Early Adopter States Research Articles

Facilitators and Barriers to Medicaid Doula Benefit Implementation in California: Perspectives From Managed Care Plans and Risk-Bearing Organizations

IntroductionMedicaid coverage of doula services is increasing as a policy strategy to reduce maternal health inequities in the United States. However, early adopter states struggled to offer accessible, equitable Medicaid doula benefits when implementation began. California began covering doula services through its Medicaid program, Medi-Cal, in 2023. Managed care plans (MCPs) and risk-bearing organizations (RBOs) play an important role in ensuring pregnant and birthing people can access doula support through Medicaid benefits. Materials and MethodsBetween 2021 and 2022, we conducted 14 interviews with MCP and RBO staff (n = 20) representing a total of 14 MCPs and RBOs. Data were analyzed in two stages: 1) rapid assessment process and 2) using the Consolidated Framework for Implementation Research (CFIR) to identify specific facilitators and barriers to Medi-Cal doula benefit implementation. ResultsWe identified 10 facilitators and 16 barriers across the five CFIR domains. Results indicate a general lack of familiarity with doula care and highlight the importance of relationship building with doulas and collaboration among plans. ConclusionsIn California, these findings can help guide improvements to emerging implementation challenges and evaluation efforts. Our findings can also help other states in the planning and Medicaid doula benefit design process.

Feeling the Threat of Race in Education: Exploring the Cultural Politics of Emotions in CRT-Ban Political Discourses

Recent attacks on critical race theory (CRT) aim to limit discussion and understanding of race (and its intersection with class, gender, and power). Racial dialogues can be uncomfortable for those who benefit from power, suggesting that resistance to CRT or any discussion of race and power in education is rooted in emotions. This study examines the role of racialized emotions in public policy discourse that surrounds CRT bans in education that have been proposed, and in many cases, passed across the United States. Focusing on four early-adopting states of the bans, the findings reveal how emotionalities of whiteness are tacitly endorsed, invited, and animated within racialized politics, as well as how these emotionalities might be disrupted.

Impact of Medicaid Expansion on Stage at Diagnosis for US Adults with Pancreatic Cancer: a Population-Based Study.

We evaluated whether Medicaid expansion is associated with earlier stage at diagnosis for pancreatic cancer taking into account key demographic, clinical, and geographic factors. We obtained Surveillance, Epidemiology, and End-Results (SEER-18) data on individuals diagnosed with pancreatic cancer from 2007 to 2016 (< 65years of age). We defined non-metastatic as either local or regional disease (vs. metastatic disease). To estimate the association of Medicaid expansion with pancreatic cancer stage at diagnosis, we used a difference-in-differences model, at the individual level, comparing those from early-adopting states in 2014 to non-early-adopting states. We utilized cluster-robust standard errors and explored the role of demographic factors (race, sex, insurance at diagnosis), clinical indicator (disease in the head of the pancreas), and county characteristics (Urban Influence Code, Social Deprivation Index). In the univariable setting, the probability of non-metastatic disease at diagnosis increased by 3.9 percentage points (ppt) for those from Medicaid expansion states post-expansion (n = 36,609). After adjustment for covariates, the ppt was attenuated to 2.7. Of particular note, we observed evidence of interactions with sex and race. The beneficial effect was less pronounced for men (increase in the probability of non-metastatic stage at diagnosis by 2.1ppt) than women (3.6ppt) and non-existent for blacks (- 3.1ppt) compared to whites (4.9ppt) and other races (4.8ppt). Medicaid expansion is associated with increased probability of non-metastatic stage at diagnosis for pancreatic cancer; however, this beneficial effect is not uniform across sex and race. This underscores the need to investigate the impact of policy and implementation strategies on pancreatic cancer survival disparities.

Current Postlaunch Implementation of State Mandates of Newborn Screening for Critical Congenital Heart Disease by Pulse Oximetry in U.S. States and Hospitals.

Our objective was to gauge adherence to nationally endorsed protocols in implementation of pulse oximetry (POx) screening for critical congenital heart disease (CCHD) in infants after mandate by all states and to assess associated characteristics. Between March and October 2019, an online questionnaire was administered to nurse supervisors who oversee personnel conducting POx screening. The questionnaire used eight questions regarding performance and interpretation of screening protocols to measure policy consistency, which is adherence to nationally endorsed protocols for POx screening developed by professional medical societies. Multilevel linear regression models evaluated associations between policy consistency and characteristics of hospitals and individuals, state of hospital location, early versus late mandate adopters, and state reporting requirements. Responses from 189 nurse supervisors spanning 38 states were analyzed. Only 17% received maximum points indicating full policy consistency, and 24% selected all four options for potential hypoxia that require a repeat screen. Notably, 33% did not recognize ≤90% SpO2 as an immediate failed screen and 31% responded that an infant with SpO2 of 89% in one extremity will be rescreened by nurses in an hour rather than receiving an immediate physician referral. Lower policy consistency was associated with lack of state reporting mandates (beta = -1.23 p = 0.01) and early adoption by states (beta = -1.01, p < 0.01). When presented with SpO2 screening values on a questionnaire, a low percentage of nurse supervisors selected responses that demonstrated adherence to nationally endorsed protocols for CCHD screening. Most notably, almost one-third of respondents did not recognize ≤90% SpO2 as a failed screen that requires immediate physician follow-up. In addition, states without reporting mandates and early adopter states were associated with low policy consistency. Implementing state reporting requirements might increase policy consistency, but some inconsistency may be the result of unique protocols in early adopter states that differ from nationally endorsed protocols. · Low adherence to nationally endorsed protocols.. · Inconsistent physician follow-up to hypoxia.. · Reporting improved consistency with national policy..

How Do Medicaid Agencies Improve Substance Use Treatment Benefits? Lessons from Three States' 1115 Waiver Experiences.

In 2015, the Centers for Medicare and Medicaid Services (CMS) urged state Medicaid programs to use 1115 waiver demonstrations to expand substance use treatment benefits. We analyzed four critical points in states' decision-making processes before expanding benefits. We conducted qualitative cross-case comparison of three states that were early adopters of the 1115 waiver request. We conducted 44 interviews with key informants from CMS, Medicaid, and other state agencies, providers, and managed care organizations. Policy makers expanded substance use treatment in response to "fragmented" care systems and unsustainable funding streams. Medicaid staff had mixed preferences for implementing new benefits via 1115 waivers or state plan amendments. The 1115 waiver process enabled states to provide coverage for residential benefits, but state plan amendments made other services permanent parts of the benefit. Medicaid agencies relied on interorganizational networks to identify evidence-based practices. Medicaid staff secured legislative support for reform by focusing on program integrity concerns and downstream effects of substance use rather than Medicaid beneficiaries' needs. Decision-making processes were influenced by Medicaid agency characteristics and interorganizational partnerships, not federal executive branch influence. Lessons from early-adopter states provide a road map for other state Medicaid agencies considering similar reform.

Rates of Diabetes-Related Major Amputations Among Racial and Ethnic Minority Adults Following Medicaid Expansion Under the Patient Protection and Affordable Care Act

It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations. To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs). This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021. States were categorized into early-adopter states (expansion by January 2014) and nonadopter states. Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population. Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (P for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, -6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, -10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion. This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.

Abstract PO-207: Impact of Medicaid expansion on stage at diagnosis for US adults with pancreatic cancer: A population-based study

Abstract Introduction: We evaluated whether expansion of state Medicaid programs is associated with earlier-stage at diagnosis for pancreatic cancer among those under the age of 65, before and after Medicaid expansion considering key demographic, clinical, and geographic covariates. Methods: We obtained Surveillance, Epidemiology, and End-Results (SEER-18) data on individuals under 65 years of age diagnosed with pancreatic cancer from 2007-2016, including Urban Influence Code (UIC) and Social Deprivation Index (SDI) data. We defined early stage as either local or regional disease (versus advanced disease). To estimate the effect of Medicaid expansion on stage at diagnosis, we used a Difference-in-Differences (DD) model, at the individual level, comparing those from early-adopting states in 2014 to non-early-adopting states. We utilized cluster-robust standard errors and explored the role of covariates including demographic factors (race, sex, insurance coverage at diagnosis), clinical indicators (disease located in the head of the pancreas), and county characteristics (UIC and SDI). Results: The probability of early-stage disease at diagnosis increased by 3.9 percentage points (ppt) for those from Medicaid expansion states post-expansion (n=36,609). After adjustment for key covariates, the ppt was attenuated to 2.7. Of note, we observed evidence of interactions with sex and race. Indeed, the beneficial effect of living in an expansion state on stage at diagnosis was less pronounced for men (increase in the probability of early stage at diagnosis by 2.1ppt) than women (3.6ppt) and non-existent for blacks (-3.1ppt) compared to whites (4.9ppt) and other races (4.8ppt). Redefining early stage to only local stage attenuated the beneficial effect for all groups and increased the negative effect for blacks. Conclusion: Medicaid expansion is associated with earlier stage at diagnosis for pancreatic cancer; however, this beneficial effect is not uniform across sex and race. This underscores the need to investigate the impact of policy changes and implementation strategies on disparities in pancreatic cancer survival. Citation Format: Erin M. Mobley, Christina Guerrier, Ian Tfirn, Michael S. Gutter, Kimberly Vigal, Keouna Pather, Brett Baskovich, Ziad Awad, Alexander S Parker. Impact of Medicaid expansion on stage at diagnosis for US adults with pancreatic cancer: A population-based study [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-207.

Impact of Medicaid Expansion on Pancreatic Cancer: An Examination of Sociodemographic Disparity in 1-Year Survival.

This study examined the effect of Medicaid expansion on 1-year survival of pancreatic cancer for nonelderly adults. We further evaluated whether sociodemographic and county characteristics alter the association of Medicaid expansion and 1-year survival. We obtained data from the Surveillance Epidemiology and End-Results dataset on individuals diagnosed with pancreatic cancer from 2007 to 2015. A Difference-in-Differences model compared those from early-adopting states to non-early-adopting states, before and after adoption (2014), while taking into consideration sociodemographic and county characteristics to estimate the effect of Medicaid expansion on 1-year survival. In the univariable Difference-in-Differences model, the probability of 1-year survival for pancreatic cancer increased by 4.8 percentage points (ppt) for those from Medicaid expansion states postexpansion (n = 35,347). After adjustment for covariates, the probability of 1-year survival was reduced to 0.8 ppt. Interestingly, after multivariable adjustment the effect of living in an expansion state on 1-year survival was similar for men and women (0.6 ppt for men vs 1.2 ppt for women), was also similar for Whites (2.6 ppt), and was higher in those of other races (5.9 ppt) but decreased for Blacks (-2.0 ppt). Those who were insured (-0.1 ppt) or uninsured (-2.2 ppt) experienced a decrease in the probability of 1-year survival; however, those who were covered by Medicaid at diagnosis experienced an increase in the probability of 1-year survival (7.4 ppt). Medicaid expansion during or after 2014 is associated with an increase in the probability of 1-year survival for pancreatic cancer; however, this effect is attenuated after adjustment for sociodemographic characteristics. Of note, the positive association was more pronounced in certain categories of key covariates suggesting further inquiry focused on these subgroups.

Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity?

Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int=.0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.

New Evidence on the Effects of Mandatory Waiting Periods for Abortion

Beyond a handful of studies examining early-adopting states in the early 1990s, little is known about the causal effects of mandatory waiting periods for abortion. In this study we evaluate the effects of a Tennessee law enacted in 2015 that requires women to make an additional trip to abortion providers for state-directed counseling at least 48 hours before they can obtain an abortion. Our difference-in-differences and synthetic-control estimates indicate that the introduction of the mandatory waiting period caused a 53–69 percent increase in the share of abortions obtained during the second trimester. Our analysis examining overall abortion rates is less conclusive but suggests a reduction caused by the waiting period. To put these estimates into context, we provide back-of-the-envelope calculations on the additional monetary costs that Tennessee’s MWP imposes on women seeking abortions.

Worsening Disparities in State-Level Uptake of Human Immunodeficiency Virus Preexposure Prophylaxis, 2014-2018.

Retrospective analysis of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) use among individuals with PrEP indications demonstrates worsening disparities in uptake between early- and late-adopting states from 2014 to 2018. To end the HIV epidemic, federal and state governments must close gaps by translating successful policies from early-adopting states to late-adopting states.

Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States.

Policy Points Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services.Drawing on extensive document reviews and in‐depth interviews in four early‐adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. ContextThe Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports.MethodsWe conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think‐tank reports, and published literature. We also conducted a systematic inductive qualitative analysis.FindingsWe identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd‐out and waiver burden.ConclusionsNotwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start‐up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.

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

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

Abstract 384: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations

Introduction: Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization. Methods: Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated. Results: Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int &lt;0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p&lt;0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, &lt;60% of patients in both state groups received other forms of GDMT despite eligibility. Conclusions: Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.

Abstract 22: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations

Introduction: Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization. Methods: Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated. Results: Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int &lt;0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p&lt;0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, &lt;60% of patients in both state groups received other forms of GDMT despite eligibility. Conclusions: Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.

Perceived Benefit of Immunization-Trained Technicians in the Pharmacy Workflow.

Clinical community pharmacists have continually restructured their workflow to serve the community by optimizing patient care outcomes. Defining the perceived benefits of having an immunizing pharmacy technician in the workflow can help to redefine the way community pharmacists operate during patient immunization. The purpose of this study is to share the opinions of supervising pharmacists that have an immunizing technician within their workflow model and highlight their contributions. Pharmacists involved in this novel workflow model were interviewed two times, once in 2017 and then in 2020, to gauge opinions over time. Findings in the results of this study included such themes as: (1) Pharmacists’ perceived improvement in workflow flexibility; (2) The choice of the correct technician to immunize within the pharmacy; (3) Pharmacists’ perceived improved workflow time prioritization; (4) Limited available training as a barrier to implementation; and (5) The initial apprehension and later acceptance of pharmacists with respect to the innovation. As technician immunization administration spreads beyond early adopter states, further research into the impact on pharmacy workflow is needed.

Effectiveness of lowering the blood alcohol concentration (BAC) limit for driving from 0.10 to 0.08 grams per deciliter in the United States

Objective: The current study evaluates of the effects of lowering the blood alcohol concentration (BAC) limit from 0.10 to 0.08 g/dL across all 50 states in the United States. Our objectives were to (1) estimate the effects of the 0.08 g/dL BAC limit on drinking driver fatal crash rates; (2) compare the effects from early-adopting states to the effects of late-adopting states; (3) determine the effects on drivers with low BACs (0.01–0.07 g/dL) and high BACs (0.08+ g/dL); and (4) estimate the lives saved since 1983 due to the adoption of 0.08 g/dL BAC laws.Methods: Our study examined annual data from the Fatality Analysis Reporting System (FARS) for each jurisdiction from 1982 through 2014. Our basic outcome measure was the ratio of drinking drivers (BAC ≥0.01 g/dL) to nondrinking drivers (BAC = 0.00 g/dL). Covariates included 0.10 BAC laws, administrative license revocation (ALR) laws, seat belt laws, minimum legal drinking age (MLDA) laws, and unemployment rates. We utilized autoregressive integrated moving average (ARIMA) models for each state, where the implementation date of the law was modeled as a zero-order transfer function in the series, in addition to any extant trends that may have been occurring simultaneously. Before determining the specific impact of the implementation of 0.08 g/dL BAC laws, we conducted a time series analysis for each state. We tested for between-state mediating factors relating to our covariates.Results: A total of 38 of the 51 jurisdictions showed that lowering the BAC limit was associated with reduced drinking driver fatal crash ratios, with 20 of those reductions being significant. The total effects showed a 10.4% reduction in annual drinking driver fatal crash rates, which is estimated to have saved an average of 1,736 lives each year between 1983 and 2014 and 24,868 lives in total. Implementing a BAC limit of 0.08 g/dL had significant impacts on both high- and low-BAC fatal crash ratios. Though early-adopting jurisdictions (1983–1999) demonstrated a larger decrease in fatal drinking driver crash ratios than did late-adopting jurisdictions (2000–2005), the results were not statistically significant (P > .05).Conclusions: Our study of the effects of lowering the BAC from 0.10 to 0.08 g/dL in the United States from 1982 to 2014 showed an overall effect of 10.4% on annual drinking driver fatal crash rates, in line with other multistate studies. This research provides strong evidence of the relationship between lowering the BAC limit for driving and the general deterrent effect on impaired-driving fatal crash rates.

The Affordable Care Act Medicaid Expansion Correlated With Increased Heart Transplant Listings in African-Americans But Not Hispanics or Caucasians

ObjectivesThe aim of this study was to determine if the Affordable Care Act (ACA) Medicaid Expansion was associated with increased census-adjusted heart transplant listing rates for racial/ethnic minorities. BackgroundUnderinsurance limits access to transplants, especially among racial/ethnic minorities. Changes in racial/ethnic listing rates post-ACA Medicaid Expansion are unknown. MethodsUsing the Scientific Registry of Transplant Recipients, we analyzed 5,651 patients from early adopter states (implemented the ACA Medicaid Expansion by January 2014) and 4,769 patients from non-adopter states (no implementation during the study period) from 2012 to 2015. Piecewise linear models, stratified according to race/ethnicity, were fit to monthly census-adjusted rates of heart transplant listings before and after January 2014. ResultsA significant 30% increase in the rate of heart transplant listings for African-American patients in early adopter states occurred immediately after the ACA Medicaid Expansion on January 1, 2014 (before 0.15 to after 0.20/100,000; increase 0.05/100,000; 95% confidence interval [CI]: 0.01 to 0.08); in contrast, the rates for African-American patients in non-adopter states remained constant (before and after 0.15/100,000; increase 0.006/100,000; 95% CI: –0.03 to 0.04). Hispanic patients experienced an opposite trend, with no significant change in early adopter states (before 0.03 to after 0.04/100,000; increase 0.01/100,000; 95% CI: –0.004 to 0.02) and a significant increase in non-adopter states (before 0.03 to after 0.05/100,000; increase 0.02/100,000; 95% CI: 0.002 to 0.03). There were no significant changes in listing rates among Caucasian patients in either early adopter states or non-adopter states. ConclusionsImplementation of the ACA Medicaid Expansion was associated with increased heart transplant listings in African-American patients but not in Hispanic or Caucasian patients. Broadening of the ACA in states with large African-American populations may reduce disparities in heart transplant listings.

The Disparate Influence of State Renewable Portfolio Standards on Renewable Electricity Generation Capacity

Several papers have used panel data analyses to examine the effectiveness of U.S. state-level renewable portfolio standards (RPS) in promoting renewable capacity development, but the findings are inconclusive. Estimation of average treatment effects, however, can mask the fact that RPS policies across states are disparate and the treatment states are heterogeneous. We use the synthetic control method to conduct individual case studies of the early adopter states. Our findings indicate that the impact of RPS policies varied across states. We find Texas to be unique among these early adopters in that the RPS policy in Texas has led to increased renewable capacity. (JEL Q42, Q48)

Application of Implementation Science Methodology to Immediate Postpartum Long-Acting Reversible Contraception Policy Roll-Out Across States.

Purpose Providing long-acting reversible contraception (LARC) in the immediate postpartum period is an evidence-based strategy for expanding women’s access to highly effective contraception and for reducing unintended and rapid repeat pregnancy. The purpose of this article is to demonstrate the application of implementation science methodology to study the complexities of rolling-out policies that promote immediate postpartum LARC use across states. Description The Immediate Postpartum LARC Learning Community, sponsored by the Association of State and Territorial Health Officials (ASTHO), is made up of multi-disciplinary, multi-agency teams from 13 early-adopting states with Medicaid reimbursement policies promoting immediate postpartum LARC. Partners include federal agencies and maternal and child health organizations. The Learning Community discussed barriers, opportunities, strategies, and promising practices at an in-person meeting. Implementation science theory and methods, including the Consolidated Framework for Implementation Research (CFIR), and a recent compilation of implementation strategies, provide useful tools for studying the complexities of implementing immediate postpartum LARC policies in birthing facilities across early adopting states. Assessment To demonstrate the utility of this framework for guiding the expansion of immediate postpartum LARC policies, illustrative examples of barriers and strategies discussed during the in-person ASTHO Learning Community meeting are organized by the five CFIR domains—intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and process. Conclusion States considering adopting policies can learn from ASTHO’s Immediate Postpartum LARC Learning Community. Applying implementation science principles may lead to more effective statewide scale-up of immediate postpartum LARC and other evidence-based strategies to improve women and children’s health.