benefits and Harms, Equity, Feasibility, and Cost-Effectiveness

The practice of medicine in recent years has emphasized the use of evidence-based clinical guidelines to help inform treatment decisions. Since its development in 2004, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has offered a systematic process for reviewing and summarizing the certainty of evidence found in the medical literature regarding various treatment options. To develop truly patient-centered care guidelines, this appraisal of the certainty of evidence must be combined with an understanding of the balance between benefits and harms, patient preferences, equity, feasibility, cost-effectiveness, and policy implications. This review examines each of these domains in detail, exploring the process and benefits of developing relevant, patient-focused guidelines directly applicable to the practice of modern medicine.

The effect of Medicaid expansion on the take-up of disability benefits by race and ethnicity

Public disability programs provide financial support to 12 million working-age individuals per year, though not all eligible individuals take up these programs. Mixed evidence exists regarding the impact of Medicaid eligibility expansion on program take-up, and even less is known about the relationship between Medicaid expansion and racial and ethnic disparities in take-up. Using 2009-2020 Current Population Survey data, we compare changes in Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) take-up among respondents with disabilities living in Medicaid expansion states to respondents with disabilities living in non-expansion states, before and after Medicaid expansion. We further explore heterogeneity by race/ethnicity. We find that Medicaid expansion reduced SSI take-up by 10% overall, particularly among White and Hispanic respondents (10% and 21%, respectively). Medicaid expansion increased SSDI take-up by 8% overall, particularly among White and Black respondents (9% and 11%, respectively). Moreover, we find that Medicaid expansion reduced the probability that respondents with disabilities had employer-sponsored health insurance by approximately 8%, suggesting that expansion may have reduced job-lock among the SSDI-eligible, contributing to the observed increase in SSDI take-up.

Comorbidity patterns in cardiovascular diseases: the role of life-stage and socioeconomic status

Cardiovascular diseases stand as a prominent global cause of mortality, their intricate origins often entwined with comorbidities and multimorbid conditions. Acknowledging the pivotal roles of age, sex, and social determinants of health in shaping the onset and progression of these diseases, our study delves into the nuanced interplay between life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Leveraging data from a cross-sectional survey encompassing Mexican adults, we unearth a robust association between these variables and the prevalence of comorbidities linked to cardiovascular conditions. To foster a comprehensive understanding of multimorbidity patterns across diverse life-stages, we scrutinize an extensive dataset comprising 47,377 cases diagnosed with cardiovascular ailments at Mexico's national reference hospital. Extracting sociodemographic details, primary diagnoses prompting hospitalization, and additional conditions identified through ICD-10 codes, we unveil subtle yet significant associations and discuss pertinent specific cases. Our results underscore a noteworthy trend: younger patients of lower socioeconomic status exhibit a heightened likelihood of cardiovascular comorbidities compared to their older counterparts with a higher socioeconomic status. By empowering clinicians to discern non-evident comorbidities, our study aims to refine therapeutic designs. These findings offer profound insights into the intricate interplay among life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Armed with data-supported approaches that account for these factors, clinical practices stand to be enhanced, and public health policies informed, ultimately advancing the prevention and management of cardiovascular disease in Mexico.

Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals

INTRODUCTION

Health economics is a thriving sub-discipline of economics. Applied health economics research is considered essential in the health care sector and is used extensively by public policy makers. For scholars, it is important to understand the history and status of health economics-when it emerged, the rate of research output, trending topics, and its temporal evolution-to ensure clarity and direction when formulating research questions.

METHODS

Nearly 13,000 articles were analysed, which were found in the collective publications of the ten most specialised health economic journals. We explored this literature using patterns of term co-occurrence and document co-citation.

RESULTS

The research output in this field is growing exponentially. Five main research divisions were identified: (i) macroeconomic evaluation, (ii) microeconomic evaluation, (iii) measurement and valuation of outcomes, (iv) monitoring mechanisms (evaluation), and (v) guidance and appraisal. Document co-citation analysis revealed eighteen major research streams and identified variation in the magnitude of activities in each of the streams. A recent emergence of research activities in health economics was seen in the Medicaid Expansion stream. Established research streams that continue to show high levels of activity include Child Health, Health-related Quality of Life (HRQoL) and Cost-effectiveness. Conversely, Patient Preference, Health Care Expenditure and Economic Evaluation are now past their peak of activity in specialised health economic journals. Analysis also identified several streams that emerged in the past but are no longer active.

CONCLUSIONS

Health economics is a growing field, yet there is minimal evidence of creation of new research trends. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

Results of Leveraging Pharmaceutical Patient Assistance Programs to Expand Access to High Cost Medications in a Student-Run Free Clinic

High costs make many medications inaccessible to patients in the United States. Uninsured and underinsured patients are disproportionately affected. Pharmaceutical companies offer patient assistance programs (PAPs) to lower the cost-sharing burden of expensive prescription medications for uninsured patients. PAPs are used by various clinics, particularly oncology clinics and those caring for underserved communities, to expand patients' access to medications. Prior studies describing the implementation of PAPs in student-run free clinics have demonstrated cost-savings during the first few years of using PAPs. However, there is a lack of data regarding the efficacy and cost savings of longitudinal use of PAPs across several years. This study describes the growth of PAP use at a student-run free clinic in Nashville, Tennessee over ten years, demonstrating that PAPs can be used reliably and sustainably to expand patients' access to expensive medications. From 2012 to 2021, we increased the number of medications available through PAPs from 8 to 59 and the number of patient enrollments from 20 to 232. In 2021, our PAP enrollments demonstrated potential cost savings of over $1.2 million. Strategies, limitations, and future directions of PAP use are also discussed, highlighting that PAPs can be a powerful tool for free clinics in serving underserved communities.

The Relationship between Health Insurance and Pharmaceutical Innovation: An Empirical Study Based on Meta-Analysis

The growing research interest in the relationship between health insurance and pharmaceutical innovation is driven by their significant impact on healthcare optimization and pharmaceutical development. The existing literature, however, lacks consensus on this relationship and provides no evidence of the magnitude of a correlation. In this context, this study employs meta-analysis to explore the extent to which health insurance affects pharmaceutical innovation. It analyzes 202 observations from 14 independent research samples, using the regression coefficient of health insurance on pharmaceutical innovation as the effect size. The results reveal that there is a strong positive correlation between health insurance and pharmaceutical innovation (r = 0.367, 95% CI = [0.294, 0.436]). Public health insurance exhibits a stronger promoting effect on pharmaceutical innovation than commercial health insurance. The relationship between health insurance and pharmaceutical innovation is moderated by the country of sample origin, data range, journal type, journal impact factor, type of health insurance, and research perspective. Our research findings further elucidate the relationship mechanism between health insurance and pharmaceutical innovation, providing a valuable reference for future explorations in pharmaceutical fields.

The Association of Medicaid expansion with prescription drug utilization and expenditure among low-income participants with asthma

OBJECTIVE

This study estimated the association between the 2014 Medicaid expansion and asthma-related prescription drug utilization and expenditures among low-income adult participants with asthma, including those with uncontrolled asthma, in the United States.

METHODS

In this national analysis, using a pooled dataset from 2007-2018 Medical Expenditure Panel Surveys (MEPS), regression discontinuity (D-RD) analyses estimated the association between Medicaid expansion and utilization of and expenditures for asthma-related prescription drugs among participants with asthma aged 26-64 with incomes below vs. at/above 138% of the federal poverty level (FPL). A sub-sample analysis was also conducted among participants with uncontrolled asthma. Utilization and expenditure outcomes were estimated using two-part models with logit as the first part and generalized linear models as the second part.

RESULTS

Utilization of and total cost for asthma-related prescription drugs increased by 1.89 fills (p < 0.001) and $306.59 (p < 0.001) among participants with asthma with income below 138% FPL after Medicaid expansion. The utilization and total cost of both short-acting bronchodilators and inhaled corticosteroids (ICSs) increased after Medicaid expansion among participants with asthma with incomes below 138% FPL. Among participants with uncontrolled asthma with incomes below 138% FPL, utilization and expenditures increased after Medicaid expansion for all asthma-related prescription drugs and short-acting bronchodilators.

CONCLUSION

Medicaid expansion was associated with increased utilization of and total expenditures for both quick-relief and preventive asthma medications among all low-income participants with asthma, but not with utilization of preventive medications among those with uncontrolled asthma.

Medicaid Expansion And Outpatient Cardiovascular Care Use Among Low-Income Nonelderly Adults, 2012-15

Adults with lower socioeconomic status have a disproportionately higher burden of cardiovascular disease. Medicaid expansion under the Affordable Care Act, which went into effect January 1, 2014, in adopting states, led to an expansion of health insurance coverage for low-income adults. To understand whether Medicaid expansion was associated with increased access to outpatient cardiovascular care in expansion states, we examined Medicaid Analytic eXtract administrative claims data for nonelderly adult beneficiaries from the period 2012-15 for two states that expanded Medicaid eligibility (New Jersey and Minnesota) and two states that did not (Georgia and Tennessee) and calculated population-level rates of cardiovascular care use. There was a 38.1 percent greater increase in expansion states in the rate of beneficiaries with outpatient visits for cardiovascular disease management associated with Medicaid expansion relative to nonexpansion states. This was accompanied by a 42.9 percent greater increase in the prescription rate for cardiovascular disease management agents. These results suggest that expansion of Medicaid eligibility was associated with an increase in cardiovascular care use among low-income nonelderly adults in expansion states.

The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries

OBJECTIVE

To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries.

DATA SOURCES

2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files.

STUDY DESIGN

We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states.

DATA COLLECTION/EXTRACTION METHODS

The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community.

PRINCIPAL FINDINGS

ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079).

CONCLUSIONS

ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.

The impact of Medicaid expansion on mental health and substance use related inpatient visits

OBJECTIVE

Under the Affordable Care Act, many states expanded their Medicaid eligibility, allowing individuals living at or below 138% of the Federal Poverty Level to receive insurance coverage. As a result, forty states and the District of Columbia have expanded Medicaid to date. Although Medicaid expansion is expected to increase access to care in general, it is not evident if it has helped increase access to mental health and substance use-related healthcare, especially in inpatient settings. Therefore, this study examines the impact of Medicaid expansion on mental health and substance use- (MHSU) related inpatient visits and the variation in payer mix.

METHODS

This study utilizes state-level quarterly inpatient visit data from the Healthcare Cost and Utilization Project's Fast Stats Database from 2005 to 2019 and performs difference-in-differences regression analyses to compare MHSU-related inpatient visit data in expansion and non-expansion states for all visits and by payer. Analyses controlled for state-level socio-demographic and health policy variables.

RESULTS

Findings indicate that Medicaid expansion did not significantly affect overall MHSU-related inpatient visits. However, Medicaid expansion was associated with 22.74% increase (P < 0.01; 95% CI: 17.76, 27.71) in the Medicaid share of MHSU-related inpatient visits, 18.31% reduction (P < 0.01; 95% CI: -22.54, -14.09) in the uninsured share of MHSU-related inpatient visits, and 4.42% reduction (P < 0.05; 95% CI: -7.83, -1.01) in the privately insured share of MHSU-related inpatient visits in expansion states compared with non-expansion states.

CONCLUSIONS

Findings show that Medicaid expansion significantly affects the payer mix associated with MHSU-related inpatient visits while it has no significant impact on the overall MHSU-related inpatient visits.

Medicaid Expansion Under the Affordable Care Act and Association With Cardiac Care: A Systematic Review

BACKGROUND

The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes.

METHODS

Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes.

RESULTS

A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities.

CONCLUSIONS

Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.

Opioid Misuse and Opioid Overdose Mortality Among the Black Population in the United States: An Integrative Review

Opioid misuse is a growing public health concern in the United States (U.S.). This problem continues to claim many lives and has affected the life expectancy of the U.S. population. In the past few years, the Black population has witnessed an increased rate of overdose deaths compared to their white counterparts. This review seeks to characterize recent trends in opioid prescription practices and overdose deaths among the Black population in the U.S. An integrative review was conducted with a literature search from CINHAL, MEDLINE, and PsycINFO databases. The literature search identified 11 articles for the analysis. All studies were quantitative. Six studies focused on overdose mortality and five on opioid prescription practices. The results indicate a rising trend in opioid overdose mortality among Black people due to the availability of synthetic opioids on the illegal drug market. Black people receive fewer opioid prescriptions and experience higher rates of opioid dose reduction compared to Whites. The Black population has experienced an increase in opioid overdose mortality compared to the White population within the last two decades. Opioid overdose deaths among Black people are highly associated with the proliferation of synthetic opioids, and Black men have been more affected than Black women. Black people experience lower rates of opioid prescription during E.R. visits compared to Whites. The issue of low opioid prescribing among Black people needs to be addressed since it affects their health outcomes and is a factor that contributes to the use of illicit synthetic opioids.

The heterogeneity of public preferences for the first healthcare visit: A discrete choice experiment in the context of Vietnam

Primary healthcare is critical in addressing the main health problems of communities. In Vietnam, the increasing healthcare demands cause major challenges, especially overcrowding. This study identified public preferences regarding the selection of healthcare facilities for first visit. A discrete choice online survey was generated from five attributes including visit duration, travel time, personal connection with medical staff, doctors' experience, and health insurance. A D_z -efficient design constructed 36 choice sets, divided into three blocks of 12 choice sets. Each block formed one version of the questionnaire, which was randomly distributed to the participants. Heterogeneity in participant preferences was analysed by a latent class model with socio demographic characteristics and experiences of the last visit. 822 participants valued doctors' experience for both minor and severe symptoms. Preference heterogeneity for minor symptoms was quick service provision, highly experienced doctors, and payment through health insurance for the first (44.18%), second (32.17%), and third classes (23.66%), respectively. Regarding severe symptoms, they favoured all five attributes, quick health service, and reduced travel time for the first, second, and third classes, respectively (heterogeneities of 58.16%, 27.79%, and 14.05%, respectively). Predictions of choice from the worst to optimal healthcare facility scenario were 8.91%-61.91% and 10.16%-69.83% for minor and severe symptoms, respectively. Knowledge regarding public preference heterogeneity supports policymakers increase public acceptance in choosing primary healthcare facilities. Visit duration and doctors' experience should be considered a priority in decision making.

Public drug insurance, moral hazard and children's use of mental health medication: Latent mental health risk-specific responses to lower out-of-pocket treatment costs

Studies have shown that reducing out-of-pocket costs can lead to higher medication initiation rates in childhood. Whether the cost of such initiatives is inflated by moral hazard issues remains a question of concern. This paper looks to the implementation of a public drug insurance program in Québec, Canada, to investigate potential low-benefit consumption in children. Using a nationally representative longitudinal sample, we harness machine learning techniques to predict a child's risk of developing a mental health disorder. Using difference-in-differences analyses, we then assess the impact of the drug program on children's mental health medication uptake across the distribution of predicted mental health risk. Beyond showing that eliminating out-of-pocket costs led to a 3 percentage point increase in mental health drug uptake, we show that demand responses are concentrated in the top two deciles of risk for developing mental health disorders. These higher-risk children increase take-up of mental health drugs by 7-8 percentage points. We find even stronger effects for stimulants (8-11 percentage point increases among the highest risk children). Our results suggest that reductions in out-of-pocket costs could achieve better uptake of mental health medications, without inducing substantial low-benefit care among lower-risk children.

Medicaid Expansion Led To Reductions In Postpartum Hospitalizations

The Affordable Care Act (ACA) Medicaid expansions increased preconception and postpartum insurance coverage among low-income birthing people, leading to greater use of outpatient care. In this study we evaluated whether the expansions affected rates of postpartum hospitalization. Our analyses took advantage of underused longitudinal hospital data from the period 2010-17 to examine hospitalizations after childbirth. We compared changes in hospitalizations among birthing people with a Medicaid-financed delivery in states that did and did not expand Medicaid under the ACA. We found a 17 percent reduction in hospitalizations during the first sixty days postpartum associated with the Medicaid expansions and some evidence of a smaller decrease in hospitalizations between sixty-one days and six months postpartum. Our findings indicate that expanding Medicaid coverage led to improved postpartum health for low-income birthing people.

Can Medicaid be a Solution to the Problem? Underinsurance in Medicaid Expansion Versus Non-Expansion States

The positive effects of Medicaid expansions have been extensively documented in the literature. However, it is not clear whether the reform has had an equally meaningful effect with respect to underinsurance, which is the state of having health insurance yet lacking adequate coverage or facing substantial financial risks upon usage of services. Based on a quasi-experimental difference-in-differences approach, we analyzed the data from a nationally representative sample to estimate the effect of Medicaid expansion on the probability of underinsurance among the non-elderly low-income adult population of the U.S. We found no evidence of significant changes in the likelihood of underinsurance due to Medicaid expansion during the first 4 years after the ACA implementation. However, a supplementary analysis of the longer-term impact (2018-2019) suggests that there might be a time lag between Medicaid expansion and its effect on underinsurance. It is important to realize that expansion of coverage alone may not be sufficient to protect millions of Americans, particularly those with low incomes, from underinsurance. It is, therefore, crucial for policymakers to build legislative frameworks that protect individuals from excessive healthcare expenses and prevent treatment avoidance or delay.

The impact of Medicaid expansion on asthma-related health care services utilization and expenditure

OBJECTIVE

The purpose of this study was to examine the effect of Medicaid expansion on asthma-related health care services utilization and expenditures among low-income adult patients with asthma aged 26-64.

METHODS

Using a pooled dataset from 2007 to 2018 Medical Expenditures Panel Surveys (MEPS), we implemented a multivariate difference-in-differences analysis, which compared changes in utilization and expenditures for asthma-related health care services among adult patients with asthma with income below 133% Federal Poverty Level (FPL) vs. above 133%-400% FPL, before and after Medicaid expansion in 2014. We used negative binomial models to analyze utilization outcomes. Expenditures were estimated using two-part models with logit as the first part and generalized linear models as the second part. Estimates were weighted for the complex multi-stage sampling design of MEPS.

RESULTS

Medicaid expansion was associated with increases in both utilization and expenditures for asthma-related prescription drugs among low-income patients with asthma, by 1.8 prescription fills (p < 0.05) and $233 (p < 0.05) per year, respectively. No statistically significant association was detected for other asthma-related health care services.

CONCLUSION

Medicaid expansion led to an increase in accessibility of prescription drugs among low-income asthma patients, but had no effect on other asthma-related health care services.

Pursuing Pharmacoequity: Determinants, Drivers, and Pathways to Progress

The United States pays more for medical care than any other nation in the world, including for prescription drugs. These costs are inequitably distributed, as individuals from underrepresented racial and ethnic groups in the United States experience the highest costs of care and unequal access to high-quality, evidence-based medication therapy. Pharmacoequity refers to equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions. Herein the authors describe the urgent need to prioritize pharmacoequity. This goal will require a bold and innovative examination of social policy, research infrastructure, patient and prescriber characteristics, as well as health policy determinants of inequitable medication access. In this article, the authors describe these determinants, identify drivers of ongoing inequities in prescription drug access, and provide a framework for the path toward achieving pharmacoequity.

Role of Subsidized Coverage Eligibility in Medication Adherence Among Patients With Hypertension and Diabetes: Evidence From the NHIS 2011-2018

Introduction

The subsidized insurance provision under the Affordable Care Act is an important instrument for health insurance coverage among middle-income nonelderly individuals. However, unlike the health impacts of the Medicaid expansion under the Affordable Care Act, the impact of subsidized insurance is relatively less explored in extant literature. This study aims to assess the role of subsidized coverage eligibility in medication adherence among nonelderly patients with hypertension and diabetes in the U.S.

Methods

Using pooled data from 8 rounds (2011-2018) of the National Health Interview Survey, we estimated a difference-in-differences model to examine the change in medication adherence among study participants with a household income of 150%-399% of the Federal Poverty Line compared with that among their counterparts with a household income of ≥400% of the Federal Poverty Line during pre‒ and post‒Affordable Care Act periods. We also performed event study analysis and falsification tests to check the validity of our quasi-experimental design. Analyses were conducted in 2022.

Results

Medication adherence in the treatment group increased by 4.5 percentage points (95% CI=2.8, 6.2) during the post‒Affordable Care Act periods, whereas the increase was only 1.8 percentage points (95% CI=0.6, 3.0) in the control group. Results of the difference-in-differences model suggest that because of the subsidized insurance under the Affordable Care Act, medication adherence in the treatment group increased by 3.1 percentage points (95% CI=1.0, 5.2) during the post‒Affordable Care Act periods, compared with that in the control group. This increase was attributable to the improved insurance coverage, which increased by 6.8 percentage points (95% CI=5.3, 8.4) in the treatment during the post‒Affordable Care Act periods.

Conclusions

Our analyses generate evidence that middle-income individuals with hypertensive or diabetic conditions, who were eligible for the subsidized coverage, benefited from this provision of the Affordable Care Act.

The effects of medicaid expansion on job loss induced mental distress during the COVID-19 pandemic in the US

The COVID-19 pandemic led to an unprecedented level of job losses in the U.S., where job loss is also associated with the loss of health insurance. This paper uses data from the 2020 Household Pulse Survey (HPS) and difference-in-difference (DD) regressions to estimate the effect of Medicaid expansion on anxiety and depression associated with job loss. Estimates show that the respondents who live in expansion states are 96.6% more likely to have Medicaid coverage, and 14.2% less likely to have moderate to severe mental distress following their job loss compared to those living in non-expansion states. The corresponding numbers associated with a family member's job loss are 36.3% and 7.6%, respectively. Next, we explore the mechanisms which suggest that the economic security provided by Medicaid is as important (if not more) as the access to or utilization of healthcare. The difference-in-difference-in-difference (DDD) estimates using just above and below the Medicare eligibility age (65) confirm these results.

Trends in Out-of-Pocket Costs for Naloxone by Drug Brand and Payer in the US, 2010-2018

Importance

Improving access to naloxone is a critical component of the nation's strategy to curb fatal overdoses in the opioid crisis. Standing or protocol orders, prescriptive authority laws, and immunity provisions have been passed by states to expand access, but less attention has been given to potential financial barriers to naloxone access.

Objective

To assess trends in out-of-pocket (OOP) costs for naloxone and examine variation in OOP costs by drug brand and payer.

Design, Setting, and Participants

This observational study analyzed US naloxone claims data from Symphony Health and associated OOP costs for individuals filling naloxone prescriptions by drug brand and payer between January 1, 2010, to December 31, 2018. The data were analyzed from March 31, 2021, to April 12, 2022.

Main Outcomes and Measures

The main measures were trends in annual number of naloxone claims (overall, by payer, and by drug brand) and mean annual OOP costs per claim (overall, by payer, and by drug brand).

Results

Of 719 612 naloxone claims (172 894 generic naloxone, 501 568 Narcan, and 45 150 Evzio) for 2010 through 2018, the number of naloxone claims among insured patients began rapidly increasing after 2014; at the same time, the mean OOP cost of naloxone increased dramatically among the uninsured population. Comparing 2014 with 2018, the mean OOP cost of naloxone decreased by 26% among those with insurance but increased by 506% among uninsured patients. For the uninsured population, the impediment of cost was even larger for certain brands of the drug. In 2016, the mean OOP cost for Evzio among uninsured patients rose to $2136.37 (a 2429% increase relative to 2015) compared with the mean cost of generic naloxone, $72.88, and the cost of Narcan in its first year, $87.95. Throughout the period, the mean OOP costs paid by uninsured patients were higher for Evzio at $1089.17 (95% CI, $884.17-$1294.17) compared with $73.62 (95% CI, $69.24-$78.00) for Narcan and $67.99 (95% CI, $61.42-$74.56) for generic naloxone.

Conclusions and Relevance

In this observational study, the findings indicated that the OOP cost of naloxone had been an increasingly substantial barrier to naloxone access for uninsured patients, potentially limiting use among this population, which constituted approximately 20% of adults with opioid use disorder.

Association of Medicaid Expansion With Medicaid Enrollment and Health Care Use Among Older Adults With Low Income and Chronic Condition Limitations

Question

Was the expansion of Medicaid to working-age adults under the Patient Protection and Affordable Care Act (ACA) associated with changes in Medicaid enrollment and health care use among older adults with low income and chronic condition limitations?

Findings

In this cross-sectional study of 7153 US adults 65 years or older with low income, ACA Medicaid expansion was associated with significant increases in the likelihood of Medicaid enrollment and outpatient health care use among those with chronic condition limitations. No associations were found between ACA Medicaid expansion and Medicaid enrollment and health care use among those without such limitations.

Meaning

In this study, expansion of Medicaid to working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were enrolled in Medicare.

Importance

Medicaid is an important source of supplemental coverage for older Medicare beneficiaries with low income. Research has shown that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with increased Medicaid coverage for previously eligible older adults with low income, but there has been little research on whether their health care use increased or whether such changes differed by beneficiaries’ health status.

Objective

To assess whether the ACA Medicaid expansion to working-age adults was associated with increased Medicaid enrollment and health care use among older adults with low income with and without chronic condition limitations.

Design, Setting, and Participants

This cross-sectional study used data from the National Health Interview Survey from 2010 to 2017 for adults 65 years or older with low income (≤100% of the federal poverty level). Data were analyzed from November 2020 to March 2022.

Exposure

Residence in a state with Medicaid expansion for working-age adults.

Main Outcomes and Measures

The main outcomes were Medicaid coverage and health care use, measured by physician office visits and inpatient hospital care. Survey weights were used in calculating descriptive statistics and regression estimates. In multivariate analysis, difference-in-differences models were used to compare changes in outcomes over time between respondents in Medicaid expansion states and respondents in nonexpansion states.

Results

Of 21 859 adults included in the study, 7153 had chronic condition limitations (4983 [70.1%] female; mean [SD] age, 76.0 [0.1] years) and 14 706 did not have chronic condition limitations (9609 [66.3%] female; mean [SD] age, 74.85 [0.08] years). Of those with chronic condition limitations, 2707 (36.7%) were enrolled in Medicaid, 2816 (39.4%) had an office visit in the past 2 weeks, and 2152 (30.7%) used inpatient hospital care in the past year. Medicaid expansion was associated with differential increases in the likelihood of having Medicaid (4.92 percentage points; 95% CI, 0.25-9.60 percentage points; P = .04) and having an office visit in the past 2 weeks (5.31 percentage points; 95% CI, 0.10-10.51 percentage points; P = .046) compared with nonexpansion. There were no differential changes between expansion and nonexpansion states in receipt of inpatient hospital care (−0.62 percentage points; 95% CI, −5.39 to 4.14 percentage points; P = .79). Among adults without chronic condition limitations, 3159 (19.8%) were enrolled in Medicaid, and no differential changes between expansion and nonexpansion states in Medicaid enrollment (−0.24 percentage points; 95% CI, −3.06 to 2.57 percentage points; P = .86) or health care use were found.

Conclusions and Relevance

In this cross-sectional study, ACA Medicaid expansion for working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were dually eligible for Medicare and Medicaid.

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want

Objective

To explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development.

Materials and Methods

We conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes.

Results

Providers lacked access to information about: patients’ ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information’s quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges.

Discussion

These findings can inform the next generation of informatics tools for minimizing patients’ out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources.

Conclusion

Results identified opportunities to fill multidisciplinary providers’ information gaps and ways in which new tools could better support medication affordability for patients.

Almost a quarter of Americans taking prescription medications have difficulty affording them. We asked 38 healthcare providers what they do to help patients get affordable medications. They try to reduce the number of medications that patients take, choose more affordable medication options, and connect them to free medications or financial help. But it is hard for providers to do these things because they don’t always know which patients have financial challenges, and they may not know how much medications cost patients. Healthcare providers use digital tools like ordering systems to pick medications for patients, but they do not always have clear price information and they do not help outside of healthcare visits with prescribers. It is also hard for healthcare providers to get information about what patients have difficulty affording medications, and about resources to help them. Healthcare providers want new and improved digital tools to help them choose medications, and to be able to compare exact medication price differences. They also want a visual sign for patients with financial challenges, and centralized information about cost reduction resources. Finally, they desire tools to help them talk to patients about mediation prices, and medication price reports for patients themselves.

Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth

BACKGROUND

Incidence of hypertensive disorders of pregnancy is increasing in the United States. Early detection is important to prevent adverse maternal and offspring outcomes. This ecological study evaluated changes in rates of hypertensive disorders of pregnancy among states that expanded Medicaid compared with states that did not expand Medicaid.

METHODS

A quasi-experimental analysis using difference-in-differences models compared changes in rates of hypertensive disorders of pregnancy in Medicaid expansion states relative to non-Medicaid expansion states from 2012 to 2019. Maternal data from singleton first live births to individuals aged 20 to 39 years were obtained from the National Center for Health Statistics. Outcomes of interest included age-adjusted rates of de novo hypertension in pregnancy (gestational hypertension or preeclampsia) and prepregnancy hypertension.

RESULTS

Data from 7 764 965 individuals with a singleton first live birth were analyzed from 17 states and Washington, DC that expanded Medicaid and 15 states that did not. Rates of de novo hypertension in pregnancy increased over the study period in both expansion (54.34 [95% CI, 48.25-60.43] to 74.87 [95% CI, 71.20-78.55] per 1000 births) and nonexpansion states (68.32 [95% CI, 61.02-75.62] to 84.79 [95% CI, 80.67-88.91] per 1000 births). In adjusted difference-in-differences analyses, expansion status was associated with a greater increase in rates of de novo hypertension in pregnancy (difference-in-differences coefficient, +8.18 [95% CI, 4.00-12.36] per 1000 live births) but a decline in rates of de novo hypertension in pregnancy complicated by low birth weight (-7.20 [95% CI, -13.71 to -0.70] per 1000 births with hypertensive disorders of pregnancy). In adjusted difference-in-differences analyses, there were no significant changes in rates of prepregnancy hypertension in expansion relative to nonexpansion states (+1.13 [95% CI, -0.09 to +2.35] per 1000 live births).

CONCLUSIONS

Between 2012 and 2019, states that expanded Medicaid had a significantly greater increase in rates of de novo hypertension, with some evidence of better outcomes among those with de novo hypertension diagnosed in pregnancy.

Changes in diabetes prescription patterns following Affordable Care Act Medicaid expansion

INTRODUCTION

Most patients with diabetes mellitus are prescribed medications to control their blood glucose. The implementation of the Affordable Care Act (ACA) led to improved access to healthcare for patients with diabetes. However, impact of the ACA on prescribing trends by diabetes drug category is less clear. This study aims to assess if long-acting insulin and novel agents were prescribed more frequently following the ACA in states that expanded Medicaid compared with non-expansion states.

RESEARCH DESIGN AND METHODS

In this analysis of a natural experiment, prescriptions reimbursed by Medicaid (US public insurance) for long-acting insulins, metformin, and novel agent medications (DPP4 inhibitors, sodium/glucose cotransporter 2 inhibitor antagonists, and glucagon-like peptide-1 receptor agonists) from 2012 to 2017 were obtained from public records. For each medication category, we performed difference-in-differences (DID) analysis modeling change in rate level from pre-ACA to post-ACA in Medicaid expansion states relative to Medicaid non-expansion states.

RESULTS

Expansion and non-expansion states saw a decline in both metformin and long-acting insulin prescriptions per 100 enrollees from pre-ACA to post-ACA. These decreases were larger in non-expansion states relative to expansion states (metformin: absolute DID = +0.33, 95% CI=0.323 to 0.344) and long-acting insulin (absolute DID: +0.11; 95% CI=0.098 to 0.113). Novel agent prescriptions in expansion states (+0.08 per 100 enrollees) saw a higher absolute increase per 100 Medicaid enrollees than in non-expansion states (absolute DID= +0.08, 95% CI=0.079 to 0.086).

CONCLUSIONS

There was a greater absolute increase for prescriptions of novel agents in expansion states relative to non-expansion states after accounting for number of enrollees. Reducing administrative barriers and improving the ability of providers to prescribe such newer therapies will be critical for caring for patients with diabetes-particularly in Medicaid non-expansion states.

National Trends in Out-of-Pocket Costs Among U.S. Adults With Diabetes Aged 18-64 Years: 2001-2017

OBJECTIVE

To assess national trends in out-of-pocket (OOP) costs among adults aged 18-64 years with diabetes in the U.S.

RESEARCH DESIGN AND METHODS

Using data from the 2001-2017 Medical Expenditure Panel Survey, we estimated total per person annual OOP costs (insurance premiums, prescription drug costs, inpatient and outpatient deductibles, copays, and other payments not covered by insurance) and high OOP cost rate, defined as the percentage of people with OOP spending >10% of their family's pretax income. We examined trends overall, by subgroup (insurance type, income level, insulin use, size of patient's employer, and whether the patient was enrolled in a high deductible health plan), and by type of service. Changes in trends were identified using joinpoint analysis; costs were adjusted to 2017 U.S. dollars.

RESULTS

From 2001 to 2017, OOP costs decreased 4.3%, from $4,328 to $4,139, and the high OOP cost rate fell 32%, from 28 to 19% (P < 0.001). Changes in the high OOP cost rate varied by subgroup, declining among those with public or no insurance and those with an income <200% of the federal poverty level (P < 0.001) but remaining stable among those with private insurance and higher income. Drug prescription OOP costs decreased among all subgroups (P < 0.001). Decreases in total (-$58 vs. -$37, P < 0.001) and prescription (-$79 vs. -$68, P < 0.001) OOP costs were higher among insulin users than noninsulin users.

CONCLUSIONS

OOP costs among U.S. nonelderly adults with diabetes declined, especially among those least able to afford them. Future studies may explore factors contributing to the decline in OOP costs and the impact on the quality of diabetes care and complication rates.

Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes

Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed.

Impact of Medicaid expansion on mental health and substance use related emergency department visits

Background: Although Medicaid expansion under the Affordable Care Act reduces uninsurance, little evidence exists on its impact on mental health and substance use (MHSU) related healthcare utilization. Therefore, the objectives of this study are to examine the impact of Medicaid expansion on emergency department visits related to mental health and substance use disorders and to examine its effect on the variation in payer mix. Methods: The study utilizes state-level quarterly emergency department (ED) visit data from Healthcare Cost and Utilization Project's Fast Stats Database, along with state socio-demographic and health policy data for the analysis. A difference-in-differences regression analysis approach was utilized in comparing MHSU-related ED visit data between expansion and non-expansion states from 2006 to 2019 for all visits and by payer mix. Results: Medicaid expansion was associated with additional 0.35 non-Medicare adult MHSU-related ED visits per 1,000 population (p < 0.05) in expansion states compared with non-expansion states. In addition, Medicaid expansion was associated with about 20.4% increase (p < 0.01) in Medicaid-share of MHSU-related ED visits, about 17.4% reduction (p < 0.01) in uninsured-share of MHSU-related ED visits, and about 3% reduction (p < 0.05) in privately-insured share of MHSU-related ED visits in expansion states compared with non-expansion states. Conclusions: The findings indicate that Medicaid expansion was associated with increased MHSU-related ED visits among the Medicaid population and the overall non-Medicare adult population, while it was associated with reductions in MHSU-related ED visits among the uninsured and privately-insured populations in expansion states compared with non-expansion states.

Health Insurance and Out-Of-Pocket Expenditure on Health and Medicine: Heterogeneities along Income

Background: Achieving universal health coverage is an important objective enshrined in the 2015 global Sustainable Development Goals. However, the rising cost of healthcare remains an obstacle to the attainment of the universal health coverage. Health insurance is considered an option to reduce out-of-pocket (OOP) expenditure on health and medicine. Nevertheless, the relationship between insurance and the OOP along welfare distributions is not well understood. This study investigates the heterogeneous association between health insurance and OOP expenditure on health and medicine, along income, using data from the Kingdom of Saudi Arabia. Methods: This study used data of 8655 individuals drawn from the Saudi Family Health Survey conducted in 2018. The study adopts Tobit models to account for possible corner solution due to individuals with zero expenditure on health. We minimize the confounding effects of non-random selection into the insurance program by estimating the Tobit equations on a sample weighted by inverse propensity scores of insurance participation. In addition, we test whether the health insurance differently relates to OOP on health and medicine amongst people with access to free medical care as opposed to those without this privilege. The study estimates separate models for OOP expenditure on health and on medicines. Results: Health insurance reduces OOP expenditure on health by 2.0% and OOP expenditure on medicine by 2.4% amongst the general population while increasing the OOP expenditure on health by 0.2% and OOP expenditure on medicine by 0.2%, once income of the insured rises. The relationship between the insurance and OOP expenditure is robust only amongst the citizens, a sub-sample that also has access to free public healthcare. Specifically, the insurance reduces OOP expenditure on health by 3.6% and OOP on medicine by 5.2% and increases OOP expenditure on health by 0.4% and OOP expenditure on medicine by 0.5% once income of the insured increases amongst Saudi citizens. In addition, targeting medicines can lead to greater changes in OOP. The relationship between insurance and OOP is stronger for medicine relative to that observed on health expenditure. Conclusion: Our findings suggest that insurance induces different effects along the income spectrum. Hence, policy needs to be aware of the possible welfare distribution impacts of upscaling or downscaling the coverage of insurance amongst the populations, while pursuing universal healthcare coverage.

An investigation of health insurance policy and behavior in a virtual environment

We introduce a new experimental approach to measuring the effects of health insurance policy alternatives on behavior and health outcomes over the life course. In a virtual environment with multi-period lives, subjects earn virtual income and allocate spending, to maximize utility, which is converted into cash payment. We compare behavior across age, income and insurance plans-one priced according to an individual's expected cost and the other uniformly priced through employer-implemented cost sharing. We find that 1) subjects in the employer-implemented plan purchased insurance at higher rates; 2) the employer-based plan reduced differences due to income and age; 3) subjects in the actuarial plan engaged in more health-promoting behaviors, but still below optimal levels, and did save at the level required, so did realize the full benefits of the plan. Subjects had more difficulty optimizing choices in the Actuarial treatment, because it required more long term planning and evaluating benefits that compounded over time. Contrary, to model predictions, the actuarial priced insurance plan did not increase utility relative to the employer-based plan.

Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, And Postpartum Contraception

The period before pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. We evaluated whether increased access to health insurance under the Affordable Care Act Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and nonexpansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures.

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

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

Welcome Mats and On-Ramps for Older Adults: The Impact of the Affordable Care Act's Medicaid Expansions on Dual Enrollment in Medicare and Medicaid

For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called "welcome mat" effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an "on-ramp" effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.

Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015

Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and -7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.

Public insurance expansions and mental health care availability

OBJECTIVE

To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.

DATA SOURCE/STUDY SETTING

The National Mental Health Services Survey (N-MHSS) 2010-2018.

STUDY DESIGN

A quasi-experimental differences-in-differences design using observational data.

DATA COLLECTION

The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.

PRINCIPAL FINDINGS

ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.

CONCLUSIONS

This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system.

ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study

The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.

The impact of Medicare Part D on opioid use among U.S. older adults

BACKGROUND

To assess the association between the implementation of Medicare Part D and the use of outpatient prescription opioids.

METHODS

Nationally representative data on community-dwelling adults aged 60-69 came from the 2000-2015 Medical Expenditure Panel Survey (MEPS) (N = 26,545). A difference-in-differences approach was used to compare opioid use between Medicare eligible (ages 66-69) and Medicare ineligible (ages 60-64) adults before and after the introduction of Part D in 2006, while controlling for socio-demographic characteristics, risk factors for opioid use, and secular trends.

RESULTS

Medicare Part D was associated with a small and statistically non-significant increase in the number of outpatient prescription opioids filled in a year (coefficient, 0.03; 95% CI, -0.08 to 0.13), in the amount of morphine milligrams equivalents (coefficient, 113.23; 95% CI, -25.47 to 251.93), and in the odds of using any prescription opioid (OR, 1.03; 95% CI, 0.85 to 1.26). There was no evidence for a heterogeneous effect of Part D across subgroups. The results were robust to the impacts of the 2007-2009 recession, the spillover effect of the Affordable Care Act, and the anticipation effect of Part D.

DISCUSSION

Although policymakers suggested that gaining access to medical care as a result of insurance expansion might have fueled the opioid epidemic, this paper found limited evidence to support this claim. While Part D took effect more than a decade ago, its long-term implication for opioid use is still relevant for the recent opioid epidemic and future health insurance expansions such as the proposed Medicare-for-all initiative.

The effect of Medicaid expansion on prescriptions for breast cancer hormonal therapy medications

OBJECTIVE

To quantify the effects of the Affordable Care Act Medicaid expansion on prescriptions for effective breast cancer hormonal therapies (tamoxifen and aromatase inhibitors) among Medicaid enrollees.

DATA SOURCE/STUDY SETTING

Medicaid State Drug Utilization Database (SDUD) 2011-2018, comprising the universe of outpatient prescription medications covered under the Medicaid program.

STUDY DESIGN

Differences-in-differences and event-study linear models compare population rates of tamoxifen and aromatase inhibitor (anastrozole, exemestane, and letrozole) use in expansion and nonexpansion states, controlling for population characteristics, state, and time.

PRINCIPAL FINDINGS

Relative to nonexpansion states, Medicaid-financed hormonal therapy prescriptions increased by 27.2 per 100 000 nonelderly women in a state. This implies a 28.8 percent increase from the pre-expansion mean of 94.2 per 100 000 nonelderly women in expansion states. The event-study model reveals no evidence of differential pretrends in expansion and nonexpansion states and suggests use grew to 40 or more prescriptions per 100 000 nonelderly women 3-5 years postexpansion.

CONCLUSIONS

Medicaid expansion may have had a meaningful impact on the ability of lower-income women to access effective hormonal therapies used to treat breast cancer.

Unmet Healthcare Needs and Healthcare Access Gaps Among Uninsured U.S. Adults Aged 50-64

Lack of health insurance (HI) is a particular problem for near-older Americans aged 50–64 because they tend to have more chronic health conditions than younger age groups and are at increased risk of disability; however, little recent research has focused on HI coverage and healthcare access among this age group. Using the U.S. National Health Interview Survey data for the years 2013 to 2018, we compared HI coverage and healthcare access between the 50–64 and 65+ age groups. Using logistic regression analysis, we then examined the sociodemographic and health characteristics of past-year healthcare access of near-older Americans without HI to those with private HI or public HI (Medicare without Medicaid, Medicaid without Medicare, Medicare and Medicaid, and VA/military HI). We estimated the odds of healthcare access among those without HI compared to those with private or public HI. Near-older Americans without HI were at least seven times more likely to have postponed or foregone needed healthcare due to costs, and only 15% to 23% as likely to have had contact with any healthcare professional in the preceding 12 months. Expanding HI to near-older adults would increase healthcare access and likely result in reduced morbidity and mortality and higher quality of life for them.

The effects of Medicaid expansion on labor market outcomes: Evidence from border counties

This paper provides new empirical evidence on the employment and earning effects of the recent Medicaid expansion. Unlike most existing studies that use a conventional state and year fixed effects approach, our main identification strategy is based on the comparison of employment and wages in contiguous county-pairs in neighboring states (i.e., border counties) with different Medicaid expansion status. Using the 2008-2016 Quarterly Census of Employment and Wages, we estimate a set of distributed lag models in order to examine the dynamic effects of Medicaid expansion. Results from our preferred specification suggest a statistically significant decrease in total employment of 1.2% 1 year after the expansion of Medicaid. This translates into a 37% decrease in employment among newly eligible Medicaid enrollees under the strong assumption that Medicaid coverage did not crowd out private insurance coverage. We also find that this disemployment effect is transitory: 2 years after the Medicaid expansion employment returns to preexpansion levels. We do not find any statistically significant effect of the Medicaid expansion on wages at any point.

Job postings in the substance use disorder treatment related sector during the first five years of Medicaid expansion

Background

Effective treatment strategies exist for substance use disorder (SUD), however severe hurdles remain in ensuring adequacy of the SUD treatment (SUDT) workforce as well as improving SUDT affordability, access and stigma. Although evidence shows recent increases in SUD medication access from expanding Medicaid availability under the Affordable Care Act, it is yet unknown whether these policies also led to a growth in hiring in the SUDT related workforce, partly due to poor data availability. Our study uses novel data to shed light on recent trends in a fast-evolving and policy-relevant labor market, and contributes to understanding data sources to track the SUDT related workforce and the effect of recent state healthcare policies on the supply side of this sector.

Methods and data

We examine hiring attempts in the SUDT and related behavioral health sector over 2010-2018 to estimate the causal effect of the 2014-and-beyond state Medicaid expansions on these outcomes through “difference-in-difference” econometric models. We use Burning Glass Technologies (BGT) data covering virtually all U.S. job postings by employers.

Findings

Nationally, we find little growth in the sector’s hiring attempts in 2010-2018 relative to the rest of the economy or to health care as a whole. However, this masks heterogeneity in the bimodal trend in SUDT job postings, with some increases in most years but a decrease in 2014 and in 2017, as well as a shift in emphasis between different occupational categories. Medicaid expansion, however, is not associated with any statistically significant change in overall hiring attempts in the SUDT related sector during this time period, although there is moderate evidence of increases among primary care physicians.

Conclusions

Although hiring attempts in the SUDT related sector as measured by the number of job advertisements have not grown substantially over time, there was a shift in the hiring landscape. Many national factors including reimbursement policy may play a role in incentivizing demand for the SUDT related workforce, but our research does not show that recent state Medicaid expansion was one such statistically detectable factor. Future research is needed to understand how aggregate labor demand signals translate into actual increases in SUDT workforce and availability.

Overturning the ACA's Medicaid Expansion Would Likely Decrease Low-Income, Reproductive-Age Women's Healthcare Spending and Utilization

In late 2020, the Supreme Court began hearing a case challenging the Affordable Care Act (ACA), which led to coverage gains for many low-income, reproductive-age women. To explore potential implications of a full ACA repeal for this population, we examined gains experienced after Medicaid expansion, assuming that such gains may be reversed. Using restricted 2013 to 2014 data from the Medical Expenditure Panel Survey for 1190 women ages 18 to 44 with household incomes below 138% of the federal poverty level, we compared the change in healthcare spending and utilization for women living in expansion states to the change in non-expansion states using a difference-in-differences design. We found that if Medicaid expansion were overturned, Medicaid coverage is likely to decrease, as well as Medicaid spending and prescription drug utilization.

Public insurance expansions and smoking cessation medications

We study the effect of public insurance on smoking cessation medication prescriptions and financing. We leverage variation in insurance coverage generated by recent Affordable Care Act expansions to Medicaid. We estimate differences-in-differences models using administrative data on the universe of Medicaid-financed prescriptions sold in retail and online pharmacies 2011-2017. Our findings suggest that these expansions increased Medicaid-financed smoking cessation prescriptions by 34%. This increase reflects new medication use and a shift in payment from private insurers and self-paying patients to Medicaid. Adjusting our estimate for changes in financing implies that Medicaid expansion lead to a 24% increase in new medication use.