Affordable Care Act Research Articles

Stability and policy threats: US public opinion after a decade of the Affordable Care Act

AbstractThe Affordable Care Act (ACA) continues to shape US politics at the elite level. We know less about whether this conflict still carries over to the broader public. Moreover, we know little about the degree to which the conflict reaches into its various policies and whether the policy threats to the ACA can affect public opinion. We fielded a large, and demographically diverse survey of US adults using Lucid (N = 6066) from July 8–21, 2020. The survey contained an experiment that introduced the topic to respondents as the 2010 health reform law, the ACA, or Obamacare and at times highlighted the potential undoing of the ACA by the US Supreme Court. Analyses were conducted using Ordinary Least Squares regression. Our findings indicate that perceptions of the ACA differ substantial based on partisanship and racial prejudice. Framing still matters in the minds of Americans and their perception of health reforms in general and its individual components by extending these differences. However, we find only very limited evidence for changes to public attitudes related to the policy threat of the Supreme Court ruling the ACA constitutional in California v. Texas. The ACA remains a political battleground in the minds of Americans. The politics of the ACA continue to be shaped by perceptions of race and partisanship.

Abstract SY15-02: Health insurance and outcome disparities in adolescents and young adults with cancer

Abstract SY15-02: Health insurance and outcome disparities in adolescents and young adults with cancer

Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review.

In the United States, there are profound and persistent racial and ethnic disparities in pregnancy-related health, emphasizing the need to promote racial health equity through public policy. There is evidence that the Affordable Care Act (ACA) increased health insurance coverage, access to health care, and health care utilization, and may have affected some pregnancy-related health outcomes (eg, preterm delivery). It is unclear, however, whether these impacts on pregnancy-related outcomes were equitably distributed across race and ethnicity. Thus, the objective of this study was to fill that gap by summarizing the peer-reviewed evidence regarding the impact of the ACA on racial and ethnic disparities in pregnancy-related health outcomes. The authors conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), using broad search terms to identify relevant peer-reviewed literature in PubMed, Web of Science, and EconLit. The authors identified and reviewed n = 21 studies and found that the current literature suggests that the ACA and its components were differentially associated with contraception-related and fertility-related outcomes by race/ethnicity. Literature regarding pregnancy health, birth outcomes, and postpartum health, however, was sparse and mixed, making it difficult to draw conclusions regarding the impact on racial/ethnic disparities in these outcomes. To inform future health policy that reduces racial disparities, additional work is needed to clarify the impacts of contemporary health policy, like the ACA, on racial disparities in pregnancy health, birth outcomes, and postpartum health.

Treatment Patterns and Survival Outcomes in Patients With Breast Cancer on Medicaid, Pre- and Post-Expansion.

The objective of this study was to evaluate the impact of Medicaid expansion on breast cancer treatment and survival among Medicaid-insured women in Ohio, accounting for the timing of enrollment in Medicaid relative to their cancer diagnosis and post-expansion heterogeneous Medicaid eligibility criteria, thus addressing important limitations in previous studies. Using 2011-2017 Ohio Cancer Incidence Surveillance System data linked with Medicaid claims data, we identified women aged 18 to 64 years diagnosed with local-stage or regional-stage breast cancer (n=876 and n=1,957 pre-expansion and post-expansion, respectively). We accounted for women's timing of enrollment in Medicaid relative to their cancer diagnosis, and flagged women post-expansion as Affordable Care Act (ACA) versus non-ACA, based on their income eligibility threshold. Study outcomes included standard treatment based on cancer stage and receipt of lumpectomy, mastectomy, chemotherapy, radiation, hormonal treatment, and/or treatment for HER2-positive tumors; time to treatment initiation (TTI); and overall survival. We conducted multivariable robust Poisson and Cox proportional hazards regression analysis to evaluate the independent associations between Medicaid expansion and our outcomes of interest, adjusting for patient-level and area-level characteristics. Receipt of standard treatment increased from 52.6% pre-expansion to 61.0% post-expansion (63.0% and 59.9% post-expansion in the ACA and non-ACA groups, respectively). Adjusting for potential confounders, including timing of enrollment in Medicaid, being diagnosed in the post-expansion period was associated with a higher probability of receiving standard treatment (adjusted risk ratio, 1.14 [95% CI, 1.06-1.22]) and shorter TTI (adjusted hazard ratio, 1.14 [95% CI, 1.04-1.24]), but not with survival benefits (adjusted hazard ratio, 1.00 [0.80-1.26]). Medicaid expansion in Ohio was associated with improvements in receipt of standard treatment of breast cancer and shorter TTI but not with improved survival outcomes. Future studies should elucidate the mechanisms at play.

The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion.

Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening. This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods. The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64. Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries. Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

Health Plan Switching and Health Care Utilization

While the Patient Protection and Affordable Care Act (ACA) helped make health insurance premiums more affordable with premium tax credits, ACA marketplace enrollees continue to face barriers to care. To investigate the effect of informational emails on plan switching and health care utilization. This randomized clinical trial was conducted during the 2021 special enrollment period in California's Affordable Care Act marketplace among households that reported receiving unemployment insurance and were enrolled in non-silver-tier plans. The trial targeted 42 470 households that became temporarily eligible for cost-sharing reduction (CSR) silver plans that covered 94% of medical costs (CSR silver 94 plans) as a result of the 2021 American Rescue Plan Act. Households were randomized to either a no-email control group or to a treatment group receiving 2 informational emails encouraging households to switch to CSR plans. The primary outcome was the switch rate to a CSR silver plan by July 31, 2021. Secondary outcomes include various measures of health care utilization in the second half of 2021 (July 1, 2021, to December 31, 2021). Health care utilization was measured by rates of practitioner visits, emergency department visits, hospitalizations, and prescription fills. Of the 42 470 households (head of household mean [SD], age, 41.4 [13.3] years; 51.7% male), 10 650 (25.1%) were in the control group and 31 820 (74.9%) were in the treatment group. The emails led to a statistically significant 3.1-percentage point (95% CI, 2.6-3.6 percentage points) increase in CSR silver 94 enrollment (a 74.8% relative increase) by July 31, 2021, and a 1.3-percentage point (95% CI, 0.2-2.4 percentage points) increase (a 2.3% relative increase) in practitioner visits by December 31, 2021. The emails had no detectable effect on prescription fills, emergency department visits, or hospitalizations. The results of this randomized clinical trial provide experimental evidence that, with access to more affordable health care, individuals are more likely to visit practitioners. ClinicalTrials.gov Identifier: NCT05891418.

Systematic Review and Meta-Analysis of the Financial Impact of 30-Day Readmissions for Selected Medical Conditions: A Focus on Hospital Quality Performance.

The Patient Protection and Affordable Care Act (ACA) established the Hospital Quality Initiative in 2010 to enhance patient safety, reduce hospital readmissions, improve quality, and minimize healthcare costs. In response, this study aims to systematically review the literature and conduct a meta-analysis to estimate the average cost of procedure-specific 30-day risk-standardized unplanned readmissions for Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia, Coronary Artery Bypass Graft (CABG), and Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA). Eligibility Criteria: This study included English language original research papers from the USA, encompassing various study designs. Exclusion criteria comprise studies lacking empirical evidence on hospital financial performance. A comprehensive search using relevant keywords was conducted across databases from January 1990 to December 2019 (updated in March 2021), covering peer-reviewed articles and gray literature. Risk of Bias: Bias in the included studies was assessed considering study design, adjustment for confounding factors, and potential effect modifiers. The review adhered to PRISMA guidelines. Employing Monte Carlo simulations, a meta-analysis was conducted with 100,000 simulated samples. Results indicated mean 30-day readmission costs: USD 16,037.08 (95% CI, USD 15,196.01-16,870.06) overall, USD 6852.97 (95% CI, USD 6684.44-7021.08) for AMI, USD 9817.42 (95% CI, USD 9575.82-10,060.43) for HF, and USD 21,346.50 (95% CI, USD 20,818.14-21,871.85) for THA/TKA. Despite the financial challenges that hospitals face due to the ACA and the Hospital Readmissions Reduction Program, this meta-analysis contributes valuable insights into the consistent cost trends associated with 30-day readmissions. This systematic review and meta-analysis provide comprehensive insights into the financial implications of 30-day readmissions for specific medical conditions, enhancing our understanding of the nexus between healthcare quality and financial performance.

Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes.

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

Abstract 811: Impact of Medicaid eligibility expansion to adults regardless of immigration status on health insurance access among Latina patients

Abstract Background: Disparities in the receipt of cancer screening and preventive services are strongly associated with health insurance status. Even after federal- and state-wide initiatives to boost access to health insurance such as the Patient Protection and Affordable Care Act (ACA) Medicaid Expansion to all individuals earning ≤138% of the federal poverty level (FPL) and nationwide individual health insurance marketplaces, Latino populations continue to have the highest uninsured rate of any racial or ethnic group in the US, with 17% of Latinos remaining uninsured compared to 5% of non-Hispanic white peers. In 2021, California and Oregon states amended their respective Medicaid program to expand eligibility to adults regardless of immigration status; which could reduce access disparities for patients from Latino communities. This study shows preliminary results of changes in health insurance status among Latina patients (who have multiple cancer prevention services recommended in middle age) receiving care in community health centers. Methods: A retrospective cohort study of Latina, non-Hispanic Black, and non-Hispanic white women ages 50-64 years receiving primary care from 382 community health clinics in California and Oregon. Using 2018, 2019, 2021, and 2022 electronic health record data, we estimated monthly rates of insured-type visits per 100 visits. We compared rates pre- and post-Medicaid eligibility expansion, both within and between race and ethnicity groups. Reported estimates were derived from generalized estimating equations Poisson regression, clustered on clinic, and adjusted for clinic-level demographics. Results: Of 41,960 patients, over half (53%) were Latina, most of whom (83%) preferred Spanish language communication. Latina patients had more uninsured visits pre-Medicaid eligibility expansion than did non-Hispanic Black and white patients (Rate: 27% versus 5% and 4%, respectively). All racial and ethnic groups experienced a decrease in uninsured visit rates, and this change was similar for all groups [Difference-in-difference Latina versus Black patients: 0.77 (95% CI 0.55, 10.7) and versus white patients: 1.02 (95% CI 0.89, 1.17)]. Overall rates of Medicaid-insured visits increased only for Latina patients [pre-to-post Relative Rate=1.06 (95% CI: 1.03-1.10)]. Both non-Hispanic Black and white patients experienced a drop in Medicaid-insured visits. Only Black patients experienced a significant decline in private-insured visits [pre-to-post RR=0.79 (95% CI: 0.70-0.89)]. Conclusion: These early results suggest an uptake of Medicaid-paid visits among Latina patients. This increase in healthcare coverage for Latina patients could significantly reduce disparities in access to primary care and especially in cancer preventive care. Citation Format: Nathalie Huguet, Jorge Kaufmann, Heather Holderness, Margaret Vieira, Gretchen Mertes, Jackilen Shannon, John Heintzman. Impact of Medicaid eligibility expansion to adults regardless of immigration status on health insurance access among Latina patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 811.

Impact of Medicaid Expansion on Trauma Patients at Extreme Risk of Mortality: A Time-Series Analysis.

The 2014 expansion of Medicaid under the Affordable Care Act (ACA) reshaped healthcare delivery in the United States. This study assessed how Medicaid expansion affected in-hospital mortality in patients with extreme risk of mortality (EROM) from traumatic injuries. Data from inpatients aged 18-64 years, registered in the National Inpatient Sample between 2007 and 2020, and identified with trauma-related All-Patient Refined Diagnosis Related Groups (APRDRG) codes, were analyzed. Within this group, a subset of patients was selected based on the APRDRG classification identifying them as at EROM for the principal unit of analysis. The cohort was divided into high-implementation (HIR) and low-implementation (LIR) regions based on Medicaid expansion coverage. In-hospital mortality was assessed using interrupted time-series analysis. Sensitivity analyses considered seasonality, autocorrelation, and exogenous events. Analysis encompassed 70381 trauma inpatient stays, corresponding to 346659 patients based on National Inpatient Sample weighting. There was a consistent monthly decline in in-hospital mortality of .08% (95% CI: -.103 to -.048; P < .001) prior to Medicaid expansion, a trend unaffected by expansion. This pattern persisted across both LIR and HIR Medicaid implementation regions. Although Medicaid enrollment increased in HIR, that in LIR remained unchanged. Over the study period, the in-hospital mortality among severely injured patients consistently decreased, and this trend was not influenced by Medicaid expansion. The statistical models and results from this study can offer valuable guidance to policymakers and healthcare leaders as they formulate more efficient and effective policies.

The Affordable Care Act and Racial Disparities in Healthcare Utilization: New Evidence From Employer Mandate

The 2010 United States Affordable Care Act (ACA) mandates small and mid-size firms to provide health insurance for full-time workers. This study investigates whether a key provision of the ACA employer mandate has reduced racial disparities in health services use among uterine cancer (UC) survivors. Employing a nationally representative Medical Expenditure Panel Survey (MEPS) data from 2008 to 2017 and the Difference-in-Differences empirical model, we find that the ACA employer mandate increases the utilization of pap smear tests among all groups of UC survivors. Additionally, our results suggest a rise in physician's office visits among non-Hispanic Black and Hispanic UC survivors driven by the announcement of the employer mandate in the post-ACA period. Our results further suggest a reduction in out-of-pocket prescription drug expenditure among UC survivors of racial and ethnic minorities. Study findings have implications for improving ethnic minority female population health outcomes.

Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study.

Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed. We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews. Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03). Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.

Impact of Medicaid expansion on pregnancy outcomes among women with gestational diabetes.

The Affordable Care Act (ACA) aims to broaden health care access and significantly impacts obstetric practices. Yet, its effect on maternal and neonatal outcomes among women with gestational diabetes across diverse demographics is underexplored. This study examines the impact of the implementation of the ACA on maternal and neonatal health in Maryland with ACA implementation and Georgia without ACA implementation. We used data from the Maryland State Inpatient Database and US Vital Statistics System to assess the ACA's influence on maternal and neonatal outcomes in Maryland, with Georgia serving as a nonexpansion control state. Outcomes compared include cesarean section (CS) rates, low Apgar scores, neonatal intensive care unit (NICU) admissions, and assisted ventilation 7 h postdelivery. We adjusted for factors including women's age, race, insurance type, preexisting conditions, prior CS, prepregnancy obesity, weight gain during pregnancy, birth weight, labor events, and antenatal practices. The study included 52 479 women: 55.8% from Georgia and 44.2% from Maryland. Post-ACA, CS rates were 45.1% in Maryland versus 48.2% in Georgia (P = 0.000). Maryland demonstrated better outcomes, including lower rates of low Agar scores (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.63-0.86]), assisted ventilation (OR, 0.79 [95% CI, 0.71-0.82]), and NICU admissions (OR, 0.76 [95% CI, 0.71-0.82]), but no significant change in CS rates (OR, 0.96 [95% CI, 0.92-1.01]). After ACA implementation, Maryland showed improved maternal and neonatal outcomes compared with Georgia, a nonexpansion state.

Gender gap in STEM entrepreneurship: Effects of the Affordable Care Act reform

AbstractResearch SummaryThis article examines whether the Affordable Care Act (ACA) health insurance reform reduced the gender gap in science, technology, engineering, and mathematics (STEM) entrepreneurship. I argue that the ACA mitigated mobility constraints imposed by employer‐provided health insurance and encouraged entrepreneurship with important contingencies: effects were limited to women because of gender differences in supply‐side cost reduction and demand‐side health insurance needs and were specific to women in STEM (vs. non‐STEM) entrepreneurship because of the human and financial capital needed to navigate insurance markets. Leveraging the ACA quasi‐experiment, I find consistent evidence of a reduced gender gap in STEM entrepreneurship. Surprisingly, the effects were driven by increased STEM entrepreneurship for married women founding unincorporated businesses. Qualitative interview insights and empirical findings provide explanations for these patterns.Managerial SummaryThis study examines whether the science, technology, engineering, and mathematics (STEM) entrepreneurial gender gap can be reduced by institutional factors mitigating labor market mobility constraints imposed by employer‐provided work benefits. Through the lens of the US ACA reform, I find that broadened access to more affordable health insurance in the alternative individual insurance markets disproportionately encouraged female (vs. male) STEM (vs. non‐STEM) entrepreneurship, thus reducing the STEM entrepreneurial gender gap. Contrary to common assumptions, this effect is driven by married (vs. unmarried) women and is in unincorporated (vs. incorporated) self‐employment. The findings help discern which groups benefit from policy efforts to promote diversity in STEM entrepreneurship and imply that the effectiveness of employer‐provided work benefits as retention tools is dependent on various worker characteristics.

Labor force effects of Medicaid and Marketplace expansions: Variation by gender, parental status, and household structure

AbstractWe revisit the Affordable Care Act (ACA)'s Medicaid expansion's labor market effects and build upon it by estimating effects of subsidized Marketplace insurance. Using American Community Survey data, we jointly model the effects of Medicaid and Marketplace expansion on labor force outcomes using simulated eligibility measures. Throughout our analysis, we focus on heterogeneity by gender, parental status, and single versus two‐headed households. Consequently, this is the first paper presenting labor outcomes of the ACA among women with children, an important group, which may be particularly responsive to increased flexibility in meeting income, childcare, and insurance needs. Even among women, we find little evidence that Medicaid eligibility reduced labor force participation. Any significant reductions among women are small in magnitude and not well corroborated by placebo tests. Alternatively, women with children gaining Marketplace eligibility had statistically significant reductions in labor force participation, reductions in hours, and increases in part‐time work.

Alignment of substance use community benefit prioritization and service lines in US hospitals: a cross-sectional study

BackgroundNon-profit hospitals in the U.S. are required by the 2010 Patient Protection and Affordable Care Act (ACA) to conduct a community health needs assessment (CHNA) every three years and to formulate an implementation strategy in response to those needs. Hospitals often identify substance use as a need relevant to their communities in their CHNAs and then must determine whether to create strategies to address such a need within their implementation strategies. The aim of this study is to assess the relationship between a hospital’s prioritization of substance use within its community benefit documents and its substance use service offerings, while considering other hospital and community characteristics.MethodsThis study of a national sample of U.S. hospitals utilizes data collected from publicly available CHNAs and implementation strategies produced by hospitals from 2018 to 2021. This cross-sectional study employs descriptive statistics and multivariable analysis to assess relationships between prioritization of substance use on hospital implementation strategies and the services offered by hospitals, with consideration of community and hospital characteristics. Hospital CHNA and strategy documents were collected and then coded to identify whether the substance use needs were prioritized by the hospital. The collected data were incorporated into a data set with secondary data sourced from the 2021 AHA Annual Survey.ResultsMultivariable analysis found a significant and positive relationship between the prioritization of substance use as a community need on a hospital’s implementation strategy and the number of the services included in this analysis offered by the hospital. Significant and positive relationships were also identified for five service categories and for hospital size.ConclusionsThe availability of service offerings is related both to a hospital’s prioritization of substance use and to its size, indicating that these factors are likely inter-related regarding a hospital’s sense of its ability to address substance use as a community need. Policymakers should consider why a hospital may not prioritize a need that is prevalent within their community; e.g., whether the organization believes it lacks resources to take such steps. This study also highlights the value of the assessment and implementation strategy process as a way for hospitals to engage with community needs.

Limited health insurance coverage of injectable neurotoxins and fillers for gender affirmation: a cross-sectional study of Affordable Care Act silver and Medicaid plans.

Injectable neurotoxins and fillers are potential options for facial gender affirmation for transgender/nonbinary patients. However, the largest barrier to access is cost/insurance coverage. The purpose of this article is to assess the extent to which Affordable Care Act (ACA) silver plans and Medicaid policies cover gender-affirming injectable neurotoxin and filler procedures. A cross-sectional study of all ACA silver plans and Medicaid policies was performed from June 22 to August 15, 2021. Plan-specific certificates of coverage, clinical policies of insurance providers, and Medicaid documents were evaluated. A total of 915 plans were reviewed (864 ACA silver plans and all 51 Medicaid policies). None potentially covered neurotoxins. Only 72 (71 ACA and 1 Medicaid) potentially covered fillers, specifically collagen injections and lipofilling. Coverage required demonstration of medical necessity or significant variation of physical appearance from the patient's experienced gender. However, of the 71 ACA plans, 69 outlined cosmetic exclusions, possibly nullifying this coverage. Data were sourced from publicly available online information in 2021. Additionally, we were unable to confirm explicit coverage of these procedures with insurance companies. The majority of ACA silver and Medicaid plans did not cover gender-affirming neurotoxin or filler procedures, limiting access to this gender-affirming care.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act

Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear. To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA. This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023. Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods. Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA. Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change. Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012–2018

BackgroundPerinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees.MethodsWe applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum.ResultsACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis.ConclusionThe ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

In Case You Haven't Heard…

The Biden‐Harris administration announced that 21.3 million people selected an Affordable Care Act (ACA) health insurance marketplace plan during the 2024 open enrollment period, according to a U.S. Department of Health and Human Services' Jan. 24 news release. Total plan selections include more than five million people — about a fourth — who are new to the marketplaces and 16 million people who renewed their coverage. Notably, open enrollment continues in four states and in Washington, D.C., through Jan. 31. “For decades, when it came to federal programs that we could depend on to keep Americans covered, three were always top of mind, Medicare, Medicaid, and Social Security, but now it's crystal clear that we need to add a fourth — the Affordable Care Act,” said HHS Secretary Xavier Becerra. “The ACA continues to be a successful, popular, and important federal program for millions of people and their families. As we celebrate the success of this most recent enrollment effort, HHS will double down on the Biden‐Harris administration's efforts to increase access to quality care and lower costs.”