Affordable Care Act 's Expansion Research Articles

Abstract C002: The effect of ACA and Medicaid expansion on hysterectomy procedures among women in Florida and California

Abstract Introduction: Disparities in healthcare reflect varying access to quality care, and the reception of quality care increases survival. Multiple factors can contribute to disparities in health care. Although the Affordable Care Act (ACA) offered the health disparities reduction by promoting access to equitable and more efficient health care, however there is still a wide gap in healthcare access, quality, and outcomes. One important factor is the lack of Medicaid expansion (ME) in all states of the US. In this study, the effect of ME is compared in California and Florida, the states with and without ME respectively, by looking into hysterectomy procedures (HP) done in these two states. Methods: We used 2009 and 2011 Florida and California State Inpatient Database (SID) of the Healthcare Cost and Utilization Project (HCUP). Our included population (n=3,043,460) were female portion of the database. The outcome variable was hysterectomy identified by ICD-9 codes. Patient-level factors including race/ethnicity, age, insurance type, income level, and other comorbidities were analyzed as explanatory variables. Logistic regression analyses were used to identify independent predictors of hysterectomy. Statistical analysis was conducted using SAS Version 9.4. Results: Among the Florida subjects, highest rate of HP is observed in Caucasian women (57.26%) followed by black women (21.85%). Also, the likelihood of HP is increased in women who are age 36-45 (39.83%) followed by age 46-55 (34.95%), and belong to the 1st and 2nd income levels (49.51%). Among the California subjects, highest rate of HP is in Caucasian women (52.35%) followed by Hispanics (29.09%), and women age 46-55 (39.69%) followed by age 36-45 (36.31%), and belong to 2nd and 3rd income levels (51.13%). Logistic regression analysis demonstrates that the odds of hysterectomy had a higher increase in Florida women in 2011 vs. 2009 (OR=1.238, 95% CI: 1.214-1.262), comparing to California (OR=1.124, 95% CI:1.107-1.141) respectively. Also, odds of HP had a higher increase among Florida women during 2011 Vs 2009 in comparison to that of California women. The increased odds were seen among the 2 lowest income levels, and insurance types. Conclusions: We found that likelihood of HP were seen more in Florida than California during years of 2009 and 2011. Also, we observed the reduction of likelihood of HP among California women during 2011 post-ACA when comparing to 2009, due to ME. However, the likelihood of HP was higher in Florida during 2011where the lack ME was a factor. Findings from this study highlights the importance of protective and preventable healthcare access for everyone regardless of races/ethnicities and other socio-economic factors, thus, brings better management of chronic diseases and improves women’s health at large. The provisions of important structures of ACA, such as Medicaid expansion, and health insurance exchange, in all states may reduce the health disparity among Medicaid holders, and self-pay patients. Citation Format: Zahra Bahrani-Mostafavi, Susan Rucker. The effect of ACA and Medicaid expansion on hysterectomy procedures among women in Florida and California [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C002.

Dermatologic visits in the emergency department before and after the Affordable Care Act

To the Editor: Compared to insured patients, uninsured patients present with more advanced dermatologic disease and have worse outcomes.1 The expansion of the Affordable Care Act (ACA) in 2014 increased Medicaid access to low-income groups, decreasing the number of uninsured Americans.2 While the frequency of self-pay outpatient dermatologic visits decreased after ACA expansion,2 the correlation between dermatologic emergency department (ED) visits and the ACA has not been studied.

The Impact of the Affordable Care Act on Insurance Coverage and Stage Among Head and Neck Squamous Cell Carcinoma Patients.

The purpose was to examine the change in percent uninsured and if there is change in T-stage, N-stage and overall-stage among nonelderly patients with newly diagnosed head and neck squamous cell carcinoma after the Affordable Care Act (ACA). The National Cancer Database was used for this study. Patients were divided between pre-ACA and post-ACA implementation with stratification between areas of ACA expansion versus non-expansion. A quasi-experimental difference-in-difference study design was undertaken. A total of 15,037 patients met the inclusion criteria. Between the pre-ACA and post-ACA periods, there was increase in proportion of percent insured with Medicaid coverage in patients residing in expansion region. There was a decrease in the proportion of patients who had advanced Tumor stage and Nodal stage decreased after implementation of ACA. With the implementation of ACA expansion, there is increased Medicaid coverage, corresponding to a decreased proportion of patients presenting with advanced T-stage and N-stage.

Patients Hospitalized for Complications of Cirrhosis may Have Benefited From Medicaid Expansion Under the Affordable Care Act.

ObjectiveThe benefit of the Affordable Care Act (ACA) for patients with cirrhosis is unclear. We determined the impact of ACA expansion on outcomes in patients hospitalized for complications of cirrhosis.Patients and MethodsWe compared hospitalizations; in-hospital outcomes; and readmissions among patients with cirrhosis identified using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, 10th Revision, codes in states that expanded Medicaid under ACA (expanded [E] states) and those that did not (nonexpanded [NE] states). Data from the State Inpatient Databases were obtained for 3 pairs of contiguous E and NE states with both pre-ACA expansion and post-ACA expansion data. The difference-in-difference analysis was performed to compare the pre- and post-ACA data between the E and NE states. The outcomes were admission rates, hospital complications, resource utilization, length of stay, in-hospital mortality, discharge destination, cost of initial hospitalization, and readmission characteristics.ResultsThere were 228,349 admissions (E states, 149,705; NE states, 78,644). After ACA implementation, the E states had lower rates of admission increase per 100,000 population (22.9 in E states vs 25.5 in NE states, P=.005), sepsis (relative risk, 0.884; P=.0084), and hepatic coma (relative risk, 0.763; P<.001) than the NE states. The length of stay was lower by 0.21 days (P=.00028), with a $587.40 lower cost per hospitalization (P=.00091), in the E states than in the NE states. The readmission rates within 30, 60, and 90 days decreased in the E states after ACA implementation but increased in the NE states after ACA implementation.ConclusionAmong patients hospitalized for cirrhosis, quality indicators, such as the rate of admission increase, complications, costs, and readmissions, were more favorable in the states that expanded Medicaid. Medicaid expansion under ACA may have benefited patients with cirrhosis.

Affordable Care Act Medicaid expansion and access to primary-care based smoking cessation assistance among cancer survivors: an observational cohort study

BackgroundSmoking among cancer survivors can increase the risk of cancer reoccurrence, reduce treatment effectiveness and decrease quality of life. Cancer survivors without health insurance have higher rates of smoking and decreased probability of quitting smoking than cancer survivors with health insurance. This study examines the associations of the Affordable Care Act (ACA) Medicaid insurance expansion with smoking cessation assistance and quitting smoking among cancer survivors seen in community health centers (CHCs).MethodsUsing electronic health record data from 337 primary care community health centers in 12 states that expanded Medicaid eligibility and 273 CHCs in 8 states that did not expand, we identified adult cancer survivors with a smoking status indicating current smoking within 6 months prior to ACA expansion in 2014 and ≥ 1 visit with smoking status assessed within 24-months post-expansion. Using an observational cohort propensity score weighted approach and logistic generalized estimating equation regression, we compared odds of quitting smoking, having a cessation medication ordered, and having ≥6 visits within the post-expansion period among cancer survivors in Medicaid expansion versus non-expansion states.ResultsCancer survivors in expansion states had higher odds of having a smoking cessation medication order (adjusted odds ratio [aOR] = 2.54, 95%CI = 1.61-4.03) and higher odds of having ≥6 office visits than those in non-expansion states (aOR = 1.82, 95%CI = 1.22-2.73). Odds of quitting smoking did not differ significantly between patients in Medicaid expansion versus non-expansion states.ConclusionsThe increased odds of having a smoking cessation medication order among cancer survivors seen in Medicaid expansion states compared with those seen in non-expansion states provides evidence of the importance of health insurance coverage in accessing evidence-based tobacco treatment within CHCs. Continued research is needed to understand why, despite increased odds of having a cessation medication prescribed, odds of quitting smoking were not significantly higher among cancer survivors in Medicaid expansion states compared to non-expansion states.

ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance.

The Patient Protection and Affordable Care Act (ACA) required new private insurance plans to provide breast pumps with no cost sharing beginning August 2012, and in January 2014 expanded this requirement to Marketplace plans and expanded Medicaid coverage. We first examined the associations between the ACA reforms in 2012 and 2014 with rates of breast pump claims between Medicaid enrollees and those with private insurance. We next examined the associations between the monthly rate of breast pump claims with breastfeeding initiation and duration by insurance type. Using 2011-2015 public and private health insurance claims in All-Payer Claims Databases from Massachusetts, Maine, and New Hampshire, we conducted a linear regression model to evaluate the associations between the 2012 and 2014 ACA health insurance reforms with rates of breast pump claims by health insurance status. We then linked the monthly rates of breast pump claims per 1,000 live births to the Pregnancy Risk Assessment Monitoring System with self-reported breastfeeding initiation and duration. We estimated probit regression models to examine the associations between monthly rates of breast pump claims per state, insurance type, age group, and breastfeeding outcomes. For the 2012 ACA reform, breast pump claims increased by 183.4 (143.7-223.1) per 1,000 live births for women with private insurance, but decreased for Medicaid enrollees (-99.3 [-139.0 to -59.6]). For the 2014 ACA reforms, the opening of health insurance Marketplaces had no effect on breast pump claims for women with private insurance (8.3 [-43.6 to 60.2]), whereas Medicaid expansion increased claims by 119.4 (67.5-171.3) per 1,000 live births for Medicaid enrollees. Every additional 10 breast pump claims per 1,000 live births was associated with a 1.08 percentage point increase in breastfeeding initiation among women with private insurance (0.108 [0.018-0.198]), but not Medicaid enrollees (0.076 [-0.078 to 0.230]). In contrast, every additional 10 breast pump claims per 1,000 live births was associated with a 1.79 percentage point increase in breastfeeding for 4 or more weeks for women with private insurance (0.179 [0.063-0.294]) and a 2.05 percentage point increase among women with public insurance (0.205 [0.033-0.376]). Interaction analysis revealed no significant differences in associations by insurance type across breastfeeding outcomes. The ACA breastfeeding coverage requirements fill a gap for women wanting to obtain a breast pump to support breastfeeding. The monthly rate of breast pump claims, as an indicator of access, translated into higher levels of breastfeeding for women with private and public insurance with the potential to reduce socioeconomic disparities.

The impact of Medicaid expansion on colorectal cancer incidence among vulnerable populations.

68 Background: With the Affordable Care Act (ACA), the number of uninsured patients in states that expanded Medicaid decreased more among racial/ethnic minorities and lower income adults. Increased access to care could influence colorectal cancer (CRC) incidence through increased screening. However, we lack research on whether Medicaid expansion differentially influenced CRC incidence among vulnerable patient subgroups. This population-based study examines whether Medicaid expansion with the ACA was associated with decreased CRC incidence among racial/ethnic minorities, and adults with lower income. Methods: We queried the Surveillance, Epidemiology, and End Results Program (SEER) database to calculate the age-adjusted incidence rates of CRC among patients under 65 years of age diagnosed between 2010 and 2018. We categorized states into two groups: states that expanded Medicaid on January 1, 2014, and states that did not expand Medicaid over the study period. We determined the change in CRC incidence before Medicaid expansion (2010-2013) and after Medicaid expansion (2014-2018). We used a difference-in-difference approach to determine whether changes in CRC incidence differed by expansion status among all patients and among subgroups stratified by race/ethnicity and other socioeconomic indicators. Results: Among the entire study cohort, from 2010-2013 to 2014-2018, rates of CRC (per 100,000) increased from 26.6 to 28.3, and this increasing rate did not differ by ACA expansion status (p=0.48). We found that the impact of ACA expansion on CRC incidence varied by race/ethnicity. The increase in CRC rates was higher among non-ACA expansion states compared to ACA expansion states for Hispanics (5.4 vs. 1.6 increase per 100,000; p=0.002), and Asian or Pacific Islanders (4.3 vs. 0.4 increase per 100,000; p=0.02), but not with Black (p=0.94), or non-Hispanic white patients (p=0.91). The change in CRC incidence between 2010-2013 and 2014-2018 did not differ by county-level household income, fraction under the federal poverty level, or education level (all p&gt;0.05). Conclusions: This study found that Medicaid expansion through the ACA might differentially benefit Hispanic and Asian patients with respect to decreases in CRC incidence. This study reports on the first 5 years after the ACA, though the true benefits of increased access to care may take longer to manifest. Additional research with longer follow-up is required to fully understand the influence of Medicaid expansion.

Preterm birth and foetal-neonatal death rates associated with the Affordable Care Act Medicaid expansion (2014-19).

The Affordable Care Act (ACA) or Patient Protection and Affordable Care Act of 2010 represented a significant expansion of insurance coverage and regulatory reform.1 While initially mandatory, the June 2012 Supreme Court ruling in ‘National Federation of Independent Business v. Sebelius’ established this reform as elective and state-dependent.2 Since 2012, 39 states (and the District of Columbia) have adopted the ACA expanded reform. The ACA expansion increased eligibility for adults with income up to 138% the federal poverty level (FPL).3 In addition, coverage of children had previously varied by state and by age groups, and under the ACA expansion, children ≤18 were covered up to 138% FPL as well. Medicaid currently provides coverage for 40–50% of all pregnancies under a 200% FPL requirement, yet 65% of women subsequently lost postpartum coverage and preventative care.4 The ACA provisions allow for greater coverage of women prior to pregnancy and postpartum, which has resulted in a 28% reduction in insurance churning among low-income women.5 In addition, the rate of uninsured adults in states, which did not adopt the ACA expansion, is twice that of ACA-expanded states.6

Dental Outcomes After Medicaid Insurance Coverage Expansion Under the Affordable Care Act

Dental coverage for adults is a state option in Medicaid, and despite significant gains in coverage after the Medicaid expansion under the Affordable Care Act (ACA), dental outcomes among adults in expansion states remain unexplored. To explore the association of state coverage of dental benefits through Medicaid expansion with clinical dental outcomes. This cross-sectional study analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2018. Included participants were low-income adults aged 19 to 64 years with income up to 138% of the federal poverty level. The study used a difference-in-differences analysis to compare changes from before to after ACA expansion in expansion states vs in control states. Changes were examined in the full sample and separately in states that did and did not provide Medicaid adult dental benefits. We defined a state as providing Medicaid adult dental benefits if it covered services beyond emergency dental benefits in 2014. Data were analyzed from November 2020 to March 2021. Medicaid expansion under the ACA. Rates of health coverage, having a dental visit, affordability of dental care in the past year, poor oral health, and teeth flossing were obtained from self-reported data. Mean number of missing teeth and prevalence of untreated decayed teeth, filled teeth, and functional dentition were obtained from clinical examination data. Among 7637 low-income adults, the mean (SD) age was 37.8 (13.4) years and 4153 (weighted percentage, 54.5 %) were women. At baseline, 1732 low-income adults in nonexpansion states compared with 2520 low-income adults in expansion states were more likely, as shown by weighted percentage, to be Black (473 individuals [21.0%] vs 508 individuals [15.1%]) and US born (1281 individuals [76.7%] vs 1613 individuals [69.6%]). In the full sample, Medicaid expansion, compared with nonexpansion, was associated with an increased rate of seeing a dentist in the prior year (12.4 percentage points; 95% CI 4.6 to 20.2 percentage points; P = .003). In expansion states that provided dental benefits, compared with nonexpansion states that provided dental benefits, the expansion was associated with increases in rates of Medicaid coverage (8.2 percentage points; 95%CI 0.5 to 15.8 percentage points; P = .04) and having seen a dentist in the previous year (11.4 percentage points, 95% CI, 3.7 to 19.1 percentage points; P = .006) and decreases in the uninsured rate (-12.6 percentage points, 95% CI -18.9 to -6.4 percentage points; P < .001) and prevalence of untreated decayed teeth (-16.8 percentage points; 95% CI, -25.5 to -8.0 percentage points; P = .001). In states without Medicaid dental benefits, the expansion was associated with an increase in the mean number of missing teeth (1.3 teeth; 95% CI 0.1 to 2.5 percentage points; P = .04) and a decrease in the prevalence of functional dentition (-8.7 percentage points; 95% CI, -14.1 to -3.3 percentage points; P = .003) compared with nonexpansion states. This study found that the combination of Medicaid expansion and coverage of Medicaid dental benefits was associated with improved oral health among low-income adults.

Primary care for new vs established Medicaid enrollees.

To understand changes in primary care (PC) utilization in Medicaid and the Children's Health Insurance Program (CHIP) 3 years after the Affordable Care Act (ACA). Secondary data analysis using Medicaid/CHIP paid claims and managed care encounters. Pre-/post-ACA trends in total enrollment and PC visits among newly enrolled and established patients were analyzed in half-year increments from the first half of 2012 to the second half of 2016. After ACA expansion, there was a temporary surge in new Medicaid/CHIP enrollment (which included surges in pre-ACA eligibility categories) and slow, steady growth in total enrollment. The percentage of new enrollees completing a PC visit within 90, 180, and 365 days of enrollment fell markedly in the first half of 2014 and then rebounded to pre-ACA levels thereafter. Conversely, the percentage of new enrollees remaining enrolled at 90, 180, and 365 days spiked upward in the first half of 2014 and gradually fell thereafter. Among established enrollees, PC visits per person exhibited a downward trend throughout the post-ACA period, driven mostly by a decline in the percentage of individuals with any PC visits. The first 6 months of ACA implementation in New Jersey were marked by a surge in Medicaid/CHIP enrollment that extended beyond the ACA target population, greater enrollment retention, and apparent bottlenecks in PC delivery. After the initial surge, new enrollees used PC at rates at least as high as in the pre-ACA period, whereas established enrollees used PC at a declining rate throughout the post-ACA period. PC delivery for new enrollees may have limited the availability of services for some established enrollees.

The Medicaid Expansion and the Uptake of Medication-assisted Treatment for Opioid Use Disorder: Evidence from the Rhode Island All-payer Claims Database, 2012–2018

This article uses the all-payer claims database for the state of Rhode Island to assess recent progress in the state toward the goal of expanding access to medication-assisted treatment (MAT) for opioid use disorder (OUD). The analysis highlights the role played by the Affordable Care Act (ACA) and the associated Medicaid expansion in furthering that goal. Using measures that account for changes in health insurance enrollment, we find that the MAT rate per 100,000 enrollees in Rhode Island effectively doubled between 2012 and 2018, while the prevalence of OUD in the sample also doubled over the same period. Taken at face value, it would appear that the growth in the MAT rate over the period was just sufficient to meet the increased need for treatment. However, when we analyze the trends in MAT rates and OUD rates separately for Medicaid enrollees and non-Medicaid enrollees, the progress in treating OUD patients with MAT seems to have been much greater for the Medicaid population. In terms of raw numbers, the largest single-year gain in the number of patients receiving MAT occurred in 2014, the year when the ACA and Medicaid expansion went into effect. Among the first-time enrollees of 2014 who received MAT, over 80 percent were Medicaid enrollees, and those individuals accounted for more than one-third of the overall increase in MAT patients from the previous year. The analysis also suggests that expanded uptake of MAT may have contributed to the decline in opioid-related mortality in Rhode Island that occurred between 2016 and 2018, although more recent (preliminary) evidence suggests that Rhode Island as well as the rest of the country saw a resurgence in opioid-related mortality in 2020.

Inducing Labor: the Impact of Health Insurance on Post-Natal Labor Supply

In this paper we analyze the role of access to health insurance plays in the widely documented, sharp fall in mother's labor supply following childbirth. Our analysis exploits variation created by the Affordable Care Act (ACA), which substantially expanded access to health insurance within the U.S., and richly detailed administrative tax data. We find that mother's relative post-childbirth employment increases by 12\% for births that occur after the insurance expansion. This labor supply response is pervasive across mother's pre-birth characteristics, and across the varied impact of the ACA expansion. Our analysis suggests that this response is likely driven by a combination of improved access to maternal health care, increased participation by mothers who do not work before birth, reduced exits among mothers who do work before birth, and a compositional changes in who gives birth following the ACA health insurance expansion.

The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon

BackgroundThe Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion. ObjectiveTo examine the association of the ACA expansion on health care access and utilization for adults ages 18–64 years who have qualified for Supplemental Security Income (SSI) in Oregon. MethodsWe used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits. ResultsThe Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon’s counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association. ConclusionsWe did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.

Positive impact of the Patient Protection and Affordable Care Act Medicaid expansion on Louisiana women with breast cancer.

Louisiana is one of the few Southern states that enacted the Medicaid expansion of the Patient Protection and Affordable Care Act (ACA). To the authors' knowledge, the issue of how this has affected the breast cancer landscape in Louisiana is unknown. The authors have postulated that ACA expansion had a positive impact for Louisiana women diagnosed with breast cancer. Data from the Louisiana Tumor Registry regarding 14,640 women aged 20 to 64 years who resided in Louisiana and were diagnosed with American Joint Committee on Cancer stage 0 to stage IV breast cancer between 2012 and 2018 were analyzed. The study period was divided into 2 groups: 1) before ACA expansion (January 1, 2012-May 31, 2016); and 2) after ACA expansion (June 1, 2016-December 31, 2018). The chi-square test and multivariable logistic regression models were used to assess the impact of ACA expansion. A P value <.05 was considered statistically significant. After ACA expansion, the rate of uninsured patients decreased from 5.4% to 3.0% (P < .0001), and the rate of Medicaid recipients increased from 11.6% to 17.7% (P < .0001). The diagnosis of stage I breast cancer increased from 36.8% to 44.7% (P < .0001), whereas the diagnosis of stage III breast cancer decreased from 10.7% to 8.5% (P < .0001). The receipt of radiotherapy after breast-conserving surgery increased from 81.2% to 84.0% (P = .0035), and the receipt of radiotherapy within 90 days increased from 57.2% to 61.7% (P = .0012). After adjustment for sociodemographic and clinical variables, the models demonstrated that ACA expansion decreased the uninsured rate by 48% (odds ratio [OR], 0.52; 95% CI, 0.43-0.63), increased the diagnosis of early-stage disease (stage0 to stage II) by 27% (OR, 1.27; 95% CI, 1.15-1.41), increased receipt of radiotherapy after breast-conserving surgery by 19% (OR, 1.19; 95% CI, 1.03-1.37), and reduced the delay of receipt of radiotherapy by 16% (OR, 0.84; 95% CI, 0.74-0.95). ACA expansion in Louisiana reduced the uninsured rate, increased the diagnosis of early-stage disease, and increased access to treatment.

Changes In Coverage And Access To Dental Care Five Years After ACA Medicaid Expansion.

With the implementation of the Affordable Care Act (ACA), millions of low-income adults gained health coverage. We examined how the ACA's expansion of Medicaid eligibility affected dental coverage and the use of oral health services among low-income adults, using data from the National Health Interview Survey from the period 2010-18. We found that the ACA increased rates of dental coverage by 18.9percentage points in states that provide dental benefits through Medicaid. In terms of utilization, expansion states that provide dental benefits saw the greatest increase in people having a dental visit in the past year (7.2percentage points). However, there was no significant change in the overall share of people who had a dental visit in the past year, although the expansion was associated with a significant increase in this metric among White adults. The expansion was also associated with a 1.4-percentage-point increase in complete teeth loss, which may be a marker of both poor oral health and the potential gaining of access to dental services (with subsequent tooth extractions). Our findings suggest that in addition to expanded coverage, policies need to tackle other barriers to accessing dental care to improve population oral health.

Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program.

Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act.

Ensuring that women with Medicaid-covered births retain coverage beyond 60days 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 6months 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 6months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.

217-OR: ADA Presidents’ Select Abstract: The Affordable Care Act Medicaid Expansion Correlated with Reduction in Lower Extremity Amputation among Minorities with Diabetic Foot Ulcerations

Objectives: Lack of insurance and non-white race are associated with increased risks of amputation. It is unclear how expanded insurance coverage affects the care of minorities with diabetes. The aim was to evaluate the effect of Medicaid expansion under the Affordable Care Act (ACA) on outcomes of minorities with diabetic foot ulcerations (DFUs). Methods: We analyzed the State Inpatient Databases from 19 states to identify people who were either uninsured or on Medicaid with DFUs from 2013 to 2015. Patients were categorized into early-adopter states (implemented the ACA expansion by January 2014) and non-adopter states. Logistic regression was performed to examine the effects of state type (early vs. non-adopter), time (pre- vs. post-ACA), and their interaction on the proportion of amputation. Results: The study included 25,493 non-white Medicaid beneficiaries and 9,863 uninsured patients with DFUs. Among the minorities aged 20 to 64 years, there was an increase (180.7%) in the number of admissions for Medicaid beneficiaries and a reduction (21.5%) in the admissions of uninsured patients in early-adopter states after expansion. In comparison, there was an increase in the number of admissions of the uninsured patients (78.2%) in non-adopter states during the same period. The odds of major amputation among non-white Medicaid beneficiaries with DFUs decreased 17.3% in early-adopter states and increased 0.9% in non-adopter states (p=0.045), while the odds of minor amputation increased 14% in early-adopter states and decreased 8.1% in non-adopter states (p=0.003). Conclusion: The ACA Medicaid expansion appears to have substantial positive effects on the care of minorities with DFUs. Racial and ethnic minorities in states that expanded Medicaid experienced a significant reduction in the number of uninsured with DFUs and a reduction in major amputations. The broadening of the ACA may reduce disparities in diabetes-related amputations. Disclosure T. Tan: None. E. Calhoun: None. S.M. Knapp: None. D.G. Marrero: None. W. Zhou: None. D.G. Armstrong: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK122126)

Association between Medicaid expansion status and metastatic disease at diagnosis in patients with melanoma.

7030 Background: The Affordable Care Act (ACA) expanded Medicaid coverage in 2010. It is unknown what impact the ACA expansion has had on a timely diagnosis for patients with melanoma. We hypothesize Medicaid ACA expansion has decreased the odds of being diagnosed with Stage IV melanoma. Methods: The National Cancer Database was queried. Analysis was restricted to patients diagnosed (dx’d) in or after 2010. Stage IV dx was the outcome variable. Predictors were dx’d at an already expanded ACA state (ES) or not (NES). Covariates were age, race, sex, education status, income, rural setting, and Charlson co-morbidity index. Univariate and Multivariate analyses were performed using logistic regression (table). The outcome model was adjusted using a generated Propensity Score as a continuous variable. An interaction term was used to evaluate for effect modification of ES on the association between race and Stage IV. Results: 219,475 patients diagnosed in 2010 or later were included. Median age was 62 years. By Univariate analysis, NES, age &gt; = 65, black race, male sex, lower educational and income level, rural area, and a higher Charlson score were significantly associated with increased odds of being dx’d with Stage IV melanoma (all p &lt; 0.001). By Multivariate Analysis, these associations persisted except for rural area and age. After adjusting for propensity score, ES patients were 9% less likely to be diagnosed with Stage IV melanoma as compared with NES patients (OR = 0.91 p &lt; 0.001; 95% CI 0.867 – 0.959). ACA expansion status was an effect modifier on the association between race and late diagnosis (p = 0.004 for interaction term). For NES patients, black race had 3.26 odds (p &lt; 0.001 95% CI 2.56 – 4.18) of being diagnosed with Stage IV as compared with white patients. The odds dropped to 1.76 (p 0.004; 95% CI 1.20 – 2.57) for ES patients. Conclusions: ES patients were less likely to be diagnosed with Stage IV melanoma as compared to NES patients. Medicaid expansion decreased the likelihood for black patients to be diagnosed with Stage IV as compared with whites. This suggests Medicaid expansion improves access to care and earlier diagnosis of melanoma and decreases racial gaps. [Table: see text]

Changes in cancer mortality rates after the adoption of the Affordable Care Act.

2003 Background: The Affordable Care Act (ACA) was designed to improve health status in the US primarily through improving access to health insurance. As adoption of Medicaid expansion varied at the state level, this study aims to compare cancer mortality rates over time between states who did (EXP) and did not adopt (NonEXP) Medicaid expansion. Methods: Age-adjusted mortality rates per 100,000 were gathered from the National Center for Health Statistics from 1999-2017 to establish trends. Only deaths due to cancer in patients less than 65 were included. Absolute change in cancer mortality was calculated from 2011-2013 and then from 2015-2017 with 2014 as washout year. Changes within subpopulations (gender, race, ethnicity) were also assessed. Mortality changes between EXP and NonEXP groups were via “difference in differences” analysis. Results: Overall age-adjusted cancer mortality in the US fell from 1999-2017 from 66.9 to 48.8 per 100,000. EXP states had higher population (157 vs 118 million) with less black/African Americans (19.2 vs 21.8 million) and more Hispanics (33.0 vs 21.7 million) than NonEXP states (all examples from 2017). The overall age-adjusted cancer mortality was consistently worse in NonEXP states, cancer mortality fell from 64.7 to 46.0 per 100,000 in EXP states and from 69.0 to 51.9 per 100,000 in NonEXP states from 1999-2017 (both trends p &lt; 0.001, comparison p &lt; 0.001). Comparing the mortality changes in the peri-ACA years (2011-2013 vs 2015-2017) between the 2 cohorts, the difference in differences between EXP and NonEXP states was -1.1 and -0.6 per 100,000 respectively (p = 0.006 EXP, p = 0.14 NonEXP). The estimated overall cancer mortality benefit gained in EXP states after Medicaid expansion (∆∆∆) is -0.5 per 100,000 (p = NS). In EXP states, this translates to an estimated 785 less cancer deaths in 2017. Age-adjusted cancer mortality per 100,000 was worse in NonEXP states for black patients (58.5 EXP vs 63.4 NonEXP in 2017) however there was no differential mortality benefit after ACA expansion when comparing between the peri-ACA years. Of the subpopulations assessed, Hispanics in EXP states had the highest differential cancer mortality benefit at -2.1 per 100,000 (p = 0.07). Conclusions: This is the first study to show a directly measured cancer survival benefit from the ACA on a national scale using a comprehensive database. Hispanic populations appear to have the highest differential cancer mortality benefit after Medicaid expansion. Further study is needed to elucidate why other populations like black patients did not appear to reap the same mortality decrease.