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MacCallum-Bridges CL, Gartner DR, Hettinger K, Zamani-Hank Y, Margerison CE. Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review. Popul Health Manag 2024. [PMID: 38574270 DOI: 10.1089/pop.2023.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
In the United States, there are profound and persistent racial and ethnic disparities in pregnancy-related health, emphasizing the need to promote racial health equity through public policy. There is evidence that the Affordable Care Act (ACA) increased health insurance coverage, access to health care, and health care utilization, and may have affected some pregnancy-related health outcomes (eg, preterm delivery). It is unclear, however, whether these impacts on pregnancy-related outcomes were equitably distributed across race and ethnicity. Thus, the objective of this study was to fill that gap by summarizing the peer-reviewed evidence regarding the impact of the ACA on racial and ethnic disparities in pregnancy-related health outcomes. The authors conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), using broad search terms to identify relevant peer-reviewed literature in PubMed, Web of Science, and EconLit. The authors identified and reviewed n = 21 studies and found that the current literature suggests that the ACA and its components were differentially associated with contraception-related and fertility-related outcomes by race/ethnicity. Literature regarding pregnancy health, birth outcomes, and postpartum health, however, was sparse and mixed, making it difficult to draw conclusions regarding the impact on racial/ethnic disparities in these outcomes. To inform future health policy that reduces racial disparities, additional work is needed to clarify the impacts of contemporary health policy, like the ACA, on racial disparities in pregnancy health, birth outcomes, and postpartum health.
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Affiliation(s)
| | - Danielle R Gartner
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | - Katlyn Hettinger
- Department of Economics, Western Kentucky University, Bowling Green, Kentucky, USA
| | - Yasamean Zamani-Hank
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Department of Family Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Claire E Margerison
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
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Testa A, Mungia R, Lee J, Jackson DB, Fahmy C, Neumann A, Samper-Ternent R. The Patient Protection and Affordable Care Act and oral health care use among formerly incarcerated people in the United States. J Am Dent Assoc 2024; 155:158-166.e6. [PMID: 38085198 DOI: 10.1016/j.adaj.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/19/2023] [Accepted: 10/26/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Formerly incarcerated people report less frequent oral health care use, despite having more substantial oral health problems. This study aimed to determine whether the adoption of the Patient Protection and Affordable Care Act (ACA) has improved oral health care use among formerly incarcerated people in the United States. METHOD Data were from Wave I (1994-1995), Wave IV (2008), and Wave V (2016-2018) of the National Longitudinal Study of Adolescent to Adult Health (n = 9,108), a nationally representative cohort study in the United States. RESULTS On the basis of the results of multiple logistic regression analysis with interaction terms, the authors found a positive and statistically significant interaction between prior incarceration and living in a state with ACA adoption on past-year oral health care use, net of potential confounding variables (incarceration × ACA: odds ratio, 1.587; 95% CI, 1.043 to 2.414). Substantively, the findings suggest that people with a history of incarceration are less likely to use oral health care, and this disparity is more likely to occur in states without ACA adoption. CONCLUSIONS ACA adoption corresponds with improvements in the receipt of oral health care among formerly incarcerated people. PRACTICAL IMPLICATIONS This study builds on prior evidence highlighting that the ACA is beneficial in connecting formerly incarcerated people to health care services and suggests that these benefits may extend to improving access to and use of oral health care.
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Roberts LS, James TG. Inclusion of People With Disabilities in Community Health Needs Assessments in Florida, United States. Health Promot Pract 2024:15248399231225642. [PMID: 38235695 DOI: 10.1177/15248399231225642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Community health needs assessments (CHNAs) play a crucial role in identifying health needs of communities. Yet, unique health needs of people with disabilities (PWDs) are often underrecognized in public health practice. In 2010, the Patient Protection and Affordable Care Act (ACA) required the implementation of standardized data collection guidelines, including disability status, among federal agencies. The extent to which guidance from ACA and the U.S. Centers for Disease Control and Prevention has impacted disability inclusion in CHNAs is unknown. This study used a content analysis approach to review CHNAs conducted by local health councils and the top 11 nonprofit hospitals in Florida (n = 77). We coded CHNAs based on mentioning disability in CHNA reports, involving disability-related stakeholders, and incorporating data on disability indicators. Findings indicate that PWDs are widely not included in CHNAs in Florida, emphasizing the need for equitable representation and comprehensive understanding of PWDs in community health planning.
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Lieff SA, Mijanovich T, Yang L, Silver D. Impacts of the Affordable Care Act Medicaid Expansion on Mental Health Treatment Among Low-income Adults Across Racial/Ethnic Subgroups, 2010-2017. J Behav Health Serv Res 2024; 51:57-73. [PMID: 37673829 DOI: 10.1007/s11414-023-09861-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/08/2023]
Abstract
This study examines whether the Affordable Care Act (ACA) Medicaid expansion (ME) was associated with changes in racial/ethnic disparities in insurance coverage, utilization, and quality of mental health care among low-income adults with probable mental illness using the National Survey on Drug Use and Health with state identifiers. This study employed difference-in-difference models to compare ME states to non-expansion states before (2010-2013) and after (2014-2017) expansion and triple difference models to examine these changes across non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino racial/ethnic subgroups. Insurance coverage increased significantly for all racial/ethnic groups in expansion states relative to non-expansion states (DD: 9.69; 95% CI: 5.17, 14.21). The proportion low-income adults that received treatment but still had unmet need decreased (DD: -3.06; 95% CI: -5.92, -0.21) and the proportion with unmet need and no mental health treatment increased (DD: 2.38; 95% CI: 0.03, 4.73). ME was not associated with reduced disparities.
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Affiliation(s)
- Sarah A Lieff
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA.
| | - Tod Mijanovich
- Department of Applied Statistics, Social Science, and Humanities, New York University Steinhardt School of Culture, Education, and Human Development, New York, NY, USA
| | - Lawrence Yang
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA
| | - Diana Silver
- Department of Public Health Policy and Management, New York University School of Global Public Health, New York, NY, USA
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Elani HW, Figueroa JF, Kawachi I, Rosenthal M. Early changes in health coverage and access to dental care associated with Medicaid expansion under the COVID-19 pandemic. Health Aff Sch 2023; 1:qxad032. [PMID: 38500761 PMCID: PMC10948102 DOI: 10.1093/haschl/qxad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
The extent to which the COVID-19 pandemic has affected early changes in health coverage and access to dental care services in states that expanded Medicaid versus those that did not is currently not well known. Using data from the National Health Interview Survey, we found that, during the first year of the COVID-19 pandemic, states that had previously expanded their Medicaid programs under the Affordable Care Act had lower uninsurance rates for White low-income adults (-8.8 percentage points; 95% CI: -16.6, -1.0) and lower dental uninsurance rates for all low-income adults (-5.4 percentage points; 95% CI: -10.4, -0.5). Our findings also suggest that the combination of Medicaid expansion with coverage of adult dental benefits in Medicaid was associated with improved dental coverage and access to dental care during the pandemic. With the expiration of the public health emergency declaration, states are considering strategies to prevent disruptions in Medicaid coverage. Our study adds to the evidence of the importance of Medicaid expansion in stabilizing health coverage during a public health crisis.
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Affiliation(s)
- Hawazin W. Elani
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA 02115, United States
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Meredith Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
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Thornton M, Mushtare R, Rescigno F, Brightman K. Accessibility of the Affordable Care Act (ACA) marketplace websites. J Commun Healthc 2022; 15:316-323. [PMID: 36911905 DOI: 10.1080/17538068.2022.2046899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) mandated that creation of online health insurance websites to ease the complex process of shopping for and enrolling into coverage. Ensuring that these sites are not only available but also meet digital accessibility standards is important so that individuals with disabilities are able to access healthcare services and efficiently obtain insurance coverage. METHOD We evaluated each of the marketplace sites in 2020 to assess whether they are digitally accessible. We employed a custom audit tool based on a subset of the Web Content Accessibility Guidelines (WCAG) 1.0 and 2.0 AA and used content analysis to compare the site's accessibility statements with best practices. RESULTS Nearly all of the ACA marketplace websites have significant room to improve their digital accessibility. Notable technical problem areas include lack of text equivalents for images, difficult site navigation, and lack of optimization for mobile use, particularly on those pages that provide instructions on how to get in-person help. CONCLUSIONS Given that access to health insurance is a primary predictor of access to health care - sites must be easy to use and accessible to all individuals regardless of ability. Barriers to online enrollment, such as those identified in this work, may exacerbate disparities in quality of care, treatment continuity and affordability for individuals with mental and physical disabilities. Entities providing health-related online information & engagement should be aware of actionable opportunities to improve digital accessibility to optimize the enrollment process for both maintaining coverage and assisting those that remain uninsured.
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Affiliation(s)
- Michele Thornton
- Health Services Administration, Department of Marketing and Management, State University of New York at Oswego, Oswego, NY, USA
| | - Rebecca Mushtare
- Interaction and Graphic Design, Department of Art and Design, State University of New York at Oswego, Oswego, NY, USA
| | | | - Kaitlin Brightman
- Risk Management and Insurance, State University of New York at Oswego, Oswego, NY, USA
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Rivera‐González AC, Roby DH, Stimpson JP, Bustamante AV, Purtle J, Bellamy SL, Ortega AN. The impact of Medicaid funding structures on inequities in health care access for Latinos in New York, Florida, and Puerto Rico. Health Serv Res 2022; 57 Suppl 2:172-182. [PMID: 35861151 PMCID: PMC9660415 DOI: 10.1111/1475-6773.14036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant). DATA SOURCES Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey. STUDY DESIGN Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households. DATA COLLECTION The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019. PRINCIPAL FINDINGS Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]). CONCLUSIONS Limited Medicaid eligibility (non-expansion of Florida's Medicaid program) and capped Medicaid funds (Puerto Rico's Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.
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Affiliation(s)
| | - Dylan H. Roby
- Health, Society, and BehaviorUniversity of California Irvine Public HealthIrvineCaliforniaUSA
| | - Jim P. Stimpson
- Health Management and PolicyDrexel University Dornsife School of Public HealthPhiladelphiaPennsylvaniaUSA
| | - Arturo Vargas Bustamante
- Health Policy and ManagementUniversity of California Los Angeles Jonathan and Karin Fielding School of Public HealthLos AngelesCaliforniaUSA
| | - Jonathan Purtle
- Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNew YorkUSA
| | - Scarlett L. Bellamy
- Epidemiology and BiostatisticsDornsife School of Public Health, Drexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Alexander N. Ortega
- Health Management and PolicyDrexel University Dornsife School of Public HealthPhiladelphiaPennsylvaniaUSA
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Adashi EY, O'Mahony DP, Cohen IG. And Then There Were Three: The Decimation of the Affordable Care Act (ACA) CO-OPs. J Am Board Fam Med 2022; 35:867-9. [PMID: 35896470 DOI: 10.3122/jabfm.2022.04.210533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/13/2022] [Accepted: 02/24/2022] [Indexed: 11/08/2022] Open
Abstract
The Consumer Operated and Oriented Plans (CO-OPs), the subject of Section 1322 of the Affordable Care Act (ACA), were to constitute "qualified nonprofit health insurance issuers." Designed with an eye toward increasing competition with the extant commercial and nonprofit insurance sector, the CO-OPs were to enhance consumer choice as well as hold down prices on the state and federal exchanges. To achieve these ends, the consumer-governed state-licensed CO-OPs were to target the individual and small-group markets. At least one qualified CO-OP was to be established in each and every state. By the fall of 2013, however, coincident with the first open enrollment period of the ACA, only 23 CO-OPs were on tap. At the time of this writing, only three of these CO-OPs remain operational in the states of Maine, Montana, and Wisconsin. Viewed in hindsight, the thorough dissolution of the CO-OPs was the product of incremental financial privation effectuated by congressional opponents of the ACA. In this Commentary, we revisit the ontogeny of the CO-OP construct, review its partisan dismantling, and explore the potential resurrection thereof.
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9
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Hallur S, Sandhu S, Herold E, Trejo A, Rasmussen D, Riggs N, Ali HM, Bettger JP. Embedding Student Volunteer Affordable Care Act Navigators in a Primary Care Clinic. Ann Fam Med 2022; 20:282. [PMID: 35318225 PMCID: PMC9199042 DOI: 10.1370/afm.2794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/28/2021] [Accepted: 09/24/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Shreyas Hallur
- Corresponding author Shreyas Hallur Duke University Box 96402 Durham, NC 27708
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Frerichs L, Bell R, Lich KH, Reuland D, Warne DK. Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act. Ethn Health 2022; 27:174-189. [PMID: 31181960 DOI: 10.1080/13557858.2019.1625873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/27/2019] [Indexed: 06/09/2023]
Abstract
Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in health insurance among AI/AN adults before and after implementation of the ACA.Design: We used data from the American Community Survey from 2008 to 2016 to examine trends in health insurance. We compared to Non-Hispanic Whites and stratified AI/AN adults with and without Indian Health Service (IHS) coverage. We used multivariate regression to evaluate the probability of health insurance post-ACA and included time period and subgroup interaction terms.Results: Public and private health insurance coverage increased post-ACA by 3.17 and 1.24 percentage points, respectively, but the percent uninsured remained high (37.7% of those with IHS coverage and 19.2% of those without). AI/AN in Medicaid Expansion states had a significantly greater percentage point (pp) increase in public insurance (6.31 pp, 95% CI 5.04-7.59) than AI/AN in non-expansion states (p < 0.001). There was a greater increase in private coverage among AI/AN without IHS compared to AI/AN with IHS coverage (p = 0.002).Conclusions: Despite improvements in healthcare insurance coverage for AI/AN, substantial disparities remain. The improvements appeared to be largely driven by Medicaid Expansion. Without specific considerations for AI/AN, future healthcare reforms could intensify health injustices and inequities they face.
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Affiliation(s)
- Leah Frerichs
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Ronny Bell
- Department of Public Health, East Carolina University, Greenville, NC, USA
- North Carolina American Indian Health Board, Winston-Salem, NC, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Dan Reuland
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Donald K Warne
- School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
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McManus KA, Schurman E, An Z, Van Hook R, Keim-Malpass J, Flickinger TE. Patient Perspective of People with HIV Who Gained Medicaid Through Medicaid Expansion: A Cross-Sectional Qualitative Study. AIDS Res Hum Retroviruses 2021; 38:580-591. [PMID: 34538069 PMCID: PMC9297321 DOI: 10.1089/aid.2021.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Given the large numbers of people with HIV (PWH) with Medicaid coverage, it is important to understand the patient experience with Medicaid. Understanding experiences with and attitudes around the program have important policy and clinical implications. The objective was to understand the patient perspective of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion. English-speaking PWH who gained Medicaid due to Medicaid expansion in 2019 were recruited at one Virginia Ryan White HIV/AIDS Program clinic. The goal was to enroll >33% of those who newly were on Medicaid for 2019. Participants were surveyed about demographic characteristics, and semistructured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using qualitative description and an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 28) met our recruitment goal. Most participants had positive feelings about Medicaid before enrollment (general: 68%; good for general health: 75%, and good for HIV care: 67%) and after enrollment (general: 93% and good for HIV care: 93%). All participants expressed incomplete understanding about Medicaid before enrollment. Seventy-nine percent needed outside help to complete enrollment. Approximately 40% described overlaps of Medicaid with other insurance/payers or gaps in insurance coverage when transitioning from one insurance/payer (such as AIDS Drug Assistance Program [ADAP] medication provision and ADAP-subsidized insurance) to Medicaid. Participants suggested more access or easier access to information about Medicaid and more explanation of Medicaid benefits would be helpful. Our findings indicate participants had mostly positive perceptions of Medicaid before and after enrollment. Even with enrollment help, participants voiced that dealing with insurance is hard. Medicaid and other programs should prioritize more access to information, smoother processes, and less burdensome enrollment/re-enrollment.
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Affiliation(s)
- Kathleen A. McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
- Global Infectious Diseases Institute, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth Schurman
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Zixiao An
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Reed Van Hook
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Jessica Keim-Malpass
- Global Infectious Diseases Institute, University of Virginia, Charlottesville, Virginia, USA
- School of Nursing, University of Virginia, Charlottesville, Virginia, USA
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Allen L, Gian CT, Simon K. The impact of Medicaid expansion on emergency department wait times. Health Serv Res 2021; 57:294-299. [PMID: 34636421 DOI: 10.1111/1475-6773.13892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To estimate the impact of Medicaid expansion on emergency department (ED) wait times. DATA SOURCES We used 2012-2017 hospital-level secondary data from the CMS Hospital Compare data warehouse. STUDY DESIGN We used a state-level difference-in-differences approach to identify the impact of Medicaid expansion on four measures of ED wait times: time before being seen by a provider; time before being sent home after being seen by a provider; boarding time spent in the ED waiting to be discharged to an inpatient room; and the percentage of patients who left without being seen. We compared outcomes in states that expanded Medicaid with those in states that did not expand Medicaid. DATA COLLECTION/EXTRACTION METHODS Our sample included all US acute care hospitals with EDs in states that did not ever expand Medicaid or that fully expanded Medicaid in January of 2014. PRINCIPAL FINDINGS Medicaid expansion was associated with a 3.1-min increase (SE: 0.994, baseline mean: 30.8 min) in the time spent waiting to see an ED provider, a relative increase of 10%. Patients who were eventually sent home after being seen by a provider experienced a 7.5-min increase (SE: 1.8, baseline mean 142.1 min) in wait time. Boarding time rose by 3.8 min (SE 1.9, baseline mean 111.4 min). The percentage of patients who left without being seen rose by 0.3 percentage points (SE: 0.09, baseline mean 2.0), a relative increase of 15.3%. CONCLUSIONS This study provides multistate evidence that Medicaid expansion increased ED wait times for patients, indicating that ED crowding may have worsened post-expansion. Future work should aim to uncover the mechanisms through which insurance expansion increased ED wait times to provide policy direction.
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Affiliation(s)
- Lindsay Allen
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Cong T Gian
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
| | - Kosali Simon
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
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McGee BT, Seagraves KB, Smith EE, Xian Y, Zhang S, Alhanti B, Matsouaka RA, Reeves M, Schwamm LH, Fonarow GC. Associations of Medicaid Expansion With Access to Care, Severity, and Outcomes for Acute Ischemic Stroke. Circ Cardiovasc Qual Outcomes 2021; 14:e007940. [PMID: 34587752 DOI: 10.1161/circoutcomes.121.007940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple states have not expanded Medicaid under the Affordable Care Act, resulting in higher uninsured rates in states with high stroke burdens. This study aimed to evaluate the association of Medicaid expansion with changes in health insurance coverage, severity of presentation, access to care, and outcomes among patients with acute ischemic stroke. METHODS A retrospective, difference-in-differences analysis of Get With The Guidelines-Stroke registry data. The study population comprised first-time ischemic stroke admissions from 2012 to 2018 for patients aged 19 to 64 in 45 states (27 that expanded Medicaid and 18 that did not). A probable low-income cohort was defined based on having Medicaid, no insurance/self-pay, or undocumented insurance. Outcomes analyzed were indicators of health insurance status, stroke severity, use of emergency services, time to acute care, in-hospital mortality, receipt of rehabilitation, discharge disposition, and level of disability. RESULTS In the starting population (N=342 765), Medicaid-covered stroke admissions rose from 12.2% to 18.1% in expansion states and from 10.0% to only 10.6% in nonexpansion states, while uninsured admissions declined from 15.0% to 6.7% in expansion states and from 24.0% to 19.2% in nonexpansion states. In the low-income cohort (N=95 086; 28% of starting population), Medicaid expansion was associated with increased odds of discharge to a skilled nursing facility (adjusted odds ratio, 1.33 [95% CI, 1.12-1.59]) and transfer to any rehabilitation facility among those eligible (adjusted odds ratio, 1.24 [95% CI, 1.08-1.41]) and lower odds of discharge home (adjusted odds ratio, 0.89 [95% CI, 0.80-0.98]). Expansion was not associated with any other outcomes. CONCLUSIONS Medicaid expansion is associated with fewer uninsured hospitalizations for acute ischemic stroke and increased rehabilitation at skilled nursing facilities. More targeted interventions may be needed to improve other stroke outcomes in the low-income US population. Future research should evaluate the impact of health care reform on primary stroke prevention.
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Affiliation(s)
- Blake T McGee
- School of Nursing, Lewis College of Nursing and Health Professions, Georgia State University, Atlanta (B.T.M.)
| | | | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas (Y.X.)
| | - Shuaiqi Zhang
- Duke Clinical Research Institute (S.Z., B.A., R.A.M.), Duke University, Durham, NC
| | - Brooke Alhanti
- Duke Clinical Research Institute (S.Z., B.A., R.A.M.), Duke University, Durham, NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute (S.Z., B.A., R.A.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (R.A.M.), Duke University, Durham, NC
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Lee H Schwamm
- Stroke Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles (G.C.F.)
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Greenberg JK, Brown DS, Olsen MA, Ray WZ. Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care. J Neurosurg Spine 2021:1-9. [PMID: 34560659 PMCID: PMC8942868 DOI: 10.3171/2021.3.spine2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study's objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States. METHODS This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18-64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery. RESULTS The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%-35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI -0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI -5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1-7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5-8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups. CONCLUSIONS Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| | - Derek S. Brown
- Brown School, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| | - Margaret A. Olsen
- Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Wilson Z. Ray
- Department of Neurological Surgery, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
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15
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Raymond S, Li L, Taioli E, Nash D, Liu B. The effect of the Affordable Care Act dependent coverage provision on HPV vaccine uptake in young adult women, National Health and Nutrition Examination Survey 2007-2016. Prev Med 2021; 148:106536. [PMID: 33798531 DOI: 10.1016/j.ypmed.2021.106536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
The human papillomavirus (HPV) vaccine protects against cancers caused by HPV. The study objective was to examine the effect of the Affordable Care Act (ACA) dependent child coverage provision on HPV vaccination initiation, HPV vaccine completion, HPV infection, and health insurance coverage among young women. Using cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), 2172 female participants were included. The impact of the dependent coverage provision on the four outcomes was examined using difference-in-difference analyses with linear probability regressions, controlling for race/ethnicity, age, income, head of household education, and family employment. ACA exposure group was operationalized by age, with those targeted by the dependent coverage provision (ages 19-25) serving as the intervention group and those similar in age but not targeted (ages 18 and 26) serving as the control group. From 2007 to 2016, HPV vaccine initiation, HPV vaccine completion, and health insurance prevalence increased and HPV infection prevalence decreased. In the difference-in-difference adjusted models, ACA exposure was not associated with HPV vaccine initiation (0.045 percentage points [95% CI -0.087, 0.178]), completion (-0.044 percentage points [95% CI -0.152, 0.063]), HPV 16/18 infection (-0.051 percentage points [95% CI -0.123, 0.021]), or health insurance (0.065 percentage points [95% CI -0.032, 0.162]) among women aged 19 to 25. The dependent coverage provision may not have addressed relevant barriers to HPV vaccination. However, given that the effect of the dependent coverage provision on HPV vaccination and health insurance has been demonstrated previously, small sample size is a concern.
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Affiliation(s)
- Samantha Raymond
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) School of Public Health, New York, NY, United States of America.
| | - Lihua Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Emanuela Taioli
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Denis Nash
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) School of Public Health, New York, NY, United States of America; Institute for Implementation Science in Population Health, CUNY, New York, NY, United States of America
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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16
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Brown EA, White BM, Jones WJ, Gebregziabher M, Simpson KN. Measuring the impact of the Affordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach. Health Res Policy Syst 2021; 19:77. [PMID: 33957934 PMCID: PMC8101185 DOI: 10.1186/s12961-021-00730-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background The Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act (ACA), was created to increase access to primary care, improve quality of care, and decrease healthcare costs. A key provision in the law that mandated expansion of state Medicaid programme changed when states were given the option to voluntarily expand Medicaid. Our study sought to measure the impact of ACA Medicaid expansion on preventable hospitalization (PH) rates, a measure of access to primary care. Methods We performed an interrupted time series analysis of quarterly hospitalization rates across eight states from 2012 to 2015. Segmented regression analysis was utilized to determine the impact of policy reform on PH rates. Results The Affordable Care Act’s Medicaid expansion led to decreased rates of PH (improved access to care); however, the finding was not significant (coefficient estimate: −0.0059, CI −0.0225, 0.0107, p = 0.4856). Healthcare system characteristics, such as Medicaid spending per enrollee and Medicaid income eligibility, were associated with a significant decrease in rates of PH (improved access to care). However, the Medicaid-to-Medicare fee index (physician reimbursement) and states with a Democratic state legislature had a significant increase in rates of PH (poor access to care). Conclusion Health policy reform and healthcare delivery characteristics impact access to care. Researchers should continue evaluating such policy changes across more states over longer periods of time. Researchers should translate these findings into cost analysis for state policy-makers to make better-informed decisions for their constituents. Contribution to knowledge Ambulatory care-sensitive conditions are a feasible method for evaluating policy and measuring access to primary care. Policy alone cannot improve access to care. Other factors (trust, communication, policy-makers’ motivations and objectives, etc.) must be addressed to improve access. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-021-00730-0.
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Affiliation(s)
- Elizabeth A Brown
- Department of Clinical Sciences, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Avenue, MSC 962, Charleston, SC, 29425, USA.
| | - Brandi M White
- Division of Health Sciences, Education, and Research, College of Health Sciences, University of Kentucky, Room 209C Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA
| | - Walter J Jones
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Ave, MSC 962, Charleston, SC, 29425, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, 135 Cannon Street, Charleston, SC, 29425, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Ave, MSC 962, Charleston, SC, 29425, USA
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17
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Gamble CR, Huang Y, Wright JD, Hou JY. Precision medicine testing in ovarian cancer: The growing inequity between patients with commercial vs medicaid insurance. Gynecol Oncol 2021; 162:18-23. [PMID: 33958212 DOI: 10.1016/j.ygyno.2021.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Precision medicine technologies have significant impact in the care of patients with ovarian cancer. Compared to affluent patients, socioeconomically vulnerable patients are less likely to have access to this testing. There is little data that demonstrate this inequity over time. METHODS We used the IBM Truven Health MarketScan Research Database to identify patients in the United States who underwent surgery for ovarian cancer between 2011 and 2017. The presence of claims for precision medicine testing within six months of surgery was assessed for each patient. Precision medicine testing included both molecular genetic testing (BRCA limited or full sequencing, somatic and germline testing) as well as ancillary pathology tests (immunohistochemistry, microsatellite instability). Demographic data was extracted. RESULTS We identified 27,181 patients who met eligibility. Of these, 88.6% had commercial insurance, and 11.4% had Medicaid. While the proportion of patients who underwent precision medicine testing increased over time for both cohorts (47.0% to 66.6% for commercially insured, 41.4% to 57.6% for Medicaid insured, p < 0.0001), the inequity in testing rates widened (5.6% disparity to 9.0%, p < 0.0001). This was driven by growing inequity in germline and somatic genetic testing (7.6% disparity to 21.3%, p < 0.0001). CONCLUSIONS There is widening inequity in precision medicine testing rates between commercially insured and Medicaid insured poate patients with ovarian cancer.
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Affiliation(s)
- Charlotte R Gamble
- Columbia University College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America.
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - June Y Hou
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
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18
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Gotlieb EG, Rhodes KV, Candon MK. Disparities in Primary Care Wait Times in Medicaid versus Commercial Insurance. J Am Board Fam Med 2021; 34:571-8. [PMID: 34088817 DOI: 10.3122/jabfm.2021.03.200496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Timely access to primary care is important, particularly among patients with acute conditions and patients seeking gateways to specialty care. Due to concerns that expanded Medicaid eligibility would compromise access to primary care among new Medicaid beneficiaries, an experimental study was conducted to test the ability to obtain timely appointments. Although access to primary care appointments for simulated Medicaid patients significantly increased, wait times also increased. This study explores the determinants of wait times and whether they pose greater barriers to Medicaid beneficiaries. METHODS We conducted linear regressions to determine the association between the number of days to scheduled appointments and the simulated patient's clinical scenario, practice-level characteristics, and county-level measures of primary care supply. RESULTS Simulated Medicaid patients faced 1.3 days longer wait times than commercially insured ones. Participation in accountable care organizations and integrated health systems was associated with longer wait times but did not seem to reduce wait time disparities across insurance types. Notably, the presence of Federally Qualified Health Centers in a given county was associated with lower wait times for simulated Medicaid patients. CONCLUSIONS These findings highlight the complexity of access disparities for Medicaid patients and provide insight for future waves of health care reform.
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19
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McManus KA, Christensen B, Nagraj VP, Furl R, Yerkes L, Swindells S, Weissman S, Rhodes A, Targonski P, Rogawski McQuade E, Dillingham R. Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans' Association With Viral Suppression. Clin Infect Dis 2021; 71:2572-2580. [PMID: 31734691 PMCID: PMC7744983 DOI: 10.1093/cid/ciz1123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background Healthcare delivery changes associated with viral suppression (VS) could contribute to the United States’ “Ending the HIV Epidemic” (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states. Methods A multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014–2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated. Results Of the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06–3.53) and engagement in care in 2014 (aPR, 1.16; 1.04–1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs’ NNT for an additional person to achieve VS is 20 (14.1–34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28–1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99–1.14) was associated with VS. Conclusions Once enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE.
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Affiliation(s)
- Kathleen A McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Center for Health Policy, University of Virginia, Charlottesville, Virginia, USA
| | | | - V Peter Nagraj
- School of Medicine Research Computing, University of Virginia, Charlottesville, Virginia, USA
| | - Renae Furl
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Lauren Yerkes
- Virginia Department of Health, Richmond, Virginia, USA
| | - Susan Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sharon Weissman
- Division of Infectious Diseases, University of South Carolina, Columbia, South Carolina, USA
| | - Anne Rhodes
- Virginia Department of Health, Richmond, Virginia, USA
| | - Paul Targonski
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA.,Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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20
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Potla S, Cole TS, Mulholland CB, Tumialán LM. Access to Neurosurgery in the Era of Narrowing Insurance Networks: Statewide Analysis of Patient Protection and Affordable Care Act Marketplace Plans in Arizona. World Neurosurg 2021; 149:e963-e968. [PMID: 33515792 DOI: 10.1016/j.wneu.2021.01.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The Patient Protection and Affordable Care Act (ACA) sought to expand access to health care for 46 million uninsured Americans. Increasing consumer coverage and ensuring affordability of care have raised concerns about ACA Marketplace plans with limited in-network physician coverage (narrow network plans). We assessed the neurosurgery coverage of ACA Marketplace plans in Arizona. METHODS The Health Insurance Marketplace website was used to identify ACA Marketplace plans in Arizona. Plan-specific details were examined to search for in-network neurosurgeons (2016-2019). Physician- and patient-level information was obtained using Intellimed health care databases, which provide specific neurosurgery diagnosis-related group information. RESULTS Although 5 insurance providers offered plans on the ACA Marketplace in Arizona, only 1 plan was available in 13 of 15 counties (87%). Evaluation of in-network coverage found that all in-network outpatient neurosurgery providers are in 5 of 15 counties (33%). Most of the other counties (9 of 10) have neurosurgery facilities, but do not have in-network access to neurosurgical care within the county (∼1.1 million people or 15% of the state population). CONCLUSIONS By narrowing the network of providers, insurance companies are attempting to maintain fiscal viability of their ACA Marketplace products. However, 10 of the 15 counties (67%) in Arizona do not have access to outpatient neurosurgical care through these plans despite the presence of neurosurgical facilities in most counties. Access to neurosurgical care requires consideration of network coverage in policies designed to expand coverage and coverage options for patients insured through the ACA Marketplace.
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Affiliation(s)
- Subodh Potla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Celene B Mulholland
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Luis M Tumialán
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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21
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Swartz JJ, Meskey J, Stuart GS, Rodriguez MI. Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act. Ann Fam Med 2021; 19:38-40. [PMID: 33431389 PMCID: PMC7800743 DOI: 10.1370/afm.2615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 11/09/2022] Open
Abstract
One-half of women in the United States use Medicaid during pregnancy. Women living in states that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA) are at risk of losing coverage post partum. We analyzed Medicaid claims and vital statistics for the state of North Carolina for the period 2011 to 2017. North Carolina did not expand Medicaid but did alter Medicaid enrollment to meet ACA requirements. After implementation, enrollment in full Medicaid during pregnancy almost doubled, and enrollment in Medicaid for pregnant women decreased. Full Medicaid offers more comprehensive coverage and does not expire at 60 days post partum, allowing for access to crucial preventive health services including contraception and primary care.
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Affiliation(s)
- Jonas J Swartz
- Division of Women's Community and Population Health, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina .,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Joseph Meskey
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Gretchen S Stuart
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Maria I Rodriguez
- Section of Family Planning, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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22
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McManus KA, Srikanth K, Powers SD, Dillingham R, Rogawski McQuade ET. Medicaid Expansion's Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic. Open Forum Infect Dis 2020; 8:ofaa595. [PMID: 33598500 PMCID: PMC7875325 DOI: 10.1093/ofid/ofaa595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/02/2020] [Indexed: 01/01/2023] Open
Abstract
Background Although the Ryan White HIV/AIDS Program supports high-quality human immunodeficiency virus (HIV) care, Medicaid enrollment provides access to non-HIV care. People with HIV (PWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME). Methods Participants were PWH ages 18–63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS. Results Among 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% federal poverty level (adjusted prevalence ratio, 1.67; 95% confidence interval [CI], 1.00–1.86) compared with others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD], −8.5%; 95% CI, −16.9 to 0.1) and Medicare (aRD, −12.5%; 95% CI, −21.2 to −3.0) had lower 2019 engagement than others. For those with VS data (n = 548), after controlling for age and baseline VS, those with Medicaid (aRD, −4.0%; 95% CI, −10.3 to 0.3) and with Medicaid due to ME (aRD, −6.2%; 95% CI, −14.1 to −0.8) were less likely to achieve VS compared with others. Conclusions Given that PWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.
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Affiliation(s)
- Kathleen A McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Center for Health Policy, University of Virginia, Charlottesville, Virginia, USA
| | - Karishma Srikanth
- Batten School of Leadership and Public Policy, University of Virginia, Charlottesville, Virginia, USA
| | - Samuel D Powers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth T Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
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23
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Modell SM, Fleming PJ, Lopez WD, Goltz HH. Work in Progress: Immigrant Health Care from the Vantage of Cancer Testing and Screening. J Immigr Minor Health 2020; 23:1-3. [PMID: 33231790 DOI: 10.1007/s10903-020-01129-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
This letter offers a perspective from cancer testing and screening on the improvements in immigrant insurance coverage and care charted in Bustamante et al.'s April 2019 article in JOIH on "Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act." Supportive evidence for their data may be found in complementary literature drawing from both the National Health Interview Survey the authors use and the Medical Expenditure Panel Survey, while post-ACA surveys and state level information suggest disparities remain for lawfully present and undocumented immigrants ineligible for Medicaid and unable to secure insurance to pay medical costs. Existent options for cancer services are discussed. Further relevant reform depends on voter awareness and collaborative efforts between consumer advocates and legislators.
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Affiliation(s)
- Stephen M Modell
- Department of Epidemiology, Center for Public Health and Community Genomics, University of Michigan School of Public Health, M5049 SPH II, 1415 Washington Hts., Ann Arbor, MI, 48109-2029, USA.
| | - Paul J Fleming
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - William D Lopez
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Heather Honore' Goltz
- Social Work Program, College of Public Service, University of Houston-Downtown, Houston, TX, USA
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24
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Frerichs L, Bell R, Lich KH, Reuland D, Warne D. Regional Differences In Coverage Among American Indians And Alaska Natives Before And After The ACA. Health Aff (Millwood) 2020; 38:1542-1549. [PMID: 31479357 DOI: 10.1377/hlthaff.2019.00076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Understanding regional variation in the effect of the Affordable Care Act (ACA) on health insurance coverage among vulnerable populations such as American Indian and Alaska Native adults has important policy implications. We used American Community Survey data for the period 2010-17 to examine unadjusted trends in health insurance coverage among American Indians and Alaska Natives across ten US regions. In each region we also used multivariate regression to evaluate the effects of the ACA on insurance coverage among American Indians and Alaska Natives and differences in effects between that group and non-Hispanic whites. In the West we observed significant improvements in public insurance among American Indians and Alaska Natives, and disparities compared to non-Hispanic whites were reduced following the ACA. Although there were unadjusted increases in insurance coverage across most regions, regression analyses suggested that there were no significant post-ACA changes in public or private health insurance coverage among American Indians and Alaska Natives in the Oklahoma, Bemidji, or Alaska regions. In sum, health insurance among American Indians and Alaska Natives increased after the ACA, but improvements were not consistent across regions. More attention is needed to improve insurance coverage among American Indians and Alaska Natives in midwestern regions.
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Affiliation(s)
- Leah Frerichs
- Leah Frerichs ( ) is an assistant professor of health policy and management at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH)
| | - Ronny Bell
- Ronny Bell is a professor of public health at East Carolina University, in Greenville, North Carolina
| | - Kristen Hassmiller Lich
- Kristen Hassmiller Lich is an associate professor of health policy and management at the Gillings School of Global Public Health, UNC-CH
| | - Daniel Reuland
- Daniel Reuland is a professor of medicine at the School of Medicine, UNC-CH
| | - Donald Warne
- Donald Warne is director of the School of Medicine and Health Sciences, University of North Dakota, in Grand Forks
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25
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Kim U, Koroukian S, Statler A, Rose J. The effect of Medicaid expansion among adults from low-income communities on stage at diagnosis in those with screening-amenable cancers. Cancer 2020; 126:4209-4219. [PMID: 32627180 PMCID: PMC8571714 DOI: 10.1002/cncr.32895] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/11/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Several states have opted to expand Medicaid under the Patient Protection and Affordable Care Act (ACA), which offers insurance coverage to low-income individuals up to 138% of the federal poverty level. This expansion of Medicaid to a medically vulnerable population potentially can reduce cancer outcome disparities, especially among patients with screening-amenable cancers. The objective of the current study was to estimate the effect of Medicaid expansion on the percentage of adults from low-income communities with screening-amenable cancers who present with metastatic disease. METHODS Using state cancer registry data linked with block group-level income data, a total of 12,760 individuals aged 30 to 64 years who were diagnosed with incident invasive breast (female), cervical, colorectal, or lung cancer from 2011 through 2016 and who were uninsured or had Medicaid insurance at the time of diagnosis were identified. This sample was probability weighted based on income to reflect potential Medicaid eligibility under the ACA's Medicaid expansion. A multivariable logistic model then was fitted to examine the independent association between the exposure (pre-expansion [years 2011-2013] vs postexpansion [years 2014-2016]) and the outcome (metastatic vs nonmetastatic disease at the time of diagnosis). RESULTS After adjusting for potential confounders, individuals who were diagnosed postexpansion were found to have 15% lower odds of having metastatic disease compared with those who were diagnosed pre-expansion (adjusted odds ratio, 0.85; 95% confidence interval, 0.77-0.93). As a control, a separate analysis that focused on individuals with private insurance who resided in high-income communities found nonsignificant postexpansion (vs pre-expansion) changes in the outcome (adjusted odds ratio, 1.02; 95% confidence interval, 0.96-1.09). CONCLUSIONS Medicaid expansion is associated with a narrowing of a critical cancer outcome disparity in adults from low-income communities.
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Affiliation(s)
- Uriel Kim
- Case Western Reserve University School of Medicine (CWRU-SOM), Center for Community Health Integration
- Case Comprehensive Cancer Center (CCCC)
| | - Siran Koroukian
- Case Comprehensive Cancer Center (CCCC)
- CWRU-SOM, Department of Population and Quantitative Health Sciences
- CCCC Population Cancer Analytics Shared Resource
| | - Abby Statler
- Case Comprehensive Cancer Center (CCCC)
- The Cleveland Clinic Foundation, Taussig Cancer Institute
| | - Johnie Rose
- Case Western Reserve University School of Medicine (CWRU-SOM), Center for Community Health Integration
- Case Comprehensive Cancer Center (CCCC)
- CCCC Population Cancer Analytics Shared Resource
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McInerney M, Winecoff R, Ayyagari P, Simon K, Bundorf MK. ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study. Inquiry 2020; 57:46958020935229. [PMID: 32720837 PMCID: PMC7388087 DOI: 10.1177/0046958020935229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.
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Sacks DW, Drake C, Abraham JM, Simon K. Same Game, Different Names: Cream-Skimming in the Post-ACA Individual Health Insurance Market. Inquiry 2020; 57:46958020933765. [PMID: 32646261 PMCID: PMC7357013 DOI: 10.1177/0046958020933765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
One of the Affordable Care Act’s (ACA) signature reforms was creating centralized Health Insurance Marketplaces to offer comprehensive coverage in the form of comprehensive insurance complying with the ACA’s coverage standards. Yet, even after the ACA’s implementation, millions of people were covered through noncompliant plans, primarily in the form of continued enrollment in “grandmothered” and “grandfathered” plans that predated ACA’s full implementation and were allowed under federal and state regulations. Newly proposed and enacted federal legislation may grow the noncompliant segment in future years, and the employment losses of 2020 may grow reliance on individual market coverage further. These factors make it important to understand how the noncompliant segment affects the compliant segment, including the Marketplaces. We show, first, that the noncompliant segment of the individual insurance market substantially outperformed the compliant segment, charging lower premiums but with vastly lower costs, suggesting that insurers have a strong incentive to enter the noncompliant segment. We show, next, that state’s decisions to allow grandmothered plans is associated with stronger financial performance of the noncompliant market, but weaker performance of the compliant segment, as noncompliant plans attract lower-cost enrollees. This finding indicates important linkages between the noncompliant and compliant segments and highlights the role state policy can play in the individual insurance market. Taken together, our results point to substantial cream-skimming, with noncompliant plans enrolling the healthiest enrollees, resulting in higher average claims cost in the compliant segment.
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Dickins KA, Buchholz SW, Ingram D, Braun LT, Hamilton RJ, Earle M, Karnik NS. Supporting Primary Care Access and Use among Homeless Persons. Soc Work Public Health 2020; 35:335-357. [PMID: 32865153 DOI: 10.1080/19371918.2020.1809589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.
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Affiliation(s)
- Kirsten A Dickins
- Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research , Boston, Massachusetts, USA
| | | | - Diana Ingram
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Lynne T Braun
- Rush University College of Nursing , Chicago, Illinois, USA
| | | | - Melinda Earle
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Niranjan S Karnik
- Rush Medical College Department of Psychiatry, Rush University College of Nursing , Chicago, Illinois, USA
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McManus KA, Ferey J, Farrell E, Dillingham R. National Survey of US HIV Clinicians: Knowledge and Attitudes About the Affordable Care Act and Opinions of its Impact on Quality of Care and Barriers to Care. Open Forum Infect Dis 2020; 7:ofaa225. [PMID: 32665960 PMCID: PMC7336569 DOI: 10.1093/ofid/ofaa225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/05/2020] [Indexed: 11/29/2022] Open
Abstract
Background The Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assessing HIV clinicians’ ACA knowledge and attitudes, this study aims to evaluate HIV clinicians’ perspectives on whether the ACA has impacted the quality of HIV care and whether it addresses the main barriers to HIV care. Methods HIV clinicians were emailed a survey weblink in 2018. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results Of the 211 survey participants, the majority (70%) answered all 4 knowledge questions correctly. About 80% knew correctly whether their state had expanded Medicaid. Participants from Medicaid expansion states were more likely to report an improved ability to provide high-quality care compared with participants from Medicaid nonexpansion states (50% vs 34%; P = .01). The average response to whether the ACA addresses the main barriers to HIV care was neutral and did not differ based on Medicaid status. The top 3 main barriers to HIV care cited were mental health, substance use, and transportation. Conclusions HIV clinicians in Medicaid expansion states were more likely to report an improved ability to provide high-quality care since ACA implementation compared with those in Medicaid nonexpansion states. However, HIV clinicians across the United States are concerned that the ACA does not address the main barriers to HIV care. To be successful, the “Ending the HIV Epidemic” initiative should address these identified barriers.
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Affiliation(s)
- Kathleen A McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Center for Health Policy, University of Virginia, Charlottesville, Virginia, USA
| | - Joshua Ferey
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth Farrell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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Montgomery TM, Stephens-Shields AJ, Schapira MM, Akers AY. Dual-Method Contraception Use Among Young Women Pre- and Post-ACA Implementation. Policy Polit Nurs Pract 2020; 21:140-150. [PMID: 32397804 DOI: 10.1177/1527154420923747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The 2012 implementation of the Patient Protection and Affordable Care Act (ACA) contraceptive coverage mandate removed financial barriers to contraception access for many insured women. Since that time, increases in sexually transmitted disease (STD) rates have been noted, particularly among Black adolescent and young adult women aged 15 to 24 years. It is unclear whether changes in dual-method contraception use (simultaneous use of nonbarrier contraceptive methods and condoms) are associated with the increase in STD rates. A repeated cross-sectional analysis was conducted among adolescent and young adult women to compare pre-ACA data from the 2006-2010 cohort and post-ACA data from the 2013-2015 cohort of the National Survey for Family Growth. A significant decrease in short-acting reversible contraception use (SARC; 78.2% vs. 67.5%; p < .01) and a significant increase in long-acting reversible contraception use (LARC; 8.9% vs. 21.8%; p < .01) were found, but no significant change in dual-method contraception use was found among pre- versus post-ACA SARC users and SARC nonusers (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 0.64-5.46, p = .25), LARC users and LARC nonusers (adjusted odds ratio [AOR]: 1.62, 95% CI: 0.42-6.18, p = .48), or White and Black women (AOR: 1.45, 95% CI: 0.66-3.18, p = .35). There was no direct association between changes in contraception use and decreased condom use and therefore no indirect association between changes in contraception use and increased STD rates. Health care providers should continue promoting consistent condom use. Additional research is needed to understand recent increases in STD rates among Black women in the post-ACA era.
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Affiliation(s)
- Tiffany M Montgomery
- Drexel University, College of Nursing and Health Professions, Philadelphia, Pennsylvania, USA
| | | | | | - Aletha Y Akers
- Children's Hospital of Philadelphia, Division of Adolescent Medicine, USA
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31
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Melnikow J, Evans E, Xing G, Durbin S, Ritley D, Daniels B, Woodworth L. Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study. Ann Fam Med 2020; 18:210-217. [PMID: 32393556 PMCID: PMC7214003 DOI: 10.1370/afm.2502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 07/07/2019] [Accepted: 08/13/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion. METHODS We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county. RESULTS Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees. CONCLUSIONS In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.
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Affiliation(s)
- Joy Melnikow
- Center for Healthcare for Policy and Research, University of California, Davis, Davis, California
| | - Ethan Evans
- Department of Social Work, California State University, Sacramento, Sacramento, California
| | - Guibo Xing
- Center for Healthcare for Policy and Research, University of California, Davis, Davis, California
| | - Shauna Durbin
- Center for Healthcare for Policy and Research, University of California, Davis, Davis, California
| | - Dominique Ritley
- Center for Healthcare for Policy and Research, University of California, Davis, Davis, California
| | - Brock Daniels
- Division of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Lindsey Woodworth
- Department of Economics, University of South Carolina, Columbia, South Carolina
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Weiner AB, Vo AX, Desai AS, Hu JC, Spratt DE, Schaeffer EM. Changes in prostate-specific antigen at the time of prostate cancer diagnosis after Medicaid expansion in young men. Cancer 2020; 126:3229-3236. [PMID: 32343403 DOI: 10.1002/cncr.32930] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/10/2020] [Accepted: 04/01/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND The objective of this study was to determine the effect of Medicaid expansion under the Patient Protection and Affordable Care Act (January 1, 2014) on the epidemiology of high-risk prostate-specific antigen (PSA) levels (≥20 ng/mL) at the time of prostate cancer (PCa) diagnosis. The authors hypothesized that better access to care would result in a reduction of high-risk features at diagnosis. METHODS A retrospective cohort study was performed of 122,324 men aged <65 years who were diagnosed with PCa within the National Cancer Database. Difference-in-difference (DID) analyses adjusting for sociodemographic variables using linear regression compared PSA levels at diagnosis before expansion (2012-2013) and after expansion (2015-2016) between men residing in states that did or did not expand Medicaid. RESULTS From 2012 to 2016, the proportion of men with PSA levels ≥20 ng/mL increased (from 18.9% to 19.8%) in nonexpansion states and decreased (from 19.9% to 18.2%) in expansion states. Compared with men in nonexpansion states, men in expansion states experienced a decline in PSA ≥20 ng/mL (DID, -2.33%; 95% CI, -3.21% to -1.44%; P < .001). Accordingly, the proportion of men presenting with high-risk disease decreased in expansion states relative to nonexpansion states (DID, -1.25%; 95% CI, -2.26% to 0.25%; P = .015). A similar statistically significant decrease in PSA levels ≥20 ng/mL was noted among black men (DID, -3.11%; 95% CI, -5.25% to 0.96%; P = .005). CONCLUSIONS In Medicaid expansion states, there was an associated decrease in the proportion of young men presenting with PSA ≥20 ng/mL at the time of PCa diagnosis. These results suggest that Medicaid expansion improved access to PCa screening. Longer term data should assess oncologic outcomes.
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Affiliation(s)
- Adam B Weiner
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amanda X Vo
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anuj S Desai
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jim C Hu
- Department of Urology, New York Presbyterian-Weill Cornell Medical College, New York, New York, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Edward M Schaeffer
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Tilhou AS, Huguet N, DeVoe J, Angier H. The Affordable Care Act Medicaid Expansion Positively Impacted Community Health Centers and Their Patients. J Gen Intern Med 2020; 35:1292-1295. [PMID: 31898120 PMCID: PMC7174462 DOI: 10.1007/s11606-019-05571-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
Community health centers (CHCs) provide primary care for underserved children and adults. The Patient Protection and Affordable Care Act (ACA) aimed to strengthen the CHC network by increasing federal funds and expanding Medicaid eligibility. The ACA also aimed to boost preventive and mental health services and to reduce health and healthcare disparities. Here, we summarize our results to-date as experts in investigating the impact of ACA Medicaid expansion on CHCs and the patients they serve. We found the ACA Medicaid expansion increased access to care and preventive services, primarily in Medicaid expansion states. Rates of physical and mental health conditions rose substantially from pre- to post-ACA in expansion states, suggesting underdiagnosis pre-ACA. Disparities in health insurance coverage by race/ethnicity decreased at CHCs, yet some remain. These findings indicate that the ACA Medicaid expansion significantly helped CHCs and patients. Insurance expansion buoyed CHCs' financial viability by increasing reimbursement. Therefore, the ACA Medicaid expansion enhanced the health of underserved patients and repeal would jeopardize these advances for CHCs and their patients.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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Shane DM, Wehby GL. Were Patient Protection and Affordable Care Act spillover gains to private dental coverage for dependents widely shared?: An analysis using Medical Expenditure Panel Survey data. J Am Dent Assoc 2020; 151:182-189. [PMID: 32130947 DOI: 10.1016/j.adaj.2019.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/17/2019] [Accepted: 11/18/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND The dependent coverage mandate policy of the Patient Protection and Affordable Care Act led to spillover increases in private dental coverage among affected young adults. The authors investigate whether such gains were widely shared across racial or ethnic groups and shared across income levels. The authors further explore the relationship between dental coverage and dental services use stratified by race or ethnicity and income using the mandate as a natural experiment. METHODS Using nationally representative Medical Expenditure Panel Survey data from 2006 through 2015, the authors used a difference-in-difference regression approach comparing changes in private dental coverage and dental services use for 19- through 25-year-olds affected by the policy with those for unaffected 27- through 30-year-olds. The authors stratified the model by race or ethnicity and income to understand potential differences in the effects of the mandate across these groups. RESULTS The authors found significant increases in private dental coverage across all racial or ethnic groups as well as across higher- and lower-income young adults. However, despite notable increases in private dental coverage, the authors found little evidence of any overall effects on dental services use. The authors did find evidence suggesting an increased relative likelihood of dental visits for 19- through 25-year-old non-Hispanic blacks compared with slightly older non-Hispanic blacks. CONCLUSIONS The spillover effect of the dependent coverage mandate on private dental coverage was widely shared across racial or ethnic groups and across income levels. PRACTICAL IMPLICATIONS Among young adults aged 19 through 25 years, increases in private dental coverage may not be enough on its own to increase the use of preventive dental services and ultimately lead to improved oral health.
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Desai AS, Pham M, Weiner AB, Siddiqui MR, Driscoll C, Jain-Poster K, Ko OS, Vo A, Kundu SD. Medicaid Expansion Did not Improve Time to Treatment for Young Patients With Metastatic Renal Cell Carcinoma. Clin Genitourin Cancer 2020; 18:e386-e390. [PMID: 32280026 DOI: 10.1016/j.clgc.2020.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/26/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The absence of health insurance coverage has been associated with worse outcomes for patients with metastatic renal cell carcinoma (mRCC). Medicaid expansion in the United States was an important provision of the Affordable Care Act, which increased the number of low-income individuals eligible for Medicaid starting in January 2014 in several states. The effect of Medicaid expansion on access to healthcare for patients with mRCC is unknown. MATERIALS AND METHODS We performed a retrospective cohort study of 6844 patients aged < 65 years with mRCC at diagnosis within the National Cancer Database. We compared the time to treatment and the rates of no insurance before (2012-2013) and after (2015-2016) expansion between patients living in states that had and had not expanded Medicaid using difference-in-difference (DID) analyses. DIDs were calculated using linear regression analysis with adjustment for sociodemographic covariates. RESULTS The rate of no insurance did not change in the expansion states compared with the nonexpansion states (DID, -0.55%; 95% confidence interval, -3.32% to 2.21%; P = .7). The percentage of patients receiving treatment within 60 days of diagnosis had increased in the expansion states from 43% to 49% and in the nonexpansion states from 42% to 46% after expansion. No change was found in treatment within 60 days of diagnosis among all patients (DID, 2.81%; 95% confidence interval, -2.61% to 8.22%; P = .3). CONCLUSIONS Medicaid expansion was not associated with improved healthcare access for patients with mRCC as reflected by timely treatment. Future work should assess the association between Medicaid expansion and oncologic outcomes.
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Affiliation(s)
- Anuj S Desai
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Minh Pham
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Adam B Weiner
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mohammad R Siddiqui
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Conor Driscoll
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ketan Jain-Poster
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Oliver S Ko
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amanda Vo
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shilajit D Kundu
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Robertson-Preidler J, Trachsel M, Johnson T, Biller-Andorno N. The Affordable Care Act and Recent Reforms: Policy Implications for Equitable Mental Health Care Delivery. Health Care Anal 2020; 28:228-248. [PMID: 32103383 DOI: 10.1007/s10728-020-00391-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act (ACA) in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article evaluates the impact of the ACA on equitable mental health care delivery according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities.
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Affiliation(s)
- Joelle Robertson-Preidler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland.
| | - Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland
| | - Tricia Johnson
- Department of Health Systems Management, College of Health Sciences, Rush University, 1700 W. Van Buren St. 126B TOB, Chicago, IL, 60612, USA
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland
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Sohn M, Talbert JC, Delcher C, Hankosky ER, Lofwall MR, Freeman PR. Association between state Medicaid expansion status and naloxone prescription dispensing. Health Serv Res 2020; 55:239-248. [PMID: 32030751 DOI: 10.1111/1475-6773.13266] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To test whether Medicaid expansion is associated with (a) a greater number of naloxone prescriptions dispensed and (b) a higher proportion of naloxone prescriptions paid by Medicaid. DATA SOURCES/STUDY SETTING We used the IQVIA National Prescription Audit to obtain data on per state per quarter naloxone prescription dispensing for the period 2011-16. STUDY DESIGN In this quasi-experimental design study, the impact of Medicaid expansion on naloxone prescription dispensing was examined using difference-in-difference estimation models. State-level covariates including pharmacy-based naloxone laws (standing/protocol orders and direct authority to dispense naloxone), third-party prescribing laws, opioid analgesic prescribing rates, opioid-involved overdose death rates, and population size were controlled for in the analysis. PRINCIPAL FINDINGS Medicaid expansion was associated with 38 additional naloxone prescriptions dispensed per state per quarter compared to nonexpansion controls, on average (P = .030). Also, Medicaid expansion resulted in an average increase of 9.86 percent in the share of naloxone prescriptions paid by Medicaid per state per quarter (P < .001). CONCLUSIONS Our study found that Medicaid expansion increased naloxone availability. This finding suggests that it will be important to consider naloxone access when making federal- and state-level decisions affecting Medicaid coverage.
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Affiliation(s)
- Minji Sohn
- College of Pharmacy, Ferris State University, Big Rapids, Michigan
| | - Jeffery C Talbert
- Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Emily R Hankosky
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Michelle R Lofwall
- Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Patricia R Freeman
- Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, Kentucky
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Corrigan KL, Nogueira L, Yabroff KR, Lin CC, Han X, Chino JP, Coghill AE, Shiels M, Jemal A, Suneja G. The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States. Cancer 2020; 126:559-566. [PMID: 31709523 PMCID: PMC6980281 DOI: 10.1002/cncr.32563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/19/2019] [Accepted: 08/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States. METHODS HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis. RESULTS Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]). CONCLUSIONS The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion.
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Affiliation(s)
| | - Leticia Nogueira
- 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
| | - Chun Chieh Lin
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia.,Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Xuesong Han
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Junzo P Chino
- Duke University School of Medicine, Durham, North Carolina.,Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina
| | - Anna E Coghill
- Cancer Epidemiology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Meredith Shiels
- Division of Cancer Epidemiology and Genetics, Infections and Immunoepidemiology Branch, National Cancer Institute, Rockville, Maryland
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Gita Suneja
- Duke University School of Medicine, Durham, North Carolina.,Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina.,Department of Radiation Oncology and Global Health, Duke Global Health Institute, Durham, North Carolina
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Chen L, Frank RG, Huskamp HA. Overturning the ACA's Medicaid Expansion Would Likely Decrease Low-Income, Reproductive-Age Women's Healthcare Spending and Utilization. Inquiry 2020; 57:46958020981462. [PMID: 33305968 PMCID: PMC7734563 DOI: 10.1177/0046958020981462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 11/21/2022]
Abstract
In late 2020, the Supreme Court began hearing a case challenging the Affordable Care Act (ACA), which led to coverage gains for many low-income, reproductive-age women. To explore potential implications of a full ACA repeal for this population, we examined gains experienced after Medicaid expansion, assuming that such gains may be reversed. Using restricted 2013 to 2014 data from the Medical Expenditure Panel Survey for 1190 women ages 18 to 44 with household incomes below 138% of the federal poverty level, we compared the change in healthcare spending and utilization for women living in expansion states to the change in non-expansion states using a difference-in-differences design. We found that if Medicaid expansion were overturned, Medicaid coverage is likely to decrease, as well as Medicaid spending and prescription drug utilization.
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Affiliation(s)
- Lucy Chen
- Harvard Graduate School of Arts and Sciences and Harvard Business School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Eliason E. The effects of the dependent coverage provision on young women's utilization of sexual and reproductive health services. Prev Med 2019; 129:105863. [PMID: 31629798 DOI: 10.1016/j.ypmed.2019.105863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/21/2019] [Accepted: 10/11/2019] [Indexed: 11/23/2022]
Abstract
The Affordable Care Act dependent coverage provision expanded insurance for young adults by allowing maintained coverage through a parent's plan until the age of 26. This study examines whether this provision was associated with changes in sexual and reproductive health service utilization among young adult women, and if effects differed by race/ethnicity. The National Survey of Family Growth data were used to examine utilization among women before (2006-2009) and after (2011-2013) enactment of the provision. A difference-in-differences model was used to evaluate the effects on four measures of sexual and reproductive health services and one measure of health insurance coverage, treating women 19-25 years old as the exposure group and women 27-34 years old as the control group. This study finds that the dependent coverage provision was associated with a significant decrease in the probability of lacking health insurance, but finds no effects on sexual and reproductive health service utilization overall. In stratified models, increases in receipt of birth control prescriptions and methods as well as birth control check-ups or tests were present only for Hispanic women. There were no significant effects on birth control counseling or information or STD service utilization for any groups. Lacking health insurance coverage decreased only among non-Hispanic White women and Hispanic women, but was not significant for non-Hispanic Black women. These results suggest that women's utilization of sexual and reproductive health services overall may not increase with parental insurance gains, but Hispanic women do increase utilization of some birth control services with this improved coverage.
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Pathman DE. Changes in Rates and Content of Primary Care Visits Within an Evolving Health Care System. Ann Fam Med 2019; 17:482-484. [PMID: 31712284 PMCID: PMC6846270 DOI: 10.1370/afm.2477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Donald E Pathman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Huguet N, Angier H, Hoopes MJ, Marino M, Heintzman J, Schmidt T, DeVoe JE. Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act. J Am Board Fam Med 2019; 32:883-889. [PMID: 31704757 PMCID: PMC7001872 DOI: 10.3122/jabfm.2019.06.190087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/03/2019] [Accepted: 06/21/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To assess the prevalence of pre-existing conditions for community health center (CHC) patients who gained insurance coverage post-Affordable Care Act (ACA). METHODS We analyzed electronic health record data from 78,059 patients aged 19 to 64 uninsured at their last visit pre-ACA from 386 CHCs in 19 states. We compared the prevalence and types of pre-existing conditions pre-ACA (2012 to 2013) and post-ACA (2014 to 2015), by insurance status and race/ethnicity. RESULTS Pre-ACA, >50% of patients in the cohort had ≥1 Pre-existing condition. Post-ACA, >70% of those who gained insurance coverage had ≥1 condition. Post-ACA, all racial/ethnic subgroups showed an increase in the number of pre-existing conditions, with non-Hispanic Black and Hispanic patients experiencing the largest increases (adjusted prevalence difference, 18.9; 95% CI, 18.2 to 19.6 and 18.3; 95% CI, 17.8 to 18.7, respectively). The most common conditions post-ACA were mental health disorders with the highest prevalence among patients who gained Medicaid (45.6%) and lowest among those who gained private coverage (30.5%). CONCLUSIONS This study emphasizes the high prevalence of pre-existing conditions among CHC patients and the large increase in the proportion of patients with at least 1 of these diagnoses post-ACA. Given how common these conditions are, repealing pre-existing condition protections could be extremely harmful to millions of patients and would likely exacerbate health care and health disparities.
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Affiliation(s)
- Nathalie Huguet
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM).
| | - Heather Angier
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Megan J Hoopes
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Miguel Marino
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - John Heintzman
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Teresa Schmidt
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Jennifer E DeVoe
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
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Abstract
Background. Health insurance access and health literacy are critical components of "enabling resources" to encourage uptake of services. We sought to test whether health literacy boosts health services utilization in the context of expanded access to health insurance stemming from the Affordable Care Act. Method. We used individual-level data from 11 states included in the Behavioral Risk Factor Surveillance System 2016. We conducted a two-stage least squares instrumental variables analysis. We instrumented improved access to health insurance stemming from Affordable Care Act Medicaid expansion. As outcome variables, we examined cost as a barrier to needed care, having a personal doctor and receipt of routine health checkups, flu shots, Pap tests, mammograms, sigmoidoscopy/colonoscopy, and dental visits in the past year. We then tested whether the relation between improved health insurance access and health services utilization was moderated by health literacy. Health literacy was measured by a dichotomized scale comprising three items: difficulties obtaining advice or information about health, difficulties understating information from health professionals, and difficulties understanding written health information. Results. We found that improving health insurance access increased the likelihood of reporting a personal doctor while reducing the likelihood of reporting cost as a barrier to care. We also found an interaction effect between health insurance and health literacy on dental visits. However, there was no significant interaction effect between insurance access and health literacy for preventive services utilization. Conclusion. Health literacy did not explain why people fail to access preventive services even when they obtain access to insurance, with the sole possible exception of dental visits among individuals with high literacy.
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Affiliation(s)
- Shiho Kino
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ichiro Kawachi
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Wadhera RK, Joynt Maddox KE, Fonarow GC, Zhao X, Heidenreich PA, DeVore AD, Matsouaka RA, Hernandez AF, Yancy CW, Bhatt DL. Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure. Circ Cardiovasc Qual Outcomes 2019; 11:e004729. [PMID: 29946015 DOI: 10.1161/circoutcomes.118.004729] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the Affordable Care Act expanded Medicaid eligibility, and millions of low-income adults gained insurance. Little is known about Medicaid expansion's effect on inpatient HF care. METHODS AND RESULTS We used the American Heart Association's Get With The Guidelines-Heart Failure registry to assess changes in inpatient care quality and outcomes among low-income patients (<65 years old) hospitalized for HF after Medicaid expansion, in expansion, and nonexpansion states. Patients were classified as low-income if covered by Medicaid, uninsured, or missing insurance. Expansion states were those that implemented expansion in 2014. Piecewise logistic multivariable regression models were constructed to track quarterly trends of quality and outcome measures in the pre (January 1, 2010-December 31, 2013) and postexpansion (January 1, 2014-June 30, 2017) periods. These measures were compared between expansion versus nonexpansion states during the postexpansion period. The cohort included 58 804 patients hospitalized across 391 sites. In states that expanded Medicaid, uninsured HF hospitalizations declined from 7.9% to 4.4%, and Medicaid HF hospitalizations increased from 18.3% to 34.6%. Defect-free HF care was increasing during the preexpansion period (adjusted odds ratio/quarter, 1.06; 95% confidence interval, 1.03-1.08) but did not change after expansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.02). Patterns were similar for other quality measures. There were no quality measures for which the rate of improvement sped up after expansion. In-hospital mortality rates remained similar during the preexpansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.96-1.02) and postexpansion periods (adjusted odds ratio, 1.00; 95% confidence interval, 0.97-1.03). Among nonexpansion states, uninsured HF hospitalizations increased (11.6% to 16.7%) as did Medicaid HF hospitalizations (17.9% to 26.6%), and no quarterly improvement was observed for most quality measures in the post compared with preexpansion period. During the postexpansion period, defect-free care and mortality did not differ between expansion and nonexpansion states. CONCLUSIONS Medicaid expansion was associated with a significant decline in uninsured HF hospitalizations but not improvements in quality of care or in-hospital mortality among sites participating in a national quality improvement initiative. Efforts beyond insurance expansion are needed to improve in-hospital outcomes for low-income patients with HF.
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Affiliation(s)
- Rishi K Wadhera
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (R.K.W., D.L.B.).,Division of Cardiology, Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W.)
| | - Karen E Joynt Maddox
- Division of Cardiology, Washington University School of Medicine, Saint Louis, MO (K.E.J.M.)
| | - Gregg C Fonarow
- The Ahmanson-UCLA (University of California, Los Angeles) Cardiomyopathy Center, Ronald Reagan UCLA Medical Center (G.C.F.)
| | - Xin Zhao
- Duke Clinical Research Institute, Durham, NC (X.Z., A.D.D., R.A.M., A.F.H.)
| | | | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (X.Z., A.D.D., R.A.M., A.F.H.)
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, NC (X.Z., A.D.D., R.A.M., A.F.H.).,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (X.Z., A.D.D., R.A.M., A.F.H.)
| | - Clyde W Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (C.W.Y.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (R.K.W., D.L.B.)
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Balio CP, Apathy NC, Danek RL. Health Information Technology and Accountable Care Organizations: A Systematic Review and Future Directions. EGEMS (Wash DC) 2019; 7:24. [PMID: 31328131 DOI: 10.5334/egems.261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Since the inception of Accountable Care Organizations (ACOs), many have acknowledged the potential synergy between ACOs and health information technology (IT) in meeting quality and cost goals. Objective: We conducted a systematic review of the literature in order to describe what research has been conducted at the intersection of health IT and ACOs and identify directions for future research. Methods: We identified empirical studies discussing the use of health IT via PubMed search with subsequent snowball reference review. The type of health IT, how health IT was included in the study, use of theory, population, and findings were extracted from each study. Results: Our search resulted in 32 studies describing the intersection of health IT and ACOs, mainly in the form of electronic health records and health information exchange. Studies were divided into three streams by purpose; those that considered health IT as a factor for ACO participation, health IT use by current ACOs, and ACO performance as a function of health IT capabilities. Although most studies found a positive association between health IT and ACO participation, studies that address the performance of ACOs in terms of their health IT capabilities show more mixed results. Conclusions: In order to better understand this emerging relationship between health IT and ACO performance, we propose future research should consider more quasi-experimental studies, the use of theory, and merging health, quality, cost, and health IT use data across ACO member organizations.
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Heintzman J, Cottrell E, Angier H, O'Malley J, Bailey S, Jacob L, DeVoe J, Ukhanova M, Thayer E, Marino M. Impact of Alternative Payment Methodology on Primary Care Visits and Scheduling. J Am Board Fam Med 2019; 32:539-49. [PMID: 31300574 DOI: 10.3122/jabfm.2019.04.180368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In 2013, Oregon initiated an Alternative Payment Methodology (APM) Experiment for select health centers, initiating capitated payments for patients with Medicaid. OBJECTIVE To use electronic health record data to evaluate the impact of APM on visit and scheduling metrics in the first wave of experiment clinics. RESEARCH DESIGN Retrospective clinic cohort. Difference-in-differences analysis using generalized linear mixed modeling across 2 time thresholds: the initiation of APM and the start of the Affordable Care Act Medicaid expansion. SUBJECTS Eight primary clinics enrolled in APM on March 1, 2013 and 10 comparison clinics not enrolled in APM during the study period (July 1, 2012 to February 28, 2015). MEASURES Independent variable: intervention status of the clinics (APM or comparison). Dependent variables: total patient encounters, total alternative encounters, new patient visits, provider appointment availability, number of appointment overbooks and no-shows/late cancellations. RESULTS Comparison clinics had smaller patient panels and more advanced practice providers than APM clinics, but both had similar proportions of Hispanic, Medicaid, and uninsured patients. APM clinics had a 20% greater increase in same-day openings than non-APM clinics across the APM implementation (Relative Ratio, 1.20; 95% CI, 1.02 to 1.42). Otherwise, there were minimal differences in APM clinics and control clinics in wait times, visit rates, patient no-shows, and overbooks. CONCLUSIONS APM clinics experienced a greater increase in same-day visits over the course of this experiment, but did not significantly differ from comparators in other visit metrics. Further research into other impacts of this experiment are necessary and ongoing.
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Leszinsky L, Candon M. Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners. Ann Fam Med 2019; 17:363-366. [PMID: 31285214 PMCID: PMC6827647 DOI: 10.1370/afm.2399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 02/25/2019] [Accepted: 03/28/2019] [Indexed: 11/09/2022] Open
Abstract
Primary care access in Medicaid improved after the Patient Protection and Affordable Care Act despite millions of new beneficiaries. One possible explanation is that practices are scheduling more appointments with advanced practitioners. To test this theory, we used data from a secret shopper study in which callers simulated new Medicaid patients and requested appointments with 3,742 randomly selected primary care practices in 10 states. Conditional on scheduling an appointment, simulated patients asked whether the practitioner was a physician or advanced practitioner. From 2012 through 2016, the proportion of appointments scheduled with advanced practitioners increased from 7.7% to 12.9% (P <.001) across the 10 states.
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Affiliation(s)
| | - Molly Candon
- University of Pennsylvania, Philadelphia, Pennsylvania .,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.,Penn Center for Mental Health, Philadelphia, Pennsylvania
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Williams SAP, Dhillon S. Women's obstetric and reproductive health care discourse in online forums: Perceived access and quality pre- and post-Affordable Care Act. Prev Med 2019; 124:50-54. [PMID: 31028754 DOI: 10.1016/j.ypmed.2019.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 04/18/2019] [Accepted: 04/20/2019] [Indexed: 11/29/2022]
Abstract
This corpus-based study examines women's framing of health issues in online forums (MedHelp.org, AphroditeWomensHealth.com, and Connect.MayoClinic.org) prior to, during, and after implementation of the Affordable Care Act (ACA). Since worldviews affect how women describe health issues, their discourse is both a way to see ideology indexed in the forums, as well as how that discourse has been shaped by policy. Posts were collected December 2016-April 2017 and annotated using the UAM (Universidad Autónoma de Madrid) Corpus Tool to examine emergent categories and compare them to three time periods: pre-, during, and post-ACA. Data within posts were coded as to the linguistic moves being made. Three frequent categories of linguistic function in the data were identified: experience-sharing, advice-requesting and offering, and rationale-offering (N = 1268). These linguistic moves were sub-divided into further categories (e.g., under advice requesting, a request for diagnosis), and a discourse-analytical perspective provides insight into the values indexed in each. Before ACA, forum participants cited access, fear, and a history of unhelpful medical visits as obstacles to seeking care. After implementation, obstacles cited were prior unhelpful visits, followed by access, and uncertainty regarding care-seeking appropriateness. While ACA implementation reduced lack of insurance as an obstacle to obtaining healthcare, online forums indicate that patients continue to find doctors' visits unhelpful, instead choosing to seek medical advice from the lay public. Patients' distrust of the medical profession persisted following ACA implementation. There is a need for public health initiatives to improve this relationship in order to augment health care outcomes.
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Affiliation(s)
- Serena A P Williams
- University of California, Davis, Department of Linguistics, Kerr Hall 1 Shields Ave, Davis, CA 95616, USA.
| | - Soneet Dhillon
- Drexel University, College of Medicine, 1 Capitol Mall, Sacramento, CA 95814, USA
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Huguet N, Valenzuela S, Marino M, Angier H, Hatch B, Hoopes M, DeVoe JE. Following Uninsured Patients Through Medicaid Expansion: Ambulatory Care Use and Diagnosed Conditions. Ann Fam Med 2019; 17:336-344. [PMID: 31285211 PMCID: PMC6827641 DOI: 10.1370/afm.2385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/15/2019] [Accepted: 02/28/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The Patient Protection and Affordable Care Act (ACA) has improved access to health insurance, yet millions remain uninsured. Many patients who remain uninsured access care at community health centers (CHCs); however, little is known about their health conditions and health care use. We assessed ambulatory care use and diagnosed health conditions among a cohort of CHC patients uninsured before enactment of the ACA (pre-ACA: January 1, 2012 to December 31, 2013) and followed them after enactment (post-ACA: January 1, 2014 to December 31, 2015). METHODS This retrospective cohort analysis used electronic health record data from CHCs in 11 US states that expanded Medicaid eligibility. We assessed ambulatory care visits and documented health conditions among a cohort of 138,246 patients (aged 19 to 64 years) who were uninsured pre-ACA and either remained uninsured, gained Medicaid, gained other health insurance, or did not have a visit post-ACA. We estimated adjusted predicted probabilities of ambulatory care use using an ordinal logistic mixed-effects regression model. RESULTS Post-ACA, 20.9% of patients remained uninsured, 15.0% gained Medicaid, 12.4% gained other insurance, and 51.7% did not have a visit. The majority of patients had ≥1 diagnosed health condition. The adjusted proportion of patients with high use (≥6 visits over 2 years) increased from pre-ACA to post-ACA among those who gained Medicaid (pre-ACA: 23%, post-ACA: 34%, P <.001) or gained other insurance (pre-ACA: 29%, post-ACA: 48%, P <.001), whereas the percentage fell slightly for those continuously uninsured. CONCLUSIONS A significant percentage of CHC patients remained uninsured; many who remained uninsured had diagnosed health conditions, and one-half continued to have ≥3 visits to CHCs. CHCs continue to be essential providers for uninsured patients.
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Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,Division of Biostatistics, School of Public Health, Oregon Health & Science University, Portland State University, Portland, Oregon
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Brigit Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,Research Department, OCHIN Inc, Portland, Oregon
| | - Megan Hoopes
- Research Department, OCHIN Inc, Portland, Oregon
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Tummalapalli SL, Leonard S, Estrella MM, Keyhani S. The Effect of Medicaid Expansion on Self-Reported Kidney Disease. Clin J Am Soc Nephrol 2019; 14:1238-1240. [PMID: 31097453 PMCID: PMC6682829 DOI: 10.2215/cjn.02310219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/23/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Nephrology and .,Department of Medicine, University of California, San Francisco, San Francisco, California; and
| | - Samuel Leonard
- Division of General Internal Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Michelle M Estrella
- Division of Nephrology and.,Division of General Internal Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, San Francisco, California; and.,Division of General Internal Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California
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