Expanded Medicaid Eligibility Research Articles

Moving opportunistically: Interstate migration after medicaid expansion.

The large-scale expansion of Medicaid eligibility following the Affordable Care Act provides an ideal setting to explore whether changes to state-provided health insurance benefits predict migration across state lines. Using the American Community Survey's person-level data from 2009 to 2019 about moving during the prior 12 months, we examine whether Medicaid's selective expansion after the Affordable Care Act prompted in-migration to states that greatly expanded Medicaid eligibility for the populations most targeted by the expansion. We find that states expanding Medicaid by the largest margin was related to higher in-migration, equating to 0.23 percentage points greater annual population growth in the target population, 0.42 percent for the disabled subpopulation, and 0.25 percent for the parent subpopulation. Our results translate to 56,659 interstate moves after Medicaid enrollment growth. The effect was concentrated among individuals who previously lived close to a state's border. The implications of this study are that high-needs individuals in certain states may be impacted by welfare magnets and modestly prone to being undercounted in projected government expenditures.

The Impact of Medicaid Expansion on Congenital Heart Surgery Outcomes: Data From the Society of Thoracic Surgeons Database

BACKGROUND: The Affordable Care Act expanded Medicaid eligibility and increased public insurance coverage for children across the United States. As only a subset of states adopted expansion of coverage, disparities in insurance coverage between expansion and nonexpansion states emerged. We examined the association between Medicaid expansion and cardiac surgery outcomes to understand the impact of Medicaid expansion in a medically complex pediatric population. We hypothesized that expansion of Medicaid eligibility would be associated with greater improvement in surgical outcomes. METHODS: The Society of Thoracic Surgeons Congenital Heart Surgery Database was used to evaluate perioperative outcomes for children 0 to 18 years undergoing cardiac surgery between January 2010 and December 2019. We used a difference-in-differences (DiD) design to estimate the impact of Medicaid expansion on surgical outcomes by comparing changes in outcomes between individuals in expansion states and those in nonexpansion states, both before and after the expansion. Outcomes included operative mortality, major complications and postoperative length of stay (PLOS). RESULTS: The interaction between Medicaid expansion and time period post- vs preexpansion was not significant for any of the outcome variables. The odds ratio (OR) for mortality related to the Medicaid expansion was 1.12 (confidence interval [CI], 0.95–1.32, P = .161). For major complications, the OR was 0.99 (CI, 0.90–1.09, P = .770). For PLOS, the incidence rate ratio was 1.02 (CI, 0.99–1.05, P = .141). CONCLUSIONS: There was an overall decline in congenital heart surgery mortality over time; however, states that expanded Medicaid eligibility did not experience a greater improvement in mortality relative to states that did not expand eligibility. Similarly, there was no significant difference in major complications or PLOS related to Medicaid expansion. Further studies are needed to examine long-term outcomes and the larger spectrum of accessibility to congenital cardiac care which may benefit from insurance coverage.

Perinatal care among Hispanic birthing people: Differences by primary language and state policy environment.

The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment. Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions. Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline-recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five-year waiting period for pregnant immigrants to access Medicaid. Survey responses from 35,779 postpartum individuals with self-reported Hispanic ethnicity who gave birth during 2016-2020. Compared to English-speaking Hispanic people, Spanish-speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage-point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage-point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish-speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage-point lower prenatal care adequacy, but 1.3 (95% CI:-1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage-point higher postpartum care quality than English-speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage-points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage-points higher. Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish-speaking and English-speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth.

Medicaid expansion and cancer stage at diagnoses during the COVID-19 pandemic in the United States.

1526 Background: Substantial cancer underdiagnosis, especially for early-stage diseases, occurred during the COVID-19 pandemic in the US in 2020. The Affordable Care Act expanded Medicaid to nonelderly adults with income up to 138% Federal Poverty Level in states that opted in, potentially facilitating residents’ access to care during pandemic-related financial and employment instability, thus aiding in timely detection of cancer. This study examines the association of Medicaid expansion with changes in cancer stage at diagnosis during the COVID-19 pandemic. Methods: Adults aged 18-64 years newly diagnosed with cancer in 2019 and 2021 were identified from the National Cancer Database. Year 2020 was excluded to avoid confounding from distinct geographic patterns of COVID-19 infections. A difference-in-differences (DD) approach was used to compare the changes in proportions of patients diagnosed at stage I/II in 2021 vs 2019 between Medicaid expansion states and non-expansion states. Adjusted DD estimates were calculated with linear probability models and stratified by key sociodemographic factors and cancer type. Results: A total of 427,368 adults newly diagnosed with cancer in 2019 and 393,961 in 2021 were identified. Patients diagnosed with stage I/II decreased nationwide, however, decreases were larger in non-expansion states (from 58.3% in 2019 to 56.9% in 2021) compared to expansion states (61.4% in 2019 to 60.7% in 2021), leading to a DD of 0.92 percentage points in early-stage cancer diagnosis associated with Medicaid expansion (95% CI =0.46-1.38). The association was strongest among individuals aged 18-44 years (DD=1.46, 95% CI=0.42-2.49), men (DD=1.46, 95% CI=0.73-2.19), those living in most socioeconomically deprived areas (DD=1.40, 95% CI=0.41-2.40) and nonmetropolitan areas (DD=1.82, 95% CI=0.56-3.09). When stratified by cancer type, the largest associations were seen for esophageal cancer (DD=3.86, 95% CI=0.26-7.45) and prostate cancer (DD=2.81, 95% CI=1.43-4.18). Conclusions: Substantial cancer underdiagnosis and declines in proportion of early-stage diagnoses continued nationwide in 2021, the second year of the COVID-19 pandemic. However, the pattern was worse in non-expansion states, suggesting a protective effect of Medicaid expansion on cancer early diagnosis during the public health emergency. Findings may inform policy makers and the public in the 10 states that have yet to expand Medicaid eligibility.

Medical care services interplay between individual and Medicaid managed care markets in expansion versus non‐expansion states

AbstractWe study enrollment, medical service utilization, and incurred expenses of individual comprehensive and Medicaid managed care plans in states with or without Medicaid expansion adopted at the Affordable Care Act (ACA) early stage 2014–2016. To make healthcare services more accessible, 27 states expanded Medicaid eligibility to cover nearly‐poor non‐elderly adults who have had incomes between 100% and 138% of federal poverty level in 2014. In non‐expansion states, early enrollees in this income cohort had to choose individual market plans rather than Medicaid. Early enrollees' enrollment choices and their health status have had a great impact on the individual market premiums and Medicaid spending. We examined health insurers' annual regulatory filings with the National Association of Insurance Commissioners for 2013–2016 and found that: First, individual comprehensive insurance enrollment grew much faster in states not expanding Medicaid eligibility. Second, after incorporating early enrollees, per member per month (PMPM) medical service utilization and expenses of individual comprehensive insurance grew much faster in non‐expansion states. Third, among major types of medical utilization and expense measures, PMPM hospital inpatient days and PMPM prescription drug expenses increased substantially since 2014. Finally, Medicaid beneficiaries generated more PMPM medical utilization and expenses in expansion states.

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.

Health insurance among survivors of childhood cancer following Affordable Care Act implementation.

The Affordable Care Act (ACA) increased private nonemployer health insurance options, expanded Medicaid eligibility, and provided preexisting health condition protections. We evaluated insurance coverage among long-term adult survivors of childhood cancer pre- and post-ACA implementation. Using the multicenter Childhood Cancer Survivor Study, we included participants from 2 cross-sectional surveys: pre-ACA (2007-2009; survivors: n = 7505; siblings: n = 2175) and post-ACA (2017-2019; survivors: n = 4030; siblings: n = 987). A subset completed both surveys (1840 survivors; 646 siblings). Multivariable regression models compared post-ACA insurance coverage and type (private, public, uninsured) between survivors and siblings and identified associated demographic and clinical factors. Multinomial models compared gaining and losing insurance vs staying the same among survivors and siblings who participated in both surveys. The proportion with insurance was higher post-ACA (survivors pre-ACA 89.1% to post-ACA 92.0% [+2.9%]; siblings pre-ACA 90.9% to post-ACA 95.3% [+4.4%]). Post-ACA insurance increase in coverage was higher among those aged 18-25 years (survivors: +15.8% vs +2.3% or less ages 26 years and older; siblings +17.8% vs +4.2% or less ages 26 years and older). Survivors were more likely to have public insurance than siblings post-ACA (18.4% vs 6.9%; odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1 to 2.6). Survivors with severe chronic conditions (OR = 4.7, 95% CI = 3.0 to 7.3) and those living in Medicaid expansion states (OR = 2.4, 95% CI = 1.7 to 3.4) had increased odds of public insurance coverage post-ACA. Among the subset completing both surveys, low- and mid-income survivors (<$40 000 and <$60 000, respectively) experienced insurance losses and gains in reference to highest household income survivors (≥$100 000), relative to odds of keeping the same insurance status. Post-ACA, more childhood cancer survivors and siblings had health insurance, although disparities remain in coverage.

More doctors in town now? Evidence from Medicaid expansions

AbstractWe examine how physicians’ practice locations are affected by Medicaid expansions. We focus on the dramatic Medicaid eligibility expansions for pregnant women that took place between the early 1980s and the early 1990s. Following a recently‐developed estimation strategy, we identify the change in OB/GYN supply due to the expansions in an event‐study framework. We find that OB/GYN counts per capita grew post‐expansion and the increase persisted for years. Our results are mainly driven by early‐career OB/GYNs and concentrated in densely populated or poor counties. Our results show that Medicaid coverage rules could be an important determinant of physician location choice.

Abstract 811: Impact of Medicaid eligibility expansion to adults regardless of immigration status on health insurance access among Latina patients

Abstract Background: Disparities in the receipt of cancer screening and preventive services are strongly associated with health insurance status. Even after federal- and state-wide initiatives to boost access to health insurance such as the Patient Protection and Affordable Care Act (ACA) Medicaid Expansion to all individuals earning ≤138% of the federal poverty level (FPL) and nationwide individual health insurance marketplaces, Latino populations continue to have the highest uninsured rate of any racial or ethnic group in the US, with 17% of Latinos remaining uninsured compared to 5% of non-Hispanic white peers. In 2021, California and Oregon states amended their respective Medicaid program to expand eligibility to adults regardless of immigration status; which could reduce access disparities for patients from Latino communities. This study shows preliminary results of changes in health insurance status among Latina patients (who have multiple cancer prevention services recommended in middle age) receiving care in community health centers. Methods: A retrospective cohort study of Latina, non-Hispanic Black, and non-Hispanic white women ages 50-64 years receiving primary care from 382 community health clinics in California and Oregon. Using 2018, 2019, 2021, and 2022 electronic health record data, we estimated monthly rates of insured-type visits per 100 visits. We compared rates pre- and post-Medicaid eligibility expansion, both within and between race and ethnicity groups. Reported estimates were derived from generalized estimating equations Poisson regression, clustered on clinic, and adjusted for clinic-level demographics. Results: Of 41,960 patients, over half (53%) were Latina, most of whom (83%) preferred Spanish language communication. Latina patients had more uninsured visits pre-Medicaid eligibility expansion than did non-Hispanic Black and white patients (Rate: 27% versus 5% and 4%, respectively). All racial and ethnic groups experienced a decrease in uninsured visit rates, and this change was similar for all groups [Difference-in-difference Latina versus Black patients: 0.77 (95% CI 0.55, 10.7) and versus white patients: 1.02 (95% CI 0.89, 1.17)]. Overall rates of Medicaid-insured visits increased only for Latina patients [pre-to-post Relative Rate=1.06 (95% CI: 1.03-1.10)]. Both non-Hispanic Black and white patients experienced a drop in Medicaid-insured visits. Only Black patients experienced a significant decline in private-insured visits [pre-to-post RR=0.79 (95% CI: 0.70-0.89)]. Conclusion: These early results suggest an uptake of Medicaid-paid visits among Latina patients. This increase in healthcare coverage for Latina patients could significantly reduce disparities in access to primary care and especially in cancer preventive care. Citation Format: Nathalie Huguet, Jorge Kaufmann, Heather Holderness, Margaret Vieira, Gretchen Mertes, Jackilen Shannon, John Heintzman. Impact of Medicaid eligibility expansion to adults regardless of immigration status on health insurance access among Latina patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 811.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.

Factors affecting women's access to primary care in the United States since the Affordable Care Act: A mixed-methods systematic review.

In the United States, the Affordable Care Act (ACA) expanded public and private health coverage, increased health insurance affordability, reduced healthcare costs, and improved healthcare quality for many. Despite ACA provisions, lack of insurance and other factors continue to affect working-age women's access to primary care services. We conducted a mixed-method systematic review to identify factors that affect women's access to primary care services since the ACA. In January 2021, MEDLINE, CINAHL, PsycINFO, and Web of Science were searched from 2010 to 2021 and an updated search was conducted in October 2023. We included 26 quantitative and qualitative studies reporting determinants, barriers and facilitators of women's primary care access for women (18 to 64 years). Studies reporting measures of potential access, such as health insurance, and measures of realized access-healthcare service utilization, were included. The Mixed-Methods Appraisal Tool (2018) was used to rate the quality of studies. Andersen's Behavioral Model of Health Services Use guided the narrative synthesis. We found consistent evidence that ACA provisions expanding state Medicaid eligibility led to improved insurance coverage, especially for lower-income groups. We found mixed evidence of associations between individual-level determinants, such as age, education, race/ethnicity, income, and different measures of access. Limited qualitative evidence suggests that insurance coverage, low-cost care, positive patient-provider relationships, social support, and translation services enhance access for immigrants and refugees. Barriers include lack of coverage, high healthcare costs, culturally unresponsive healthcare services, poor patient-provider relationships, and transportation issues. Adoption of ACA's expanded Medicaid eligibility criteria would expand insurance coverage to women living in non-expansion states. Innovative healthcare policies, programs, and interventions at the federal, state, and local levels are needed. Suggested strategies include interventions expanding primary healthcare service availability and patient navigation services, and promotion of health literacy, culturally sensitive services, and provider bias education/training.

The effect of Medicaid expansion on the take-up of disability benefits by race and ethnicity.

Public disability programs provide financial support to 12 million working-age individuals per year, though not all eligible individuals take up these programs. Mixed evidence exists regarding the impact of Medicaid eligibility expansion on program take-up, and even less is known about the relationship between Medicaid expansion and racial and ethnic disparities in take-up. Using 2009-2020 Current Population Survey data, we compare changes in Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) take-up among respondents with disabilities living in Medicaid expansion states to respondents with disabilities living in non-expansion states, before and after Medicaid expansion. We further explore heterogeneity by race/ethnicity. We find that Medicaid expansion reduced SSI take-up by 10% overall, particularly among White and Hispanic respondents (10% and 21%, respectively). Medicaid expansion increased SSDI take-up by 8% overall, particularly among White and Black respondents (9% and 11%, respectively). Moreover, we find that Medicaid expansion reduced the probability that respondents with disabilities had employer-sponsored health insurance by approximately 8%, suggesting that expansion may have reduced job-lock among the SSDI-eligible, contributing to the observed increase in SSDI take-up.

Medicaid Expansion And Outpatient Cardiovascular Care Use Among Low-Income Nonelderly Adults, 2012-15.

Adults with lower socioeconomic status have a disproportionately higher burden of cardiovascular disease. Medicaid expansion under the Affordable Care Act, which went into effect January 1, 2014, in adopting states, led to an expansion of health insurance coverage for low-income adults. To understand whether Medicaid expansion was associated with increased access to outpatient cardiovascular care in expansion states, we examined Medicaid Analytic eXtract administrative claims data for nonelderly adult beneficiaries from the period 2012-15 for two states that expanded Medicaid eligibility (New Jersey and Minnesota) and two states that did not (Georgia and Tennessee) and calculated population-level rates of cardiovascular care use. There was a 38.1percent greater increase in expansion states in the rate of beneficiaries with outpatient visits for cardiovascular disease management associated with Medicaid expansion relative to nonexpansion states. This was accompanied by a 42.9percent greater increase in the prescription rate for cardiovascular disease management agents. These results suggest that expansion of Medicaid eligibility was associated with an increase in cardiovascular care use among low-income nonelderly adults in expansion states.

Association of Medicaid Expansion Under the Affordable Care Act With Medicaid Coverage in the Prepregnancy, Prenatal, and Postpartum Periods.

We evaluated how the Affordable Care Act (ACA) Medicaid eligibility expansion affected perinatal insurance coverage patterns for Medicaid-enrolled beneficiaries who gave birth overall and by race/ethnicity. We also examined state-level heterogeneous impacts. Using the 2011-2013 Medicaid Analytic eXtract and the 2016-2018 Transformed Medicaid Statistical Information System Analytic File databases, we identified 1.4 million beneficiaries giving birth in 2012 (pre-ACA expansion cohort) and 1.5 million in 2017 (post-ACA expansion cohort). We constructed monthly coverage rates for the two cohorts by state Medicaid expansion status and obtained difference-in-differences estimates of the association of Medicaid expansion with coverage overall and by race/ethnicity group (non-Hispanic White, non-Hispanic Black, and Hispanic). To explore state-level heterogeneous impacts, we divided the expansion and non-expansion states into groups based on the differences in the income eligibility limits for low-income parents in each state between 2012 and2017. Medicaid expansion was associated with 13 percentage points higher coverage in the 9 to 12months before giving birth, and 11 percentage points higher coverage at 6 to 12months postpartum. Hispanic birthing individuals had the greatest relative increases in coverage, followed by non-Hispanic White and non-Hispanic Black individuals. In Medicaid expansion states, those who experienced the greatest increases in income eligibility limits for low-income parents generally saw the greatest increases in coverage. In non-expansion states, there was less heterogeneity between state groupings. Pregnancy-related Medicaid eligibility did not have major changes in the 2010s. However, states' adoption of ACA Medicaid expansion after 2012 was associated with increased Medicaid coverage before, during, and after pregnancy. The increases varied by race/ethnicity and across states.

Utilization of access to colorectal cancer screening modalities in low-income populations after medicaid expansion.

Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA's Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants. To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States. This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status. A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55). Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across all low-income populations, but not all races or levels of education.

Residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling by adults with lower incomes: Is increased access to primary care enough?

We investigate whether living in a state that expanded Medicaid eligibility is associated with receiving alcohol screening and brief counseling among nonelderly, low-income adults and a subgroup with chronic health conditions caused or exacerbated by alcohol use. Data are from the 2017 and 2019 Behavioral Risk Factor Surveillance System (N = 15,743 low-income adults; n = 7062 with a chronic condition). We used propensity score-weighted, covariate-adjusted, modified Poisson regression to estimate associations between residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling. Models estimated associations in the overall sample and chronic conditions subsample, as well as differential associations across sex, race, and ethnicity using interaction terms. Living in a state that expanded Medicaid eligibility was associated with being asked whether one drank (prevalence ratio (PR) = 1.15, 95% confidence interval (CI) = 1.08, 1.22), but not with further alcohol screening, guidance about harmful drinking, or advice to reduce drinking. Among individuals with alcohol-related chronic conditions, expansion state residence was associated with being asked about drinking (PR = 1.13, 95% CI = 1.05, 1.20) and, among past 30-day drinkers with chronic conditions, being asked how much one drank (PR = 1.28, 95% CI = 1.04, 1.59) and about binge drinking (PR = 1.43, 95% CI = 1.03, 1.99). Interaction terms suggest that some associations differ by race and ethnicity. Living in a state that expanded Medicaid is associated with a higher prevalence of receiving some alcohol screening at a check-up in the past 2 years among low-income residents, particularly among individuals with alcohol-related chronic conditions, but not with the receipt of high-quality screening and brief counseling. Policies may have to address provider barriers to delivery of these services in addition to access to care.

The long term relationship between childhood Medicaid expansions and severe chronic conditions in adulthood

AbstractWe test whether the expansions of children's Medicaid eligibility in the 1980s–1990s resulted in long‐term health benefits in terms of severe chronic conditions. Still relatively rare in the field, we use prospective individual‐level panel data from the Panel Study of Income Dynamics (PSID) along with the higher quality income measures from the Cross‐National Equivalent File (adjusting for taxes, transfers and household size). We observe severe chronic conditions (high blood pressure/heart disease, cancer, diabetes, or lung disease) at ages 30–56 (average age 43.1) for 4670 respondents who were also prospectively observed during childhood (i.e., at ages 0–17). Our analysis exploits within‐region temporal variation in childhood Medicaid eligibility and adjusts for state‐ and individual‐level controls. We uniquely concentrate attention on adjusting for childhood income. A standard deviation greater childhood Medicaid eligibility significantly reduces the probability of severe chronic conditions in adulthood by 0.05 to 0.12 (16%–37.5% reduction from mean 0.32). Across the range of observed childhood Medicaid eligibility, the probability is approximately cut in half. Greater childhood Medicaid eligibility also substantially reduces childhood income disparities in severe chronic conditions. At higher levels of childhood Medicaid eligibility, we find no significant childhood income disparities in adult severe chronic conditions.

Association between state Medicaid policies and accrual of Black and Hispanic patients to cancer clinical trials.

1510 Background: The U.S. Medicaid health insurance program may play a key role in mitigating racial and ethnic disparities in cancer clinical trial enrollment, given Medicaid’s disproportionate representation of these populations and its coverage of the routine costs of trial participation in some states. We sought to evaluate the effect of Medicaid expansion under the Affordable Care Act (ACA) on changes in the accrual of racial and ethnic minority patients in cancer clinical trials, across all states and specifically those mandating Medicaid coverage of routine trial costs. Methods: The study used anonymous enrollment data from Medidata Rave, a large commercial clinical trial data collection platform. We conducted a retrospective difference-in-differences (DID) analysis to examine accrual demographics in states that expanded Medicaid eligibility under the ACA compared with non-expansion states, before and after expansion; and assessed effect modification based on state-mandated Medicaid coverage of routine trial costs. Participants included adults enrolled in interventional cancer clinical trials from 2012-2019, located in U.S. hospital referral regions with &gt;5% Black or Hispanic population. The primary outcome was participant race/ethnicity, defined dichotomously as Black or Hispanic (vs non-Black, non-Hispanic). We used ordinary least squares regression to model participant race/ethnicity as a function of (1) an indicator for trial enrollment in an expansion state after policy implementation, (2) state fixed effects, and (3) year fixed effects, with standard errors clustered at the state level. To assess effect modification, we stratified the main model across states with and without coverage mandates of routine trial costs. Results: The study included 75,700 participants across 1,409 clinical trials and 351 sites. In expansion states, the proportion of participants who identified as Black and/or Hispanic increased from 13.4% before expansion to 13.8% after expansion (0.4 percentage-point [PP] change, 95% CI -0.8 to 1.7). In non-expansion states, this proportion decreased from 17.0% to 15.2% (-1.7 PP change, 95% CI -3.7 to 0.2). These trends yielded a non-significant DID estimate of 2.0 PP (95% CI -1.0 to 5.0). In stratified analyses, Medicaid expansion was associated with a 4.5 PP (95% CI 0.4 to 8.6) increase in the enrollment of Black and/or Hispanic participants in states with coverage mandates, but not in states without coverage mandates (1.1 PP, 95% CI -2.6 to 4.8). Conclusions: Medicaid expansion was associated with a significant increase in the proportion of Black and Hispanic oncology trial participants in states that mandated Medicaid coverage of the routine costs of trial participation, but not overall across all states. These findings suggest that Medicaid policies have the potential to advance equitable enrollment in cancer clinical trials.

Racial disparities in cancer mortality in patients with gastrointestinal malignancies following Medicaid expansion.

6546 Background: Racial minorities experience disparities in receipt of cancer treatment and survival. The optional Medicaid expansion provision of the Affordable Care Act provided federal funding to participating states to improve healthcare access for disadvantaged populations by expanding Medicaid eligibility criteria. This study aimed to investigate the effect of Medicaid expansion on racial disparities in mortality among patients with gastrointestinal malignancies. Methods: A cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma (PDAC), colorectal cancer (CRC), and gastric adenocarcinoma (GC) of any stage was conducted using the National Cancer Database (2009-2019). Difference-in-difference analysis (DID) was performed to compare adjusted 2-year mortality separately among Black and White patients residing in Medicaid expansion states (MES) and non-expansion states (non-MES) before (2009-2013) and after (2014-2019) expansion. Differences in receipt of surgery and chemotherapy were also evaluated. Results: A total of 86,052 patients were included for analysis, including 19,188 patients with PDAC, 60,404 with CRC, and 6,460 with GC. Two-year mortality decreased among Black patients with PDAC residing in MES compared to non-MES following expansion (DID -9.4%, p&lt;0.001) (Table). Mortality also decreased among Black and White patients with CRC in MES compared to non-MES following expansion (DID -4.2%, p &lt; 0.001 and -2.9%, p = 0.047). Among patients with GC, Black patients in MES experienced a marked reduction in mortality compared to non-MES (DID -7.7%, p = 0.07). Both Black and White stage 3-4 PDAC patients had an increase in receipt of chemotherapy in MES following expansion (DID 3.7%, p=0.28 and DID 2.7%, p=0.20). Rates of surgery, but not chemotherapy receipt, increased among Black patients with stage 4 CRC in MES following expansion (DID 5.7%, p=0.03 and 1.0%, p=0.66, respectively). A greater increase in receipt of chemotherapy was observed among Black patients with stage 4 GC in MES than in non-MES (DID 11%, p=0.06). Conclusions: Medicaid expansion was associated with a greater reduction in 2-year mortality rates for Black patients residing in MES than for those in non-MES. Existing racial disparities in mortality remained the same or worsened in non-MES but in almost all cases were mitigated in MES following Medicaid expansion. [Table: see text]

Examining the effect of Medicaid expansion on early detection of head and neck cancer of the oral cavity and pharynx by HPV-type and generosity of dental benefits.

Over a decade of evidence supports the claim that increased access to insurance through Medicaid expansions improves early detection of cancer. Yet, evidence linking Medicaid expansions to early detection of head and neck cancers (HNC) of the oral cavity and pharynx, specifically, may be limited by the lack of attention to Human Papillomavirus (HPV) etiology, generosity of dental coverage, and valid inference analyzing state cancer registry data. This studyreexamined the effect of Medicaid expansion on early detection of HPV+/- HNC in states offering extensive dental benefits. Specialized data from the Surveillance, Epidemiology, and End Results (SEER) program was analyzed to account for, previously unmeasurable, differential detection patterns of HNCs associated with HPV. Then, to identify the effect of increasing Medicaid eligibility on staging patterns in states offering extensive benefits amidst potentially non-common trends between states, a "Triple Differences" design identifies the differential effect of Medicaid Expansion (with dental coverage) on HPV-negative HNCs relative to the change in HPV-positive HNCs. For valid inference analyzing a small number of state clusters (12) in cancer registry data, each regression model applies a Wild Cluster Bootstrap. Expanding Medicaid eligibility was found to be associated with a decrease in the proportion of distant-stage diagnoses of HPV(-) HNCs, but only among states which increased Medicaid dental generosity at the time of Medicaid expansion. These results suggest that adding extensive Medicaid dental benefits was the primary mechanism impacting HNC detection. This study highlights the potential positive spillover effects of policies which increase access to public dental coverage for low-income adults, while also showing the limitation of access to dental services for improving early detection of HPV+ HNCs.