Children's Health Insurance Program Research Articles

Medicaid and the Children's Health Insurance Program: Understanding These Programs to Promote Advancements

Medicaid and the Children's Health Insurance Program together represent the largest healthcare coverage programs in the United States, providing benefits for approximately one in four residents and more than half of all children. Both programs are funded by a combination of federal and state dollars with more than 70% of beneficiaries enrolled in managed care plans. The size and scope of these programs underpin the importance of a working knowledge to understand healthcare delivery in the United States. This primer provides an overview of several interrelated topics for an improved understanding of the Medicaid and Children's Health Insurance Program programs for orthopaedic surgeons, other clinicians, healthcare administrators, policy makers, and business leaders.

Health Insurance and Self-Rated Health from Adolescence to Early Midlife in the U.S.

Although health insurance is a critical tool for wellbeing across the life course, few studies have explored the long-term health implications of shifts in insurance coverage. This study examined whether changes in insurance types from adolescence to early midlife were associated with early midlife self-rated health. This study used data from Wave I (1994-1995; average age 15.7 years), Wave IV (2008-2009; average age 28.7 years), and Wave V (2016-2018; average age 37.6 years) of Add Health, including 6,765 respondents from 1994-2018. Logistic regression was used to examine the association between health insurance status from adolescence to early midlife and early midlife self-rated health. The analyses were conducted from March - August 2024. Relative to having private insurance in adolescence and early midlife, the following health insurance statuses in adolescence and early midlife were significantly associated with poorer early midlife self-rated health: public in adolescence and early midlife (AOR=3.34; 95% CI=1.89, 5.91); uninsured in adolescence to public at early midlife (AOR=3.29; 95% CI=1.85, 5.85); private in adolescence to public at early midlife (AOR=3.36; 95% CI=2.46, 4.58), and private in adolescence to uninsured at early midlife (AOR=1.68; 95% CI=1.10, 2.55). Health insurance statuses from adolescence to early midlife, specifically having or switching into public insurance, may be associated with poorer health in early midlife among individuals who were adolescents in the early 1990s. More research is needed to explore how insurance reform such as the Children's Health Insurance Program may have mitigated this association in future cohorts.

Navigating the Labyrinth of Pregnancy-Related Coverage for Undocumented Immigrants: An Assessment of Current State and Federal Policies.

Insurance coverage for prenatal care, labor and delivery care, and postpartum care for undocumented immigrants consists of a patchwork of state and federal policies, which varies widely by state. According to federal law, states must provide coverage for labor and delivery through Emergency Medicaid. Various states have additional prenatal and postpartum coverage for undocumented immigrants through policy mechanisms such as the Children's Health Insurance Program's "unborn child" option, expansion of Medicaid, and independent state-level mechanisms. Using a search of state Medicaid and federal government websites, we found that 27 states and the District of Columbia provide additional coverage for prenatal care, postpartum care, or both, while 23 states do not. Twelve states include any postpartum coverage; 7 provide coverage for 12 months postpartum. Although information regarding coverage is available publicly online, there exist many barriers to access, such as lack of transparency, lack of availability of information in multiple languages, and incorrect information. More inclusive and easily accessible policies are needed as the first step toward improving maternal health among undocumented immigrants, a population trapped in a complicated web of immigration policy and a maternal health crisis. (Am J Public Health. Published online ahead of print August 15, 2024:e1-e10. https://doi.org/10.2105/AJPH.2024.307750).

Health Insurance Type and Outpatient Specialist Care Among Children With Asthma

Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance. To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type. In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024. Medicaid vs private insurance. The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time. Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma. In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.

Academic Medicine and Rural Health System Partnerships: Enhancing Education While Advancing Physician Workforce Priorities.

A worsening shortage of rural physicians paralleling increasing health disparities demands attention. Past and ongoing efforts to address this shortage have had positive effects and can inform new strategies to achieve even greater impact. Interventions have included the development of regional medical school campuses and rural-focused tracks to recruit medical students from rural areas, expansion of rural-based graduate medical education (GME) programs and tracks, and use of institutional and individual financial incentives for rural-based training and/or practice. National policy has also taken aim at this challenge with provisions aimed at expanding rural GME in the Medicare, Medicaid, and State Children's Health Insurance Program Balanced Budget Refinement Act of 1999 and the Consolidated Appropriations Act of 2021. Additionally, several states have funded growth in GME, and supportive pathways for Medicare reimbursement and for Veterans Administration funding have been implemented. The authors recommend a new strategy for bolstering the rural physician workforce, focused on using academic-rural partnerships to incorporate rural rotations as a routine part of GME. They explain how the current health care landscape supports this approach and outline additional steps toward implementation. Centralized data collection and analysis are noted as essential to guide future efforts.

Survey-Reported Coverage in 2019-2022 and Implications for Unwinding Medicaid Continuous Eligibility

Policy changes and the COVID-19 pandemic affected health coverage rates, and the "unwinding" of Medicaid's continuous coverage provision in 2023 and 2024 may cause widespread coverage loss. Recent coverage patterns in national survey and administrative data can inform these issues. To assess national and state changes in survey-based Medicaid, private insurance, and uninsured rates between 2019 and 2022, as well as how these changes compare with administrative Medicaid enrollment totals. This cross-sectional study analyzes nationally representative survey data for all US residents in the American Community Survey (ACS) from 2019 to 2022 compared with administrative data on Medicaid and the Children's Health Insurance Program from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted between June 2023 and January 2024. The COVID-19 pandemic, the Medicaid continuous coverage provision, and policy efforts to increase Marketplace coverage. Medicaid coverage (self-reported [ACS] and administratively recorded [CMS]), survey-reported uninsured, Medicare, and private insurance status. A nationally representative sample consisted of 12 506 584 US residents of all ages (survey-weighted 59.7% aged 19-64 years and 50.6% female). CMS statistics showed an increase in Medicaid coverage of 5.2 percentage points as a share of the population from 2019 to 2022. However, changes in the uninsured rate and survey-reported Medicaid were smaller: -1.2 (95% CI, -1.3 to -1.2) percentage points and 1.3 (95% CI, 1.2-1.4) percentage points, respectively. There was a 3.9 percentage point increase in the ACS's "undercount" of Medicaid enrollment, compared with CMS data, from 2019 to 2022. This undercount was larger among children than adults but smaller in states that recently expanded Medicaid. Rates of additional forms of coverage (such as private insurance) among those in Medicaid also grew during this time. In this cross-sectional study, the uninsured rate declined considerably from 2019 to 2022 but was just one-fourth as large as the growth in administrative Medicaid enrollment under the pandemic continuous coverage provision. Survey-based Medicaid growth was far smaller than administrative growth. This suggests that many people who remained enrolled in Medicaid during the pandemic did not realize that their coverage had continued. These findings have implications for projecting uninsured changes during unwinding, as well as the effect of continuous coverage policies on continuity of care.

Healthcare Utilization Among Infants Covered by Medicaid and Newly Diagnosed With Respiratory Syncytial Virus.

Infants covered by Medicaid have higher respiratory syncytial virus (RSV) hospitalization rates than those with commercial insurance, but findings are limited to the inpatient setting. This birth cohort study describes healthcare encounters for RSV across all settings among infants covered by Medicaid and the Children's Health Insurance Program. Medicaid claims for infants born and residing in Arizona (AZ), California (CA), Florida (FL), Michigan (MI), North Carolina (NC), New York (NY), and Texas (TX) were analyzed for first diagnosis of RSV in 2016-2018 using International Classification of Diseases, Tenth Revision codes. Encounters on the day of first diagnosis were examined by setting in 7 states and by setting and race in CA, FL, and NC. A total of 80 945 infants were diagnosed with RSV in 7 states in 2016-2018. The highest encounter rates for first RSV diagnosis were in the emergency department (ED) in 5 states (11.0-33.4 per 1000 in AZ, CA, FL, MI, and NY) and outpatient setting in 2 states (54.8 and 68.5 per 1000 in TX and NC). Significantly higher outpatient encounter rates were found in CA and NC for White infants compared to non-White infants. In NC, ED encounter rates were significantly higher for non-White infants than White infants, whereas in CA, the rates were comparable. In these 2 states, hospitalization rates were similar across groups. In FL, compared with White infants, non-White infants had significantly higher encounter rates in each setting on the day of first RSV diagnosis. This is the first study to describe the burden of RSV by setting and race. Medicaid infants who are newly diagnosed with RSV have the highest burden in ED and outpatient settings.

CMS releases tobacco cessation bulletin

The Centers for Medicare and Medicaid Services' Center for Medicaid and CHIP [Children's Health Insurance Program] Services on March 7 released a new informational bulletin, “Strategies to Improve Delivery of Tobacco Cessation Services.” The purpose of this informational bulletin is to highlight strategies that states have used to improve the delivery of tobacco cessation services to help more Medicaid and CHIP beneficiaries quit smoking. The bulletin includes an overview of state tobacco cessation coverage requirements and authorities in Medicaid and CHIP and outlines the benefits of helping beneficiaries quit smoking. Smoking is the leading preventable cause of disease and death in the United States, causing about 480,000 deaths annually and costing more than $600 billion each year in direct medical care and lost productivity, according to the bulletin. Tobacco use is particularly salient for the populations enrolled in Medicaid. In 2021, approximately one in five (21.5%) adults who were enrolled in Medicaid smoked cigarettes, compared to about one in nine (8.6%) adults with private health insurance and about one in 10 (11.5%) adults overall.

Pediatric Medical Subspecialist Use in Outpatient Settings

A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time. To quantify rates of outpatient pediatric medical subspecialty use. This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS. Calendar year and type of medical subspecialty. Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings. Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]). The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.

The Effects of Health Insurance Coverage on Workforce Engagement of Family Caregivers of Children With Intellectual Disability and Autism.

For many families of children with intellectual disability and autism (ID/ASD), private health insurance and public programs, such as Medicaid and the Children's Health Insurance Program (CHIP), are critical sources of support. The purpose of this study was to examine the impact of health insurance coverage on workforce engagement of parents of children with ID/ASD. The study utilized 2014-2018 pooled National Health Interview Survey data to construct national estimates and test the effects of health insurance status on parent workforce outcomes. Primary findings indicate significantly higher odds of workforce absence (OR = 2.83, p < .0038) and unemployment (OR = 8.91, p < .0038) among parents with children with ID/ASD using public health insurance, compared to the reference group. Additionally, parents of children with ID/ASD who were uninsured were found to experience significantly higher unemployment (OR = 4.86, p < .0038) than the reference group. Findings have policy and research implications related to workforce engagement for parents, including issues impacting health insurance coverage, specifically related to Medicaid and CHIP.

The role of primary care providers in testing for sexually transmitted infections in the MassHealth Medicaid program.

The objective of this study was to determine the prevalence and predictors of testing for sexually transmitted infections (STIs) under an accountable care model of health care delivery. Data sources were claims and encounter records from the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) for enrollees aged 13 to 64 years in 2019. This cross-sectional study examines the one-year prevalence of STI testing and evaluates social determinants of health and other patient characteristics as predictors of such testing in both primary care and other settings. We identified visits with STI testing using procedure codes and primary care settings from provider code types. Among 740,417 members, 55% were female, 11% were homeless or unstably housed, and 15% had some level of disability. While the prevalence of testing in any setting was 20% (N = 151,428), only 57,215 members had testing performed in a primary care setting, resulting in an 8% prevalence of testing by primary care clinicians (PCCs). Members enrolled in a managed care organization (MCO) were significantly less likely to be tested by a primary care provider than those enrolled in accountable care organization (ACO) plans that have specific incentives for primary care practices to coordinate care. Enrollees in a Primary Care ACO had the highest rates of STI testing, both overall and by primary care providers. Massachusetts' ACO delivery systems may be able to help practices increase STI screening with explicit incentives for STI testing in primary care settings.

Prevalence and Economic Burden of Keratoconus in the United States

To assess the prevalence and economic burden of keratoconus in the United States. Retrospective cohort study. Patients enrolled in Medicaid and Children's Health Insurance Program (CHIP) who were diagnosed with keratoconus between 2016 and 2019 were included. The data reported to the Centers for Disease Control and Prevention (CDC) Vision and Eye Health Surveillance System (VEHSS) were analyzed. The crude prevalence rates (national and statewise) were obtained from the database and extrapolated to estimate the keratoconus case count in the United States. The keratoconus prevalence was compared between male and female individuals using the Mann-Whitney test, whereas Brown-Forsythe 1-way analysis of variance was used to compare prevalence between age and racial groups. The Dunnett T3 multiple comparison test was used for intergroup comparison. Finally, the economic burden of keratoconus was assessed by inflation-adjusted direct costs to patients and total cases in the country. In the cohort of 69,502,000 patients enrolled for Medicaid and CHIP, the national prevalence of keratoconus was computed to be 0.04% in 2019 and had increased from 0.03% in 2016. The highest prevalence of keratoconus was observed in patients 18 to 39 years of age, followed by patients 40 to 64 years of age; comparable prevalence rates were observed in these age groups in the Black population. The prevalence was moderately higher in female compared to male individuals; however, significantly higher keratoconus prevalence was observed in Black female individuals compared to male individuals. A significantly high prevalence of keratoconus was observed in the Black population, followed by Hispanic population. In 2019, the average inflation-adjusted lifetime cost of keratoconus treatment was USD 28,766.69, with a cumulative economic burden of USD 3.8 billion. In the United States, keratoconus is most prevalent in individuals 18 to 39 years of age. The keratoconus prevalence is higher in the Black population, specifically female individuals, and the diagnosis is often delayed in these patients.

Pediatric nurse practitioner workforce shortage threatens child health equity: Key contributors and recommendations.

The pediatric nurse practitioner (PNP) workforce shortage has begun to limit access to providers participating in Medicaid and/or the Children's Health Insurance Program, threatening child health equity in the United States. The following are key contributors: an emphasis on adult-focused NP programs and subsequent reduction in undergraduate pediatric content, common practice of student advisement to choose family NP programs, decreased PNP student enrollment leading to nonurban pediatric program closures, an acute shortage of PNP preceptors, and invisibility of the PNP workforce in national workforce data and strategic planning. We outline feasible action steps that nurses, NPs, educators, physicians, and policymakers can take to support PNP workforce growth to advance child health equity in the United States.

Medicaid and the Children's Health Insurance Program: Optimization to Promote Equity in Child and Young Adult Health.

The American Academy of Pediatrics envisions a child and adolescent health care system that provides individualized, family-centered, equitable, and comprehensive care that integrates with community resources to help each child and family achieve optimal growth, development, and well-being. All infants, children, adolescents, and young adults should have access to this system. Medicaid and the Children's Health Insurance Program (CHIP) provide critical support and foundation for this vision. Together, the programs currently serve about half of all children, many of whom are members of racial and ethnic minoritized populations or have complex medical conditions. Medicaid and CHIP have greatly improved the health and well-being of US infants, children, adolescents, and young adults. This statement reviews key program aspects and proposes both program reforms and enhancements to support a higher-quality, more comprehensive, family-oriented, and equitable system of care that increases access to services, reduces disparities, and improves health outcomes into adulthood. This statement recommends foundational changes in Medicaid and CHIP that can improve child health, achieve greater equity in health and health care, further dismantle structural racism within the programs, and reduce major state-by-state variations. The recommendations focus on (1) eligibility and duration of coverage; (2) standardization of covered services and quality of care; and (3) program financing and payment. In addition to proposed foundational changes in the Medicaid and CHIP program structure, the statement indicates stepwise, coordinated actions that regulation from the Centers for Medicare and Medicaid Services or federal legislation can accomplish in the shorter term. A separate technical report will address the origins and intents of the Medicaid and CHIP programs; the current state of the program including variations across states and payment structures; Medicaid for special populations; program innovations and waivers; and special Medicaid coverage and initiatives.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children

Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN. To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN. This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023. Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration). Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN. Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04). In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

Health Services Use Among Children With Prenatal Substance Exposure or Neonatal Abstinence Syndrome.

Infants with prenatal substance exposure or neonatal abstinence syndrome (NAS) use health services more often than other children; however, little is known about their use of mental health services and psychotropic medication. The sample (N=1,004,085) consisted of infants born in 2016 in 38 states who were followed through the fifth year of life and enrolled each year in Medicaid or the Children's Health Insurance Program. Infants with prenatal substance exposure or NAS were identified with ICD-10 diagnosis codes; procedure and revenue codes documented their service use. Rates of any mental health visit and of psychotropic medication use were higher among infants with prenatal substance exposure or NAS compared with infants without either condition; these patterns persisted during most years of the 5-year study. Infants' elevated mental health services use through their first 5 years of life highlights the importance of early screening and subsequent engagement in school-based mental health interventions.

Scaling Family Voices and Engagement to Measure and Improve Systems Performance and Whole Child Health: Progress and Lessons from the Child and Adolescent Health Measurement Initiative.

The 1997 legislation authorizing the United States Child Health Insurance Program sparked progress to measure and publicly report on children's healthcare services quality and system performance. To meet the moment, the national Child and Adolescent Health Measurement Initiative (CAHMI) public-private collaboration was launched to put families at the center of defining, measuring and using healthcare performance information to drive improved services quality and outcomes. Since 1996 the CAHMI followed an intentional path of collaborative action to (1) articulate shared goals for child health and advance a comprehensive, life-course and outcomes-based healthcare performance measurement and reporting framework; (2) collaborate with families, providers, payers and government agencies to specify, validate and support national, state and local use of dozens of framework aligned measures; (3) create novel public-facing digital data query, collection and reporting tools that liberate data findings for use by families, providers, advocates, policymakers, the media and researchers (Data Resource Center, Well Visit Planner); and (4) generate field building research and systems change agendas and frameworks (Prioritizing Possibilities, Engagement In Action) to catalyze prevention, flourishing and healing centered, trauma-informed, whole child and family engaged approaches, integrated systems and supportive financing and policies. Lessons call for a restored, sustainable family and community engaged measurement infrastructure, public activation campaigns, and undeterred federal, state and systems leadership that implement policies to incentivize, resource, measure and remove barriers to integrated systems of care that scale family engagement to equitably promote whole child, youth and family well-being. Population health requires effective family engagement.

Trends in Medicare Reimbursement for Interventional Radiology Procedures: 2007-2020.

Declining physician reimbursement has been occurring across multiple specialties due to changes in Medicare legislation, including theDeficit Reduction Omnibus Reconciliation Act (DRA),the Balanced Budget Act, and the Sustainable Growth Rate. The purpose of this study was to evaluate trends in Medicare reimbursement rates for various procedural classes in interventional radiology from 2007 to 2020. Common interventional radiology procedures were selected across multiple procedural classes: gastrointestinal, biliary, urinary, fallopian dilatation, other injection/change/removal, iliac vascular, femoral/popliteal vascular, tibial/peroneal vascular, hepatobiliary, and vascular emergency. The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for current procedural terminology (CPT) codes to extract reimbursement data. All monetary data were adjusted for inflation using the United States consumer price index (CPI). The compound annual growth rate (CAGR) and average annual change in reimbursement were calculated based on these adjusted trends. Aside from urinary and vascular emergency procedures, all other procedural classes experienced decreases in inflation-adjusted Medicare reimbursement from 2007 to 2020. The greatest mean decrease in reimbursement rates was observed in biliary procedures (-$21.25), while the largest mean increase in reimbursement rates was observed in vascular emergency procedures ($3.23). All procedures with increases in reimbursement rates and 36.8% of procedures with decreases in reimbursement rates have a CPT code change between 2007 and 2020. After accounting for inflation, reimbursement rates were shown to decline for all procedural classes except for urinary and vascular emergencies. Congressional policies, such as the Deficit Reduction Act (DRA) and the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015, may clarify some of these trends.

Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care.

To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation. Retrospective, Observational cohort study. Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019. Adult patients that electively underwent 1 of 19 major procedures. None. The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 (n = 2,103,836) and PostM: 2016-2019 (n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts. We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

Expansion of Telehealth Availability for Mental Health Care After State-Level Policy Changes From 2019 to 2022

Although telehealth services expanded rapidly during the COVID-19 pandemic, the association between state policies and telehealth availability has been insufficiently characterized. To investigate the associations between 4 state policies and telehealth availability at outpatient mental health treatment facilities throughout the US. This cohort study measured whether mental health treatment facilities offered telehealth services each quarter from April 2019 through September 2022. The sample comprised facilities with outpatient services that were not part of the US Department of Veterans Affairs system. Four state policies were identified from 4 different sources. Data were analyzed in January 2023. For each quarter, implementation of the following policies was indexed by state: (1) payment parity for telehealth services among private insurers; (2) authorization of audio-only telehealth services for Medicaid and Children's Health Insurance Program (CHIP) beneficiaries; (3) participation in the Interstate Medical Licensure Compact (IMLC), permitting psychiatrists to provide telehealth services across state lines; and (4) participation in the Psychology Interjurisdictional Compact (PSYPACT), permitting clinical psychologists to provide telehealth services across state lines. The primary outcome was the probability of a mental health treatment facility offering telehealth services in each quarter for each study year (2019-2022). Information on the facilities was obtained from the Mental Health and Addiction Treatment Tracking Repository based on the Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Service Locator. Separate multivariable fixed-effects regression models were used to estimate the difference in the probability of offering telehealth services after vs before policy implementation, adjusting for characteristics of the facility and county in which the facility was located. A total of 12 828 mental health treatment facilities were included. Overall, 88.1% of facilities offered telehealth services in September 2022 compared with 39.4% of facilities in April 2019. All 4 policies were associated with increased odds of telehealth availability: payment parity for telehealth services (adjusted odds ratio [AOR], 1.11; 95% CI, 1.03-1.19), reimbursement for audio-only telehealth services (AOR, 1.73; 95% CI, 1.64-1.81), IMLC participation (AOR, 1.40, 95% CI, 1.24-1.59), and PSYPACT participation (AOR, 1.21, 95% CI, 1.12-1.31). Facilities that accepted Medicaid as a form of payment had lower odds of offering telehealth services (AOR, 0.75; 95% CI, 0.65-0.86) over the study period, as did facilities in counties with a higher proportion (>20%) of Black residents (AOR, 0.58; 95% CI, 0.50-0.68). Facilities in rural counties had higher odds of offering telehealth services (AOR, 1.67; 95% CI, 1.48-1.88). Results of this study suggest that 4 state policies that were introduced during the COVID-19 pandemic were associated with marked expansion of telehealth availability for mental health care at mental health treatment facilities throughout the US. Despite these policies, telehealth services were less likely to be offered in counties with a greater proportion of Black residents and in facilities that accepted Medicaid and CHIP.