Expanded Medicaid Coverage Research Articles

Resettlement needs of refugee women in the United States: An American Academy of Nursing consensus paper

When people must flee their homes due to persecution or conflict, they embark on a journey from loss toward safety that is a global concern and the resettlement country’s responsibility. Refugees experience stressors as they secure basic needs such as adequate nutrition, healthcare, transportation, housing, education, and income-generating activities. For refugee women, these stressors are further exacerbated by gender related roles and experiences. Addressing the unique healthcare needs of refugee women is vital to their wellbeing as they resettle into life in the United States. Access to care that is provided with cultural humility and fosters trust is critical. Policies are needed that expand health literacy programs and interpreting services, grow, diversify, and train the physical healthcare workforce, grow and diversify the mental healthcare workforce, expand Medicaid coverage in all 50 states, develop and fund peer to peer education programs for refugee women, finance access to care and programmatic services and expand federal funding toward refugee health research.

Expansion of Medicaid Coverage of Continuous Glucose Monitor Reduces Health Disparity in Children and Young Adults With Type 1 Diabetes.

Continuous glucose monitor (CGM) usage improves glycemia in people with type 1 diabetes (PWD) and is accepted as the standard of care. The CGM utilization is lower in patients with public insurance and minorized ethnicities. In 2022, California Medicaid reduced its barriers to obtaining CGM coverage for PWD. It is unknown whether this policy change is sufficient to increase CGM usage. We hypothesize that the change in Medicaid coverage improved CGM uptake in children and young adults with T1D. Data were extracted from electronic medical record of a large urban children's hospital in 2021 and 2022. The CGM usage was determined based on clinician documentation or the presence of CGM downloads. Kruskal-Wallis tests, Wald tests, and χ2 tests were used to test hypothesis (P < .05). Mixed effects logistical regression analyses were performed. We included 878 and 892 PWD (age ≤ 21 years) in 2021 and 2022, respectively. In 2022, Medicaid insured 59.3% of patients. Between 2021 and 2022, CGM usage did not change for privately insured patients (84%) but increased from 41% to 58% for patients receiving Medicaid. In our mixed effects logistic regression model, CGM usage was higher in 2022 and in English speakers. Public insurance, black race, and patients' age were negatively associated with CGM usage. Our results suggest that Medicaid expansion of CGM coverage increases its utilization for pediatric PWD but did not eliminate the disparity. Future studies are needed to identify barriers that preclude equity in technology uptake.

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.

The Role of Medicaid Expansion on the Receipt of Adjuvant Chemotherapy in Patients With Lung Cancer

ObjectiveWe aimed to utilize a nationally representative database to study the effect of Medicaid expansion on the receipt of adjuvant chemotherapy in eligible patients. Materials and MethodsRetrospective review of the National Cancer Database (NCDB) was performed between 2006 and 2019. Patients with clinical T1-T3, N1, and M0 were included. Patients with nodal disease or tumors > 4 cm were eligible for adjuvant therapy. Demographic and clinical information were collected. A difference-in-difference analysis was performed to compare changes in the rate of adjuvant chemotherapy. ResultsTotal 9954 eligible patients were treated in states that expanded Medicaid coverage in January 2014 or later, with 4809 patients treated in the pre-expansion years (2012-2013) and 5145 patients treated in the postexpansion years (2017-2018). Following Medicaid expansion, eligible patients were more likely to receive adjuvant therapy (70.2% vs. 62.3%; P < .001). Compared with the pre-expansion period, patients who received adjuvant therapy were more likely to use Medicaid insurance postexpansion (7.8% vs. 5%, P < .001). Among patients using Medicaid coverage only, a greater percentage started adjuvant therapy within 8 weeks of resection following Medicaid expansion (46.6% vs. 38.3%, P = .048). The observed difference-in-difference in the change in adjuvant therapy rate from the pre-expansion period to the postexpansion period between expansion and nonexpansion states was 1.25% (95% Bootstrap CI −0.36% to −3.18%). There was a modest survival benefit in expansion states postexpansion. ConclusionMedicaid expansion appears to be associated with increased access to care, as shown by the increased receipt of adjuvant systemic therapy in eligible patients.

Effect of Medicaid expansion on cancer treatment and survival among Medicaid beneficiaries and the uninsured.

The Affordable Care Act expanded Medicaid coverage for people with low income in the United States. Expanded insurance coverage could promote more timely access to cancer treatment, which could improve overall survival (OS), yet the long-term effects of Medicaid expansion (ME) remain unknown. We evaluated whether ME was associated with improved timely treatment initiation (TTI) and 3-year OS among patients with breast, cervical, colon, and lung cancers who were affected by the policy. Medicaid-insured or uninsured patients aged 40-64 with stage I-III breast, cervical, colon, or non-small cell lung cancer within the National Cancer Database (NCDB). A difference-in-differences (DID) approach was used to compare changes in TTI (within 60 days) and 3-year OS between patients in ME states versus nonexpansion (NE) states before (2010-2013) and after (2015-2018) ME. Adjusted DID estimates for TTI and 3-year OS were calculated using multivariable linear regression and Cox proportional hazards regression models, respectively. ME was associated with a relative increase in TTI within 60 days for breast (DID = 4.6; p < 0.001), cervical (DID = 5.0 p = 0.013), and colon (DID = 4.0, p = 0.008), but not lung cancer (p = 0.505). In Cox regression analysis, ME was associated with improved 3-year OS for breast (DID hazard ratio [HR] = 0.82, p = 0.009), cervical (DID-HR = 0.81, p = 0.048), and lung (DID-HR = 0.87, p = 0.003). Changes in 3-year OS for colon cancer were not statistically different between ME and NE states (DID-HR, 0.77; p = 0.075). Findings suggest that expanded insurance coverage can improve treatment and survival outcomes among low income and uninsured patients with cancer. As the debate surrounding ME continues nationwide, our findings serve as valuable insights to inform the development of policies aimed at fostering accessible and affordable healthcare for all.

Association of Medicaid coverage with emergency department utilization after self-harm in Korea: A nationwide registry-based study.

Self-harm presents an important public health challenge. It imposes a notable burden on the utilization of emergency department (ED) services and medical expenses from patients and family. The Medicaid system is vital in providing financial support for individuals who struggle with medical expenses. This study explored the association of Medicaid coverage with ED visits following incidents of self-harm, utilizing nationwide ED surveillance data in Korea. Data of all patients older than 14 years who presented to EDs following incidents of self-harm irrespective of intention to end their life, including cases of self-poisoning, were gathered from the National ED Information System (NEDIS). The annual self-harm visit rate (SHVR) per 100,000 people was calculated for each province and a generalized linear model analysis was conducted, with SHVR as a dependent variable and factors related to Medicaid coverage as independent variables. A 1% increase in Medicaid enrollment rate was linked to a significant decrease of 14% in SHVR. Each additional 1,000 Korean Won of Medicaid spending per enrollee was correlated with a 1% reduction in SHVR. However, an increase in Medicaid visits per enrollee and an extension of Medicaid coverage days were associated with an increase in SHVR. SHVR exhibited a stronger associated with parameters of Medicaid coverage in adolescents and young adults than in older adult population. Expansion of Medicaid coverage coupled with careful monitoring of shifts in Medicaid utilization patterns can mitigate ED overloading by reducing visits related to self-harm.

Investing in School Mental Health: Strategies to Wisely Spend Federal and State Funding.

In the context of the current youth mental health crisis, it is prudent to reconsider how resources are allocated to facilitate the delivery of effective and comprehensive supports and services to children and adolescents. Schools are the main delivery sites for youth mental health services. Many districts have adopted comprehensive school mental health systems (CSMHS) to provide a multitiered approach comprising mental health promotion, prevention, and intervention to students via partnerships between school and community health and behavioral health providers. COVID-19 relief funding and other new federal and state investments in school mental health have led to expansions of school mental health programming in most states. An impending federal funding cliff necessitates an examination of how to wisely invest now to achieve the greatest positive future impact on youth mental health. To capitalize on opportunities to sustain effective school mental health and maximize return on investment, states may consider four strategies: leverage cross-sector partnerships to advance school mental health policies and funding, strengthen and expand Medicaid coverage of CSMHS, establish and enhance data systems, and create state technical assistance and professional development support for CSMHS implementation through local education agencies.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors

IntroductionAs expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage. MethodsIn this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18–64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release. ResultsThe size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7–15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48–2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use. ConclusionsConditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states.

Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line. A two-way fixed-effects model was used to analyze serial cross-sectional observational data. Seventeen metro areas in 13 US states took part in the study. Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD. State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation). The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584). US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Abstract A134: The impact of the Affordable Care Act on the colorectal cancer landscape in Louisiana

Abstract Louisiana (LA) is the only state in the deep south opting to expand Medicaid. This, along with the federal tax subsidies for low income individual to buy insurance on the health marketplace, facilitated health care access to medically underserved populations in LA. This study examines the differences in sociodemographic characteristics of those diagnosed with colorectal cancer (CRC) before and after the Patient Protection and Affordable Care Act (ACA) was implemented in LA, highlighting differences in receipt of timely CRC treatment and survival rates. Patient demographics, cancer treatment, and outcomes data were obtained from the Louisiana Tumor Registry and the sample population included adults diagnosed with CRC. Pre-ACA was defined from 1/2012-6/30/2016 and the post-ACA was 7/1/2016- 12/31/2020. Variables examined were age, race, sex, poverty, socioeconomic status, insurance, marital status, distance to urban center, stage of diagnosis, number of tumors, type and date of any treatment received. Descriptive analysis summarized sociodemographic and cancer diagnosis variables for the sample across the two time periods. Logistic regression analysis was used to examine the impact of ACA and Kaplan-Meier plots and cox regression analysis was used to examine the impact of ACA on survival rates. 20,497 people were diagnosed with CRC during the study time period (pre-ACA 10,044 vs post-ACA 10,453) and there were significant differences noted with age, marital status, poverty, SES, insurance, and all cancer diagnosis variables. The number of uninsured dropped by two-thirds (6% vs 2%, &amp;lt;0.001) while the number of those on Medicaid increased (6.5% vs 14%, &amp;lt;0.001). There were no significant differences in diagnosis by race in the overall sample however, among the Medicaid population, pre-ACA, 57% of those diagnosed were Black vs 40% who were White. Post-ACA, 50% of those diagnosed were Black vs 46% White. The percentage of patients diagnosed at Stage I increased post-ACA by 1% while the percentage of patients diagnosed at Stage III decreased by 2% (&amp;lt;0.0001). The percentage of those diagnosed without tumors increased from 74% pre-ACA to 78% post-ACA. The number of those who received chemotherapy and radiation also increased pre vs post-ACA. Regression models showed significant impact of ACA on stage of diagnosis, receipt of timely treatment, and uninsured rates. There were no significant differences in survival time across the two time periods, however, separated by insurance status, the Medicaid and private insurance populations saw significant improvements in survival time post-ACA. Expanded Medicaid coverage through Healthy LA began in the summer of 2016. Since then, more than 732,000 individuals have benefited from Medicaid expansion coverage and 92,607 have received federal subsidies. The results of this study present evidence to other southern states on the advantages of Medicaid expansion in cancer treatment and survival. Citation Format: Bilikisu Elewonibi, Malesa Pereira, Yaqi Zou. The impact of the Affordable Care Act on the colorectal cancer landscape in Louisiana [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A134.

Long-Term Impact of Medicaid Expansion on Prostate Cancer Screening.

Prostate cancer is the most common noncutaneous malignancy in men. The updated PSA testing 2018 United States Preventive Services Task Force guidelines recommend shared decision-making for men ages 55 to 69. In 2010, the Affordable Care Act expanded Medicaid coverage to childless adults earning < 138% of the federal poverty level. Thereafter, individual states have chosen to adopt or defer Medicaid expansion at different times. This allows for the opportunity to study the effects of expansion on a population that did not previously qualify for Medicaid. We examine the long-term association of Medicaid expansion on prostate cancer screening. Data from the Behavioral Risk Factor Surveillance System were extracted for childless men earning less than 138% of the federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were classified into 4 expansion categories: very early expansion states, early expansion states, late expansion states, and nonexpansion states. Prevalence of PSA screening was determined for each category of expansion. Difference-in-difference analyses were used to understand variations in very early expansion states, early expansion states, and late expansion states trends with reference to nonexpansion states. PSA screening prevalence decreased in very early expansion states (27.76% vs 18.50%), early expansion states (33.79% vs 18.09%), late expansion states (36.08% vs 19.14%), and nonexpansion states (38.82% vs 24.40%) from 2012 to 2020. However, the difference-in-difference analyses did not show statistically significant results among any of the years and expansion category groups in our study period. PSA screening prevalence decreased in all states, regardless of expansion category. No long-term effect of Medicaid expansion on PSA screening prevalence was observed among states with different expansion statuses.

Influence of Medicaid Expansion on Head and Neck Squamous Cell Carcinoma Presentation and Survival.

To compare head and neck squamous cell carcinoma stage at presentation and survival in Medicaid-expanded states versus nonexpanded states. Retrospective cohort. Northwestern University Feinberg School of Medicine. The Head and Neck with human papillomavirus Status Database within the Surveillance, Epidemiology, and End Results (SEER) Program was queried for cases of head and neck squamous cell carcinoma (HNSCC) diagnosed in the years 2010 to 2016. Cases were grouped according to their respective state Medicaid expansion status. Multivariable logistic regressions and multivariable Cox proportional hazards models were used to evaluate associations with stage IV disease and survival. Compared to nonexpanded states, Medicaid-expanded states had a significantly larger proportion of Medicaid patients (20.3% vs 16.7%, P = .0009) and a significantly smaller proportion of uninsured patients (1.7% vs 10.1%, P < .0001). The case selection process resulted in 2215 patients meeting inclusion criteria. In multivariable analysis, cases under Medicaid expansion were 31% less likely to present with stage IV disease compared to cases in nonexpanded states (odds ratio: 0.69, 95% confidence interval [CI]: 0.51-0.93). In the multivariable Cox proportional hazards model, cases under Medicaid expansion had significantly better mortality outcomes and were 32% less likely to die compared to cases in nonexpanded states (hazard ratio: 0.68, 95% CI: 0.55-0.84). Medicaid expansion is associated with fewer stage IV cases and improved survival of HNSCC cases. These findings support continued efforts to expand Medicaid coverage.

Association of Medicaid Expansion With Postpartum Depression Treatment in Arkansas

ABSTRACT Approximately 1 in 8 individuals experience postpartum depression in the United States. Among them, 17% had their care covered by Medicaid and 10% had their care covered by a commercial payer. Postpartum depression is also more common among American Indian/Alaska Native (22%), Asian/Pacific Islander (19%), and Black (18%) individuals than White individuals (11%). Adverse postpartum health outcomes include reduced maternal quality of life, greater difficulty with social and partner relationships, increased odds of unemployment, and adverse child health outcomes. Effective treatments for postpartum depression include antidepressant medications and psychotherapy. Yet, these therapies are often underused, particularly among Medicaid enrollees and Black individuals, due to systemic racism and lack of access to health care, childcare, and transportation. One solution that has been suggested includes expanding Medicaid coverage to a year postpartum. One study in Oregon found that Medicaid expansion increased screening for and treatment of postpartum depression. The aim of this study was to compare the differences in treatment for postpartum depression among individuals whose births were covered by Medicaid versus commercial payers. This was a cohort study conducted in Arkansas with a difference-in-differences regression design. Data were collected from the state’s birth certificate records and all-payer claims database. Included were all births between January and June 2013, when Medicaid postpartum coverage ended 60 days after childbirth, and between January 2014 and December 2015, after the state expanded Medicaid postpartum coverage beyond 60 days if the individual’s income was below 138% of the federal poverty level. The primary outcomes were the filling of ≥1 antidepressant prescriptions and the number of days supplied in the first 60 days (early postpartum period) and 61 days to 6 months after childbirth (later postpartum period). The secondary outcomes were psychotherapy visits and a diagnosis of depression in the 6 months after childbirth. A total of 60,990 individuals gave birth in Arkansas between 2013 and 2015. Of these births, 71.7% were covered by Medicaid and 28.3% by commercial payers. Compared with individuals with commercially paid births, individuals who had a Medicaid-covered birth were younger (mean age, 25.5 vs 29.4 years), more likely to identify as Hispanic (10.8% vs 3.0%), and less likely to have a college or higher level of education (5.1% vs 55.5%). In the later postpartum period, 4.2% of those with Medicaid coverage filled a prescription for antidepressants before the expansion of Medicaid. In 2015, with Medicaid expansion, the likelihood of filling an antidepressant prescription in the later postpartum period increased by 110% (adjusted difference-in-differences, 4.6; 95% confidence interval [CI], 2.9–6.3). Similarly, in the early postpartum period, the likelihood of individuals with Medicaid filling an antidepressant prescription increased by 28% (adjusted difference-in-differences, 1.9; 95% CI, 0.2–3.7). The percentages of individuals with commercial coverage who filled antidepressant prescriptions did not change between 2013 and 2015. Before expansion, 0.2% of individuals with Medicaid coverage and 1.3% of those with commercial coverage had psychotherapy visit in the later postpartum period. This increased by 0.8 percentage points (95% CI, 0.5–1.2) after Medicaid was expanded. No change was associated with Medicaid expansion in the early postpartum period. Before Medicaid expansion, individuals with commercial coverage who had been diagnosed with depression within the first 60 days postpartum received an average 72-day supply of antidepressants in the later postpartum period, compared with those with Medicaid coverage who received a 23-day supply (95% CI, 20.7–25.4). Medicaid expansion was associated with a 61% increase in antidepressant prescriptions filled. In conclusion, Medicaid expansion in Arkansas helped to narrow the disparity of postpartum care between individuals covered by Medicaid and those covered by commercial payers. After the expansion of Medicaid in 2014, more Medicaid enrollees filled antidepressant prescriptions, underwent psychotherapy, had greater continuity of treatment for postpartum depression, and had an increased antidepressant supply beyond the first 60 days after delivery.

Rebuilding a Reproductive Future Informed by Disability and Reproductive Justice.

Rebuilding a Reproductive Future Informed by Disability and Reproductive Justice.

151-LB: Expansion of Medicaid Coverage of Continuous Glucose Monitor Reduces Health Disparity

Background: Continuous glucose monitor (CGM) usage improves glycemia in people with type 1 diabetes (PWT1D) and is accepted as the standard of care. CGM utilization is lower in patients with public insurance and minorized ethnicities. In 2022, California Medicaid expanded CGM coverage to all PWT1D without requiring a minimum number of glucose tests per day. It is unknown if this policy change is sufficient to increase CGM usage. We hypothesize that Medicaid expansion narrowed but did not eliminate the disparity in CGM usage. Methods: Data was extracted from electronic medical record of a large urban children's hospital in 2021 and 2022. CGM usage was determined based on clinician documentation or the presence of CGM downloads. We limited the data query to PWT1D who were seen at least once in the diabetes clinic each year. Chi-square and student T-tests were used to determine statistical significance (P&amp;lt;0.05). Results: We included 1471 and 1355 PWT1D in 2021 and 2022, respectively. Medicaid insured 66.8% and 62.2% of the patients in 2021 and 2022, respectively. CGM usage increased 1.4-fold in the entire patient population (2021: 52.2%, 2022: 71.1%). Between 2021 and 2022, CGM usage increased 1.6-fold (39% to 63%) and 1.1-fold (77% to 85%) for those with Medicaid and private insurances, respectively. CGM usage increased in all race/ethnicities, with the largest increase seen in patients who identify as Black and Latino (2021 vs 2022: White 69% vs 83%, Latino 38% vs 60%, Black 15% to 50%, P≤ 0.0001 for all comparisons). CGM usage increased 1.3-fold (58% to 74%) in English speakers and 2.1-fold (29% to 59%) in non-English speakers. Conclusion: Our results demonstrate that Medicaid expansion of CGM coverage increases its utilization for pediatric PWT1D. Despite increased CGM usage in marginalized community, disparity persists among patients with public insurance, minority races/ethnicities, and non-English language. Future studies are needed to identify barriers that preclude equity in technology uptake. Disclosure B. Miyazaki: None. T. Zeier: None. R. O. Barber: None. J. C. Espinoza: Consultant; Sanofi, Research Support; NIH - National Institutes of Health, FDA, Speaker's Bureau; Glooko, Inc. L. C. Chao: None. Funding U.S. Food and Drug Administration (P50FD006425 to J.C.E.)

Medicaid expansion and risk of eclampsia

Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

Did the Affordable Care Act’s Medicaid Expansion Change Cohabitation Trends?

This study builds on past research to examine whether the Medicaid expansion provision of the Affordable Care Act (ACA) affected cohabitation rates among adults ages 18–40. This provision of the ACA was designed to expand health insurance coverage for low-income individuals. The expansion has been demonstrated to have effects beyond increased access to health services, including effects on financial health, marriage, fertility, and child support payments. Nationally representative data from the 2007 to 2019 Current Population Surveys (N = 45,129–695,629) were used to estimate difference-in-difference models of the effect of the Medicaid expansion on cohabitation. Results indicate generally positive effects of the Medicaid expansion on cohabitation, but effects are primarily limited to states expanding in 2014 and are seen 2 years after expansion. Subgroup analyses indicate some heterogeneity by parenthood and race/ethnicity; results are robust to the exclusion of early and late expansion states and to a wider age range. Findings are consistent with behavior around eligibility notches and changes in non-economic factors post-expansion that may influence cohabitation decisions. As states continue to expand Medicaid coverage, such trends may be increasingly evident.

Impact of Medicaid Expansion on the Treatment and Outcomes of Intrahepatic Cholangiocarcinoma

IntroductionThe Affordable Care Act increased insurance coverage for patients residing in states that expanded Medicaid coverage, but its impact on the outcomes of intrahepatic cholangiocarcinoma (ICC) is not clear. Therefore, we examine the impact of Medicaid expansion (ME) on access to treatment and outcomes of ICC. MethodsWe queried the National Cancer Database (NCDB) data for patients with a diagnosis of ICC (2010–2018). Difference-in-difference (DID) analysis was performed to assess the impact of January 2014 ME on curative-intent surgical resection, multimodal therapy, neoadjuvant chemotherapy, 30-day mortality, and overall survival (OS). ResultsOf the 2150 patients included in the study,1574 (73.2%) and 576 (26.8%) patients lived in non-ME and ME states, respectively. On adjusted DID, ME was independently associated with receipt of curative-intent surgical resection (DID coefficient: 0.05, 95% confidence interval [95% CI]: 0.04–0.06, p = 0.002) and multimodal therapy (DID coefficient: 0.08, 95% CI: 0.06–0.10, p = 0.004). In addition, ME was associated with improved OS in ME states (hazard ratio [HR]: 0.73, 95% CI: 0.62–0.87, p = 0.001) but not in non-ME states (HR: 0.95, 95% CI: 0.80–1.12, p = 0.536). ConclusionME status consistently predicted increased utilization of care processes that improved ICC outcomes, including greater rates of curative-intent surgery and multimodal therapy.

The Future of Public Mental Health: Challenges and Opportunities.

Policy Points Social policies such as policies advancing universal childcare to expand Medicaid coverage of home- and community-based care for seniors and people with disabilities and for universal preschool are the types of policies needed to address social determinants of poor mental health. Population-based global budgeting approaches like accountable care and total cost of care models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve. Policies expanding reimbursement for services delivered by peer support specialists are needed. People with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services.

Insurance-Based Disparities in Congenital Cardiac Operations in the Era of the Affordable Care Act

A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010–2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13–1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01–1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7–9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500–31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort.Graphical Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010–2018