Trends in delaying and forgoing medical care due to cost and the association with insurance status among US adults with diabetes, 2009-2023.

Health Reform and the Scope of Benefits for Mental Health and Substance Use Disorder Services

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability. To determine the association of Medicaid expansion with health insurance coverage among persons with a disability. Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019. Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties). Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA's Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% - 16.2% = -9.1%) and without a disability (21.2% - 34.9% = -13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference-estimated Medicaid coverage was -4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P < .001). Medicaid expansion was associated with a 3% higher private insurance rate for persons with a disability than for persons without a disability. Medicaid expansion appeared to be associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. This study's findings suggest that the reduction in the uninsured rate and gains in Medicaid coverage were greater for persons without a disability than for persons with a disability.

The article summarizes points from the report "Patterns of Health Insurance Coverage Around the Time of Pregnancy Among Women with Live-Born Infants-Pregnancy Risk Assessment Monitoring System, 29 States, 2009" published in 2015 in the "MMWR Surveillance Summaries" by the U.S. Centers for Disease Control and Prevention. It comments on the Pregnancy Risk Assessment Monitoring System which used weighted data from 29 states in calculating confidence intervals and prevalence estimates. It found around a third of women were transitioning between health insurance coverage types or lacked health insurance.

The dynamics of health care delivery for children and adolescents have greatly evolved over the last 5 years. The growth of managed care has been especially rapid, and has coincided with other fundamental changes—declines in private coverage, growth of Medicaid, welfare reform, and the creation of the state Child Health Insurance Program (CHIP).1 Over the past 10 years, the number of children covered through employer-sponsored plans and other private plans has dropped.2 During this same period, changes to Medicaid have begun to de-couple eligibility from welfare eligibility, theoretically enabling states to expand coverage. For children, this movement from private to public coverage has accelerated the movement to managed care systems. Between 1991 and 1997, Medicaid enrollment in managed care plans increased from 9.5% to 47.8% of total Medicaid enrollment.3 Recent estimates suggest that over half of these Medicaid managed care enrollees are children.4 However, little is known about the impact of these trends on children's access to and use of services, let alone the quality and outcomes of that care. This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of 2 national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, we have provided a detailed description of the datasets, and review some of the fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues. ### MEPS The MEPS is conducted to provide nationally representative estimates of health care use, …

Disparities in the prevalence of comorbidities among US adults by state Medicaid expansion status

Background: After the Affordable Care Act (ACA) implementation, insurance coverage rates increased, yet the proportion of US adults with hypertension (HTN) and controlled HTN decreased from 2009–2010 to 2017–2018. We analyzed the US adult nonelderly population with a HTN diagnosis from 2009–2010 to 2021–2023 to test how the association of insurance status with controlled HTN has changed over time. Methods: Our analysis used data from the National Health and Nutrition Examination Survey (NHANES) and included all survey cycles from 2009 to 2023 (except for 2019–2020 which was excluded due to a suspension of data collection resulting from the COVID-19 pandemic), and our analytic sample included all respondents with a completed interview between the ages of 18 and 64 years who received a HTN diagnosis from a doctor or other healthcare professional. Results: The weighted proportion of adults with controlled HTN increased in those with Medicaid from 2009–2010 to 2017–2018 (7%–16%), decreased in those with private insurance (69%–62%), increased in those with other forms of insurance (7%–13%), and peaked in 2011–2012 (19%) in the uninsured population. The prevalence of uncontrolled HTN increased overall from 2009–2010 to 2021–2023 (25%–29%). Uninsured adults (odds ratio [OR]: 1.58; 95% confidence interval [CI]: 1.26–1.97; P &lt; 0.001) were more likely to have uncontrolled HTN compared to adults with private insurance, and the NHANES cycle itself was associated with uncontrolled HTN (OR: 1.06; 95% CI: 1.02–1.11; P = 0.009). However, after including interaction terms between insurance status and NHANES cycle, there was no association between uncontrolled HTN and insurance status. Conclusion: The analysis found no evidence, suggesting that the association between insurance status and uncontrolled HTN has changed over time since ACA implementation after including interaction terms between insurance status and the earliest NHANES cycle.

Flavonoid Intake Varies by Racial/Ethnic Groups Within Sociodemographic Categories

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

The COVID-19 pandemic has been associated with increased unemployment rates and long periods when individuals were without health insurance. Little is known about how Medicaid expansion facilitates Medicaid enrollment as a buffer to coverage loss owing to unemployment. To compare changes in health insurance coverage status associated with pandemic-related unemployment among previously employed adults in states that have vs have not expanded Medicaid eligibility. This cohort study included US adults aged 27 to 64 years who were employed at baseline in the 2020 to 2021 Current Population Survey's Annual Social and Economic Supplement, which included calendar years 2019 to 2020 (32 462 person-years). Data analyses were conducted between November 2021 and April 2022. Job loss (ie, new unemployment) experienced during 2020. Primary outcomes were coverage status (ie, uninsured status) and source of coverage (ie, employer sponsored, marketplace, and Medicaid). Using 2-way person-by-year fixed-effects regression models, changes in coverage status associated with unemployment in states that expanded Medicaid were compared with states that did not expand Medicaid. Additional analyses were performed based on prepandemic coverage status. The cohort included 16 231 adults (mean age, 46.8 [95% CI, 46.6-47.0] years; 51.6% women). New unemployment was associated with an increase of 2.9 (95% CI, 1.1-4.6) percentage points (P = .002) in the proportion of uninsured adults in Medicaid expansion states and an increase of 10.7 (95% CI, 2.4-18.9) percentage points (P = .01) in nonexpansion states. Workers were 5.4 (95% CI, 1.9-8.9) percentage points (P = .003) more likely to enroll in Medicaid after a job loss if they lived in a Medicaid expansion state compared with workers experiencing job loss in nonexpansion states. In this cohort study of US adults, unemployment-related Medicaid enrollment was more frequent in Medicaid expansion states during the COVID-19 pandemic. Medicaid expansion led to a smaller increase in uninsured adults because those who lost private insurance coverage (eg, employer sponsored) appeared more able to transition to Medicaid after job loss.

This study examined associations between access-related measures and out-of-system health services utilization (general medicine and mental health services) among patients with bipolar disorder at a U.S. Department of Veterans Affairs (VA) medical center. VA patients (N=391) with bipolar disorder answered questions about health services access (non-VA insurance coverage, travel distance to their VA facility, service-connected disability status, and difficulty receiving needed mental health care) and out-of-system services utilization. Multivariable Tobit regression was used to evaluate associations between access measures and propensity to receive out-of-system services. More than half the veterans (56%) reported some non-VA utilization. Out-of-system utilization was more likely among patients who were married, younger, homeless, with private insurance, without service-connected disabilities, and who reported access difficulties. Out-of-system utilization was associated with multiple measures of access and indicators specific to VA and non-VA providers. Enhancing health system access for patients with bipolar disorder may reduce out-of-system utilization, potentially enhancing continuity of care.

Predictors of Neighborhood Risk for Late-Stage Melanoma: Addressing Disparities through Spatial Analysis and Area-Based Measures

This study estimated the rates of health insurance coverage in the U.S. civilian noninstitutionalized population with schizophrenia and assessed whether basic access to health care varied across health insurance categories. Data from the Medical Expenditures Panel Survey collected between 2002 and 2006 were used. The sample contained 328 records representing 493,006 noninstitutionalized civilian persons with schizophrenia. Eighty-seven percent had Medicaid or Medicare, 8% received care through the Veterans Health Administration, and 15% had private insurance for at least one day during the year. About 7% were uninsured all of the year. The uninsured tended to be male (92%), nonwhite (54%), and unmarried (97%), and 30% of the uninsured had not had a medical checkup in more than five years. Almost all U.S. adults with schizophrenia were found to receive government health insurance, yet a measurable minority remained uninsured. These national estimates highlight opportunities for improving health service delivery for this vulnerable population.

Effects of the Medicaid expansion under the Affordable Care Act on health insurance coverage, health care access, and use for people with disabilities.

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know