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Christine PJ, Goldman AL, Morgan JR, Yan S, Chatterjee A, Bettano AL, Binswanger IA, LaRochelle MR. Insurance Instability for Patients With Opioid Use Disorder in the Year After Diagnosis. JAMA HEALTH FORUM 2024; 5:e242014. [PMID: 39058507 PMCID: PMC11282441 DOI: 10.1001/jamahealthforum.2024.2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/21/2024] [Indexed: 07/28/2024] Open
Abstract
Importance Transitions in insurance coverage may be associated with worse health care outcomes. Little is known about insurance stability for individuals with opioid use disorder (OUD). Objective To examine insurance transitions among adults with newly diagnosed OUD in the 12 months after diagnosis. Design, Setting, and Participants Longitudinal cohort study using data from the Massachusetts Public Health Data Warehouse. The cohort includes adults aged 18 to 63 years diagnosed with incident OUD between July 1, 2014, and December 31, 2014, who were enrolled in commercial insurance or Medicaid at diagnosis; individuals diagnosed after 2014 were excluded from the main analyses due to changes in the reporting of insurance claims. Data were analyzed from November 10, 2022, to May 6, 2024. Exposure Insurance type at time of diagnosis (commercial and Medicaid). Main Outcomes and Measures The primary outcome was the cumulative incidence of insurance transitions in the 12 months after diagnosis. Logistic regression models were used to generate estimated probabilities of insurance transitions by insurance type and diagnosis for several characteristics including age, race and ethnicity, and whether an individual started medication for OUD (MOUD) within 30 days after diagnosis. Results There were 20 768 individuals with newly diagnosed OUD between July 1, 2014, and December 31, 2014. Most individuals with newly diagnosed OUD were covered by Medicaid (75.4%). Those with newly diagnosed OUD were primarily male (67% in commercial insurance, 61.8% in Medicaid). In the 12 months following OUD diagnosis, 30.4% of individuals experienced an insurance transition, with adjusted models demonstrating higher transition rates among those starting with Medicaid (31.3%; 95% CI, 30.5%-32.0%) compared with commercial insurance (27.9%; 95% CI, 26.6%-29.1%). The probability of insurance transitions was generally higher for younger individuals than older individuals irrespective of insurance type, although there were notable differences by race and ethnicity. Conclusions and Relevance This study found that nearly 1 in 3 individuals experience insurance transitions in the 12 months after OUD diagnosis. Insurance transitions may represent an important yet underrecognized factor in OUD treatment outcomes.
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Affiliation(s)
- Paul J. Christine
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Department of General Internal Medicine, Denver Health and Hospital Authority, Denver, Colorado
| | - Anna L. Goldman
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jake R. Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Shapei Yan
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Avik Chatterjee
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Amy L. Bettano
- Office of Population Health, Massachusetts Department of Public Health, Boston
| | - Ingrid A. Binswanger
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Colorado Permanente Medical Group, Denver
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Marc R. LaRochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Nelson DB, Singer PM, Fung V. Implementing automated Medicaid eligibility renewals was not associated with higher levels of program participation. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae071. [PMID: 38841719 PMCID: PMC11152203 DOI: 10.1093/haschl/qxae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
Increasing participation in Medicaid among eligible individuals is critical for improving access to care among low-income populations. The administrative burdens of enrolling and renewing eligibility are a major barrier to participation. To reduce these burdens, the Affordable Care Act required states to adopt automated renewal processes that use available databases to verify ongoing eligibility. By 2019, nearly all states adopted automated renewals, but little is known about how this policy affected Medicaid participation rates. Using the 2015-2019 American Community Survey, we found that participation rates among nondisabled, nonelderly adults and children varied widely by state, with an average of 70.8% and 90.7%, respectively. Among Medicaid-eligible adults, participation was lower among younger adults, males, unmarried individuals, childless households, and those living in non-expansion states compared with their counterparts. State adoption of automated renewals varied over time, but participation rates were not associated with adoption. This finding could reflect limitations to current automated renewal processes or barriers to participation outside of the eligibility renewal process, which will be important to address as additional states expand Medicaid and pandemic-era protections on enrollment expire.
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Affiliation(s)
- Daniel B Nelson
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
| | - Phillip M Singer
- Department of Political Science, University of Utah, Salt Lake City, UT 84112, United States
| | - Vicki Fung
- Department of Medicine, Mongan Institute, Massachusetts General Hospital, Boston, MA 02114, United States
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Berlin NL, Albright BB, Moss HA, Offodile AC. Catastrophic health expenditures, insurance churn, and non-employment among women with breast cancer. JNCI Cancer Spectr 2024; 8:pkae006. [PMID: 38331405 PMCID: PMC11003299 DOI: 10.1093/jncics/pkae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Breast cancer treatment and survivorship entails a complex and expensive continuum of subspecialty care. Our objectives were to assess catastrophic health expenditures, insurance churn, and non-employment among women younger than 65 years who reported a diagnosis of breast cancer. We also evaluated changes in these outcomes related to implementation of the Affordable Care Act. METHODS The data source for this study was the Medical Expenditure Panel Survey (2005-2019), which is a national annual cross-sectional survey of families, providers, and insurers in the United States. To assess the impact of breast cancer, comparisons were made with a matched cohort of women without cancer. We estimated predicted marginal probabilities to quantify the effects of covariates in models for catastrophic health expenditures, insurance churn, and non-employment. RESULTS We identified 1490 respondents younger than 65 years who received care related to breast cancer during the study period, representing a weight-adjusted annual mean of 1 062 129 patients. Approximately 31.8% of women with breast cancer reported health expenditures in excess of 10% of their annual income. In models, the proportion of women with breast cancer who experienced catastrophic health expenditures and non-employment was inversely related to increasing income. During Affordable Care Act implementation, mean number of months of uninsurance decreased and expenditures increased among breast cancer patients. CONCLUSIONS Our study underscores the impact of breast cancer on financial security and opportunities for patients and their families. A multilevel understanding of these issues is needed to design effective and equitable strategies to improve quality of life and survivorship.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin B Albright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Haley A Moss
- Division of Gynecologic Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Anaeze C Offodile
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Ranchoff BL, Jeung C, Zeber JE, Simon GE, Ericson KM, Qian J, Geissler KH. Transitions in health insurance among continuously insured patients with schizophrenia. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:25. [PMID: 38409218 PMCID: PMC10897200 DOI: 10.1038/s41537-024-00446-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
Changes in health insurance coverage may disrupt access to and continuity of care, even for those who remain insured. Continuity of care is especially important in schizophrenia, which requires ongoing medical and pharmaceutical treatment. However, little is known about continuity of insurance coverage among those with schizophrenia. The objective was to examine the probability of insurance transitions for individuals with schizophrenia who were continuously insured and whether this varied across insurance types. The Massachusetts All-Payer Claims Database identified individuals with schizophrenia aged 18-64 who were continuously insured during a two-year period between 2014 and 2018. A logistic regression estimated the association of having an insurance transition - defined as having a change in insurance type - with insurance type at the start of the period, adjusting for age, sex, ZIP code in the lowest quartile of median income, and ZIP code with concentrated poverty. Overall, 15.1% had at least one insurance transition across a 24-month period. Insurance transitions were most frequent among those with plans from the Marketplace. In regression adjusted results, individuals covered by the traditional Medicaid program were 20.2 percentage points [pp] (95% confidence interval [CI]: 24.6 pp, 15.9 pp) less likely to have an insurance transition than those who were insured by a Marketplace plan. Insurance transitions among individuals with schizophrenia were common, with more than one in six people having at least one transition in insurance type during a two-year period. Given that even continuously insured individuals with schizophrenia commonly experience insurance transitions, attention to insurance transitions as a barrier to care access and continuity is warranted.
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Affiliation(s)
- Brittany L Ranchoff
- School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA.
| | - Chanup Jeung
- School of Public Health, State University of New York at Albany, Albany, NY, USA
| | - John E Zeber
- School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Keith M Ericson
- National Bureau for Economic Research, Cambridge, MA, USA
- Boston University Questrom School of Business, Boston, MA, USA
| | - Jing Qian
- School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Kimberley H Geissler
- Department of Healthcare Delivery and Population Sciences, UMass Chan Medical School-Baystate, Springfield, MA, USA
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Barnes JM, Yabroff KR, Chino F. Unwinding of Medicaid Continuous Enrollment Exposes Millions to Disrupted Care-"Be Kind, Rewind". JAMA Oncol 2024; 10:157-158. [PMID: 38095902 DOI: 10.1001/jamaoncol.2023.5725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
This Viewpoint discusses the causes and consequences of Medicaid unwinding and disenrollment and proposes solutions to minimize disenrollment and improve coverage uptake and health care access.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - K Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
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Nelson DB, Goldman AL, Zhang F, Yu H. Continuous Medicaid coverage during the COVID-19 public health emergency reduced churning, but did not eliminate it. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad055. [PMID: 38223316 PMCID: PMC10786332 DOI: 10.1093/haschl/qxad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Preserving insurance coverage in the wake of pandemic-related job loss was a priority in early 2020. To this end, the Families First Coronavirus Response Act implemented a continuous coverage policy in Medicaid to shore up access to health insurance. Prior to the pandemic, Medicaid enrollees experienced frequent coverage disruptions, known as "churning." The effect of the continuous coverage policy on churning during the COVID-19 public health emergency (PHE) is unknown. We performed a difference-in-differences analysis of nonelderly Medicaid enrollees using longitudinal national survey data to compare a 2019-2020 cohort exposed to the policy with a control cohort in 2018-2019. We found that the policy led to reduced transitions to uninsurance among adults, although not among children. The policy prevented over 300 000 transitions to uninsurance each month. However, disenrollment from Medicaid persisted at a low rate, despite the continuous coverage policy. As the PHE unwinds, policymakers should consider long-term continuous coverage policies to minimize churning in Medicaid.
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Affiliation(s)
- Daniel B. Nelson
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
| | - Anna L. Goldman
- Department of Medicine, Boston University School of Medicine, Boston, MA 02118, United States
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
| | - Hao Yu
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
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Hanchate AD, Abdelfattah L, Lin MY, Lasser KE, Paasche-Orlow MK. Affordable Care Act Medicaid Expansion was Associated With Reductions in the Proportion of Hospitalizations That are Potentially Preventable Among Hispanic and White Adults. Med Care 2023; 61:627-635. [PMID: 37582292 PMCID: PMC10894451 DOI: 10.1097/mlr.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Using data on 5 years of postexpansion experience, we examined whether the coverage gains from Affordable Care Act Medicaid expansion among Black, Hispanic, and White individuals led to improvements in objective indicators of outpatient care adequacy and quality. RESEARCH DESIGN For the population of adults aged 45-64 with no insurance or Medicaid coverage, we obtained data on census population and hospitalizations for ambulatory care sensitive conditions (ACSCs) during 2010-2018 in 14 expansion and 7 nonexpansion states. Our primary outcome was the percentage share of hospitalizations due to ACSC out of all hospitalizations ("ACSC share") among uninsured and Medicaid-covered patients. Secondary outcomes were the population rate of ACSC and all hospitalizations. We used multivariate regression models with an event-study difference-in-differences specification to estimate the change in the outcome measures associated with expansion in each of the 5 postexpansion years among Hispanic, Black, and White adults. PRINCIPAL FINDINGS At baseline, ACSC share in the expansion states was 19.0%, 14.5%, and 14.3% among Black, Hispanic, and White adults. Over the 5 years after expansion, Medicaid expansion was associated with an annual reduction in ACSC share of 5.3% (95% CI, -7.4% to -3.1%) among Hispanic and 8.0% (95% CI, -11.3% to -4.5%) among White adults. Among Black adults, estimates were mixed and indicated either no change or a reduction in ACSC share. CONCLUSIONS After Medicaid expansion, low-income Hispanic and White adults experienced a decrease in the proportion of potentially preventable hospitalizations out of all hospitalizations.
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Affiliation(s)
- Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Lindsey Abdelfattah
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Meng-Yun Lin
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Michael K. Paasche-Orlow
- Division of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Boston, MA
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Qin X, Huckfeldt P, Abraham J, Yee D, Virnig BA. Was Unstable Medicaid Coverage Among Older Medicare Beneficiaries Associated With Worse Clinical Outcomes? Evidence From the Delivery of Breast Cancer Care. Med Care 2023; 61:611-618. [PMID: 37440716 DOI: 10.1097/mlr.0000000000001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes. OBJECTIVES Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries. RESEARCH DESIGN Population-based cohort study. SUBJECTS A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database. MEASURES We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups. RESULTS Duals had poorer outcomes than those who were "never dual." Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support. CONCLUSIONS These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.
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Affiliation(s)
- Xuanzi Qin
- Department of Health Policy and Management, University of Maryland School of Public Health, MD
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Peter Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Jean Abraham
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Douglas Yee
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Beth A Virnig
- Division of Health Policy and Management, University of Minnesota School of Public Health
- University of Florida College of Public Health and Health Professions, Gainesville, FL
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Eom KY, Rothenberger SD, Jarlenski MP, Schoen RE, Cole ES, Sabik LM. Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion. Cancer Med 2023; 12:15455-15467. [PMID: 37329270 PMCID: PMC10417095 DOI: 10.1002/cam4.6168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages. OBJECTIVES Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015. RESEARCH DESIGN Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use. SUBJECTS We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion. MEASURES Outcome measures include receiving any CRC testing and by modality. RESULTS About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests. CONCLUSIONS CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.
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Affiliation(s)
- Kirsten Y. Eom
- Department of Medicine at the MetroHealth System at Case Western Reserve UniversityClevelandOhioUSA
| | - Scott D. Rothenberger
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Marian P. Jarlenski
- Department of Health Policy & ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Evan S. Cole
- Department of Health Policy & ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
| | - Lindsay M. Sabik
- Department of Health Policy & ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
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Fu SJ, Arnow K, Barreto NB, Aouad M, Trickey AW, Spain DA, Morris AM, Knowlton LM. Insurance churn after adult traumatic injury: A national evaluation among a large private insurance database. J Trauma Acute Care Surg 2023; 94:692-699. [PMID: 36623273 DOI: 10.1097/ta.0000000000003861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Traumatic injury leads to significant disability, with injured patients often requiring substantial health care resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact health care access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury. METHODS Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using Injury Severity Score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS, <9), moderate (ISS, 9-15), severe (ISS, 16-24), and very severe (ISS, >24) injuries. Kaplan-Meier analysis was used to compare time with insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn. RESULTS Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared with patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured. CONCLUSION Increasing severity of traumatic injury is associated with higher levels of health coverage churn among the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury. LEVEL OF EVIDENCE Economic and Value Based Evaluations; Level III.
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Affiliation(s)
- Sue J Fu
- From the S-SPIRE, Department of Surgery (S.J.F., K.A., N.B.B., A.W.T., D.A.S., A.M., L.K.), Division of General Surgery, Stanford University School of Medicine, Stanford, California; Department of Economics (M.A.), School of Social Sciences, University of California-Irvine, Irvine, California
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Hogg-Graham R, Mamaril CB, Benitez JA, Gatton K, Mays GP. Impact of state Medicaid expansion on cross-sector health and social service networks: Evidence from a longitudinal cohort study. Health Serv Res 2023; 58:634-641. [PMID: 36815298 PMCID: PMC10154156 DOI: 10.1111/1475-6773.14144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE To examine the impact of state Medicaid expansion on the delivery of population health activities in cross-sector health and social services networks. Community networks are multisector, interorganizational networks that provide services ranging from the direct provision of individual social services to the implementation of population-level initiatives addressing community outcomes. DATA SOURCES We used data measuring the composition of cross-sector population health networks 2006-2018 National Longitudinal Survey of Public Health Systems (NALSYS) linked with the Area Health Resource File. STUDY DESIGN A difference-in-differences approach was used to examine the impact of expansion on organization engagement in population health activities and network structure. DATA COLLECTION/EXTRACTION METHODS Stratified random sampling of local public health jurisdictions in the United States. We restricted our data to jurisdictions serving populations of 100,000 or more and states that had NALSYS observations across all time periods, resulting in a final sample size of 667. PRINCIPAL FINDINGS Results from our adjusted difference-in-differences estimates indicated that Medicaid expansion was associated with a 2.3 percentage point increase in the density of population health networks (p < 0.10). Communities in states that expanded Medicaid experienced significant increases in the participation of local public health, local government, hospital, nonprofit, insurer, and K-12 schools. Of the organizations with significant increases in expansion communities, nonprofits (7.7 percentage points, p < 0.01), local public health agencies (6.5 percentage points, p < 0.01), hospitals (5.8 percentage points, p < 0.01), and local government agencies (6.0 percentage points, p < 0.05) had the largest gains. CONCLUSIONS Our study found increases in cross-sector participation in population health networks in states that expanded Medicaid compared with nonexpansion states, suggesting that additional coverage gains are associated with positive changes in population health network structure.
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Affiliation(s)
- Rachel Hogg-Graham
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Cezar B Mamaril
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Joseph A Benitez
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, Kentucky, USA.,Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Kelsey Gatton
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Glen P Mays
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Campus, Aurora, Colorado, USA
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Affiliation(s)
- Leighton Ku
- The George Washington University, Washington, DC
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13
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Izguttinov A, Trogdon JG. Can Medicaid be a Solution to the Problem? Underinsurance in Medicaid Expansion Versus Non-Expansion States. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231202640. [PMID: 37776294 PMCID: PMC10542319 DOI: 10.1177/00469580231202640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/18/2023] [Accepted: 09/01/2023] [Indexed: 10/02/2023]
Abstract
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.
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Affiliation(s)
- Aniyar Izguttinov
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, USA
| | - Justin G. Trogdon
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, USA
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Ndumele CD, Lollo A, Krumholz HM, Schlesinger M, Wallace J. Long-Term Stability of Coverage Among Michigan Medicaid Beneficiaries : A Cohort Study. Ann Intern Med 2023; 176:22-28. [PMID: 36469920 DOI: 10.7326/m22-1313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Medicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. No studies have used long-run data to assess the recent use of the program by beneficiaries. OBJECTIVE To assess patterns of short- and long-term enrollment among beneficiaries, using a 10-year longitudinal panel of Michigan Medicaid eligibility data. DESIGN Primary analyses assessing trends in Medicaid enrollment among cohorts of existing and new beneficiaries. SETTING Administrative records from Michigan Medicaid for the period 2011 to 2020. PARTICIPANTS 3.97 million Medicaid beneficiaries. MEASUREMENTS Short- and long-term enrollment in the program. RESULTS The sample includes 3.97 million unique beneficiaries enrolled at some point between 2011 and 2020. Among a cohort of 1.23 million beneficiaries enrolled in 2011, over half (53%) were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period (67%) on Medicaid. These beneficiaries, however, experienced substantial lapses in coverage, as only 25% were continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period. LIMITATION Primary estimates from a single state. CONCLUSION For many beneficiaries, Medicaid has served as their primary source of coverage for at least a decade. This pattern would justify increasing investments in the program to improve long-term health outcomes. PRIMARY FUNDING SOURCE Self-funded.
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Affiliation(s)
- Chima D Ndumele
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (C.D.N., A.L., M.S., J.W.)
| | - Anthony Lollo
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (C.D.N., A.L., M.S., J.W.)
| | - Harlan M Krumholz
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, and Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (H.M.K.)
| | - Mark Schlesinger
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (C.D.N., A.L., M.S., J.W.)
| | - Jacob Wallace
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (C.D.N., A.L., M.S., J.W.)
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15
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Grembowski D, Leibbrand C. A conceptual model of health insurance stability in the United States health care system. Health Serv Manage Res 2022:9514848221146677. [DOI: 10.1177/09514848221146677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.
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Affiliation(s)
- David Grembowski
- Health Systems and Population Health, University of Washington, Seattle, WA, USA
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16
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Ku L, Platt I. Duration and Continuity of Medicaid Enrollment Before the COVID-19 Pandemic. JAMA HEALTH FORUM 2022; 3:e224732. [PMID: 36525256 PMCID: PMC9856506 DOI: 10.1001/jamahealthforum.2022.4732] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Importance COVID-19 relief legislation created a temporary moratorium on Medicaid disenrollment, but when the public health emergency ends, states will begin to "unwind" Medicaid enrollment. Prepandemic data shed light on factors that can affect Medicaid coverage stability. Objective To assess factors associated with the duration and continuity of Medicaid enrollment. Design, Setting, and Participants In this cross-sectional analyses of a Medicaid data set for 2016 that was released by the Agency for Healthcare Research and Quality in June of 2022, we analyze a nationally representative data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016. We focus on 22 million nondisabled, nonelderly adults for this analysis. The data were analyzed between July and September of 2022. Main Outcomes and Measures The main outcomes were the average months of Medicaid enrollment in 2016 and the probability of churning, defined as a break in coverage between 2 periods of enrollment during the calendar year. We compared these outcomes by eligibility category, state, demographic characteristics, and key Medicaid policies, including whether the state expanded Medicaid and whether it used ex parte reviews (automated reviews of other administrative data to reduce renewal paperwork burdens). Results In this cross-sectional analysis, we analyze a nationally representative Medicaid data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016, released by the Agency for Healthcare Research and Quality in June of 2022. The analysis focused on nonelderly, nondisabled adults (aged 18-64 years) with a weighted population size of 22.7 million, of which 18.4% were Black, 19.2% were Latino, 39.5% were White, 7.3% were other/Asian/Native American, and 15.5% had unknown race. Multivariable regression analysis indicated that those living in states that expanded Medicaid but did not use ex parte reviews had longer average duration (0.31 months longer; 95% CI, 0.03-0.59) and lower risk of churning(odds ratio [OR], .40; 95% CI, 0.39-0.40), whereas those living in nonexpansion states that used ex parte reviews had lower odds of churning (OR, .68; 95% CI, 0.66-0.70) but also had shorter average duration (3.1 months shorter; 95% CI, -3.4 to -2.8). Those living in expansion states that used ex parte reviews also had reduced churning (OR, .83; 95% CI, 0.82-0.85). The average duration varied widely by state, even after adjustments for demographic and state policy factors. Conclusions and Relevance If state Medicaid programs revert to prepandemic policies after the temporary moratorium ends, Medicaid coverage, particularly for nondisabled, nonelderly adults, is likely to become less stable again. Medicaid expansions are associated with improved continuity, but ex parte review may have a more complex role.
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Affiliation(s)
- Leighton Ku
- Center for Health Policy Research, Milken Institute School of Public Heath, George Washington University, Washington, DC
| | - Isabel Platt
- Center for Health Policy Research, Milken Institute School of Public Heath, George Washington University, Washington, DC
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17
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Yabroff KR, Han X, Zhao J, Kirby J, Nogueira L, Zheng Z. Association of Health Insurance Coverage Disruptions With Mortality Risk Among US Working-Age Adults. JAMA HEALTH FORUM 2022; 3:e224258. [PMID: 36416817 PMCID: PMC9685485 DOI: 10.1001/jamahealthforum.2022.4258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This cohort study assesses associations of a prior coverage disruption with mortality risk among large, nationally representative cohorts of working-age adults with public or private health insurance coverage.
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Affiliation(s)
- K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, Georgia
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, Georgia
| | - James Kirby
- Center for Financing, Access and Cost Trends, The Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, Georgia
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, Georgia
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18
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Zhao J, Han X, Nogueira L, Fedewa SA, Jemal A, Halpern MT, Yabroff KR. Health insurance status and cancer stage at diagnosis and survival in the United States. CA Cancer J Clin 2022; 72:542-560. [PMID: 35829644 DOI: 10.3322/caac.21732] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 12/30/2022] Open
Abstract
Previous studies using data from the early 2000s demonstrated that patients who were uninsured were more likely to present with late-stage disease and had worse short-term survival after cancer diagnosis in the United States. In this report, the authors provide comprehensive data on the associations of health insurance coverage type with stage at diagnosis and long-term survival in individuals aged 18-64 years who were diagnosed between 2010 and 2013 with 19 common cancers from the National Cancer Database, with survival follow-up through December 31, 2019. Compared with privately insured patients, Medicaid-insured and uninsured patients were significantly more likely to be diagnosed with late-stage (III/IV) cancer for all stageable cancers combined and separately. For all stageable cancers combined and for six cancer sites-prostate, colorectal, non-Hodgkin lymphoma, oral cavity, liver, and esophagus-uninsured patients with Stage I disease had worse survival than privately insured patients with Stage II disease. Patients without private insurance coverage had worse short-term and long-term survival at each stage for all cancers combined; patients who were uninsured had worse stage-specific survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors. Expanding access to comprehensive health insurance coverage is crucial for improving access to cancer care and outcomes, including stage at diagnosis and survival.
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Affiliation(s)
- Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Stacey A Fedewa
- Department of Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Michael T Halpern
- National Cancer Institute at the National Institutes of Health, Bethesda, Maryland
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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19
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Koroukian SM, Dong W, Albert JM, Kim U, Eom KY, Rose J, Owusu C, Zanotti KM, Cooper GS, Tsui J. Post-Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage. Med Care 2022; 60:821-830. [PMID: 36098269 DOI: 10.1097/mlr.0000000000001779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The mechanisms underlying improvements in early-stage cancer at diagnosis following Medicaid expansion remain unknown. We hypothesized that Medicaid expansion allowed for low-income adults to enroll in Medicaid before cancer diagnosis, thus increasing the number of stably-enrolled relative to those who enroll in Medicaid only after diagnosis (emergently-enrolled). METHODS Using data from the 2011-2017 Ohio Cancer Incidence Surveillance System and Medicaid enrollment files, we identified individuals diagnosed with incident invasive breast (n=4850), cervical (n=1023), and colorectal (n=3363) cancer. We conducted causal mediation analysis to estimate the direct effect of pre- (vs. post-) expansion on being diagnosed with early-stage (-vs. regional-stage and distant-stage) disease, and indirect (mediation) effect through being in the stably- (vs. emergently-) enrolled group, controlling for individual-level and area-level characteristics. RESULTS The percentage of stably-enrolled patients increased from 63.3% to 73.9% post-expansion, while that of the emergently-enrolled decreased from 36.7% to 26.1%. The percentage of patients with early-stage diagnosis remained 1.3-2.9 times higher among the stably-than the emergently-enrolled group, both pre-expansion and post-expansion. Results from the causal mediation analysis showed that there was an indirect effect of Medicaid expansion through being in the stably- (vs. emergently-) enrolled group [risk ratios with 95% confidence interval: 1.018 (1.010-1.027) for breast cancer, 1.115 (1.064-1.167) for cervical cancer, and 1.090 (1.062-1.118) for colorectal cancer. CONCLUSION We provide the first evidence that post-expansion improvements in cancer stage were caused by an increased reliance on Medicaid as a source of stable insurance coverage.
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Affiliation(s)
- Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University
- Case Comprehensive Cancer Center, Case Western Reserve University
- Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Weichuan Dong
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University
| | - Jeffrey M Albert
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University
| | - Uriel Kim
- Kellogg School of Management, Northwestern University, Evanston, IL
| | - Kirsten Y Eom
- Public Health Research Institute, The MetroHealth System and Case Western Reserve University
| | - Johnie Rose
- Case Comprehensive Cancer Center, Case Western Reserve University
- Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Cynthia Owusu
- Case Comprehensive Cancer Center, Case Western Reserve University
- Department of Internal Medicine, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University
| | - Kristine M Zanotti
- Case Comprehensive Cancer Center, Case Western Reserve University
- Department of Obstetrics and Gynecology, Gynecologic Oncology, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Gregory S Cooper
- Case Comprehensive Cancer Center, Case Western Reserve University
- Department of Internal Medicine, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University
| | - Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
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20
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Goldman AL, Gordon SH. Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff. J Gen Intern Med 2022; 37:3570-3576. [PMID: 35277806 PMCID: PMC9585127 DOI: 10.1007/s11606-022-07437-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 01/26/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Affordable Care Act takes a "patchwork" approach to expanding coverage: Medicaid covers individuals with incomes 138% of the federal poverty level (FPL) in expansion states, while subsidized Marketplace insurance is available to those above this income cutoff. OBJECTIVE To characterize the magnitude of churning between Medicaid and Marketplace coverage and to examine the impact of the 138% FPL income cutoff on stability of coverage. DESIGN We measured the incidence of transitions between Medicaid and Marketplace coverage. Then, we used a differences-in-differences framework to compare insurance churning in Medicaid expansion and non-expansion states, before and after the ACA, among adults with incomes 100-200% of poverty. PARTICIPANTS Non-elderly adult respondents of the Medical Expenditure Panel Survey 2010-2018 MAIN MEASURES: The annual proportion of adults who (1) transitioned between Medicaid and Marketplace coverage; (2) experienced any coverage disruption. KEY RESULTS One million U.S. adults transitioned between Medicaid and Marketplace coverage annually. The 138% FPL cutoff in expansion states was not associated with an increase in insurance churning among individuals with incomes close to the cutoff. CONCLUSIONS Transitions between Medicaid and Marketplace insurance are uncommon-far lower than pre-ACA analyses predicted. The 138% income cutoff does not to contribute significantly to insurance disruptions.
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Affiliation(s)
- Anna L Goldman
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
- Boston Medical Center, Boston, MA, USA.
| | - Sarah H Gordon
- Boston University School of Public Health, Boston, MA, USA
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21
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Donohue JM, Cole ES, James CV, Jarlenski M, Michener JD, Roberts ET. The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity. JAMA 2022; 328:1085-1099. [PMID: 36125468 DOI: 10.1001/jama.2022.14791] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. OBJECTIVE To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. EVIDENCE REVIEW Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. FINDINGS Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. CONCLUSIONS AND RELEVANCE Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.
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Affiliation(s)
- Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | | | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jamila D Michener
- Department of Government and School of Public Policy, Cornell University, Ithaca, New York
| | - Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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22
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Edmonds A, Belenky N, Adedimeji AA, Cohen MH, Wingood G, Fischl MA, Golub ET, Johnson MO, Merenstein D, Milam J, Konkle-Parker D, Wilson TE, Adimora AA. Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States. Womens Health Issues 2022; 32:450-460. [PMID: 35562308 PMCID: PMC9532344 DOI: 10.1016/j.whi.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 03/03/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND As employment, financial status, and residential location change, people can gain, lose, or switch health insurance coverage, which may affect care access and health. Among Women's Interagency HIV Study participants with HIV and participants at risk for HIV attending semiannual visits at 10 U.S. sites, we examined whether the prevalence of coverage types and rates of coverage changes differed by HIV status and Medicaid expansion in their states of residence. METHODS Geocoded addresses were merged with dates of Medicaid expansion to indicate, at each visit, whether women lived in Medicaid expansion states. Age-adjusted rate ratios (RRs) and rate differences of self-reported insurance changes were estimated by Poisson regression. RESULTS From 2008 to 2018, 3,341 women (67% Black, 71% with HIV) contributed 43,329 visits at aged less than 65 years (27% under Medicaid expansion). Women with and women without HIV differed in their proportions of visits at which no coverage (14% vs. 19%; p < .001) and Medicaid enrollment (61% vs. 51%; p < .001) were reported. Women in Medicaid expansion states reported no coverage and Medicaid enrollment at 4% and 69% of visits, respectively, compared with 20% and 53% of visits for those in nonexpansion states. Women with HIV had a lower rate of losing coverage than those without HIV (RR, 0.81; 95% confidence interval [CI], 0.70 to 0.95). Compared with nonexpansion, Medicaid expansion was associated with lower coverage loss (RR, 0.62; 95% CI, 0.53 to 0.72) and greater coverage gain (RR, 2.32; 95% CI, 2.02 to 2.67), with no differences by HIV status. CONCLUSIONS Both women with HIV and women at high risk for HIV in Medicaid expansion states had lower coverage loss and greater coverage gain; therefore, Medicaid expansion throughout the United States should be expected to stabilize insurance for women and improve downstream health outcomes.
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Affiliation(s)
- Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Nadya Belenky
- RTI International, Research Triangle Park, North Carolina
| | - Adebola A Adedimeji
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Mardge H Cohen
- Department of Medicine, Stroger Hospital, Cook County Bureau of Health Services, Chicago, Illinois
| | - Gina Wingood
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Margaret A Fischl
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Elizabeth T Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Daniel Merenstein
- Department of Family Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Joel Milam
- Department of Epidemiology and Biostatistics, Susan & Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, California
| | - Deborah Konkle-Parker
- Department of Medicine, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Tracey E Wilson
- Department of Community Health Sciences, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, New York
| | - Adaora A Adimora
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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23
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Dague L, Burns M, Friedsam D. The Line between Medicaid and Marketplace: Coverage Effects from Wisconsin's Partial Expansion. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2022; 47:293-318. [PMID: 34847221 DOI: 10.1215/03616878-9626852] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
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.
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Patterns in Medicaid Coverage and Service Utilization Among People with Serious Mental Illnesses. Community Ment Health J 2022; 58:729-739. [PMID: 34448985 DOI: 10.1007/s10597-021-00878-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
Disruptions in Medicaid adversely affect service use and outcomes among individuals with serious mental illnesses (SMI). A retrospective longitudinal study examined Medicaid coverage and service utilization patterns among individuals with SMI (N = 8358) from 2007 to 2010. Only 36% of participants were continuously enrolled in Medicaid and 20% experienced multiple enrollment disruptions. Mental health diagnosis did not predict continuous coverage; however, individuals with schizophrenia were 19% more likely to have multiple coverage disruptions than those with depression (b = - 0.21; p < 0.01). Single and multiple coverage disruptions were associated with decreased rates of outpatient service days utilized (IRR = 0.77 and 0.65, respectively, p < 0.001) and decreased odds of not using acute care services (OR 0.26 and 0.19, respectively, p < 0.001). Future research should explore mechanisms underlying Medicaid stability and develop interventions that facilitate insurance stability and service utilization.
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25
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Counts NZ, Kuklinski MR, Wong V, Feinberg ME, Creedon TB. Comparison of Estimated Incentives for Preventing Postpartum Depression in Value-Based Payment Models Using the Net Present Value of Care vs Total Cost of Care. JAMA Netw Open 2022; 5:e229401. [PMID: 35471567 PMCID: PMC9044113 DOI: 10.1001/jamanetworkopen.2022.9401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Strong financial incentives are critical to promoting widespread implementation of interventions that prevent postpartum depression. Value-based payment (VBP) approaches could be adapted to capture longer-term value and offer stronger incentives for postpartum depression prevention by sharing the expected future health care savings estimated by reduced postpartum depression incidence with clinicians. OBJECTIVE To evaluate whether sharing 5-year expected savings estimated by reduced postpartum depression incidence offers stronger incentives for prevention than traditional VBP under a variety of circumstances. DESIGN, SETTING, AND PARTICIPANTS This decision analytic model used a simulated cohort of 1000 Medicaid-enrolled pregnant individuals. Health care costs for individuals receiving postpartum depression preventive intervention or not, over 1 or 5 years post partum, in a variety of scenarios, including varying rates of Medicaid churn (ie, transitions to a new Medicaid managed care plan, commercial insurance plan, or loss of coverage) were estimated for the period 2020 to 2025. The model was developed between March 5 and July 30, 2021. EXPOSURE Sharing 100% of 1-year actual health care cost saving vs 50% of 5-year estimated health care cost savings associated with reduced postpartum depression incidence. MAIN OUTCOMES AND MEASURES The main outcome was the amount of clinician incentive shared in a VBP model from providing preventive interventions. The likelihood of the health care payer realizing a positive return on investment if it shared 50% of 5-year expected savings with a clinician up front was also measured. RESULTS The simulated cohort was designed to be reflective of the demographics characteristics of pregnant individuals receiving Medicaid; however, no specific demographic features were simulated. Providing preventive interventions for postpartum depression resulted in an estimated 5-year savings of $734.12 (95% credible interval [CrI], $217.21-$1235.67) per person. Without health insurance churn, sharing 50% of 5-year expected savings could offer more than double the financial incentives for clinicians to prevent postpartum depression compared with traditional VBP ($367.06 [95% CrI, $108.61-$617.83] vs $177.74 [95% CrI, $52.66-$296.60], respectively), with a high likelihood of positive return for the health care payer (91%). As health insurance churn increased, clinician incentives from sharing estimated savings decreased (73% reduction with 50% annual churn). CONCLUSIONS AND RELEVANCE In this decision analytic model of VBP approaches to incentivizing postpartum depression prevention, VBP based on 5-year expected savings offered stronger incentives when churn was low. Policy should support health care payers and clinicians to share estimated savings and overcome health insurance churn issues to promote wide-scale implementation of interventions to prevent perinatal mental health conditions.
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Affiliation(s)
- Nathaniel Z. Counts
- Mental Health America, Alexandria, Virginia
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York
| | - Margaret R. Kuklinski
- Social Development Research Group, University of Washington School of Social Work, Seattle
| | - Venus Wong
- Department of General Internal Medicine, Stanford Medicine, Stanford, California
| | - Mark E. Feinberg
- Department of Health and Human Development, The Pennsylvania State University, University Park
| | - Timothy B. Creedon
- Health Equity Research Lab, Cambridge Health Alliance, Cambridge, Massachusetts
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Albright BB, Nitecki R, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States. Am J Obstet Gynecol 2022; 226:384.e1-384.e13. [PMID: 34597606 PMCID: PMC10016333 DOI: 10.1016/j.ajog.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emeline M Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Fang H, Frean M, Sylwestrzak G, Ukert B. Trends in Disenrollment and Reenrollment Within US Commercial Health Insurance Plans, 2006-2018. JAMA Netw Open 2022; 5:e220320. [PMID: 35201308 PMCID: PMC8874349 DOI: 10.1001/jamanetworkopen.2022.0320] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE The commercial health insurance market is characterized by consistently high enrollee turnover. Turnover can disrupt care continuity for patients and create challenges for insurers in managing the health of their enrollee populations. Yet the extent to which enrollees reenroll is not widely known. OBJECTIVE To characterize rates of disenrollment (hereafter, external turnover) and reenrollment in commercial health plans. DESIGN, SETTING, AND PARTICIPANTS In this retrospective longitudinal cohort study, trends in turnover and reenrollment in commercial health plans between January 1, 2006, and August 31, 2018, were analyzed. Data analysis was conducted from January 21, 2020, through December 23, 2021. Participants included 3 018 633 primary members and their dependents with employer-sponsored coverage. MAIN OUTCOMES AND MEASURES Primary outcomes included external turnover from commercial coverage and subsequent reenrollment into any line of business with the insurer (commercial, Medicaid Managed Care, and Medicare Advantage). Within commercial coverage, external turnover was analyzed separately for group (ie, employer-sponsored) and individual markets. RESULTS In the sample of 3 018 633 members, 50.2% were men; mean (SD) age, including dependents, was 30.68 (19.05) years. A total of 2.2% of members experienced external turnover each month and 21.5% experienced external turnover each year. The individual market had the highest average monthly turnover rate of 3.4% compared with 2.1% in the group market. December had the highest rate of external turnover, with 13.8% experiencing external turnover in the individual market and 6.9% of members experiencing external turnover in the group market. Fourteen percent of the members who left the insurer from an individual plan reenrolled with the insurer after 1 year, and 34% had reenrolled after 5 years. Among members who left the insurer from a group plan, 12% reenrolled after 1 year and 32% reenrolled after 5 years. After 10 years, reenrollment reached 47% in the 2 markets. More than 80% of enrollees returned to the same line of business and within the same state, suggesting findings may generalize to smaller insurers. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that insurers may benefit from investing in members' long-term health outcomes despite substantial short-term turnover rates.
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Affiliation(s)
- Hanming Fang
- Department of Economics, University of Pennsylvania, Philadelphia
| | | | | | - Benjamin Ukert
- Anthem Inc, Wilmington, Delaware
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
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Neiman PU, Mouli VH, Taylor KK, Ayanian JZ, Dimick JB, Scott JW. The Impact of Medicare Coverage on Downstream Financial Outcomes for Adults Who Undergo Surgery. Ann Surg 2022; 275:99-105. [PMID: 34914661 PMCID: PMC10088463 DOI: 10.1097/sla.0000000000005272] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the effects of gaining access to Medicare on key financial outcomes for surgical patients. SUMMARY BACKGROUND DATA Surgical care poses a significant financial burden, especially among patients with insufficient financial risk protection. Medicare may mitigate the risk of these adverse circumstances, but the impact of Medicare eligibility on surgical patients remains poorly understood. METHODS Regression discontinuity analysis of national, cross-sectional survey and cost data from the 2008 to 2018 National Health Interview Survey and Medical Expenditure Panel Survey. Patients were between the ages of 57 to 72 with surgery in the past 12 months. The primary outcomes were the presence of medical debt, delay/deferment of care due to cost, total annual out-of-pocket costs, and experiencing catastrophic health expenditures. RESULTS Among 45,982,243 National Health Interview Survey patients, Medicare eligibility was associated with a 6.6 percentage-point decrease (95% confidence interval [CI]: -9.0% to -4.3) in being uninsured (>99% relative reduction), 7.6 percentage-point decrease (24% relative reduction) in having medical debt (95%CI: -14.1% to -1.1%), and 4.9 percentage-point decrease (95%CI: -9.4% to -0.4%) in deferrals/delays in medical care due to cost (28% relative reduction). Among 33,084,967 Medical Expenditure Panel Survey patients, annual out-of-pocket spending decreased by $1199 per patient (95%CI: -$1633 to -$765), a 33% relative reduction, and catastrophic health expenditures decreased by 7.3 percentage points (95%CI: -13.6% to -0.1%), a 55% relative reduction. CONCLUSIONS Medicare may reduce the economic burden of healthcare spending and delays in care for older adult surgical patients. These findings have important implications for policy discussions regarding changing insurance eligibility thresholds for the older adult population.
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Affiliation(s)
- Pooja U Neiman
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Vibav H Mouli
- University of Michigan Medical School, Ann Arbor, MI
| | - Kathryn K Taylor
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Stanford University, Stanford, CA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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Ji X, Castellino SM, Mertens AC, Zhao J, Nogueira L, Jemal A, Yabroff KR, Han X. Association of Medicaid Expansion With Cancer Stage and Disparities in Newly Diagnosed Young Adults. J Natl Cancer Inst 2021; 113:1723-1732. [PMID: 34021352 PMCID: PMC9989840 DOI: 10.1093/jnci/djab105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/22/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Young adults (YAs) experience higher uninsurance rates and more advanced stage at cancer diagnosis than older counterparts. We examined the association of the Affordable Care Act Medicaid expansion with insurance coverage and stage at diagnosis among YAs newly diagnosed with cancer. METHODS Using the National Cancer Database, we identified 309 413 YAs aged 18-39 years who received a first cancer diagnosis in 2011-2016. Outcomes included percentages of YAs without health insurance at diagnosis, with stage I (early-stage) diagnoses, and with stage IV (advanced-stage) diagnoses. We conducted difference-in-difference (DD) analyses to examine outcomes before and after states implemented Medicaid expansion compared with nonexpansion states. All statistical tests were 2-sided. RESULTS The percentage of uninsured YAs decreased more in expansion than nonexpansion states (adjusted DD = -1.0 percentage points [ppt], 95% confidence interval [CI] = -1.4 to -0.7 ppt, P < .001). The overall percentage of stage I diagnoses increased (adjusted DD = 1.4 ppt, 95% CI = 0.6 to 2.2 ppt, P < .001) in expansion compared with nonexpansion states, with greater improvement among YAs in rural areas (adjusted DD = 7.2 ppt, 95% CI = 0.2 to 14.3 ppt, P = .045) than metropolitan areas (adjusted DD = 1.3 ppt, 95% CI = 0.4 to 2.2 ppt, P = .004) and among non-Hispanic Black patients (adjusted DD = 2.2 ppt, 95% CI = -0.03 to 4.4 ppt, P = .05) than non-Hispanic White patients (adjusted DD = 1.4 ppt, 95% CI = 0.4 to 2.3 ppt, P = .008). Despite the non-statistically significant change in stage IV diagnoses overall, the percentage declined more (adjusted DD = -1.2 ppt, 95% CI = -2.2 to -0.2 ppt, P = .02) among melanoma patients in expansion relative to nonexpansion states. CONCLUSIONS We provide the first evidence, to our knowledge, on the association of Medicaid expansion with shifts to early-stage cancer at diagnosis and a narrowing of rural-urban and Black-White disparities in YA cancer patients.
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Affiliation(s)
- Xu Ji
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sharon M Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ann C Mertens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
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Balio CP, Blackburn J, Yeager VA, Simon KI, Menachemi N. Many States Were Able To Expand Medicaid Without Increasing Administrative Spending. Health Aff (Millwood) 2021; 40:1740-1748. [PMID: 34724415 DOI: 10.1377/hlthaff.2020.01695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.
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Affiliation(s)
- Casey P Balio
- Casey P. Balio is a research assistant professor at the Center for Rural Health Research, Department of Health Services Management and Policy, East Tennessee State University, in Johnson City, Tennessee. She was a doctoral candidate at the Indiana University Richard M. Fairbanks School of Public Health, in Indianapolis, Indiana, at the time this article was written
| | - Justin Blackburn
- Justin Blackburn is an associate professor in the Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health
| | - Valerie A Yeager
- Valerie A. Yeager is an associate professor in the Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health
| | - Kosali I Simon
- Kosali I. Simon is the Herman B. Wells Endowed Professor at the Paul H. O'Neill School of Public and Environmental Affairs and associate vice provost for health sciences, Indiana University, in Bloomington, Indiana
| | - Nir Menachemi
- Nir Menachemi is the Fairbanks Endowed Chair, a professor, and head of the Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, and a scientist at the Regenstrief Institute, in Indianapolis, Indiana
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31
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Albright BB, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Associations of Insurance Churn and Catastrophic Health Expenditures With Implementation of the Affordable Care Act Among Nonelderly Patients With Cancer in the United States. JAMA Netw Open 2021; 4:e2124280. [PMID: 34495338 PMCID: PMC8427370 DOI: 10.1001/jamanetworkopen.2021.24280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Health insurance coverage is dynamic in the United States, potentially changing from month to month. The Patient Protection and Affordable Care Act (ACA) aimed to stabilize markets and reduce financial burden, particularly among those with preexisting conditions. OBJECTIVE To describe the risks of insurance churn (ie, gain, loss, or change in coverage) and catastrophic health expenditures among nonelderly patients with cancer in the United States, assessing for changes associated with ACA implementation. DESIGN, SETTING, AND PARTICIPANTS This retrospective, cross-sectional study uses data from the Medical Expenditure Panel Survey, a representative sample of the US population from 2005 to 2018. Respondents included were younger than 65 years, identified by health care use associated with a cancer diagnosis code in the given year. Statistical analysis was conducted from July 30, 2020, to January 5, 2021. EXPOSURES The Patient Protection and Affordable Care Act. MAIN OUTCOMES AND MEASURES Survey weights were applied to generate estimates for the US population. Annual risks of insurance churn (ie, any uninsurance or insurance change or loss) and catastrophic health expenditures (spending >10% income) were calculated, comparing subgroups with the adjusted Wald test. Weighted multivariable linear regression was used to assess for changes associated with ACA implementation. RESULTS From 6069 respondents, we estimated a weighted mean of 4.78 million nonelderly patients (95% CI, 4.55-5.01 million; female patients: weighted mean, 63.9% [95% CI, 62.2%-65.7%]; mean age, 50.3 years [95% CI, 49.7-50.8 years]) with cancer annually in the United States. Patients with cancer experienced lower annual risks of insurance loss (5.3% [95% CI, 4.5%-6.1%] vs 7.6% [95% CI, 7.4%-7.8%]) and any uninsurance (14.6% [95% CI, 13.3%-16.0%] vs 24.1% [95% CI, 23.5%-24.7%]) but increased risk of catastrophic health expenditures (expenses alone: 12.4% [95% CI, 11.2%-13.6%] vs 6.3% [95% CI, 6.2%-6.5%]; including premiums: 26.6% [95% CI, 25.0%-28.1%] vs 16.5% [95% CI, 16.1%-16.8%]; P < .001) relative to the population without cancer. Patients with cancer from low-income families and with full-year private coverage were at particularly high risk of catastrophic health expenditures (including premiums: 81.7% [95% CI, 74.6%-88.9%]). After adjustment, low income was the factor most strongly associated with both insurance churn and catastrophic spending, associated with annual risk increases of 6.5% (95% CI, 4.2%-8.8%) for insurance loss, 17.3% (95% CI, 13.4%-21.2%) for any uninsurance, and 37.4% (95% CI, 33.3%-41.6%) for catastrophic expenditures excluding premiums (P < .001). In adjusted models relative to 2005-2009, full ACA implementation (2014-2018) was associated with a decreased annual risk of any uninsurance (-4.2%; 95% CI, -7.4% to -1.0%; P = .01) and catastrophic spending by expenses alone (-3.0%; 95% CI, -5.3% to -0.8%; P = .008) but not including premiums (0.4%; 95% CI, -2.8% to 4.5%; P = .82). CONCLUSIONS AND RELEVANCE In this cross-sectional study, US patients with cancer faced significant annual risks of insurance churn and catastrophic health spending. Despite some improvements with ACA implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship.
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Affiliation(s)
- Benjamin B. Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junzo P. Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Emeline M. Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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Cavanaugh S, Mostashari F, Gee R. What Medicare Can Teach Medicaid About Value-Based Care. JAMA HEALTH FORUM 2021; 2:e211513. [DOI: 10.1001/jamahealthforum.2021.1513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Rebekah Gee
- Health Care Services Division, Louisiana State University, New Orleans
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Auty SG, Shafer PR, Dusetzina SB, Griffith KN. Association of Medicaid Managed Care Drug Carve Outs With Hepatitis C Virus Prescription Use. JAMA HEALTH FORUM 2021; 2:e212285. [PMID: 35977199 PMCID: PMC8796891 DOI: 10.1001/jamahealthforum.2021.2285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/28/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Medicaid enrolls a disproportionate share of US adults with hepatitis C virus (HCV), and most receive Medicaid benefits through managed care organizations (MCOs). Medicaid MCOs often impose stricter requirements to access HCV medications than traditional fee-for-service Medicaid, which may inhibit use. Though Medicaid MCOs generally cover prescription drugs, several states have carved out direct-acting antiviral HCV medications from MCO coverage and opted to cover them under fee-for-service. Whether these carve outs were associated with changes in medication use is unknown. Objective To examine the association between Medicaid-covered HCV medication fills and carve outs of these medications from MCO coverage. Design Setting and Participants This cross-sectional study examined changes in fills of Medicaid-covered direct-acting antiviral HCV medications in 4 states (Indiana, Michigan, New Hampshire, and West Virginia) that carved out these drugs from Medicaid MCOs between 2015 and 2017. A synthetic control approach was used to compare changes in HCV prescription fills between states that did and did not carve out these medications from MCO prescription drug coverage. Data of direct-acting antiviral HCV prescription fills were obtained from the Medicaid State Drug Utilization Data files, January 2015 to June 2020. Data analysis was conducted from November 2020 to June 2021. Exposures Carve outs of direct-acting antiviral HCV medications from Medicaid MCO prescription drug coverage. Main Outcomes and Measures Direct-acting antiviral HCV prescriptions filled per 100 000 Medicaid enrollees. Results In this cross-sectional study, carve outs were associated with a mean quarterly increase of 22.1 (95% CI, 12.7-34.1) HCV prescriptions per 100 000 Medicaid enrollees, a relative increase of 86.3% compared with synthetic control states. Compared with each state's respective synthetic control, HCV prescription fills were associated with an increase of 11.5 (95% CI, 5.1-19.0) HCV prescription fills per 100 000 Medicaid enrollees per quarter in Indiana, 36.6 (95% CI, 23.5-53.9) in Michigan, 20.7 (95% CI, 11.1-32.8) in West Virginia, and 43.6 (95% CI, 25.9-68.4) in New Hampshire. Conclusions and Relevance In this cross-sectional study of data from 39 states and the District of Columbia, carve outs of direct-acting antiviral HCV medications from Medicaid MCO prescription drug coverage were associated with significant increases in HCV medication use. Given their clinical benefits, greater uptake of HCV medication may help improve the health of Medicaid enrollees with HCV and reduce the economic burden of untreated HCV on the US health care system.
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Affiliation(s)
- Samantha G. Auty
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Paul R. Shafer
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kevin N. Griffith
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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Determinants of Diabetes Disease Management, 2011-2019. Healthcare (Basel) 2021; 9:healthcare9080944. [PMID: 34442081 PMCID: PMC8393363 DOI: 10.3390/healthcare9080944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/17/2021] [Accepted: 07/21/2021] [Indexed: 11/25/2022] Open
Abstract
This study estimated the effects of Medicaid Expansion, demographics, socioeconomic status (SES), and health status on disease management of diabetes over time. The hypothesis was that the introduction of the ACA and particularly Medicaid Expansion would increase the following dependent variables (all proportions): (1) provider checks of HbA1c, (2) provider checks of feet, (3) provider checks of eyes, (4) patient education, (5) annual physician checks for diabetes, (6) patient self-checks of blood sugar. Data were available from the Behavioral Risk Factor Surveillance System for 2011 to 2019. We filtered the data to include only patients with diagnosed non-gestational diabetes of age 45 or older (n = 510,991 cases prior to weighting). Linear splines modeled Medicaid Expansion based on state of residence as well as implementation status. Descriptive time series plots showed no major changes in proportions of the dependent variables over time. Quasibinomial analysis showed that implementation of Medicaid Expansion had a statistically negative effect on patient self-checks of blood sugar (odds ratio = 0.971, p < 0.001), a statistically positive effect on physician checks of HbA1c (odds ratio = 1.048, p < 0.001), a statistically positive effect on feet checks (odds ratio = 1.021, p < 0.001), and no other significant effects. Evidence of demographic, SES, and health status disparities existed for most of the dependent variables. This finding was especially significant for HbA1c checks by providers. Barriers to achieving better diabetic care remain and require innovative policy interventions.
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Yabroff KR, Zhao J, Halpern MT, Fedewa SA, Han X, Nogueira LM, Zheng Z, Jemal A. Health Insurance Disruptions and Care Access and Affordability in the U.S. Am J Prev Med 2021; 61:3-12. [PMID: 34148626 DOI: 10.1016/j.amepre.2021.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Health insurance is associated with better care in the U.S., but little is known about the associations of coverage disruptions (i.e., periods without insurance) with care access, receipt, and affordability. METHODS Adults aged 18-64 years with current private (n=124,746), public (n=30,932), or no (n=31,802) insurance coverage were identified from the 2011-2018 National Health Interview Survey. Data were analyzed in 2020. Separate multivariable logistic regressions evaluated the associations of having coverage disruptions or being uninsured with care access, receipt, and affordability. RESULTS Overall, 5.0% of currently insured adults with private and 10.7% with public insurance reported a coverage disruption in the previous year, representing nearly 9.1 million adults in 2018. Among currently uninsured, 24.9% reported coverage loss within the previous year, representing nearly 8.1 million adults in 2018. Among adults with current private or current public coverage, disruptions were associated with lower receipt of all preventive services (AOR=0.42, 95% CI=0.37, 0.46 and AOR=0.48, 95% CI=0.40, 0.58, respectively), with forgoing any needed care because of cost (AOR=4.79, 95% CI=4.44, 5.17 and AOR=4.28, 95% CI=3.86, 4.75), and with medication nonadherence because of cost (AOR=3.55, 95% CI=3.13, 4.03 and AOR=4.09, 95% CI=3.43, 4.88) compared with that among adults with continuous coverage (p<0.05). Longer disruptions among currently insured adults were significantly associated with worse care access, receipt, and affordability, with dose-response patterns. Currently uninsured adults, especially those with longer uninsured periods, reported significantly worse care access, receipt, and affordability than currently insured adults with coverage disruptions or continuous coverage. CONCLUSIONS Findings highlight the importance of continuous insurance coverage; disruptions owing to the COVID-19 pandemic will likely have adverse consequences for care access and affordability.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia.
| | - Jingxuan Zhao
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Michael T Halpern
- Division of Cancer Control & Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Stacey A Fedewa
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Leticia M Nogueira
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
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Austin AE, Naumann RB, Short NA. Association of Medicaid Expansion with Suicide Deaths among Nonelderly U.S. Adults. Am J Epidemiol 2021; 190:1760-1769. [PMID: 34467410 DOI: 10.1093/aje/kwab130] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Hill SC, Abdus S. The effects of Medicaid on access to care and adherence to recommended preventive services. Health Serv Res 2021; 56:84-94. [PMID: 33616926 PMCID: PMC7839643 DOI: 10.1111/1475-6773.13603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To quantify the impact of Medicaid enrollment on access to care and adherence to recommended preventive services. DATA SOURCE 2005-2015 Medical Expenditure Panel Survey Household Component. STUDY DESIGN We examined several access measures and utilization of several preventive services within the past year and within the time frame recommended by the United States Preventive Services Task Force, if more than a year. We estimated local average treatment effects of Medicaid enrollment using a new, two-stage regression model developed by Nguimkeu, Denteh, and Tchernis. This model accounts for both endogenous and underreported Medicaid enrollment by using a partial observability bivariate probit regression as the first stage. We identify the model with an exogenous measure of Medicaid eligibility, the simulated Medicaid eligibility rate by state, year, and parents vs childless adults. A wide range of changes in Medicaid eligibility occurred during the time period studied. DATA COLLECTION/EXTRACTION METHODS Sample of low-income, nonelderly adults not receiving disability benefits. PRINCIPAL FINDINGS Medicaid enrollment decreased the probability of having unmet needs for medical care by 7.5 percentage points and the probability of experiencing delays getting prescription drugs by 7.7 percentage points. Medicaid enrollment increased the probability of having a usual source of care by 16.5 percentage points, the probability of having a routine checkup by 17.1 percentage points, and the probability of having a flu shot in past year by 12.6 percentage points. CONCLUSION Medicaid enrollment increased access to care and use of some preventive services. Additional research is needed on impacts for subgroups, such as parents, childless adults, and the smaller and generally older populations for whom screening tests are recommended.
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Affiliation(s)
- Steven C. Hill
- Division of Research & ModelingCenter for Financing, Access, and Cost TrendsAgency for Healthcare Research & QualityDepartment of Health and Human ServicesRockvilleMarylandUSA
| | - Salam Abdus
- Division of Research & ModelingCenter for Financing, Access, and Cost TrendsAgency for Healthcare Research & QualityDepartment of Health and Human ServicesRockvilleMarylandUSA
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Yan LD, Ali MK, Strombotne KL. Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis. Am J Prev Med 2021; 60:189-197. [PMID: 33191065 PMCID: PMC10420391 DOI: 10.1016/j.amepre.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/31/2020] [Accepted: 08/06/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. METHODS A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008-2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18-64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. RESULTS In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= -16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. CONCLUSIONS Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.
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Affiliation(s)
- Lily D Yan
- Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts; Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts.
| | - Mohammed K Ali
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia; Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kiersten L Strombotne
- Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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A Method for Examining Geographic Variation When Denominators Are Unknown, Populations Vary, and Time is of the Essence: Back Surgery as an Example. Spine (Phila Pa 1976) 2020; 45:E1699-E1702. [PMID: 33231946 DOI: 10.1097/brs.0000000000003717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
: Level of Evidence: 3.
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Soni A. The effects of public health insurance on health behaviors: Evidence from the fifth year of Medicaid expansion. HEALTH ECONOMICS 2020; 29:1586-1605. [PMID: 32822116 DOI: 10.1002/hec.4155] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 07/07/2020] [Accepted: 07/27/2020] [Indexed: 06/11/2023]
Abstract
This study examines the longer term relationship between public health insurance expansions and health behaviors. I leverage geographic and temporal variation in the implementation of the Affordable Care Act-facilitated Medicaid expansions and provide the first estimates of the expansions' behavioral impacts during their first 5 years. Using national survey data from the 2010 to 2018 Behavioral Risk Factors Surveillance System and a difference-in-differences regression design, I show that the Medicaid expansions increase utilization of certain forms of preventive care, while reducing heavy drinking. I also find suggestive evidence that the expansions reduce smoking and increase the probability of exercise. These results stand in contrast with earlier studies that used only 2 or 3 years of postexpansion data and found no detectable effect of the Medicaid expansions on health behaviors in the short run. My results, combined with evidence from previous studies, suggest that public insurance expansions may not prompt an immediate change in health behaviors, but newly eligible populations do increase investments in healthy behaviors over time. In the long run, Medicaid expansions may help reduce engagement in risky behaviors like drinking and smoking among low-income people.
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Affiliation(s)
- Aparna Soni
- School of Public Affairs, American University, Washington, DC, USA
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Marseille E, Kahn JG, Yazar-Klosinski B, Doblin R. The cost-effectiveness of MDMA-assisted psychotherapy for the treatment of chronic, treatment-resistant PTSD. PLoS One 2020; 15:e0239997. [PMID: 33052965 PMCID: PMC7556534 DOI: 10.1371/journal.pone.0239997] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/17/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic posttraumatic stress disorder (PTSD) is a disabling condition that generates considerable morbidity, mortality, and both medical and indirect social costs. Treatment options are limited. A novel therapy using 3,4-methylenedioxymethamphetamine (MDMA) has shown efficacy in six phase 2 trials. Its cost-effectiveness is unknown. METHODS AND FINDINGS To assess the cost-effectiveness of MDMA-assisted psychotherapy (MAP) from the health care payer's perspective, we constructed a decision-analytic Markov model to portray the costs and health benefits of treating patients with chronic, severe, or extreme, treatment-resistant PTSD with MAP. In six double-blind phase 2 trials, MAP consisted of a mean of 2.5 90-minute trauma-focused psychotherapy sessions before two 8-hour sessions with MDMA (mean dose of 125 mg), followed by a mean of 3.5 integration sessions for each active session. The control group received an inactive placebo or 25-40 mg. of MDMA, and otherwise followed the same regimen. Our model calculates net medical costs, mortality, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Efficacy was based on the pooled results of six randomized controlled phase 2 trials with 105 subjects; and a four-year follow-up of 19 subjects. Other inputs were based on published literature and on assumptions when data were unavailable. We modeled results over a 30-year analytic horizon and conducted extensive sensitivity analyses. Our model calculates expected medical costs, mortality, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Future costs and QALYs were discounted at 3% per year. For 1,000 individuals, MAP generates discounted net savings of $103.2 million over 30 years while accruing 5,553 discounted QALYs, compared to continued standard of care. MAP breaks even on cost at 3.1 years while delivering 918 QALYs. Making the conservative assumption that benefits cease after one year, MAP would accrue net costs of $7.6 million while generating 288 QALYS, or $26,427 per QALY gained. CONCLUSION MAP provided to patients with severe or extreme, chronic PTSD appears to be cost-saving while delivering substantial clinical benefit. Third-party payers are likely to save money within three years by covering this form of therapy.
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Affiliation(s)
- Elliot Marseille
- Health Strategies International, Oakland, California, United States of America
- University of California, San Francisco, California, United States of America
- * E-mail:
| | - James G. Kahn
- University of California, San Francisco, California, United States of America
| | - Berra Yazar-Klosinski
- Multidisciplinary Association for Psychedelic Studies (MAPS), Santa Cruz, California, United States of America
| | - Rick Doblin
- Multidisciplinary Association for Psychedelic Studies (MAPS), Santa Cruz, California, United States of America
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Dunlop AL, Joski P, Strahan AE, Sierra E, Adams EK. Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act. Womens Health Issues 2020; 30:426-435. [PMID: 32958368 DOI: 10.1016/j.whi.2020.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ensuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods. METHODS We used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services. RESULTS Women who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use. CONCLUSIONS Ohio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.
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Affiliation(s)
- Anne L Dunlop
- Emory University Nell Hodgson Woodruff School of Nursing, Emory University School of Medicine, Atlanta, Georgia
| | - Peter Joski
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Andrea E Strahan
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | - E Kathleen Adams
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia.
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Zhao J, Han X, Nogueira L, Zheng Z, Jemal A, Yabroff KR. Health Insurance Coverage Disruptions and Access to Care and Affordability among Cancer Survivors in the United States. Cancer Epidemiol Biomarkers Prev 2020; 29:2134-2140. [PMID: 32868319 DOI: 10.1158/1055-9965.epi-20-0518] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lack of health insurance is associated with having problems with access to high-quality care. We estimated prevalence and evaluated associations of insurance coverage disruptions and access to health care and affordability among cancer survivors in the United States. METHODS Adult cancer survivors ages 18 to 64 years with current private or public health insurance were identified from the 2011 to 2018 National Health Interview Survey (n = 7,186). Health insurance coverage disruption was measured as self-reports of any time in the prior year without coverage. Outcomes included preventive services use, problems with care affordability, and cost-related medication nonadherence in the prior year. We used separate multivariable logistic models to evaluate associations between coverage disruptions and study outcomes by current insurance coverage. RESULTS Among currently insured survivors, 3.7% [95% confidence interval (95% CI), 3.0%-4.4%] with private, and 7.8% (95% CI, 6.5%-9.4%) with public insurance reported coverage disruptions in 2011 to 2018. We estimated that approximately 260,000 survivors ages 18 to 64 years had coverage disruptions in 2018. Among privately and publicly insured survivors, those with coverage disruptions were less likely to report all preventive services use (16.9% vs. 36.2%; 14.6% vs. 25.3%, respectively) and more likely to report any problems with care affordability (55.0% vs. 17.7%; 71.1% vs. 38.4%, respectively) and any cost-related medication nonadherence (39.4% vs. 10.1%; 36.5% vs. 16.3%, respectively) compared with those continuously insured (all P < 0.05). CONCLUSIONS Coverage disruptions in the prior year were associated with problems with health care access and affordability among currently insured survivors. IMPACT Reducing coverage disruptions may help improve access and affordability for survivors.
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Affiliation(s)
- Jingxuan Zhao
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia.
| | - Xuesong Han
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Leticia Nogueira
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Zhiyuan Zheng
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - K Robin Yabroff
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
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Moss HA, Wu J, Kaplan SJ, Zafar SY. The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review. J Natl Cancer Inst 2020; 112:779-791. [PMID: 32277814 PMCID: PMC7825479 DOI: 10.1093/jnci/djaa043] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum. METHODS A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria. RESULTS A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities. CONCLUSIONS Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.
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Affiliation(s)
| | - Jenny Wu
- Duke University School of Medicine, Durham NC, USA
| | | | - S Yousuf Zafar
- Duke Cancer Institute, Duke-Margolis Center for Health Policy, Durham, NC, USA
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Yabroff KR, Reeder-Hayes K, Zhao J, Halpern MT, Lopez AM, Bernal-Mizrachi L, Collier AB, Neuner J, Phillips J, Blackstock W, Patel M. Health Insurance Coverage Disruptions and Cancer Care and Outcomes: Systematic Review of Published Research. J Natl Cancer Inst 2020; 112:671-687. [PMID: 32337585 PMCID: PMC7357319 DOI: 10.1093/jnci/djaa048] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/12/2020] [Accepted: 03/27/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival. METHODS We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively. RESULTS Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions. CONCLUSIONS Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Michael T Halpern
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Ana Maria Lopez
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Anderson B Collier
- Children’s Cancer Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Joan Neuner
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Manali Patel
- Stanford University School of Medicine, Stanford, CA, USA
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Chen L, Sommers BD. Work Requirements and Medicaid Disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018. Am J Public Health 2020; 110:1208-1210. [PMID: 32552024 DOI: 10.2105/ajph.2020.305697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To identify risk factors for Medicaid disenrollment after the implementation of Arkansas's work requirements.Methods. Using a 2018 telephone survey of 1208 low-income adults aged 30 to 49 years in Arkansas (expansion state with work requirements implemented in June 2018), Kentucky (expansion state with proposed work requirements blocked by courts), Louisiana (expansion state without work requirements), and Texas (nonexpansion state), we assessed Medicaid disenrollment rates among the age group targeted by Arkansas's policy.Results. The Medicaid disenrollment rate was highest in Texas (12.8%), followed by Arkansas (10.5%), Kentucky (5.8%), and Louisiana (2.8%). Over half of those who disenrolled in Texas and Arkansas became uninsured, compared with less than a quarter in Kentucky and Louisiana. In multivariate models, Arkansas had significantly higher disenrollment compared with the 3 comparison states; men and non-Hispanic Whites experienced higher disenrollment than women and racial minorities. In Arkansas, having a chronic condition was associated with higher disenrollment.Conclusions. As states debate work requirements and Medicaid reforms, our findings provide insights for policymakers about which populations may be most vulnerable to losing Medicaid coverage.
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Affiliation(s)
- Lucy Chen
- Lucy Chen is with the Harvard Graduate School of Arts and Sciences and the Harvard Business School, Boston, MA. Benjamin D. Sommers is with the Harvard T. H. Chan School of Public Health and Brigham and Women's Hospital, Boston, MA
| | - Benjamin D Sommers
- Lucy Chen is with the Harvard Graduate School of Arts and Sciences and the Harvard Business School, Boston, MA. Benjamin D. Sommers is with the Harvard T. H. Chan School of Public Health and Brigham and Women's Hospital, Boston, MA
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