Health Insurance Reform Research Articles

Childcare needs as a barrier to healthcare among women in a safety-net health system

BackgroundChildcare needs are an understudied social determinant of health. The effect of childcare needs on access to healthcare must be understood to inform health system interventions and policy reform. This study sought to characterize childcare needs, access to childcare, and prior experience with navigating childcare needs in healthcare settings among women in a safety-net population.MethodsWe conducted a cross-sectional study of patient-reported survey data collected in-person between April and October 2019. Surveys were administered in waiting rooms of ambulatory services in a large, urban safety-net health system in Dallas, Texas. Survey respondents were derived from a random convenience sample of women waiting for outpatient appointments. Participants were screened for having children under the age of 13 and/or childcare responsibilities for inclusion in the sample. Outcomes of interest included self-reported delayed or missed care, reasons for delayed or missed care, perceived difficulty in accessing childcare, prior methods for managing childcare during healthcare appointments, and prior experience with childcare centers.ResultsAmong the 336 respondents (96.7% response rate), 121 (36.0%) reported delaying or missing a mean 3.7 appointments/year. Among women with delayed or missed care, 54.5% reported childcare barriers as the primary reason for deferral of care, greater than transportation (33%) or insurance (25%) barriers. Respondents rated childcare access as more difficult than healthcare access. Delayed or missed care due to childcare was more common among White (68.8%) and Black (55.0%) women compared to Hispanic women (34.3%). Common methods of navigating childcare needs during scheduled appointments included bringing children to appointments (69.1%) and re-scheduling or missing the scheduled appointment (43.0%). 40.6% of patients reported leaving an appointment before completion due to childcare needs.ConclusionsChildcare needs are a leading barrier to healthcare among women accessing care in safety-net settings. Unmet childcare needs result in deferral of care, which may impact health outcomes. Childcare access is perceived as more challenging than healthcare access itself. Health system and policy interventions are needed to address childcare as a social determinant of health.

Insurance Disparities in Quality of Care Among Patients With Head and Neck Cancer

Significant insurance status disparities have been demonstrated in head and neck cancer (HNC) outcomes. The effects of insurance status on HNC outcomes may be explained by differential access to high-quality care. To evaluate the association of insurance status with the quality of the treating hospital and receipt of guideline-compliant care among patients with HNC. This retrospective cohort study of data from the California Cancer Registry dataset linked with discharge records and hospital characteristics from the California Department of Health Care Access and Information included adult patients with HNC diagnosed between January 1, 2010, and December 31, 2019. Data were analyzed from May 10, 2023, to March 25, 2024. Insurance status: commercial, Medicare, Medicaid, uninsured, other, or unknown. Quality of the treating hospital (tertiles), receipt of National Comprehensive Cancer Network guideline-compliant care, and overall survival. A total of 23 933 patients (mean [SD] age, 64.8 [12.3] years; 75.3% male) met the inclusion criteria. Treatment in top-tertile hospitals (hazard ratio, 0.87; 95% CI, 0.79-0.95) was associated with improved overall survival compared with treatment in bottom-tertile hospitals. Medicare (odds ratio [OR], 0.78; 95% CI, 0.73-0.84), Medicaid (OR, 0.60; 95% CI, 0.54-0.66), and uninsured (OR, 0.38; 95% CI, 0.29-0.49) status were associated with lower likelihood of treatment in high-quality hospitals compared with commercial insurance. Among patients with advanced disease, Medicaid (OR, 0.72; 95% CI, 0.62-0.83) and uninsured (OR, 0.64; 95% CI, 0.44-0.93) patients were less likely to receive dual-modality therapy. Among patients with surgically resected advanced disease, Medicaid coverage (OR, 0.73; 95% CI, 0.58-0.93) was associated with lower likelihood of receiving adjuvant radiotherapy. This study found significant insurance disparities in quality of care among patients with HNC. These findings highlight the need for continued health insurance reform in the US to improve the quality of insurance coverage, in addition to expanding access to health insurance.

The Task‐Sharing Path to Safe and Accessible Anaesthesia Care in India: The Role of Professional Associations in Health Policy Reform

ABSTRACTThe worldwide anaesthesia workforce shortage is a concern and ‘shared responsibility’ for all the national or state anaesthetic societies and Ministries of Health. The Lancet Commission on Global Surgery estimated the need for 143 million additional surgeries each year globally. These would be included in the World Health Organization's (WHO) 44 essential surgeries to be performed at district hospitals. However, insufficient availability of safe anaesthesia is a key barrier. The World Federation of Societies of Anaesthesiologists (WFSA) recommends at least five specialist physician‐anaesthesia providers per 100,000 population. India requires at least 60,000 additional physician‐anaesthesiologists over the next 10 years. This paper discusses the two‐decade journey of a policy initiative by the Ministry of Health and Family Welfare (MoHFW) in India to create a new category of a physician with Life Saving Anaesthetic Skills (LSAS). This addressed the shortage of anaesthetists specifically for the dire emergency obstetric situations at the First Referral hospitals. The annual training capacity for physicians for LSAS training was 40–100 in 5 of the poorest states of India, with the maximum shortages of anaesthetists. On following up a sample of 838 LSAS physicians, only about two‐thirds were able to practice their life‐saving skills. The MoHFW innovated further by pairing a physician trained in Emergency Obstetric Care with an LSAS‐physician (buddy‐pairing) as a functioning team. For comparison, we discuss the midwife model supported by the professional association of obstetricians in India. The flexible, ‘team‐based’ task‐sharing approach optimizes anaesthesia care within available resources. Leadership and vision from the professional societies of anaesthesiology are key to policy reform in India. National engagement can be facilitated through support for district‐level non‐specialist physician provider with life‐saving anaesthesia skills training, engagement in research and formulation of the national surgical and anaesthesia plans to achieve universal healthcare in India.

Occupation and demand for health services in Italy: Ways and means to reduce the opportunity costs imposed on patients

This paper explores whether and to which extent employment condition and working hours influence individuals’ decision process in consuming primary care. The hypothesis is that the higher the workers’ opportunity cost in terms of earning forgone, the less the demand for General Practitioner (GP) visits. Using survey data provided by the Italian National Institute of Statistics (ISTAT), we estimate a negative binomial regression model of GP visits as a function of employment related variables, controlling for a rich set of individual demographic characteristics, socio-economic variables, health status, supply and geographical factors. We show that self-employed workers, managers and cadres use significantly less primary care services notwithstanding the access is free. We conclude that they have higher opportunity costs than white and blue collars since they suffer more from the loss of earnings related to the absence from work. Self-employed individuals often face barriers to accessing healthcare services, such as lack of employer-sponsored health insurance and concerns about lost income during time off for medical appointments. As a result, they may delay seeking healthcare until their condition becomes more severe, leading to poorer health outcomes. Managers and cadres, on the other hand, may have greater access to healthcare services due to higher income levels and better job benefits. However, they may still face challenges such as long working hours and job-related stress, which can impact their ability to prioritize their health and seek timely medical care.From a policy perspective, our results suggest potential policy interventions aimed at addressing barriers to healthcare access for self-employed workers and promoting equitable healthcare utilization across different employment groups. Policy recommendations may include measures to enhance financial support (tax deductions for medical expenses, subsidies for health insurance premiums, or grants to cover the costs of healthcare-related absences from work), increase healthcare accessibility (enhancing the availability of mobile clinics, and extending operating hours for primary care facilities to accommodate the needs of working individuals) and raise awareness about preventive care among self-employed workers (workplace wellness programs, and incentives for regular health check-ups, screenings and healthy lifestyle choices, can encourage managers and self-employed workers to prioritize preventive measures). These policy implications are essential for ensuring equitable and universal access to healthcare services for all workers, regardless of their employment status.

Supply chain/transaction cost insights into the profitability of health insurers during 2020, the start of COVID‐19

AbstractVarious US populations make up different health care markets/segments, and health insurers specialize in serving specific populations. US health insurers soared in profits during 2020, the first year of the Covid‐19 pandemic. The profit gains were unequal among segments. This research uses a supply chain/transaction costs economics (SC/TCE) model to find insights into the profitability differences. The SC/TCE model consists of three spheres of profitability determinants: health care characteristics, transactions costs differentials, and governance methods. Our univariate analyses combined with weighted regression results reveal that, for Medicaid, a significant increase in profitability was associated with a decrease in medical expenses, whereas the opposite is observed for the group and Medicare Advantage plans. Another finding is that transaction costs differentials led to significant increases in profitability for group and Medicare plans with opposite results for Medicaid plans. These results provide important practical implications for policymakers.

The impact of the 2014 Medicaid expansion on the health, health care access, and financial well-being of low-income young adults.

Prior to the 2014 Affordable Care Act (ACA) expansion, 37% of young adults ages 19-25 in the United States were low-income and a third lacked health insurance coverage-both the highest rates for any age group in the population. The ACA's Medicaid eligibility expansion, therefore, would have been significantly beneficial to low-income young adults. This study evaluates the effect of the ACA Medicaid expansion on the health, health care access and utilization, and financial well-being of low-income young adults ages 19-25. Using 2010-2017 National Health Interview Survey data, I estimate policy effects by applying a difference-in-differences design leveraging the variation in state implementation of the expansion policy. I show that Medicaid expansion improved health insurance coverage, health care access, and financial well-being for low-income young adults in expansion states, but had no effect on their health status and health care utilization. I also find that the policy was associated with larger gains in health coverage for racial minorities relative to their Non-Hispanic White counterparts. With the continued health policy reform debates at the state and federal levels, the empirical evidence from this study can help inform policy decisions that aim to improve health care access and utilization among disadvantaged groups.

Trends in Use and Evidence of Adherence to Risk Evaluation and Mitigation Strategy Pregnancy Testing Requirements for Thalidomide, Lenalidomide, and Pomalidomide in the USA, 2000-2020.

Lenalidomide, pomalidomide, and thalidomide are effective treatments for multiple myeloma but are teratogenic. To mitigate this risk, the US Food and Drug Administration (FDA) required risk evaluation and mitigation strategy (REMS) programs for these drugs, which include pregnancy testing among women of childbearing potential-twice before initiation, weekly in the first month on treatment, and every 2-4 weeks thereafter. We evaluated dispensing trends of lenalidomide, pomalidomide, and thalidomide and assessed adherence to REMS pregnancy testing requirements among at-risk patients taking these drugs. Using three US health insurance claims databases (Optum Clinformatics® [2004-2020], Merative Marketscan [2003-2019], and Medicaid [2000-2018]), we assessed monthly use of the drugs, patient characteristics and treatment persistence among drug initiators, and claims-based evidence for adherence to pregnancy testing requirements among initiators with child-bearing potential. Lenalidomide was the most prescribed agent following its approval in 2006 and through the end of the study period. A total of 48,311 lenalidomide (mean age = 59 years [standard deviation (SD) = 16]), 17,550 thalidomide (mean age = 65 years [SD = 12]), and 6560 pomalidomide initiators (mean age = 65 years [SD = 11]) were identified; 45% of initiators of each drug were women. Among initiators under follow-up on day 90, 70% were still on therapy. Initiators of childbearing potential comprised 3% (N = 1,920) of all initiators; among this cohort, 12% had evidence in claims data of two pregnancy tests before initiation, and 9% with at least 33 days of follow-up of four tests during the first month of treatment. By contrast, 52% who received a refill had claims-based evidence of a pregnancy test within 7 days of dispensing. Although most patients who initiated lenalidomide, pomalidomide, and thalidomide were not of child-bearing potential, further investigation into actual non-adherence to pregnancy testing is needed.

A Blueprint for U.S. Health Insurance Reform.

The current U.S. health insurance "system" was not deliberately planned and constructed but has emerged piecemeal over the past half-century through a series of incremental and haphazard reforms. That policy history also reveals a clear but unfulfilled societal commitment to providing access to essential health care regardless of resources. To fulfill this obligation, the solution proposed in this article has 2 key elements: 1) universal coverage that is automatic, free, and basic, and 2) the option to buy supplemental coverage in a well-designed market. Such a system could, if desired, be created without raising taxes and without disrupting or changing the delivery of medical care.

Prevalence of Genital Herpes and Antiviral Treatment.

Genital herpes is a common sexually transmitted infection caused by the herpes simplex virus. Contemporary US population-based epidemiologic data on genital herpes are limited. This study aimed to provide nationally representative estimates of genital herpes prevalence and treatment using a large US health insurance claims database. This observational cohort study used administrative claims data from HealthVerity. Crude and age- and sex-standardized prevalence rates of genital herpes and recurrent genital herpes were calculated for the years 2019 to 2021. The distribution of patients with prevalent genital herpes who received episodic or suppressive antiviral therapy was also estimated. From 2019 to 2021, the standardized prevalence of genital herpes and recurrent genital herpes ranged from 236 to 280 cases per 100,000 person-years and 81 to 98 cases per 100,000 person-years, respectively. The prevalence of genital herpes was highest among those aged 25 to 29 years (prevalence range, 497-582 years), female patients (prevalence range, 348-404 years), and those with a history of HIV infection (prevalence range, 1608-2080 years). The prevalence of recurrent genital herpes was also highest in these groups. From 2019 to 2021, two-thirds of patients (65%-68%) with prevalent genital herpes received antiviral medications; the majority received episodic therapy (80%) rather than suppressive therapy (20%). The burden of genital herpes and recurrent genital herpes in the United States is substantial, with the highest rates observed in young adults, women, and immunocompromised individuals. About two-thirds receive antiviral treatment each year.

Benefit Design And Biosimilar Coverage In Medicare Part D: Evidence And Implications From Recent Reforms.

There is substantial disparity between Medicare Part D and employer-sponsored health insurance plans in the coverage of biosimilars and their reference biologics. These disparities may be due to design elements of Part D plans that encourage the adoption of more expensive biologic drugs. We undertook several analyses to illustrate the dynamics of benefit design incentives over time, compare formulary coverage in Part D plans with that of employer-sponsored plans, and study how the Bipartisan Budget Act of 2018 affected Part D formulary coverage. Using these analyses of Part D reforms enacted through the Bipartisan Budget Act, we discuss the implications of elements of the Inflation Reduction Act of 2022 that will be implemented in 2025. Biosimilar coverage increased by 23percentage points five quarters after the Bipartisan Budget Act was implemented. We predict that the Inflation Reduction Act will also have a positive effect on biosimilar coverage. Given ample evidence of a relationship between drug coverage and utilization, our results suggest that Medicare patients and the federal government could realize substantial savings if Part D formularies resembled those of employer-sponsored plans.

From Financial Risk Management to Promotive Health: A Paradigm Shift in Employer-sponsored Health Insurance?

Health insurance serves to contain financial loss arising from an insured individual’s healthcare costs. We investigate an evolving paradigm shift in employer-sponsored health insurance by which workplace health promotion has increasingly gained coverage. The question for analytical investigation is why and how the Affordable Care Act (ACA) succeeded in integrating health promotion into private health insurance in the United States. Survey data (2008–2020) from the Employer Health Benefits, Annual Survey was disaggregated by insurance attributes and employer characteristics relative to health promotion benefits. Pertinent regulatory policies were content-analysed. The ACA offers a viable policy vehicle for mandating strategic, ex ante coverage of preventive and wellness services, and chronic disease management, nudging insurers to offer related benefits. Such policy is underpinned by insurer and employer incentives, including state-based individual mandates, the medical loss ratio, state-driven workplace initiatives and employee participation rewards. While health promotion reduces long-run healthcare costs and risk of disease and improves worker health and productivity, absent carefully devised incentives and rewards, compelling insurers and employers to cover promotive health is unlikely to achieve the objectives and imperatives of healthcare reform. Such policy could even have adverse, albeit unintended, consequences that outweigh their intended outcomes, as insurers may devise ‘backdoor’ strategies once regulatory costs become burdensome.

HSR24-159: Relationship Between Durable Transfusion Independence (TI) and Survival Outcomes in Patients (Pts) With Lower-Risk Myelodysplastic Syndrome (LR-MDS): An Analysis From US Health Insurance Claims Data.

HSR24-159: Relationship Between Durable Transfusion Independence (TI) and Survival Outcomes in Patients (Pts) With Lower-Risk Myelodysplastic Syndrome (LR-MDS): An Analysis From US Health Insurance Claims Data.

Patterns of immunotherapy utilization for non-small cell lung cancer in Texas pre- and post-regulatory approval.

Immunotherapy has shown remarkable benefits for non-small cell lung cancer (NSCLC) since approved by the US Food and Drug Administration (FDA). Texas, however, ranks below the national average in access to treatment for NSCLC. This retrospective cohort study assessed first-line immunotherapy treatment patterns and associated factors pre- and post-FDA approval in Texas. Patients ≥18years diagnosed with NSCLC from the Texas Cancer Registry database (2011-2018) and were stratified into pre- and post-FDA approval era. The rates of immunotherapy utilization were examined, and the average annual percent change (AAPC) in immunotherapy utilization across patient subgroups was compared. Multivariable logistic regression was used to identify associations of patient characteristics with immunotherapy utilization for patients with metastatic- and all-stage NSCLC. A total of 13,501 and 9509 patients with NSCLC were identified in pre-post-approval periods, respectively. Post-approval, immunotherapy utilization increased from 1.7 to 13.0%, and AAPC from 54.8 to 82.7%. Pre-approval, patients living in a county with ≥20% of households below the poverty level were less likely to receive immunotherapy (OR=0.73, 95% CI=0.61-0.94) while patients with private insurance were more likely to receive immunotherapy (OR=1.56, 95% CI=1.10-2.23). Post-approval, socioeconomic disparities were more prominent (10-19.9 and ≥20% of households below the poverty level: OR=0.77, 95% CI=0.66-0.90 and OR=0.71, 95% CI=0.60-0.86, respectively). Patients with metastatic NSCLC showed similar patterns of socioeconomic disparities pre- and post-approval. Our findings suggest that patients' socioeconomic status hinders immunotherapy utilization for NSCLC in Texas. This emphasizes the need for state health policy reforms such as Medicaid expansion and tailored cancer care strategies.

Antidepressant discontinuation patterns and characteristics across sociodemographic groups in the United States

BackgroundWhile antidepressants are frequently used, less is known about contemporary discontinuation patterns, especially across different sociodemographic populations. MethodsPatients 16–84 years initiating antidepressants between 2016 and 2019 within a large US health insurer were identified. The association between patient characteristics and time until antidepressant discontinuation was evaluated using adjusted Cox proportional hazard regression. ResultsAcross 1,365,576 patients, mean time to discontinuation was 168.1 days (SD: 223.6). Men were more likely to discontinue than women (HR: 0.94, 95%CI: 0.94–0.94). Younger patients (16–24 years) were more likely to discontinue than older patients. Patients who were non-White (Asian HR: 1.33, 95%CI: 1.31–1.34; Black HR: 1.27, 95%CI: 1.27–1.28; Hispanic HR: 1.34, 95%:CI 1.34–1.35), with evidence of a substance use disorder (HR: 1.31, 95%CI: 1.27–1.35), or taking tricyclic antidepressants (HR:1.26, 95%CI: 1.25–1.27) were more likely to discontinue. LimitationsInformation on reasons for discontinuation was not available, and wide standard deviations for the primary outcome were reported. The results may not be generalized to non-commercially insured beneficiaries. ConclusionsDiscontinuation is common within the first 6 months of treatment but varies across populations, highlighting patients who may benefit from potential intervention.

The Current Healthcare Industry in South Africa

The current South African Healthcare (SAHC) system remains a dual healthcare system, consisting of the public and private healthcare sector. Albeit it unevenly distributed from a gross budget perspective, the gross national spend leans disproportionately towards the private sector coverage of healthcare. This equates to R 243Bn serving approximately 20% of the population as opposed to a similar public budgeted spend of R 247Bn serving approximately 80% of the population. In effect, the private sector serves a minority of the employed population. The SA Government has historically made large government Information and Communication Technology (ICT) investments within the public health sector, regionally based, where the return on capital investments have not been realised. The SAHC sector remains siloed. Health technology is advancing globally, and being propagated by the World Health Organisation (WHO) resulting in a global digital health strategy adopted by many countries. The South African National Department of Health (NDoH) has recently subscribed to its own local version of a ‘Digital Health Strategy’, in accordance with the WHO. The South African Public Healthcare technological infrastructure, in its current state, is deficient with many challenges needing urgent upgrading. The proposed digital or ehealth strategy and the proposed National Health Insurance (NHI) will require the reengineering of a national infrastructural and technological (ICT) environment from the ground upwards. Furthermore, this can only be achieved by reengineering the current state of the public healthcare technological infrastructure including the building infrastructure. This will include a transformation of national legislation. These projects and initiatives must be nationally managed within the ambit of improving the management capacity across all regions and districts that needs to be nationally coordinated. This effort can only be achieved by performing synchronised and well-coordinated implementations of such projects nationally across the SA Public Healthcare sector. This includes the integration of healthcare technologies, or national assets, from district to national level. This study provides further insights into these opportunities and challenges currently facing the South African Public Healthcare sector in preparation for the National Health Insurance (NHI) reform currently in review by the President. It further aims to assist in an approach to a solution addressing this national healthcare crisis.

Specialty drug use for autoimmune conditions varies by race and wage among employees with employer-sponsored health insurance.

The relationship between race and ethnicity, wage status, and specialty medication (SpRx) use among employees with autoimmune conditions (AICs) is poorly understood. Insight into sociodemographic variations in use of these medications can inform health equity improvement efforts. To assess the association of race and ethnicity and wage status on SpRx use and adherence patterns among employees with AICs enrolled in employer-sponsored health insurance. In this observational, retrospective cohort analysis, data were obtained from the IBM Watson MarketScan database for calendar year 2018. Employees were separated into race and ethnicity subgroups based on employer-provided data. Midyear employee wage data were used to allocate employees into the following annual income quartiles: $47,000 or less, $47,001-$71,000, $71,001-$106,000, and $106,001 or more. The lowest quartile was further divided into 2 groups ($35,000 or less and $35,001-$47,000) to better evaluate subgroup differences. Outcomes included monthly days SpRx-AIC supply, proportion of days covered (PDC), and medication discontinuation rates. Generalized linear regressions were used to assess differences while adjusting for patient and other characteristics. From a sample of more than 2,000,000 enrollees, race and ethnicity data were available for 617,117 (29.8%). Of those, 47,839 (7.8%) were identified as having an AIC of interest, with prevalence rates of AICs differing by race within wage categories. Among those with AICs, 5,358 (11.2%) had filled at least 1 SpRx-AIC prescription. Following adjustment, except for the highest wage category, prevalence of SpRx-AIC use was significantly less among Black and Hispanic subpopulations. Black patients had significantly lower SpRx-AIC use rates than White patients (≤$35,000: 4.9 vs 9.4%, >$35,000-$47,000: 5.5 vs 10.6%, >$47,000-$71,000: 8.5 vs 11.1%, and >$71,000-$106,000: 9.1 vs 12.7%; P <0.001 for all). For Hispanic patients, prevalence rates were significantly lower than White patients in 3 different wage categories (≤$35,000: 4.5 vs 9.4%, >$35,000-$47,000: 6.1 vs 10.6%, and >$71,000-$106,000: 8.6 vs 12.7%; P < 0.001). PDC and 90-day discontinuation rates did not differ among race and ethnicity groups within the respective wage bands. Race and ethnicity and wage-related disparities exist in SpRx use, but not PDC or discontinuation rates for treatment of AICs among non-White and low-income populations with employer-sponsored insurance, and may adversely impact clinical outcomes.

Out-of-pocket costs for diabetes medications in employer-sponsored health insurance plans.

Out-of-pocket costs of diabetes medications other than insulin can be quite high for individuals with employer-sponsored health insurance.

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

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

Changes in Health Care Workers’ Economic Outcomes Following Medicaid Expansion

The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Time-varying state-level adoption of Medicaid expansion. Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Heading for health policy reform: transforming regions of care from geographical place into governance object

This article analyses how regional actors and national authorities shape and transform ‘the region’ from a geographical place into an object of governance for organising and delivering older person care. Drawing on an extensive ethnographic research project in the Netherlands, our findings show that these actors in interaction constitute the region through three practices: consistently creating urgency to foreground regional problems and solutions; renegotiating regulatory policies to facilitate regional care provision; and reconstructing care infrastructures to materialise regional care provision. Actors use and obtain power from co-existing and interacting institutional arrangements to develop new regional care arrangements. This evokes new interdependencies that reconfigure existing governance arrangements. Studying governance objects in-the-making reveals the required iterations, reconsiderations, and adjustments as processes within a given (ambiguous) institutional context, and which lead to institutional change. As regional organisation policies are increasingly scrutinised, this article provides an interesting and important contribution to this field.