Affordable Care Act Medicaid Expansion Research Articles

PO457 Voices For Healthy Kids Model For Successful Policy Implementation to Prevent Childhood Obesity

Ensuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods.We used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services.Women who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use.Ohio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.

Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease

The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. Living in a Medicaid expansion state. The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.

Did the Affordable Care Act Medicaid Expansion Impact Vascular Admissions and Operations?

Eguia, Emanuel MD, MHA; Cobb, Adrienne N. MD; Janjua, Haroon M. MS; Bechara, Carlos MD; Shames, Murray L. MD, FACS; Kuo, Paul C. MD, MS, MBA Author Information

PHP370 - AMBULATORY CARE TRENDS IN THE EMERGENCY DEPARTMENT

Ambulatory Care Sensitive Conditions (ACSCs) are illnesses where management should be achieved by regular consultation with a primary care physician. ACSCs are often a metric for access to primary care. The Patient Protection and Affordable Care Act(ACA) of 2010 offered significant regulatory changes expanding access to low income insurance (Medicaid). By evaluating the rate of ACSCs in the Emergency Department(ED) over time, we aimed to evaluate the impact of ACA Medicaid expansion. The US National Emergency Department Sample—a representative 20 percent sample of ED visits-- offering a sample of 25 million in 2006 and 31 million by 2014. ACSCs were adapted from the Agency for Healthcare Quality and Research(AHRQ) prevention quality indicators guidebook. Dental insurance was not impacted by ACA and therefore Dental ACSCs were evaluated as a baseline comparison. The rates of ACSCs remained largely unchanged at 7.68% of observations with a decrease of 0.33% over the study period. Dental specific ACSC rates were consistent as well starting at 1.63% and ending at 1.66%. Age, gender, and income bracket characteristics were consistent throughout the 9 year period. Congestive Heart Failure had the largest decrease of 0.55%. Urinary Tract Infections was the highest at 2.15% and grew the most by 0.32%. Evaluation of primary payer amongst ACSC specific events revealed the rate of privately insured patients decreased by 5.02% and Medicaid recipients increased by 9.63%. The rate of self-pay and Medicare offered slight decreases of 1.49% and 2.65% each. Payer changes indicate a significant shift in healthcare costs. Stable income bracket frequency juxtaposed to primary payer changes may reveal poorer citizens dropping low quality private plans upon Medicaid qualification. Despite payer shifts and payment access, there has not been a reduction in ACSC’s. Study extension is needed for further evaluation as States continue with ACA implementation.

Affordable Care Act's Medicaid Expansion and Use of Regionalized Surgery at High-Volume Hospitals

The Affordable Care Act (ACA)'s Medicaid expansion has increased access to surgical care overall. Whether it was associated with reduced disparities in use of regionalized surgery at high-volume hospitals (HVH) remains unknown. Quasi-experimental evaluations of this expansion were performed to examine the use of regionalized surgery at HVH among racial/ethnic minorities and low-income populations. Data from State Inpatient Databases (2012 to 2014), the American Hospital Association Annual Survey Database, and the Area Resource File from Health Resources and Services Administration, were used to examine 166,558 nonelderly (ages 18 to 64) adults at 468 hospitals, who underwent 1 of 4 regionalized surgical procedures in 3 expansion (KY, MD, NJ) and 2 nonexpansion states (NC, FL). Thresholds of HVH were defined using the top quintile of visits per year. Interrupted time series were performed to measure the impact of expansion on use rates of regionalized surgery at HVH overall, by race/ethnicity, and by income. Overall, ACA's expansion was not associated with accelerated use rates of regionalized surgical procedures at HVH (odds ratio [OR] 1.016, p= 0.297). Disparities in use of regionalized surgical procedures at HVH among ethnic/racial minorities and low-income populations were unchanged; minority vs white (OR 1.034 p= 0.100); low-income vs high-income (OR 1.034, p= 0.122). Early findings from ACA's Medicaid expansion revealed no impact on the use rates of regionalized surgery at HVH overall or on disparities among vulnerable populations. Although these results need ongoing evaluation, they highlight potential limitations in ACA's expansion in reducing disparities in use of regionalized surgical care.

Publicly Funded Family Planning: Lessons From California, Before And After The ACA's Medicaid Expansion.

California has a long tradition of providing publicly funded family planning services to low-income residents. The Affordable Care Act (ACA) increased contraceptive coverage in 2012, and in January2014 it extended Medicaid eligibility by increasing the income cut-off from 100percent to 138percent of the federal poverty level and allowing individuals without dependent children to enroll. We assessed the impact of the ACA's Medicaid expansion on low-income Californian women's receipt of health insurance and needed health care, including contraceptive counseling and prescription contraception, using data for the period 2013-16 from 4,567 women ages 18-44 with low incomes (less than 138percent of poverty). After the ACA expansion, the proportion of uninsured low-income women in California decreased significantly, while the share enrolled in Medicaid increased. However, the proportion of the women who reported using health care and family planning services remained unchanged. Despite the ACA's explicit attention to contraceptive services, improvements in the delivery of family planning services have yet to be fully realized in California.

Association of State Medicaid Expansion With Rate of Uninsured Hospitalizations for Major Cardiovascular Events, 2009-2014.

Cardiovascular disease is the leading primary diagnosis among all hospital discharges, and insurance status is associated with patient outcomes. The association of state-level policy decisions regarding the Affordable Care Act (ACA) Medicaid expansion with rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality has not been investigated to date. To investigate whether the rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality varied by state-level policy on ACA Medicaid expansion. For this cohort study, difference-in-differences analysis of data from the Healthcare Cost and Utilization Project State Inpatient Databases of 30 US states on 524 848 non-Medicare hospitalizations in 2014 and a mean of 516 811 non-Medicare hospitalizations per year from 2009 to 2013 was performed for major cardiovascular events (defined as a composite of acute myocardial infarction, stroke, and heart failure) from January 1, 2009, through December 31, 2014. Analyses were completed September 1, 2017. State Medicaid expansion as of January 1, 2014. Comparison of mean payer mix proportions (uninsured, Medicaid, and privately insured) and in-hospital mortality between expansion and nonexpansion states for the years preceding the ACA Medicaid expansion (2009-2013) and the year after the ACA Medicaid expansion (2014). Of the 801 819 hospitalizations in the 17 expansion states in 2014, 428 503 (53.4%) patients were men, 514 036 (64.1%) were white, and 365 797 (45.6%) were aged 65 to 84 years. Of 719 459 hospitalizations in the 13 nonexpansion states in 2014, 383 311 (53.3%) patients were men, 492 136 (68.4%) were white, and 335 781 (46.7%) were aged 65 to 84 years. There were 281 184 non-Medicare hospitalizations for major cardiovascular events in the 17 expansion states and 243 664 non-Medicare hospitalizations in the 13 nonexpansion states in 2014. In multivariable regression analyses, the expansion states had a significant 5.8-percentage point decrease in the proportion of uninsured hospitalizations after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, -0.058; 95% CI, -0.075 to -0.042; P < .001). The expansion states also had a significant 8.4-percentage point increase in the Medicaid share after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, 0.084; 95% CI, 0.065 to 0.102; P < .001). In-hospital mortality did not change significantly after Medicaid expansion in either the expansion states (before ACA, 3.8% vs after ACA, 3.7%) or the nonexpansion states (4.0% vs 4.0%). States that expanded Medicaid during the ACA implementation had a significantly greater reduction in the proportion of uninsured hospitalizations for major cardiovascular events compared with the nonexpansion states. This study suggests that expansion status was not associated with in-hospital mortality rates in the first year after ACA implementation.

Comparison of Insurance Status and Diagnosis Stage Among Patients With Newly Diagnosed Cancer Before vs After Implementation of the Patient Protection and Affordable Care Act

Having health insurance is a strong determinant of cancer outcomes in the United States, and Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) may have reduced the prevalence of uninsured patients. Prior research has only assessed the aggregate effects of expansions, and little is known about changes in uninsured patients by state and key sociodemographic groups, including sex, race/ethnicity, census tract-level poverty, and rurality. To examine changes in the percentage of uninsured patients and stage at diagnosis among nonelderly patients with cancer by state and key sociodemographic groups after implementation of the ACA. This study used difference-in-differences analysis to determine the percentage of uninsured patients and early-stage cancer diagnoses among patients aged 18 to 64 years from the population-based cancer registries of 40 states before (January 1, 2010, to December 31, 2013) and after (January 1, 2014, to December 31, 2014) the ACA Medicaid expansion. Data analysis was performed from November 2017 to April 2018. Changes in the percentage of uninsured patients and early-stage diagnoses. A total of 2 471 154 patients (mean age, 52.7 years; age range, 18-64 years; 51.4% female; 70.9% non-Hispanic white) were included from Medicaid expansion (n = 1 234 156) and nonexpansion (n = 1 236 998) states. In 2014, the percentage of uninsured patients decreased in almost all states. However, decreases were greater in expansion than nonexpansion states and were greatest in expansion states with high baseline uninsured rates. For example, the percentage of uninsured patients decreased from 8.3% before implementation of the ACA to 2.1% (-6.2 difference) after implementation of the ACA in the expansion state of Kentucky compared with 9.1% to 7.5% (-1.5 difference) in the nonexpansion state of Tennessee. In expansion states, the decreases in the percentage of uninsured patients were higher among minorities and patients in high-poverty or rural areas, diminishing or eliminating disparities. In contrast, sociodemographic disparities in the percentage of uninsured patients remained high in nonexpansion states. Stage at diagnosis shifted slightly to earlier stage for most cancer types in Medicaid expansion states. This study found state variation in reductions in the percentage of uninsured patients among nonelderly patients with cancer after implementation of the ACA, with larger decreases in expansion than nonexpansion states. Disparities in the percentage of uninsured patients by race/ethnicity, census tract-level poverty, and rurality were diminished or eliminated in Medicaid expansion states but remained high in nonexpansion states, highlighting the promising role of Medicaid expansion in reducing disparities among sociodemographic subpopulations. Future studies should monitor changes in cancer presentation, treatment, and outcomes after implementation of the ACA.

Changes in Buprenorphine-Naloxone and Opioid Pain Reliever Prescriptions After the Affordable Care Act Medicaid Expansion

Expanding Medicaid eligibility could affect prescriptions of buprenorphine with naloxone, an established treatment for opioid use disorder, and opioid pain relievers (OPRs). To examine changes in prescriptions of buprenorphine with naloxone and OPRs after the US Affordable Care Act Medicaid expansion. In this cohort study, longitudinal, patient-level, retail pharmacy claims were extracted from IQVIA real-world data from an anonymized, longitudinal, prescription database. The sample included 11.9 million individuals who filled 2 or more prescriptions for a prescription opioid during at least 1 year between January 1, 2010, and December 31, 2015, from California, Maryland, and Washington (expansion states) and Florida and Georgia (nonexpansion states). Data analysis was conducted from August 1, 2017, to May 31, 2018. Data were aggregated to county-year observations (N = 2082) and linked to county-level covariates. For each outcome, a difference-in-differences regression model was estimated comparing changes before and after expansion in expansion vs nonexpansion counties. Models were adjusted for county demographics, uninsured rate, and overdose mortality in the baseline year (2010). Presence of Medicaid expansion in the year. For buprenorphine with naloxone and OPRs, rates per 100 000 county residents were calculated separately for any prescriptions overall and by different payment sources. Mean days of medication per county among people filling prescriptions for these agents were also determined. The study sample included 11.9 million individuals (expansion states: 40.9% men; mean [SD] age, 44.1 [13.8] years; nonexpansion states: 41.0% men; mean [SD] age, 43.7 [13.7] years). In expansion counties, 68.8 individuals per 100 000 county residents filled buprenorphine with naloxone and 5298.3 filled OPR prescriptions in 2010. After expansion, buprenorphine with naloxone fills per 100 000 county residents increased significantly in expansion relative to nonexpansion counties (8.7; 95% CI, 1.7 to 15.7). Opioid pain reliever fills per 100 000 county residents did not significantly change in expansion counties relative to nonexpansion counties (327.4; 95% CI -202.5 to 857.4). The rate of OPRs per 100 000 county residents paid for by Medicaid significantly increased (374.0; 95% CI, 258.3 to 489.7). There were no significant changes in days per 100 000 county residents of either medication after expansion. Medicaid expansion significantly increased buprenorphine with naloxone prescriptions per 100 000 county residents in expansion counties, suggesting that expansion improved access to opioid use disorder treatment. Expansion did not significantly increase the overall rate per 100 000 county residents of OPR prescriptions, but increased the population with OPRs paid for by Medicaid. This finding therefore suggests the growing importance of Medicaid in pain management and addiction prevention.

Impact Of Medicaid Expansion On Coverage And Treatment Of Low-Income Adults With Substance Use Disorders.

Extensive undertreatment of substance use disorders has focused attention on whether the expansion of eligibility for Medicaid under the Affordable Care Act (ACA) has promoted increased coverage and treatment of these disorders. We assessed changes in coverage and substance use disorder treatment among low-income adults with the disorders following the 2014 ACA Medicaid expansion, using data for 2008-15 from the National Survey on Drug Use and Health. The percentage of low-income expansion state residents with substance use disorders who were uninsured decreased from 34.4percent in 2012-13 to 20.4percent in 2014-15, while the corresponding decrease among residents of nonexpansion states was from 45.2percent to 38.6percent. However, there was no corresponding increase in overall substance use disorder treatment in either expansion or nonexpansion states. The differential increase in insurance coverage suggests that Medicaid expansion contributed to insurance gains, but corresponding treatment gains were not observed. Increasing treatment may require the integration of substance use disorder treatment with other medical services and clinical interventions to motivate people to engage in treatment.

The role of health insurance on treatment for opioid use disorders: Evidence from the Affordable Care Act Medicaid expansion

We estimate the effect of health insurance coverage on opioid use disorder treatment utilization and availability by exploiting cross-state variation in effective dates of Medicaid expansions under the Affordable Care Act. Using a difference-in-differences design, we find that aggregate opioid admissions to specialty treatment facilities increased 18% in expansion states, most of which involved outpatient medication-assisted treatment (MAT). Opioid admissions from Medicaid beneficiaries increased 113% without crowding out admissions from individuals with other health insurance. These effects appeared to be driven by market entry of select MAT providers and by greater acceptance of Medicaid payments among existing MAT providers. Moreover, effects were largest in expansion states with comprehensive MAT coverage. Our findings suggest that Medicaid expansions resulted in substantial utilization and availability gains to clinically efficacious and cost-effective pharmacological treatments, implying potential benefits of expanding Medicaid to non-expansion states and extending MAT coverage.

Association of Medicaid Expansion Under the Affordable Care Act With Outcomes and Access to Rehabilitation in Young Adult Trauma Patients

Trauma is the leading cause of death and disability among young adults in the United States. Young adults are also the age group most likely to be uninsured. Implementation of Medicaid expansion through the Affordable Care Act (ACA) has increased insurance coverage, but its associations with trauma care and outcomes among young adults nationwide remain unknown. We examined whether Medicaid expansion, in its first year, was associated with changes in insurance coverage and improved outcomes in young adults hospitalized for traumatic injury. To assess the associations of ACA Medicaid expansion with insurance coverage, in-hospital mortality, failure to rescue, access to rehabilitation, and unplanned readmissions among hospitalized young adult trauma patients across many US states. We used the Healthcare Cost and Utilization Project State Inpatient Databases to examine changes in insurance coverage and risk adjusted outcomes among young adults (age 19 to 44 years) who were hospitalized for injuries before and after Medicaid expansion and open enrollment occurred (2012-2013 vs 2014) in 11 US states that expanded Medicaid through the ACA. We also performed difference-in-difference analyses to compare these changes between 3 expansion states and 3 non-expansion states within the same geographic region. Of the 141 187 trauma patients hospitalized across 11 Medicaid expansion states, 43 871 (31.1%) were women, and the mean (SD) age was 31.4 (7.6) years. Medicaid expansion was associated with an increase in Medicaid coverage from 16 229 individuals (16.7%) to 15 358 individuals (34.9%) (difference: 18.2% [95% CI, 16.5%-20.0%]; P < .001), a decrease in lack of insurance from 27 016 individuals (27.8%) to 5589 individuals (12.7%) (difference: -15.1% [95% CI, -16.8% to -13.5%]; P < .001), and an increase in discharge to rehabilitation from 9220 individuals (11.4%) to 4736 individuals (12.6%) (difference: 1.16% [95% CI, 0.55%-1.77%]; P < .001). We found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions. Similar results were found when 3 of these states were compared with 3 geographically and demographically similar states that had not enacted Medicaid expansion. The first year of implementation of Medicaid expansion and open enrollment across 11 selected US states was associated with significant increases in Medicaid coverage, reductions in uninsured rates, and increased access to postdischarge rehabilitation among young adults hospitalized for injury. However, this study found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions.

The Effects Of Medicaid Expansion Under The ACA: A Systematic Review.

Expanding eligibility for Medicaid was a central goal of the Affordable Care Act (ACA), which continues to be debated and discussed at the state and federal levels as further reforms are considered. In an effort to provide a synthesis of the available research, we systematically reviewed the peer-reviewed scientific literature on the effects of Medicaid expansion on the original goals of the ACA. After analyzing seventy-seven published studies, we found that expansion was associated with increases in coverage, service use, quality of care, and Medicaid spending. Furthermore, very few studies reported that Medicaid expansion was associated with negative consequences, such as increased wait times for appointments-and those studies tended to use study designs not suited for determining cause and effect. Thus, there is evidence to document improvements in several areas of health care delivery following the ACA Medicaid expansion. We outline areas for future research that can further reduce current knowledge gaps.

The effect of the affordable care act Medicaid expansions on financial wellbeing

We examine the effect of the Medicaid expansions under the 2010 Patient Protection and Affordable Care Act (ACA) on consumer financial outcomes using data from a major credit reporting agency for a large, national sample of adults. We employ the synthetic control method to compare individuals living in states that expanded Medicaid to those that did not. We find that the Medicaid expansions significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies among those residing in zip codes with the highest share of low-income, uninsured individuals. Our estimates imply a reduction in collection balances of approximately $1140 among those who gain Medicaid coverage due to the ACA. Our findings suggest that the ACA Medicaid expansions had important financial impacts beyond increasing health care use.

Oregon Medicaid Expenditures After the 2014 Affordable Care Act Medicaid Expansion: Over-time Differences Among New, Returning, and Continuously Insured Enrollees.

There is interest in assessing health care utilization and expenditures among new Medicaid enrollees after the 2014 Medicaid expansion. Recent studies have not differentiated between newly enrolled individuals and those returning after coverage gaps. To assess health care expenditures among Medicaid enrollees in the 24 months after Oregon's 2014 Medicaid expansions and examine whether expenditure patterns were different among the newly, returning, and continuously insured (CI). Retrospective cohort study using inverse-propensity weights to adjust for differences between groups. Oregon adult Medicaid beneficiaries insured continuously from 2014 to 2015 who were either newly, returning, or CI. Monthly expenditures for inpatient care, prescription drugs, total outpatient care, and subdivisions of outpatient care: emergency department, dental, mental and behavioral health, primary care, and specialist care. After initial increases, newly and returning insured (RI) outpatient expenditures dropped below CI. Expenditures for emergency department and dental services among the RI remained higher than among the newly insured. Newly insured mental and behavioral health, primary care, and specialist expenditures plateaued higher than RI. Prescription drug expenditures increased over time for all groups, with CI highest and RI lowest. All groups had similar inpatient expenditures over 24 months post-Medicaid expansion. Our findings reveal that outpatient expenditures for new nonpregnant, non-dual-eligible Oregon Medicaid recipients stabilized over time after meeting pent-up demand, and prior insurance history affected the mix of services that individuals received. Policy evaluations should consider expenditures over at least 24 months and should account for enrollees' prior insurance histories.

MP82-03 IMPACT OF LATE MEDICAID EXPANSION ON PROSTATE CANCER SCREENING

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII1 Apr 2018MP82-03 IMPACT OF LATE MEDICAID EXPANSION ON PROSTATE CANCER SCREENING Daniel Pucheril, Alexander P. Cole, Sebastian Berg, Sean A. Fletcher, Dimitar Zlatev, Steven L. Chang, Jesse Sammon, Mani Menon, Adam S. Kibel, and Quoc-Dien Trinh Daniel PucherilDaniel Pucheril More articles by this author , Alexander P. ColeAlexander P. Cole More articles by this author , Sebastian BergSebastian Berg More articles by this author , Sean A. FletcherSean A. Fletcher More articles by this author , Dimitar ZlatevDimitar Zlatev More articles by this author , Steven L. ChangSteven L. Chang More articles by this author , Jesse SammonJesse Sammon More articles by this author , Mani MenonMani Menon More articles by this author , Adam S. KibelAdam S. Kibel More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2731AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A key provision of the Affordable Care Act (ACA) was the expansion of Medicaid to childless adults living at <138% of the federal poverty level (FPL). Aside from a few early expansion states, the majority of states adopting the provision expanded coverage in January 2014 and are categorized as late expansion states (LES). Non-expansion states (NES) opposed expansion and did not adopt these broader provisions. Our objective was to determine the effects of this policy change on prostate cancer screening (PSAS) by comparing trends in LES and NES. METHODS The 2014 and 2016 Behavioral Risk Factor Surveillance System surveys reflect 2013 and 2015 health behaviors, and were queried for men 40-64, without history of prostate cancer, with a household income<138% FPL, and residing in NES or LES. Descriptive statistics, stratified by expansion status and year, were generated for covariates. The Chi-Square test was used to compare proportions between years within state categories. Difference-in-differences (DID) analyses were employed to compare trends in men with health insurance, a personal physician, and undergoing PSAS. Within a multivariable logistic regression model, the interaction term year*state expansion status was used to determine the significance of DID estimates. RESULTS A weighted 8.8 million (n=14,979) men met inclusion criteria. PSAS significantly declined from 2014 to 2016 in both NES (22.6% to 16.4%, p=0.0006) and LES (20.5% to 15.8%, p=0.003). In LES, the proportion of men with health insurance significantly increased from 2014 to 2016 (75.5% to 82.7%, p=0.0002), however the proportion of insured men in NES was constant. Additionally, the proportion of respondents with a personal physician was unchanged from 2014 to 2016 in both NES and LES. DID analysis determined a significant difference in health insurance trends between 2014 and 2016 for LES compared to NES (+6.9%, p=0.008). DID estimates were not significant for comparisons of trends for PSAS or access to a personal physician. CONCLUSIONS The ACA's Medicaid expansion provision has led to significant gains in insurance coverage for eligible persons in LES compared to NES, however, these gains have not translated into significantly different rates of access to a personal physician or PSAS. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1106 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Daniel Pucheril More articles by this author Alexander P. Cole More articles by this author Sebastian Berg More articles by this author Sean A. Fletcher More articles by this author Dimitar Zlatev More articles by this author Steven L. Chang More articles by this author Jesse Sammon More articles by this author Mani Menon More articles by this author Adam S. Kibel More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults

BackgroundRacial/ethnic and socioeconomic disparities in trauma care and outcomes among young adults are well documented. As the Patient Protection and Affordable Care Act Medicaid expansion has increased insurance coverage among young adults, we aimed to investigate its impact on disparities in insurance coverage and outcomes among hospitalized young adult trauma patients. Materials and methodsWe used the healthcare cost and utilization project state inpatient databases to examine changes in insurance coverage and risk-adjusted outcomes from before (2012-2013) to after (2014) Medicaid expansion among young adults (age 19-44) hospitalized for injury across 11 Medicaid expansion states. Changes were compared across racial/ethnic and community-level income groups. We also compared changes in disparities between three expansion and three nonexpansion states in the US south. ResultsIn the first year of Medicaid expansion, non-Hispanic black trauma patients experienced a large decrease in uninsurance (34.3%-14.2%, P < 0.01), reducing the disparity in uninsurance between non-Hispanic black and non-Hispanic white patients (P < 0.05). There were no differences across racial/ethnic groups in changes in in-hospital mortality, failure to rescue, discharge to rehabilitation, or 30-d unplanned readmissions. Socioeconomic disparities in discharge to rehabilitation decreased (1.63% versus 0.06% increase among patients from the lowest and highest income communities, P < 0.05). In contrast, in the selected southern states, Medicaid expansion was associated with the introduction of a disparity in discharge to inpatient rehabilitation between Hispanics and non-Hispanic whites. ConclusionsMedicaid expansion, in its first year, decreased racial and socioeconomic disparities in uninsurance and socioeconomic disparities in access to rehabilitation.

Employment Effects of the Affordable Care Act Medicaid Expansions

We examine whether the recent expansions in Medicaid from the Affordable Care Act reduced “employment lock” among childless adults who were previously ineligible for public coverage. We compare employment in states that chose to expand Medicaid versus those that chose not to expand, before and after implementation. We find that although the expansion increased Medicaid coverage by 3.0 percentage points among childless adults, there was no significant impact on employment.

Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions

Importance Lack of insurance coverage has been associated with delays in seeking care, more complicated diseases at the time of diagnosis, and decreased likelihood of receiving optimal surgical care. The Patient Protection and Affordable Care Act’s (ACA) Medicaid expansion has increased coverage among millions of low-income Americans, but its effect on care for common surgical conditions remains unknown. Objective To evaluate the association of the ACA’s Medicaid expansion with access to timely and recommended care for common and serious surgical conditions. Design, Setting, and Participants This quasi-experimental, difference-in-differences study used hospital administrative data to compare patient-level outcomes in expansion vs nonexpansion states before (2010-2013) vs after (2014-2015) expansion. A total of 293 529 patients aged 18 to 64 years with appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD), or aortic aneurysm admitted to an academic medical center or affiliated hospital in 27 Medicaid expansion states and 15 nonexpansion states from January 1, 2010, through September 31, 2015, were included in the study. Data analysis was performed from November 1, 2016, to March 3, 2017. Exposures State adoption of Medicaid expansion. Main Outcomes and Measures Presentation with early uncomplicated disease (diverticulitis without abscess, fistula, or sepsis; nonruptured aortic aneurysm at time of repair; and PAD without ulcerations or gangrene) and receipt of optimal management (cholecystectomy for acute cholecystitis, laparoscopic approach for cholecystectomy or appendectomy, and limb salvage for PAD). Results Of the 293 529 study patients (128 392 [43.7%] female and 165 137 [56.3%] male), 225 572 had admissions in Medicaid expansion states and 67 957 had admissions in nonexpansion states. Medicaid expansion was associated with a 7.5–percentage point decreased probability of patients being uninsured (95% CI, −12.2 to −2.9; P = .002) and an 8.6–percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P P = .001) and a 2.6–percentage point increase in the probability of receiving optimal management (95% CI, 0.8-4.4; P = .006). Conclusions and Relevance The ACA’s Medicaid expansion was associated with increased insurance coverage and improved receipt of timely care for 5 common surgical conditions. Health care systems and policymakers should be aware of the influence of insurance coverage expansion (or its repeal) on presentation with and management of surgical disease.

Medicaid Expansion and Infant Mortality in the United States.

To explore the effect of Medicaid expansion on US infant mortality rate. We examined data from 2010 to 2016 and 2014 to 2016 to compare infant mortality rates in states and Washington, DC, that accepted the Affordable Care Act Medicaid expansion (Medicaid expansion states) and states that did not (non-Medicaid expansion states), stratifying data by race/ethnicity. Mean infant mortality rate in non-Medicaid expansion states rose (6.4 to 6.5) from 2014 to 2016 but declined in Medicaid expansion states (5.9 to 5.6). Mean difference in infant mortality rate in Medicaid expansion versus non-Medicaid expansion states increased from 0.573 (P = .08) in 2014 to 0.838 in 2016 (P = .006) because of smaller declines in non-Medicaid expansion (11.0%) than in Medicaid expansion (15.2%) states. The 14.5% infant mortality rate decline from 11.7 to 10.0 in African American infants in Medicaid expansion states was more than twice that in non-Medicaid expansion states (6.6%: 12.2 to 11.4; P = .012). Infant mortality rate decline was greater in Medicaid expansion states, with greater declines among African American infants. Future research should explore what aspects of Medicaid expansion may improve infant survival.