Medicaid Versus Marketplace Coverage For Near-Poor Adults: Effects On Out-Of-Pocket Spending And Coverage

Assessing Diversity, Equity, and Inclusion in Patient-Facing Websites in Neurosurgical Departments in the United States

BACKGROUND

Patient-facing websites serve as essential platforms for disseminating information, engaging with patients, and increasing access to neurosurgical resources and services. Diversity, Equity, and Inclusion are at the forefront of issues facing the field of neurosurgery, especially concerning race and gender disparities in regards to providers in the field.

METHODS

Data were collected in regards to the race and gender of patients and providers displayed on the neurosurgery department's patient-facing website in addition to accommodations for disabilities, decreased ability to pay, and language.

RESULTS

Patients who were White were depicted more commonly than those of color (69% vs. 31%, P < 0.00001). White patients also were over-represented when compared with the average demographics of the communities in which the hospitals served (P = 0.03846). Neurosurgical providers who were White outnumbered those of color (70% vs. 30%, P < 0.00001). The racial depiction of providers was comparable with racial disparities currently observed in neurosurgery (P = 0.59612). Female neurosurgery providers were seen less than male providers on patient-facing websites (P < 0.00001) but were seen more commonly on patient-facing websites than the percentage of practicing neurosurgeons they currently comprise (28% vs. 8%, P < 0.00001).

CONCLUSIONS

The results of this study suggest that patient-facing websites of neurosurgical departments are an area of improvement in regards to Diversity, Equity, and Inclusion in the field of neurosurgery. Disparities are noted in regards to the racial depiction of patients and further call to attention racial and gender disparities in the field of neurosurgery.

Evaluating the impact of the Medicaid expansion program on diabetes hospitalization

Diabetes is the most expensive chronic disease in the United States, and hospital inpatient care accounts for 30% of the total medical expenditures. Medical costs for people with limited resources are covered by Medicaid, a joint federal and state program, and its expansion that extent the coverage to those with incomes up to 138% of the federal poverty level. We investigated the impact of Medicaid expansion on diabetes hospitalizations by states and payer, among adults aged 19 to 64 years old, 5 years after the expansion. We found that Medicaid expansion decreased total diabetes hospitalization in most states and a diabetes hospitalization payer mix shifted from private insurance and uninsured to Medicaid. The percentage of diabetes hospitalizations paid by Medicaid increased by 11% (95% CI 7%, 16%), while the percentage paid by private insurance decreased by 6% (95% CI - 8%, - 3%) and the percentage of uninsured diabetes hospitalization decreased by 13% (95% CI - 18%, - 9%).

Association between vaccination rates and COVID-19 health outcomes in the United States: a population-level statistical analysis

BACKGROUND

Population-level vaccine efficacy is a critical component of understanding COVID-19 risk, informing public health policy, and mitigating disease impacts. Unlike individual-level clinical trials, population-level analysis characterizes how well vaccines worked in the face of real-world challenges like emerging variants, differing mobility patterns, and policy changes.

METHODS

In this study, we analyze the association between time-dependent vaccination rates and COVID-19 health outcomes for 48 U.S. states. We primarily focus on case-hospitalization risk (CHR) as the outcome of interest, using it as a population-level proxy for disease burden on healthcare systems. Performing the analysis using Generalized Additive Models (GAMs) allowed us to incorporate real-world nonlinearities and control for critical dynamic (time-changing) and static (temporally constant) factors. Dynamic factors include testing rates, activity-related engagement levels in the population, underlying population immunity, and policy. Static factors incorporate comorbidities, social vulnerability, race, and state healthcare expenditures. We used SARS-CoV-2 genomic surveillance data to model the different COVID-19 variant-driven waves separately, and evaluate if there is a changing role of the potential drivers of health outcomes across waves.

RESULTS

Our study revealed a strong and statistically significant negative association between vaccine uptake and COVID-19 CHR across each variant wave, with boosters providing additional protection during the Omicron wave. Higher underlying population immunity is shown to be associated with reduced COVID-19 CHR. Additionally, more stringent government policies are generally associated with decreased CHR. However, the impact of activity-related engagement levels on COVID-19 health outcomes varied across different waves. Regarding static variables, the social vulnerability index consistently exhibits positive associations with CHR, while Medicaid spending per person consistently shows a negative association. However, the impacts of other static factors vary in magnitude and significance across different waves.

CONCLUSIONS

This study concludes that despite the emergence of new variants, vaccines remain highly correlated with reduced COVID-19 harm. Therefore, given the ongoing threat posed by COVID-19, vaccines remain a critical line of defense for protecting the public and reducing the burden on healthcare systems.

THE IMPACT OF ELIGIBILITY FOR MEDICAID VERSUS SUBSIDIZED PRIVATE HEALTH INSURANCE ON MEDICAL SPENDING, SELF-REPORTED HEALTH, AND PUBLIC PROGRAM PARTICIPATION

We use a regression discontinuity design to understand the impact of a sharp change in eligibility for Medicaid versus subsidized marketplace insurance at 138 percent of the federal poverty line on coverage, medical spending, health status, and other public program participation. We find a 5.5 percentage point shift from Medicaid to private insurance, with no net change in coverage. The shift increases individual health spending by $341 or 2 percent of income, with larger increases at higher points in the spending distribution. Two-thirds of the increase is from premiums and one-thirdfrom out-of-pocket medical spending. Self-rated health and other public program participation appear unchanged. We find no evidence of bunching below the eligibility threshold, which suggests either that individuals are willing to pay more for private insurance or that optimization frictions are high.

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.

Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance

BACKGROUND

Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains.

OBJECTIVE

Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans.

DESIGN

Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases.

MAIN MEASURES

Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain.

KEY RESULTS

Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes.

CONCLUSION

Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.

Health insurance expansion and family violence prevention: A conceptual framework

Family violence, including child maltreatment (CM) and intimate partner violence (IPV), plagues far too many American families, particularly those in low-income communities. CM and IPV are intertwined and impose a significant emotional, health and financial burden on children and families and an economic burden on our country. Although these and other forms of violence are influenced by shared risk factors across the socioecological spectrum, prevention efforts typically intervene on a single type of violence at a microsystem level via individual or family intervention. Research is needed to identify policies operating at macrosystem levels that reduce, at scale, multiple forms of violence affecting children. In this paper, we propose a three-step theory of change through which health insurance expansions might reduce rates of CM and IPV, using Medicaid expansion as an exemplar. The proposed framework can inform research examining the link between health insurance and the primary prevention of CM and IPV.

The Line between Medicaid and Marketplace: Coverage Effects from Wisconsin's Partial Expansion

CONTEXT

States have experimented with the income eligibility threshold between Medicaid coverage and access to subsidized Marketplace plans in an effort to increase coverage for low-income adults while meeting other state priorities, particularly a balanced budget. In 2014, Wisconsin opted against adopting an ACA Medicaid expansion, instead setting the Medicaid eligibility threshold at 100% of the poverty level-a state-funded partial expansion. Childless adults gained new eligibility, while parents and caregivers with incomes between 101-200% of poverty lost existing eligibility.

METHODS

We used Wisconsin's all-payer claims database to assess health insurance gains, losses, and transitions among low-income adults affected by this partial expansion.

FINDINGS

We found that less than one third of adults who lost Medicaid eligibility definitely took up commercial coverage, and many returned to Medicaid. Among those newly eligible for Medicaid, there was little evidence of crowd-out. Both groups experienced limited continuity of coverage. Overall, new Medicaid enrollment of childless adults was offset by coverage losses among parents and caregivers, rendering Wisconsin's overall coverage gains similar to nonexpansion states.

CONCLUSIONS

Wisconsin's experience demonstrates the difficulty in relying on the Marketplace to cover the near poor and suggests that full Medicaid expansion more effectively increases coverage.

The Affordable Care Act Medicaid expansion: A difference-in-differences study of spillover participation in SNAP

The Affordable Care Act’s Medicaid expansion to individuals with adults under 138 percent of the federal poverty level led to insurance coverage for millions of Americans in participating states. This study investigates Medicaid expansion’s potential spillover participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program). In addition to providing public insurance, the policy connects individuals to SNAP, affecting social determinants of health such as hunger. We use difference-in-differences regression to estimate the effect of the Medicaid expansion on SNAP participation among approximately 414,000 individuals from across the United States. The Current Population Survey is used to answer the main research question, and the SNAP Quality Control Database allows for supplemental analyses. Medicaid expansion produces a 2.9 percentage point increase (p = 0.002) in SNAP participation among individuals under 138 percent of federal poverty. Subgroup analyses find a larger 5.0 percentage point increase (p = 0.002) in households under 75 percent of federal poverty without children. Able-Bodied Adults Without Dependents (ABAWDs) are a category of individuals with limited access to SNAP. Although they are a subset of adults without children, we found no spillover effect for ABAWDs. We find an increase in SNAP households with $0 income, supporting the finding that spillover was strongest for very-low-income individuals. Joint processing of Medicaid and SNAP applications helps facilitate the connection between Medicaid expansion and SNAP. Our findings contribute to a growing body of evidence that Medicaid expansion does more than improve access to health care by connecting eligible individuals to supports like SNAP. SNAP recipients have increased access to food, an important social determinant of health. Our study supports reducing administrative burdens to help connect individuals to safety net programs. Finally, we note that ABAWDs are a vulnerable group that need targeted program outreach.

Analysis of US Household Catastrophic Health Care Expenditures Associated With Chronic Disease, 2008-2018

This cross-sectional study evaluates trends in catastrophic health care expenditures associated with chronic diseases in US households from 2008 to 2018.

Medicaid Expansion's Impact on Emergency Department Use by State and Payer

OBJECTIVES

The Affordable Care Act's Medicaid Expansion Program influences healthcare use by increasing insurance coverage. Of particular interest is how this will affect inefficient and expensive emergency department (ED) visits. We estimated the impact of the Medicaid expansion on ED use by states and payer (Medicaid, private insurance, and uninsured) 5 years after the implementation of the Medicaid expansion and illustrated the use of the generalized synthetic control method.

METHODS

In this quasi-experiment study, we implemented the generalized synthetic control method to compare states with Medicaid expansion and states without Medicaid expansion. Data were from the Healthcare Cost Utilization Project Fast Stats, which cover >95% of all ED visits. We included states with complete data from 2010 to 2018.

RESULTS

Overall, the Medicaid expansion increased Medicaid share of ED visits (average treatment effect on the treated [ATT] 11.39%; 95% confidence interval [CI] 8.76-14.02) and decreased private share of ED visits (ATT -5.80%; 95% CI -7.40 to -4.12) and uninsured share of ED visits (ATT -6.66%; 95% CI -9.78 to -3.55).

CONCLUSIONS

Medicaid Expansion Program shifted ED payer mix to Medicaid ED visits from private insurance and uninsured ED visits for adults at age of 19 to 64 years, whereas its effect on total ED volume is mixed among states. States that experienced the largest increase in Medicaid enrollment seem to experience an increase in ED visits although such results did not reach statistical significance.

Better Late Than Never: Effects of Late ACA Medicaid Expansions for Parents on Family Health-Related Financial Well-Being

Public health insurance eligibility for low-income adults has improved adult economic well-being. But whether parental public health insurance eligibility has spillover effects on children’s health insurance coverage and family health-related financial well-being is less understood. We use the 2016 to 2020 National Survey of Children’s Health (NSCH) to estimate the effects of Medicaid expansions through the Affordable Care Act (ACA) for parents on child health insurance coverage, parents’ employment decisions due to child health, and family health-related financial well-being. We compare children in low-income families in states that expanded Medicaid for parents after 2015 to states that never expanded in a difference-in-differences framework. We find that these expansions were associated with increases in children’s public health insurance coverage by 5.5 percentage points and reductions in private coverage by 5 percentage points. We additionally find that parents were less likely to avoid changing jobs for health insurance reasons and children’s medical expenses were less likely to exceed $1000. We find no evidence that the expansions affected children’s dual coverage and uninsurance. Our estimates are robust to falsification and sensitivity analyzes. Our findings also suggest that benefits on children’s medical expenses are concentrated in the families with the greatest financial need.

Association of Medicaid vs Marketplace Eligibility on Maternal Coverage and Access With Prenatal and Postpartum Care

Importance

Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown.

Objective

To compare maternal coverage and care by Medicaid vs marketplace eligibility.

Design, Setting, and Participants

A retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey.

Exposures

Eligibility for Medicaid or marketplace coverage under the Affordable Care Act.

Main Outcomes and Measures

Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use.

Results

The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified.

Conclusions and Relevance

In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

How did the Affordable Care Act Medicaid Expansion Affect Coverage and Access to Care for Low-Income Parents Who Were Eligible for Medicaid Before the Law Was Passed?

We use the National Health Interview Survey from 2010 to 2017 and a difference-in-differences approach to assess the impact of the Affordable Care Cct (ACA) Medicaid expansion on coverage and access to care for a subset of low-income parents who were already eligible for Medicaid when the ACA was passed. Any gains in coverage would typically be expected to improve access to and affordability of care, but there were concerns that by increasing the total population with coverage and thereby straining provider capacity, that the ACA would reduce access to care for individuals who were already eligible for Medicaid prior to the passage of the law. We found that the expansion reduced uninsurance among previously eligible parents by 12.6 percentage points, or a 40 percent decline from their 2012–2013 uninsurance rate. Moreover, these effects grew stronger over time with a 55 percent decline in uninsurance 2 to 3 years following expansion. Though we identified very few statistically significant impacts of the expansion on affordability of care, descriptive estimates show substantial declines in unmet needs due to cost and problems paying family medical bills. Descriptively, we find no significant increases in provider access problems for previously eligible parents, and very limited evidence that the Medicaid expansion was associated with more constrained provider capacity. Though sample size constraints were likely a factor in our ability to identify impacts on access and affordability measures, our overall findings suggest that the ACA Medicaid expansion positively affected our sample of low-income parents who met pre-ACA Medicaid eligibility criteria.

Examination of Elective Bariatric Surgery Rates Before and After US Affordable Care Act Medicaid Expansion

Importance

There is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion.

Objective

To examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years.

Design Setting and Participants

This cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021.

Exposure

Living in a Medicaid expansion state.

Main Outcomes and Measures

The main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals.

Results

Of the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals.

Conclusions and Relevance

This cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals.

Effects of the ACA on Health Care Coverage for Adults With Substance Use Disorders

OBJECTIVE

The authors assessed changes in health care coverage in nationally representative samples of low- and middle-income adults with and without substance use disorders following the 2014 Affordable Care Act marketplace launch and Medicaid expansion.

METHODS

Data from the 2012-2018 (N=407,985) National Survey on Drug Use and Health identified low- and middle-income nonelderly adults with alcohol, marijuana, cocaine, or heroin use disorders. A sociodemographically adjusted difference-in-differences analysis assessed the trends in Medicaid and individually purchased private insurance between adults with and without substance use disorders.

RESULTS

Between 2012-2013 and 2015-2016, the percentages without health insurance significantly declined for adults with substance use disorders (from 27.8% to 18.7%) and for those without these disorders (from 22.6% to 14.6%). These trends were related to gains in Medicaid and in individually purchased private insurance but not to gains in employer-based private insurance coverage. Between 2015-2016 and 2017-2018, however, the percentages without health insurance among adults with substance use disorders (18.7% to 18.4%) and without these disorders (14.7% to 14.7%) was little changed.

CONCLUSIONS

With insurance gains having stalled and the downturn of the U.S. economy, there is renewed urgency to extend health care coverage to middle- and low-income adults with substance use disorders that meets their substance use and general health needs.

Health services utilization, out-of-pocket expenditure, and underinsurance among insured non-elderly cancer survivors in the United States, 2011-2015

BACKGROUND

High out-of-pocket (OOP) expenditure and inadequate insurance coverage may adversely affect cancer survivors. We aimed to characterize the extent and correlates of healthcare utilization, OOP expenditures, and underinsurance among insured cancer survivors.

METHODS

We used 2011-2015 Medical Expenditure Panel Survey data to identify a nationally representative sample of insured non-elderly adult (age 18-64 years) cancer survivors. We used negative binomial, two-part (logistic and Generalized Linear Model with log link and gamma distribution), and logistic regression models to quantify healthcare utilization, OOP expenditures, and underinsurance, respectively, and identified sociodemographic correlates for each outcome.

RESULTS

We identified 2738 insured non-elderly cancer survivors. Adjusted average utilization of ambulatory, non-ambulatory, prescription medication, and dental services was 14.4, 0.51, 24.9, and 1.4 events per person per year, respectively. Higher ambulatory and dental services utilization were observed in older adults, females, non-Hispanic Whites, survivors with a college degree and high income, compared to their counterparts. Nearly all (97.7%) survivors had some OOP expenditures, with a mean adjusted OOP expenditure of $1552 per person per year. Adjusted mean OOP expenditures for ambulatory, non-ambulatory, prescription medication, dental, and other health services were $653, $161, $428, $194, and $83, respectively. Sociodemographic variations in service-specific OOP expenditures were generally consistent with respective utilization patterns. Overall, 8.8% of the survivors were underinsured.

CONCLUSION

Many insured non-elderly cancer survivors allocate a substantial portion of their OOP expenditure for healthcare-related services and experience financial vulnerability, resulting in nearly 8.8% of the survivors being underinsured. Utilization of healthcare services varies across sociodemographic groups.

The Affordable Care Act's Insurance Marketplace Subsidies Were Associated With Reduced Financial Burden For US Adults

Research suggests that the Affordable Care Act (ACA) Medicaid expansions improved financial protection for the poor. However, evidence is limited on whether subsidies offered through the ACA Marketplaces, the law's other major coverage expansion, were associated with reduced financial burden. Using national survey data from the period 2008-17, we examined changes in household health care spending among low-income adults eligible for both Marketplace premium subsidies and cost-sharing reductions (139-250 percent of the federal poverty level) and middle-income adults eligible only for premium subsidies (251-400 percent of the federal poverty level), using high-income adults ineligible for subsidies (greater than 400 percent of the federal poverty level) as controls. Among low-income adults, Marketplace subsidy implementation was associated with 17 percent lower out-of-pocket spending and 30 percent lower probability of catastrophic health expenditures. In contrast, middle-income adults did not experience reduced financial burden by either measure. These findings highlight the successes and limitations of Marketplace subsidies as debate continues over the ACA's future.

The Impact of the Affordable Care Act Medicaid Expansion on Racial/Ethnic and Sex Disparities in HIV Testing: National Findings from the Behavioral Risk Factor Surveillance System

INTRODUCTION

Over half of Americans have not been tested for HIV in their lifetime, and over a third of all HIV diagnoses are made less than a year before progression to AIDS. The Affordable Care Act (ACA) Medicaid expansion of 2014 had potential to improve HIV and other health screenings. We assessed the differential impacts of Medicaid expansion on racial/ethnic and racial/ethnic-sex disparities in HIV testing.

METHODS

Using Behavioral Risk Factor Surveillance System data from all 50 states and D.C., we sampled low-income (≤ 138% of the federal poverty level) adults ages 19-64 who were non-pregnant and non-disabled. Using a difference-in-differences (DD) and triple difference-in-differences (DDD) study design, we assessed differential impacts by race/ethnicity (White, Black, Hispanic, and other) and race/ethnicity-sex between 2011 and 2013 and 2014-2018. Outcomes were (1) ever having received an HIV test and (2) having received an HIV test in the last year.

RESULTS

Overall, Medicaid expansion was associated with a significant increase in HIV testing (p = 0.003). White females and Black males appeared most likely to benefit from this increase (DD 4.5 and 4.8 percentage points; p = 0.001 and 0.130 respectively). However, despite having baseline higher rates of HIV diagnosis, Black and Hispanic females did not have increased rates of ever having HIV testing following Medicaid expansion (DD - 1.9 and 0.9 percentage points; p = 0.391 and 0.703, respectively), including when compared to a White male reference subgroup and across other race/ethnicity-sex subgroups.

CONCLUSIONS

Medicaid expansion was associated with an increased overall probability of HIV testing among low-income, nonelderly adults, but certain groups including Black females were not more likely to benefit from this increase, despite being disproportionately affected by HIV at baseline. Targeted and culturally informed interventions to increase Medicaid enrollment and access to primary care may be needed to expand HIV testing in vulnerable groups.

Health Insurance Coverage: What Comes After The ACA?

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All.

Association of Medicaid Expansion with Suicide Deaths among Nonelderly U.S. Adults

In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nonelderly adults (18-64 years) with incomes up to 138% of the federal poverty level. The association of Medicaid expansion with suicide, a leading cause of death in the U.S., has not been examined. We used 2005-2017 National Violent Death Reporting System data for eight Medicaid expansion and seven non-expansion states. We examined the association of Medicaid expansion with rates of suicide death among nonelderly adults per 100,000 population using a difference-in-differences approach. Adjusting for state-level confounders, Medicaid expansion states had 1.2 (95% CI -2.5, 0.1) fewer suicide deaths per 100,000 population per year in the post-expansion period than would have been expected if they had followed the same trend in suicide rates as non-expansion states. Medicaid expansion was associated with reductions in suicide rates among women, men, those 30-44 years, white, non-Hispanic individuals, and those without a college degree. Medicaid expansion was not associated with a change in suicide rates among those 18-29 or 45-64 years, and non-white or Hispanic individuals. Overall, Medicaid expansion was associated with reductions in rates of suicide death among nonelderly adults. Further research on inequities in expansion benefits is needed.

Three Statistical Approaches for Assessment of Intervention Effects: A Primer for Practitioners

INTRODUCTION

Statistical methods to assess the impact of an intervention are increasingly used in clinical research settings. However, a comprehensive review of the methods geared toward practitioners is not yet available.

METHODS AND MATERIALS

We provide a comprehensive review of three methods to assess the impact of an intervention: difference-in-differences (DID), segmented regression of interrupted time series (ITS), and interventional autoregressive integrated moving average (ARIMA). We also compare the methods, and provide illustration of their use through three important healthcare-related applications.

RESULTS

In the first example, the DID estimate of the difference in health insurance coverage rates between expanded states and unexpanded states in the post-Medicaid expansion period compared to the pre-expansion period was 5.93 (95% CI, 3.99 to 7.89) percentage points. In the second example, a comparative segmented regression of ITS analysis showed that the mean imaging order appropriateness score in the emergency department at a tertiary care hospital exceeded that of the inpatient setting with a level change difference of 0.63 (95% CI, 0.53 to 0.73) and a trend change difference of 0.02 (95% CI, 0.01 to 0.03) after the introduction of a clinical decision support tool. In the third example, the results from an interventional ARIMA analysis show that numbers of creatinine clearance tests decreased significantly within months of the start of eGFR reporting, with a magnitude of drop equal to -0.93 (95% CI, -1.22 to -0.64) tests per 100,000 adults and a rate of drop equal to 0.97 (95% CI, 0.95 to 0.99) tests per 100,000 per adults per month.

DISCUSSION

When choosing the appropriate method to model the intervention effect, it is necessary to consider the structure of the data, the study design, availability of an appropriate comparison group, sample size requirements, whether other interventions occur during the study window, and patterns in the data.

Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults

IMPORTANCE

There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical.

OBJECTIVE

To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a propensity score-matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL.

EXPOSURES

Health insurance through Colorado Medicaid or Colorado's state-based Marketplace.

MAIN OUTCOMES AND MEASURES

The primary analytical approach was a multivariate regression analysis of the propensity score-matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care-sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score-matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020.

RESULTS

The propensity score-matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P < .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P < .001). No differences in ambulatory care-sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P < .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P < .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid.

CONCLUSIONS AND RELEVANCE

In this cross-sectional propensity score-matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.

Private/marketplace insurance in community health centers 5 years post-affordable care act in medicaid expansion and non-expansion states

Community health centers (CHCs) play an important role in providing care for the safety net population. After implementation of the Affordable Care Act, many patients gained insurance through state and federal marketplaces. Using electronic health record data from 702,663 patients in 257 clinics across 20 states, we sought to explore the following differences between Medicaid expansion and non-expansion state CHCs: (1) trends in private/marketplace insurance post-expansion, and (2) whether CHC patients retain private/marketplace insurance. We found that patients in non-expansion state CHCs relied more heavily on private/marketplace insurance than patients in expansion states and had increases in private/marketplace-insured visits from 2014 through 2018. Additionally, there appeared to be seasonal variation in private/marketplace-insured visits that were more pronounced in non-expansion states. While a greater percentage of patients in non-expansion states retained private/marketplace insurance than in expansion states, a greater percentage of those who did not retain it became uninsured. In comparison, a greater percentage of patients in expansion states who lost private/marketplace insurance gained other types of health insurance. CHCs' ability to provide adequate care for vulnerable populations relies, in part, on federal grants as well as reimbursement from insurers: decreases in either could result in reduced capacity or quality of care for patients seen in CHCs.

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.

ACCESS TO HEALTHCARE INSURANCE INCREASES THE RATES OF SURGERY FOR DIVERTICULITIS

OBJECTIVE

The goal of this study was to examine the effect of the Affordable Care Act Medicaid expansion on rates of hospitalization and surgery for diverticulitis.

STUDY SETTINGS

Data were obtained from the Healthcare Cost and Utilization Project State Inpatient Databases from 2010 to 2014.

STUDY DESIGN

Retrospective cohort study analyzing adult patients undergoing surgery for diverticulitis in the expansion and nonexpansion states, pre (2010-2013) and post (2014) Medicaid expansion.

FINDINGS

There were a total of 159,419 patients in our cohort analysis. 75,575 (49%) in expansion states and 81,844 (51%) in non-expansion states. In multivariable Poisson regression, the rate of surgical procedures for diverticular disease increased among Medicaid patients (IRR 1.80; p<.01) whereas surgery rates in self-pay patients decreased (IRR 0.67; p<.01) in expansion states compared to non-expansion states.

CONCLUSIONS

In states that expanded Medicaid coverage under the Affordable Care Act, the rate of surgery for diverticular disease in Medicaid patients increased. Therefore, legislation that increases healthcare access may increase the utilization of surgical care for diverticular disease.

State strategies to address medicaid prescription spending: negotiated pricing vs price transparency

This research longitudinally examines the association between levels of state Medicaid prescription spending and the state strategies intended to constrain cost increases: the negotiated pricing strategy, as indicated by state rebate programs, and the price transparency strategy, as indicated by state operation of All-Payer Claims Databases. The findings demonstrate evidence that state Medicaid prescription spending is influenced by the negotiated pricing strategy, especially Managed Care Organization (MCO) rebates under the Patient Protection and Affordable Care Act, but not influenced by the price transparency strategy. State decisions for MCO rebates, such as carving prescription benefits into managed care benefits, were effective in containing levels of Medicaid prescription spending over time, while other single- and multi-state rebate programs were not. Based on these findings, state policymakers may consider utilizing the MCO rebate program to address increases in Medicaid prescription spending.

Shifting threats and rhetoric: how Republican governors framed Medicaid expansion

The 2012 Supreme Court decision in National Federation of Independent Business v Sebelius gave states the option to adopt the Medicaid expansion as part of the Affordable Care Act. Many states, especially those under Republican control, have since grappled with their decision to implement the expansion. We conduct a comparative analysis of how Republican governors framed their stance on the Medicaid expansion. We analyze public statements on the Medicaid expansion published in two major in-state newspapers from all Republican governors from June 2012 through June 2018. In total we collected, coded and analyzed 3277 statements from 66 newspapers. Several key themes emerge from our analysis. While every Republican governor used oppositional framing as part of their rhetorical response to the Medicaid expansion, the policy had a destabilizing effect on the previously unified opposition to health reform. We find that Republican framing split after the results of the 2012 election and that overall Republican governors shifted towards more supportive framing prior to the 2016 presidential election. Republican governors transformed how they framed their stance towards Medicaid expansion after Donald Trump was elected in 2016, with both supportive and oppositional moral-based framing of expansion increasing. These findings inform how policymakers use rhetoric to support their stance on controversial policies in a hyper-partisan and polarized political environment.

Association of Medicaid Expansion Under the Affordable Care Act With Insurance Status, Cancer Stage, and Timely Treatment Among Patients With Breast, Colon, and Lung Cancer

IMPORTANCE

The effect of the Patient Protection and Affordable Care Act's Medicaid expansion on cancer care delivery and outcomes is unknown. Patients with cancer are a high-risk group for whom treatment delays are particularly detrimental.

OBJECTIVE

To examine the association between Medicaid expansion and changes in insurance status, stage at diagnosis, and timely treatment among patients with incident breast, colon, and non-small cell lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

This quasi-experimental, difference-in-differences (DID) cross-sectional study included nonelderly adults (aged 40-64 years) with a new diagnosis of invasive breast, colon, or non-small cell lung cancer from January 1, 2011, to December 31, 2016, in the National Cancer Database, a hospital-based registry capturing more than 70% of incident cancer diagnoses in the United States. Data were analyzed from March 8 to August 15, 2019.

EXPOSURES

Residence in a state that expanded Medicaid on January 1, 2014.

MAIN OUTCOMES AND MEASURES

The primary outcomes were insurance status, cancer stage, and timely treatment within 30 and 90 days of diagnosis.

RESULTS

A total of 925 543 patients (78.6% women; mean [SD] age, 55.0 [6.5] years; 14.2% black; and 5.7% Hispanic) had a new diagnosis of invasive breast (58.9%), colon (14.6%), or non-small cell lung (26.5%) cancer; 48.3% resided in Medicaid expansion states and 51.7% resided in nonexpansion states. Compared with nonexpansion states, the percentage of uninsured patients decreased more in expansion states (adjusted DID, -0.7 [95% CI, -1.2 to -0.3] percentage points), and the percentage of early-stage cancer diagnoses rose more in expansion states (adjusted DID, 0.8 [95% CI, 0.3 to 1.2] percentage points). Among the 848 329 patients who underwent cancer-directed therapy within 365 days of diagnosis, the percentage treated within 30 days declined from 52.7% before to 48.0% after expansion in expansion states (difference, -4.7 [95% CI, -5.1 to -4.5] percentage points). In nonexpansion states, this percentage declined from 56.9% to 51.5% (difference, -5.4 [95% CI, -5.6 to -5.1] percentage points), yielding no statistically significant DID in timely treatment associated with Medicaid expansion (adjusted DID, 0.6 [95% CI, -0.2 to 1.4] percentage points).

CONCLUSIONS AND RELEVANCE

This study found that, among patients with incident breast, colon, and lung cancer, Medicaid expansion was associated with a decreased rate of uninsured patients and increased rate of early-stage cancer diagnosis; no evidence of improvement or decrement in the rate of timely treatment was found. Further research is warranted to understand Medicaid expansion's effect on the treatment patterns and health outcomes of patients with cancer.

Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study

OBJECTIVE

To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17).

DESIGN

Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions.

SETTING

United States.

PARTICIPANTS

A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey.

MAIN OUTCOMES AND MEASURES

Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons.

RESULTS

37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions.

CONCLUSION

Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.

Macroeconomic Feedback Effects of Medicaid Expansion: Evidence from Michigan

CONTEXT

Medicaid expansion has costs and benefits for states. The net impact on a state's budget is a central concern for policy makers debating implementing this provision of the Affordable Care Act. How large is the state-level fiscal impact of expanding Medicaid, and how should it be estimated?

METHODS

We use Michigan as a case study for evaluating the state-level fiscal impact of Medicaid expansion, with particular attention to the importance of macroeconomic feedback effects relative to the more straightforward fiscal effects typically estimated by state budget agencies. We combine projections from the state of Michigan's House Fiscal Agency with estimates from a proprietary macroeconomic model to project the state fiscal impact of Michigan's Medicaid expansion through 2021.

FINDINGS

We find that Medicaid expansion in Michigan yields clear fiscal benefits for the state, in the form of savings on other non-Medicaid health programs and increases in revenue from provider taxes and broad-based sales and income taxes through at least 2021. These benefits exceed the state's costs in every year.

CONCLUSIONS

While these results are specific to Michigan's budget and economy, our methods could in principle be applied in any state where policy makers seek rigorous evidence on the fiscal impact of Medicaid expansion.

The Impact of the Affordable Care Act Medicaid Expansion on Vascular Surgery

BACKGROUND

The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility such that all adults with an income level up to 138% of the federal poverty threshold in 2014 qualified for Medicaid benefits. Prior studies have shown that the ACA Medicaid expansion was associated with increased access to care. The impact of the ACA Medicaid expansion on patients undergoing complex care for major vascular pathology has not been evaluated.

METHODS

The Healthcare Cost and Utilization Project State Inpatient Database was used to identify patients undergoing care for major vascular pathology in 6 states from 2010 to 2014. The analysis cohort included adult patients between the ages of 18 and 64 years who underwent a nonemergent surgical procedure for an abdominal aortic aneurysm, thoracic aortic aneurysm, carotid artery stenosis, peripheral vascular disease, or chronic kidney disease. Poisson regression was used to determine the incidence rate ratios (IRRs).

RESULTS

There were a total of 83,960 patients in the study cohort. Compared with nonexpansion states, inpatient admissions for Medicaid patients with an abdominal or thoracic aneurysm and carotid stenosis diagnosis increased significantly (IRR, 1.20, 1.27, 1.06, respectively; P < 0.05) in states that expanded Medicaid. Vascular-related surgeries increased for carotid endarterectomy, lower extremity revascularization, lower extremity amputation, and arteriovenous fistula in expansion states (IRR, 1.24, 1.10, 1.11, 1.16, respectively; P < 0.05) compared with nonexpansion states.

CONCLUSIONS

In states that expanded Medicaid coverage under the ACA, the rate of vascular-related surgeries and admissions for Medicaid patients increased. We conclude that expanding insurance coverage results in enhanced access to vascular surgery.

Medicaid And Private Insurance Coverage For Low-Income Asian Americans, Native Hawaiians, And Pacific Islanders, 2010-16

To determine how low-income Asian American, Native Hawaiian, and Pacific Islander (AANHPI) adults gained health insurance coverage-specifically, via Medicaid or private insurance-under the Affordable Care Act, we used a difference-in-differences approach to compare uninsurance rates in 2010-13 and 2015-16. In Medicaid expansion states, adjusted Medicaid coverage gains were 9.67 percentage points larger than in nonexpansion states; however, adjusted private coverage gains in expansion states were 10.19 percentage points lower. These results indicate that, in contrast to the case for other racial/ethnic groups, for AANHPI the Medicaid coverage increases in expansion states were of similar magnitude to the private insurance coverage increases in nonexpansion states. Reasons for this may include differences in willingness to enroll in public versus private coverage, barriers related to language or citizenship status, or other factors. Future studies are needed to understand these patterns and promote health equity for this population.

Association of Medication Nonadherence Among Adult Survivors of Stroke After Implementation of the US Affordable Care Act

Importance

Among adults with chronic disease, survivors of stroke have high out-of-pocket financial burdens. The US government enacted the Affordable Care Act (ACA) in 2010 and implemented the law in 2014 to provide more low-income adults with health insurance coverage.

Objective

To assess whether ACA implementation is associated with cost-related nonadherence (CRN) to medication among adult survivors of stroke.

Design, Setting, and Participants

This study analyzed data from the 2000 to 2016 National Health Interview Survey, an in-person household survey of the noninstitutionalized US population conducted annually by the National Center for Health Statistics. Conducted at the University of Michigan Medical School, Ann Arbor, from July 24, 2017, to February 28, 2018, the study had a sample of 13 930 survivors of stroke. Analyses were stratified by age (45-64 years vs ≥65 years). Time was treated as a continuous variable and as a categorical variable across 4 periods (2000-2005, historical control; 2006-2010, economic recession and peak unemployment; 2011-2013, before ACA implementation; and 2014-2016, after ACA implementation). Percentages are weighted to reflect US population estimates.

Main Outcomes and Measures

The primary outcome was the self-report of CRN, defined as the inability to afford prescribed medications within the past 12 months.

Results

Among the 13 930 total survivors of stroke, 38.1% were aged 45 to 64 years (50.5% were female and 49.5% were male, with a mean [SE] age of 56.0 [0.10] years), and 61.9% were aged 65 years or older (54.9% were female and 45.1% were male, with a mean [SE] age of 76.2 [0.09] years). From 2011 to 2013 through 2014 to 2016, Medicaid increased (from 24.0% [95% CI, 21.0%-27.2%] in 2011-2013 to 30.8% [95% CI, 27.3%-34.6%] in 2014-2016; P < .001) and uninsurance decreased (from 13.7% [95% CI, 11.3%-16.4%] to 6.8% [95% CI, 5.3%-8.8%]; P < .001) among survivors of stroke aged 45 to 64 years. Among survivors aged 45 to 64 years, CRN increased over time before ACA implementation (from 18.6% [95% CI, 16.5%-20.9%] in 2000-2005, to 22.6% [95% CI, 19.7%-25.9%] in 2006-2010, to 23.8% [95% CI, 20.7%-27.3%] in 2011-2013) and decreased after ACA implementation to 18.1% (95% CI, 15.4%-21.3%; P = .01) in 2014 to 2016. The period after ACA implementation was associated with lower odds of CRN after adjustment for sociodemographics, year, and clinical factors (odds ratio [OR], 0.63; 95% CI, 0.47-0.85). The difference was attenuated after further adjustment for health insurance coverage (OR, 0.76; 95% CI, 0.56-1.03).

Conclusions and Relevance

After the ACA implementation, health insurance coverage increased and CRN decreased among adult survivors of stroke, suggesting that further expansion of Medicaid coverage is likely to be advantageous for survivors.

The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care

INTRODUCTION

This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures.

METHODS

We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion.

RESULTS

117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]).

CONCLUSIONS

Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.

Persisting Gaps in Coverage and Services of Illinois Women Who Acquired Insurance After Implementation of the Affordable Care Act

OBJECTIVES

Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services.

METHODS

We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education.

RESULTS

We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03).

CONCLUSIONS

The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Effect of Medicaid Expansion on Health Insurance Coverage and Access to Care Among Adults With Depression

OBJECTIVE

Multiple studies have detailed the relationship between Medicaid expansion under the Affordable Care Act and various health and financial outcomes. However, fewer studies have examined Medicaid expansion's effects on individuals with psychiatric diagnoses. This study sought to determine the relationship between Medicaid expansion and various health and financial outcomes among low-income adults with depression.

METHODS

This quasi-experimental study used a random-digit-dial survey of U.S. citizens ages 19-64 with incomes below 138% of the federal poverty level. Surveys were conducted in three southern states (two expansion states, Arkansas and Kentucky, and one nonexpansion state, Texas) between 2013 and 2016. The study sample consisted of those with a positive screen for depression-score of ≥2 on the two-item Patient Health Questionnaire (N=4,853). Survey-weighted difference-in-differences regressions were conducted with insurance status, health care access and utilization, and affordability of care as outcomes of interest. Subgroup analyses stratified the sample on the basis of the respondent's residence in a health professional shortage area (HPSA) in mental health and severity of depression.

RESULTS

Medicaid expansion was associated with a significant reduction in the proportion of adults with depression who lacked health insurance (-23 percentage points, 95% confidence interval=-32 to -14, p<.001). Medicaid expansion was also associated with significant reductions in delaying care and medications because of cost. These changes were similar regardless of residence in a mental health HPSA and severity of depression.

CONCLUSIONS

Medicaid expansion was associated with improved access to care and medication among persons with depression, even in areas with relative shortages of mental health professionals.