Continuous Medicaid Coverage Research Articles

Medicaid Coverage Continuity is Associated with Lymphoma Stage among Children and Adolescents/Young Adults

Lymphoma is the third leading cause of cancer among children and adolescents/young adults (AYAs) in the United States, with later-stage diagnoses often linked to worse outcomes. Continuous health insurance coverage is crucial for facilitating early cancer detection and diagnosis. Among Medicaid-insured children and AYAs diagnosed with lymphoma, this study examines whether the timing of Medicaid enrollment and coverage continuity are associated with stage at diagnosis. Using the SEER-Medicaid data, we identified children and AYAs (aged 0-39 years) newly diagnosed with lymphoma between 2007-2013 in 12 states that were linked to the administrative Medicaid data. Medicaid enrollment patterns were categorized into continuous Medicaid (preceding and through diagnosis), newly gained Medicaid (at or shortly after diagnosis), and other Medicaid enrollment patterns. We defined late-stage as Ann-Arbor stage IV (vs. stage I-III). Multiple logistic regressions were estimated, with marginal effects (MEs) reported. Of 3,524 patients identified, 37.8% had continuous Medicaid, followed by newly gained Medicaid (35.2%) and other Medicaid enrollment patterns (27.0%). Compared to patients continuously enrolled in Medicaid, those with newly gained Medicaid and with other Medicaid enrollment patterns were 54% (ME=13.9 percentage points [ppt]; 95% confidence interval [CI]=8.5 to 19.2; p<0.001) and 18% (ME=4.6 ppt; 95% CI=2.2 to 7.0; p<0.001), respectively, more likely to present with stage IV lymphoma. Together, having continuous Medicaid coverage before diagnosis was associated with a lower likelihood of late-stage lymphoma at diagnosis; however, only three in eight Medicaid-insured children and AYAs with lymphoma were continuously enrolled in Medicaid before their diagnosis.

Effects of the continuous Medicaid coverage provision of the family first coronavirus response act on postpartum Medicaid coverage, depression symptoms, and birth control use.

The 2020 Family First Coronavirus Response Act (FFCRA) extended Medicaid coverage for enrollees without rechecking eligibility. Before that, women were eligible for Medicaid coverage up to 60 days postpartum. We examine the FFCRA's effect on Medicaid postpartum coverage, depression symptoms, and birth control use beyond 60 days after delivery. We use data from the 2016-2021 Pregnancy Risk Assessment Monitoring System (PRAMS). The primary sample includes 56,828 women who were income eligible up to 60 days postpartum or beyond in their state. We employ a difference-in-differences design comparing outcomes before and after the FFCRA between women who were not income eligible for Medicaid coverage beyond 60 days postpartum in their state and those who were income eligible. We estimate models without and with controlling for state-specific trends in outcomes over time. N/A. There is an 8.1 percentage-point increase in the likelihood of having Medicaid coverage without controlling for state-specific trends, and 5.4 percentage-points when controlling for state-specific trends (both p < 0.05). There is a decline in likelihood of being uninsured by 3 percentage-points (p < 0.05) without state-specific trends and a smaller and non-significant decline when including state-specific trends. Estimated effects on depression symptoms and birth control use are small and statistically non-significant. Following the FFCRA, there was an increase in Medicaid coverage beyond 60 days postpartum among women who would have been income ineligible for Medicaid after 60 days. However, there is a less pronounced effect on likelihood of being uninsured, which might be partly due to some switching from private to Medicaid coverage. There were no discernable effects on depression symptoms and birth control use. Examining additional health and health care utilization measures over a longer postpartum period is needed to further understand the FCCRA effects on these outcomes.

Association Between Medicaid Coverage Continuity and Survival in Patients With Newly Diagnosed Pediatric and Adolescent Cancers.

Many patients with cancer do not gain Medicaid coverage until a cancer diagnosis, which can reduce access to early cancer detection and timely treatment, potentially driving inferior survival. Little is known about whether continuous Medicaid coverage prediagnosis through postdiagnosis (v gaining Medicaid at/after diagnosis) provides survival benefits for pediatric/adolescent oncology patients. We identified patients newly diagnosed with cancer at age 21 years or younger in a large pediatric health system between 2007 and 2016. Electronic medical records (EMRs) were linked to Medicaid administrative data to differentiate insurance continuity patterns during the 6 months preceding through the 6 months after cancer diagnosis (assessment window): continuous Medicaid, newly gained Medicaid (at or after diagnosis), and other Medicaid enrollment patterns. For patients not linked to Medicaid data, we used EMR-reported insurance types at diagnosis. We followed patients from 6 months postdiagnosis up to 5 years, death, or December 2020, whichever came first. Multivariable regressions estimated all-cause and cancer-specific survival, controlling for sociodemographic and cancer-related factors. Among 1,800 patients included in the analysis, 1,293 (71.8%) had some Medicaid enrollment during the assessment window; among them, 47.6% had continuous Medicaid and 36.3% had newly gained Medicaid. Patients not linked with Medicaid data had private (26.9%) or other/no insurance (1.2%) at diagnosis. Compared with patients with continuous Medicaid, those with newly gained Medicaid had higher risks of all-cause death (hazard ratio [HR], 1.41 [95% CI, 1.10 to 1.81]; P = .008) and cancer-specific death (HR, 1.46 [95% CI, 1.12 to 1.90]; P = .005). Continuous Medicaid coverage throughout cancer diagnosis is associated with survival benefits for pediatric/adolescent patients. This finding has critical implications as millions of American individuals have been losing coverage since the unwinding of the Medicaid Continuous Enrollment Provision.

Health Insurance Continuity and Mortality in Children and Adolescents/Young Adults with Blood Cancer.

Many uninsured patients do not receive Medicaid coverage until a cancer diagnosis, potentially delaying access to care for early cancer detection and treatment. We examine the association of Medicaid enrollment timing and patterns with survival among children and adolescents/young adults (AYAs) diagnosed with blood cancers, where disease onset can be acute and early detection is critical. We identified 28,750 children and AYAs (0-39 years) newly diagnosed with blood cancers from the 2006-2013 SEER-Medicaid data. Enrollment patterns included continuous Medicaid (preceding through diagnosis), newly gained Medicaid (at/shortly after diagnosis), other noncontinuous Medicaid enrollment, and private/other insurance. We assessed cumulative incidence of death from diagnosis, censoring at last follow-up, five years post-diagnosis, or December 2018, whichever occurred first. Multivariable survival models estimated the association of insurance enrollment patterns with risk of death. One-fourth (26.1%) of the cohort were insured by Medicaid; of these, 41.1% had continuous Medicaid, 34.9% had newly gained Medicaid, and 24.0% had other noncontinuous enrollment. The cumulative incidence of all-cause death five-year post-diagnosis was highest in patients with newly gained Medicaid (30.2%, 95%CI = 28.4-31.9%), followed by other noncontinuous enrollment (23.2%, 95%CI = 21.3-25.2%), continuous Medicaid (20.5%, 95%CI = 19.1-21.9%), and private/other insurance (11.2%; 95%CI = 10.7-11.7%). In multivariable models, newly gained Medicaid was associated with a higher risk of all-cause (hazard ratio = 1.39, 95%CI = 1.27-1.53) and cancer-specific death (hazard ratio = 1.50, 95%CI = 1.35-1.68), compared to continuous Medicaid. Continuous Medicaid coverage is associated with survival benefits among pediatric and AYA patients diagnosed with blood cancers; however, less than half of Medicaid-insured patients have continuous coverage before diagnosis.

Outcomes for Patients with Diabetic Foot Ulcers Following Transition from Medicaid to Commercial Insurance.

This study investigates the outcomes of Medicaid beneficiaries with diabetic foot ulcers (DFUs) who had transitioned to commercial insurance. We utilized the PearlDiver claims database to identify adult patients diagnosed with a new DFU between 2010 and 2019. The study cohort comprised 8856 Medicaid beneficiaries who had at least three years of continuous enrollment after DFU diagnosis. Medicaid beneficiaries who transitioned to Medicare during follow-up were excluded. Adjusted comparisons of outcomes were performed by propensity matching the two groups for age, gender, and Charlson Comorbidity Index (CCI) in a 1:1 ratio. We used logistic regression and Kaplan-Meier estimate to evaluate the association between insurance change (from Medicaid to commercial insurance) and major amputation. Among the 8856 Medicaid beneficiaries with DFUs, 66% (n = 5809) had transitioned to commercial insurance coverage during follow-up. The overall major amputation rate was 2.8% (n = 247), with a lower rate observed in patients who transitioned to commercial insurance compared to those with continuous Medicaid coverage (2.6% vs. 3.2%, p < 0.05). In multivariable analysis, Medicaid beneficiaries who transitioned to commercial insurance had a 27% lower risk of major amputation (study cohort: odds ratios [OR] 0.75, 95% CI 0.56-0.97, p = 0.03; matched cohort: OR 0.65, 95% 0.22, 0.55, p = 0.01) compared to those with continuous Medicaid coverage. Transitioning from Medicaid to commercial insurance may be associated with a lower risk of major amputation among Medicaid beneficiaries with DFUs.

Health insurance coverage and experiences of intimate partner violence and postpartum abuse screening among rural US residents who gave birth 2016-2020.

Intimate partner violence (IPV) is elevated among rural residents and contributes to maternal morbidity and mortality. Postpartum health insurance expansion efforts could address multiple causes of maternal morbidity and mortality, including IPV. The objective of this study was to describe the relationship between perinatal health insurance, IPV, and postpartum abuse screening among rural US residents. Using 2016-2020 data on rural residents from the Pregnancy Risk Assessment Monitoring System, we assessed self-report of experiencing physical violence by an intimate partner and rates of abuse screening at postpartum visits. Health insurance at childbirth and postpartum was categorized as private, Medicaid, or uninsured. We also measured insurance transitions from childbirth to postpartum (continuous private, continuous Medicaid, Medicaid to private, and Medicaid to uninsured). IPV rates varied by health insurance status at childbirth, with the highest rates among Medicaid beneficiaries (7.7%), compared to those who were uninsured (1.6%) or privately insured (1.6%). When measured by insurance transitions, the highest IPV rates were reported by those with continuous Medicaid coverage (8.6%), followed by those who transitioned from Medicaid at childbirth to private insurance (5.3%) or no insurance (5.9%) postpartum. Nearly half (48.1%) of rural residents lacked postpartum abuse screening, with the highest proportion among rural residents who were uninsured at childbirth (66.1%) or postpartum (52.1%). Rural residents who are insured by Medicaid before or after childbirth are at elevated risk for IPV. Medicaid policy efforts to improve maternal health should focus on improving detection and screening for IPV among rural residents.

Q&A: Continuous Coverage Unwinding and Medicaid Expansion on the Ground in Two North Carolina Counties.

After three years of continuous Medicaid coverage as permitted by COVID-19-related waivers, in 2023 counties had to begin redeterminations of eligibility, "unwinding" this continuous coverage. As unwinding and eligibility determination continues, Medicaid expansion has begun, and county public health leaders are navigating uncertain but exciting waters. Lisa Macon Harrison, MPH, of Granville Vance Public Health, and Joshua Swift, MPH, of Forsyth County Department of Public Health, share their experiences, concerns, and hopes for the future.

Unwinding of Continuous Medicaid Coverage Among Patients at Community Health Centers

This retrospective cohort study uses data from the Accelerating Data Value Across a National Community Health Center Network to assess patterns of Medicaid disenrollment during the first 6 months after the end of continuous enrollment.

Effects of the Families First Coronavirus Response Act on Coverage Continuity and Access for Medicaid Beneficiaries.

The Families First Coronavirus Response Act (FFCRA) enacted in March 2020 prohibited states from redetermining Medicaid eligibility until March 31st, 2023. However, there has been little direct evidence on how the FFCRA affected coverage continuity, health care access and utilization among Medicaid beneficiaries. In this cross-sectional study, we employ data from the 2015 to 2022 National Health Interview Survey and a difference-in-differences design to study the FFCRA effects by comparing changes in outcomes between Medicaid and privately insured individuals over time. The sample is limited to non-elderly adults aged 19 to 64 years with income below 300% of the federal poverty level. We find that Medicaid beneficiaries experienced a decline in coverage interruptions in 2021 and 2022 relative to privately insured individuals. Additionally, Medicaid beneficiaries had improved access in 2021, with less reporting of unaffordable healthcare needs and delayed medical care due to cost. There were no discernable effects on hospitalizations, ED visits, and doctor/health professional visits. The continuous Medicaid coverage provision under the FFCRA was associated with enhanced coverage stability and improved access to care for Medicaid beneficiaries. Findings highlight potential benefits from new policy initiatives to improve Medicaid coverage continuity.

Health Insurance Continuity Is Associated with Stage at Diagnosis Among Children, Adolescents, and Young Adults Newly Diagnosed with Lymphoma

Background: Many uninsured patients do not gain Medicaid coverage until the point of, or after, their cancer diagnosis, which can limit access to early cancer detection and delay diagnosis and treatment, leading to poorer survival outcomes. Our previous research found that gaining Medicaid at, or after, diagnosis (vs. continuous Medicaid coverage) is significantly associated with inferior survival among children and adolescents/young adults (AYAs) with lymphoma, a leading cause of pediatric and AYA cancers. However, whether this relationship is mediated by lymphoma stage at diagnosis is unknown. To fill this knowledge gap, the current study examines the association between Medicaid coverage continuity and disease stage among this vulnerable population. Methods: We identified 13,655 children and AYAs (ages 0-39 years) newly diagnosed with lymphoma between 2007-2012, using the linked Surveillance, Epidemiology, and End Results (SEER) registries and Medicaid enrollment data. To measure coverage continuity, we categorized patients into those with 1) continuous Medicaid (enrolled in Medicaid for ≥12 months prior to and through diagnosis), 2) newly gained Medicaid (enrolled in the month of or within 12 months after diagnosis), 3) other patterns of noncontinuous Medicaid, 4) private insurance at diagnosis, 5) other insurance types at diagnosis (Medicare, TRICARE, Military, VA, or Indian/Public Health Service), and 6) unknown or no insurance at diagnosis. The last 3 groups comprised patients not linked to Medicaid enrollment data; thus their insurance continuity patterns were unknown, and their insurance status at the time of diagnosis was extracted from SEER registries. The association between coverage continuity and late-stage diagnosis was examined with separate multivariable logistic regression models among all patients and by cancer subtypes (Hodgkin lymphoma, non-Hodgkin lymphoma). Late-stage was defined as stage IV (vs. stage I-III) using the Ann-Arbor staging classification. Regressions also adjusted for sex, race/ethnicity, age at diagnosis, diagnosis year, rurality, neighborhood socioeconomic status (SES), and state of residence. Results: Half of our sample had private insurance (50.3%), followed by Medicaid insurance (26.9%), other insurance type (10.3%), and unknown (7.9%) or no insurance (4.7%). Among Medicaid-insured patients, 40.1% had newly gained Medicaid, followed by continuous Medicaid (32.5%) and other patterns of noncontinuous Medicaid (27.3%). Overall, one-fourth (24.8%) of the sample had stage IV lymphoma (Figure 1). Compared with privately insured patients, the adjusted percentage of stage IV diagnoses was 16.8 percentage points (ppt; 95% CI=14.6-19.0, p&amp;lt;0.001), 10.6 ppt (95% CI=8.2-13.0, p&amp;lt;0.001), and 4.9 ppt (95% CI=2.7-7.1, p&amp;lt;0.001) higher in patients with newly gained Medicaid, other patterns of noncontinuous Medicaid, and continuous Medicaid, respectively. Among the subset of Medicaid-insured patients, the adjusted percentage of stage IV diagnoses was 10.7 ppt (95% CI=7.5-13.8, p&amp;lt;0.001) and 5.4 ppt (95% CI=3.1-7.6, p&amp;lt;0.001) higher among patients with newly gained Medicaid and other patterns of noncontinuous Medicaid, respectively, compared to those with continuous Medicaid. These patterns persisted across lymphoma subtypes. Notably, coverage continuity patterns varied by sociodemographic factors, with non-Hispanic Black (vs. non-Hispanic White) patients, AYAs ages 15-39 years (vs. pediatric patients ages ≤14), and residents of non-metropolitan (vs. metropolitan) areas or lower SES neighborhoods significantly more likely to have newly gained Medicaid. Conclusions: Less than one-third of Medicaid-insured children and AYAs with lymphoma had continuous insurance coverage prior to cancer diagnosis. Lacking continuous Medicaid coverage was significantly associated with advanced-stage lymphoma diagnosis.

Continuous Medicaid coverage during the COVID-19 public health emergency reduced churning, but did not eliminate it.

Preserving insurance coverage in the wake of pandemic-related job loss was a priority in early 2020. To this end, the Families First Coronavirus Response Act implemented a continuous coverage policy in Medicaid to shore up access to health insurance. Prior to the pandemic, Medicaid enrollees experienced frequent coverage disruptions, known as "churning." The effect of the continuous coverage policy on churning during the COVID-19 public health emergency (PHE) is unknown. We performed a difference-in-differences analysis of nonelderly Medicaid enrollees using longitudinal national survey data to compare a 2019-2020 cohort exposed to the policy with a control cohort in 2018-2019. We found that the policy led to reduced transitions to uninsurance among adults, although not among children. The policy prevented over 300 000 transitions to uninsurance each month. However, disenrollment from Medicaid persisted at a low rate, despite the continuous coverage policy. As the PHE unwinds, policymakers should consider long-term continuous coverage policies to minimize churning in Medicaid.

Healthcare Use Among Black and White Congenital Heart Disease Medicaid Enrollees.

Congenital heart disease (CHD) is the most common birth anomaly in the US. Research shows lost-to-follow-up trends and racial disparities in healthcare use. This study examines racial differences in healthcare use among Medicaid-covered children with CHD. Using 2010-2019 claims data from a pediatric Medicaid Accountable Care Organization, 960 Black and White children with complex CHD and ≥ 3years of continuous Medicaid coverage were identified. Three cohorts were constructed (starting age: < 1-year-olds, 1-5-year-olds, 6-15-year-olds) and followed for 3years. Multivariate analysis assessed annual healthcare use (cardiology, primary care, emergency department) by race, adjusting for patient and provider covariates. Overall, 51% of patients had an annual cardiology visit, and 54% had an annual primary care visit. Among the 1-5-year-old cohort, Black children were predicted to be 13% less likely to have an annual cardiology visit compared to their White counterparts (p = 0.001). Older Black children were predicted to be more likely to have a primary care visit compared to their White counterparts. Nearly half of Medicaid-enrolled children with complex CHD did not receive recommended cardiology care. Young Black children were less likely to receive an annual cardiac visit, while older Black children were more likely to receive primary care. While the percentage with an annual cardiac visit was low, the majority had seen a cardiologist within the 3-year window, suggesting these children are still receiving cardiology care, if less frequently than recommended. Opportunities exist for cardiology and primary care to collaborate to ensure patients receive timely recommended care.

North Carolina's Medicaid Transformation: the Early Enrollee Experience.

On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined the early enrollee experience in terms of engagement in plan selection, provider continuity, use of primary care visits, and assistance with social needs. Using electronic health records (EHR) covering pre- and post-transition periods (1/1/2019-5/31/2022) from the largest provider network in western North Carolina, we identified all children and adults under age 65 with continuous Medicaid or private coverage. We conducted primary surveys of a random sample of Medicaid-covered enrollees and obtained self-reported rates of engagement in plan selection, continuity of provider access, and receipt of social need assistance. We used comparative interrupted time series models to estimate the relative change in primary care visits associated with the transition. Our EHR-based study cohorts included 4859 Medicaid and 5137 privately insured enrollees, with 398 Medicaid enrollees in the primary surveys. We found that 77.3% of survey participants reported that the managed care plan they were on was not chosen but automatically assigned to them, 13.1% reported insufficient information about the transition, and 19.2% reported lacking assistance with plan choice. We found that 5.9% were assigned to a different primary care provider. Over 29% reported not receiving any additional social need assistance. The transition was associated with a 7.1% reduction (95% CI, -11.5 to -2.7%) in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees. Medicaid enrollees in North Carolina may have had limited awareness and engagement in the transition process and experienced a reduction in primary care visits. As the state's transition process gains a foothold, future policy needs to improve enrollee engagement and develop evidence on healthcare utilization and patient outcomes.

Health insurance continuity and survival among children, adolescents, and young adults with blood cancer: An analysis based on SEER-Medicaid data.

6504 Background: Many previously uninsured patients do not receive Medicaid coverage until the point of, or after, cancer diagnosis, which may delay access to life-saving therapies. We examined whether continuous Medicaid coverage prior to diagnosis (vs. gaining Medicaid at, or after, diagnosis) provides a survival benefit in children and adolescents/young adults (AYAs) newly diagnosed with blood cancer. Methods: Using the linked SEER cancer registry-Medicaid enrollment data, we assessed coverage during the six months prior to, the month of, and the six months after cancer diagnosis (13-month window) in 29,873 children and AYAs (aged 0-39 years) diagnosed with blood cancer in 2006-2013. To measure insurance continuity, we categorized patients who had: (1) continuous Medicaid (enrolled for ≥6 months prior to through diagnosis), (2) newly gained Medicaid at/after diagnosis (enrollment only at or ≤6 months after diagnosis), (3) other patterns of noncontinuous Medicaid, (4) private insurance, (5) other insurance, or (6) uninsured/unknown insurance. The last three groups contain patients in SEER not linked to Medicaid enrollment data; these patients’ insurance at diagnosis was available in SEER. Kaplan-Meier (KM) survival curve of 5-year overall survival was stratified by insurance continuity category. Associations between insurance continuity and survival were examined using Cox proportional hazard models, for all blood cancers combined and by cancer type (leukemia, lymphoma, myeloma). Models also adjusted for age, sex, race/ethnicity, rurality, neighborhood socioeconomic status, and diagnosis year. Results: Of our sample, 44.1% had private insurance, followed by Medicaid (28.3%), other insurance (9.6%), and no insurance (3.9%) or unknown insurance (14.1%). Of Medicaid-insured patients, 44.9% had continuous Medicaid, 38.9% gained Medicaid at/after diagnosis, and 16.2% experienced other noncontinuous patterns. The KM-estimated 5-year survival probability was 89.3% for privately insured patients, followed by other insurance (88.1%), continuous Medicaid (78.2%), other patterns of noncontinuous Medicaid (74.3%), and newly gained Medicaid at/after diagnosis (70.6%; p&lt;0.001). In multivariable analysis, patients who newly gained Medicaid at/after diagnosis had a hazard ratio (HR) for death of 2.63 (95%CI=2.42-2.87), whereas patients with continuous Medicaid and those with other noncontinuous patterns had HRs of 2.08 (95%CI=1.90-2.28) and 2.31 (95%CI=2.04-2.60), respectively, compared to privately insured patients. This finding persisted across blood cancer types. Conclusions: Less than half of Medicaid-insured children and AYAs with blood cancer had continuous insurance coverage prior to and following cancer diagnosis. Lacking continuous Medicaid coverage was associated with inferior survival.

Continuous Eligibility And Coverage Policies Expanded Children's Medicaid Enrollment.

We examined children's Medicaid participation during 2019-21 and found that as of March 2021, states newly adopting continuous Medicaid coverage for children during the COVID-19 pandemic experienced a 4.62percent relative increase in children's Medicaid participation compared to states with previous continuous eligibility policies.

Prenatal syphilis screening among pregnant Medicaid enrollees by sexually transmitted infection history as well as race and ethnicity

Congenital syphilis can cause severe morbidity, including miscarriage and stillbirth, and rates are increasing rapidly within the United States. However, congenital syphilis can be prevented with early detection and treatment of syphilis during pregnancy. Current screening recommendations propose that all women should be screened early in pregnancy, whereas women with elevated risks for congenital syphilis should be screened again later in pregnancy. The rapid increase in congenital syphilis rates suggests that there are still gaps in prenatal syphilis screening. This study aimed to examine associations between the odds of prenatal syphilis screening and sexually transmitted infection history or other patient characteristics across 3 states with elevated rates of congenital syphilis. We used the Medicaid claims data from Kentucky, Louisiana, and South Carolina for women with deliveries between 2017 and 2021. Within each state, we examined the log-odds of prenatal syphilis screening as a function of the mother's health history, demographic factors, and Medicaid enrollment history. Patient history was established using a 4-year lookback period of the Medicaid claims data; in state A, sexually transmitted infection surveillance data were used to improve the sexually transmitted infection history. The prenatal syphilis screening rates varied by state, ranging from 62.8% to 85.1% of deliveries to women without a recent history of sexually transmitted infections and from 78.1% to 91.1% of deliveries to women with a previous sexually transmitted infection. For the main outcome of syphilis screening at any time during pregnancy, deliveries associated with previous sexually transmitted infections had 1.09 to 1.37 times higher adjusted odds ratios of undergoing screening. Deliveries to women with continuous Medicaid coverage throughout the first trimester also had higher odds of syphilis screening at any time (adjusted odds ratio, 2.45-3.15). Among deliveries to women with a previous sexually transmitted infection, only 53.6% to 63.6% underwent first-trimester screening and this rate was still just 55.0% to 69.5% when considering only deliveries to women with a previous sexually transmitted infection and full first-trimester Medicaid coverage. Fewer delivering women underwent third-trimester screening (20.3%-55.8% of women with previous sexually transmitted infection). Compared with deliveries to White women, deliveries to Black women had lower odds of first-trimester screening (adjusted odds ratio, 0.85 in all states) but higher odds of third-trimester screening (adjusted odds ratio, 1.23-2.03), potentially impacting maternal and birth outcomes. For state A, linkage to surveillance data doubled the rate of detection of a previous sexually transmitted infection because 53.0% of deliveries by women with a previous sexually transmitted infection would not have had sexually transmitted infection history detected using Medicaid claims alone. A previous sexually transmitted infection and continuous preconception Medicaid enrollment were associated with higher rates of syphilis screening, but Medicaid claims alone do not fully capture the sexually transmitted infection history of patients. The overall screening rates were lower than would be expected given that all women should undergo prenatal screening, but the rates in the third trimester were particularly low. Of note, there are gaps in early screening for non-Hispanic Black women who had lower odds of first-trimester screening when compared with non-Hispanic White women despite being at elevated risk for syphilis.

Healthcare Utilization for Medicaid-Insured Children with Medical Complexity: Differences by Sociodemographic Characteristics.

To compare differences in healthcare utilization and costs for Medicaid-insured children with medical complexity (CMC) by race/ethnicity and rurality. Retrospective cohort of North Carolina (NC) Medicaid claims for children 3-20years old with 3years continuous Medicaid coverage (10/1/2015-9/30/2018). Exposures were medical complexity, race/ethnicity, and rurality. Three medical complexity levels were: without chronic disease, non-complex chronic disease, and complex chronic disease; the latter were defined as CMC. Race/ethnicity was self-reported in claims; we defined rurality by home residence ZIP codes. Utilization and costs were summarized for 1year (10/1/2018-9/30/2019) by complexity level classification and categorized as acute care (hospitalization, emergency [ED]), outpatient care (primary, specialty, allied health), and pharmacy. Per-complexity group utilization rates (per 1000 person-years) by race/ethnicity and rurality were compared using adjusted rate ratios (ARR). Among 859,166 Medicaid-insured children, 118,210 (13.8%) were CMC. Among CMC, 36% were categorized as Black non-Hispanic, 42.7% White non-Hispanic, 14.3% Hispanic, and 35% rural. Compared to White non-Hispanic CMC, Black non-Hispanic CMC had higher hospitalization (ARR = 1.12; confidence interval, CI 1.08-1.17) and ED visit (ARR = 1.17; CI 1.16-1.19) rates; Hispanic CMC had lower ED visit (ARR = 0.77; CI 0.75-0.78) and hospitalization rates (ARR = 0.79; CI 0.73-0.84). Black non-Hispanic and Hispanic CMC had lower outpatient visit rates than White non-Hispanic CMC. Rural CMC had higher ED (ARR = 1.13; CI 1.11-1.15) and lower primary care utilization rates (ARR = 0.87; CI 0.86-0.88) than urban CMC. Healthcare utilization varied by race/ethnicity and rurality for Medicaid-insured CMC. Further studies should investigate mechanisms for these variations and expand higher value, equitable care delivery for CMC.

Impact of insurance type and timing of Medicaid enrollment on survival among adolescents and young adults with cancer.

Adolescents and young adults (AYAs) with public or no insurance experience later stage at diagnosis and worse overall survival compared with those with private insurance. However, prior studies have not distinguished the survival impact of continuous Medicaid coverage prior to diagnosis compared with gaining Medicaid coverage at diagnosis. We linked a cohort of AYAs aged 15-39 who were diagnosed with 13 common cancers from 2005 to 2014 in the California Cancer Registry with California Medicaid enrollment files to ascertain Medicaid enrollment, with other insurance determined from registry data. We used Cox proportional hazards regression to evaluate the impact of insurance on survival, adjusting for clinical and demographic characteristics. Among 62218 AYAs, over 65% had private/military insurance, 10% received Medicaid at diagnosis, 13.2% had continuous Medicaid, 4.1% had discontinuous Medicaid, 1.7% had other public insurance, 3% were uninsured, and 2.6% had unknown insurance. Compared with those with private/military insurance, individuals with Medicaid insurance had significantly worse survival regardless of when coverage began (received Medicaid at diagnosis: hazard ratio [95% confidence interval]: 1.51 [1.42-1.61]; continuously Medicaid insured: 1.42 [1.33-1.52]; discontinuous Medicaid: 1.64 [1.49, 1.80]). Analyses of those with Medicaid insurance only demonstrated slightly worse cancer-specific survival among those with discontinuous Medicaid or enrollment at diagnosis compared with those with continuous enrollment, but results were not significant stratified by cancer site. AYAs with Medicaid insurance experience worse cancer-specific survival compared with those with private/military insurance, yet continuous enrollment demonstrates slight survival improvements, providing potential opportunities for future policy intervention.

Pharmacist Provision of Hormonal Contraception in the Oregon Medicaid Population.

To describe early utilization of pharmacist prescription of contraception in Oregon's Medicaid program. Using Oregon Medicaid claims data, we conducted a retrospective analysis and quantified overall and monthly trends in pharmacist-prescribed contraceptives from January 1, 2016, to December 31, 2017. Our population was restricted to patients obtaining a new prescription for oral and transdermal methods and who had continuous Medicaid coverage during the study period. We summarized demographic and utilization characteristics, including whether patients were continuing or switching methods or initiating contraception. New prescriptions were those written to patients who did not have one for hormonal contraception in the prior 30 days. To assess program safety, we examined rates of prescriptions to patients with medical contraindications to contraceptive use. Among the 3,614 patients receiving a new prescription for oral or transdermal contraceptives in the Oregon Medicaid program from all health care providers, 367 (10%) received their prescription from a pharmacist. Five months after implementation, pharmacists filled an average of 61 prescriptions per month as the prescriber. Most claims originated from retail chain pharmacies (94%) in urban locations (71%). The majority of patients who were prescribed contraception by pharmacists (73.8%) had no history of contraceptive prescriptions in the preceding 30 days (n=252). Ages ranged from 13 to 49 years, fewer patients lived in a rural location (35.7%), most received a combined hormonal pill (90.5%), and the average day's supply dispensed was 65 (range of 21-364 days). Fewer than 5% (12) of patients had a diagnostic code indicating a possible contraindicating comorbidity. Among Medicaid enrollees, we found that 10% of all new oral and transdermal contraceptive prescriptions were written by pharmacists.

Access to care among Medicaid and uninsured patients in community health centers after the Affordable Care Act

BackgroundThe Affordable Care Act expanded Medicaid and increased federal funding for Community Health Centers (CHCs). To examine the role of Medicaid coverage on care patterns for those with available safety net care, we assessed differences in access to care for CHC patients with continuous Medicaid coverage vs. gaps in insurance coverage in the last year.MethodsWe used data on adult respondents from the 2014 Health Center Patient Survey (N = 1720) with continuous Medicaid coverage vs. those with some period without insurance coverage in the last 12 months. We examined reported need for any medical care, mental health care, prescription drugs, dental care, and referrals for care outside of the CHC in the last 12 months, and reports of being delayed or unable to get needed care by insurance status. We used logistic regression to assess the association between insurance status and care access, adjusting for patient characteristics.ResultsPatients with insurance gaps and continuous Medicaid coverage reported similar levels of need for most types of care in the last 12 months, but those with insurance gaps were significantly more likely to report having difficulty obtaining medical care, prescription drugs, dental care, and completing outside referrals. Of those with incomplete referrals for care outside of the CHC, patients with insurance gaps were more likely than those with continuous Medicaid to cite cost or insurance-related reasons for not following up (70% vs. 19%, p < 0.01).ConclusionsHaving continuous Medicaid coverage appeared to mitigate barriers to care for CHC patients compared to having intermittent or no insurance coverage over the last year. Policies that increase disruptions in Medicaid coverage could adversely impact access to care, even among those with available safety net care.