Gain Medicaid Coverage Research Articles

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

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

Heterogeneous effects of Medicaid coverage on cardiovascular risk factors: secondary analysis of randomized controlled trial

ObjectivesTo investigate whether health insurance generated improvements in cardiovascular risk factors (blood pressure and hemoglobin A1c (HbA1c) levels) for identifiable subpopulations, and using machine learning to identify characteristics of people...

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

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

How Medicaid Financial Eligibility Rules Exclude Financially and Medically Vulnerable Older Adults

ABSTRACT Millions of older Americans rely on Medicaid because it is the largest payer of long-term services and supports. To qualify for the program, low-income individuals age 65 and over must meet income standards based on the dated Federal Poverty Level as well as asset tests that are often viewed as quite stringent. There has long been concern that current eligibility standards exclude many adults with significant health and financial vulnerabilities. We use updated household socio-demographic and financial information to simulate the impacts of five alternative financial eligibility standards on the number and profile of older adults that would gain Medicaid coverage. The study clearly demonstrates that a large number of financially- and health-vulnerable older adults are excluded from the Medicaid program under current policy. The study highlights the implications for policymakers of updating Medicaid financial eligibility standards to assure that Medicaid benefits are targeted to vulnerable older adults who need them.

Medicaid Expansion and Medical Debt: Evidence From Louisiana, 2014-2019.

Objectives. To identify the association between Medicaid eligibility expansion and medical debt. Methods. We used difference-in-differences design to compare changes in medical debt for those gaining coverage through Louisiana's Medicaid expansion with those in nonexpansion states. We matched individuals gaining Medicaid coverage because of Louisiana's Medicaid expansion (n = 196 556) to credit report data on medical debt and compared them with randomly selected credit reports of those living in Southern nonexpansion state zip codes with high rates of uninsurance (n = 973 674). The study spanned July 2014 through July 2019. Results. One year after Louisiana Medicaid expansion, medical collections briefly rose before declining by 8.1 percentage points (95% confidence interval [CI] = -0.107, -0.055; P ≤ .001), or 13.5%, by the third postexpansion year. Balances also briefly rose before falling by 0.621 log points (95% CI = -0.817, -0.426; P ≤ .001), or 46.3%. Conclusions. Louisiana's Medicaid expansion was associated with a reduction in the medical debt load for those gaining coverage. These results suggest that future Medicaid eligibility expansions may be associated with similar improvements in the financial well-being of enrollees.

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

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

The Affordable Care Act Is Associated With Increased Coverage and Decreased Charges, but Limited Improvement in Access to Vascular Surgery for Medicaid Patients

The Centers for Medicare and Medicaid Services estimate that 10 million people gained Medicaid coverage following implementation of the Patient Protection and Affordable Care Act (ACA); yet, it remains unclear how the expansion of Medicaid coverage has affected vascular surgical practice. We examined patients (18-65 years) in the National Inpatient Sample undergoing vascular procedures and total charges pre-ACA implementation (2006-2013) and post-ACA implementation (2014-October 2015). Western and Southern US census regions were surrogate exposure markers for Medicaid expansion status. International Classification of Diseases, 9th edition, procedure codes identified carotid endarterectomy, carotid artery stenting, abdominal aortic aneurysm repair (AAA) repair, endovascular AAA repair (EVAR), thoracic EVAR (TEVAR), major amputation (AMP), minor amputation (mAMP), and arteriovenous fistula/graft creation. Generalized linear models with modified Poisson distributions were calculated to compare pre- versus post-ACA outcomes, adjusted for gender and race/ethnicity. A difference-in-differences (DiD) analysis was conducted to compare post-ACA changes in vascular surgery access for Western versus Southern regions. A total of 196,684 procedures (South) and 76,031 procedures (West) were included. The proportion of uninsured patients undergoing surgery in the West decreased from 6.8% pre-ACA to 3.4% post-ACA but increased from 7.3% pre-ACA to 10.2% post-ACA in the South (P < .001). A significantly greater proportion of vascular procedures were covered by Medicaid in the West (pre-ACA 19.8% vs post-ACA 37.1%) compared to the South (pre-ACA 12.9% vs post-ACA 24.8%; P < .001; Figure). Total charges were reduced in the West (median pre-ACA $65,601 [interquartile range (IQR), $84,893], post-ACA ($55,718 [IQR, $83,950]) compared to the South (pre-ACA $44,124 [IQR, $55,079], post-ACA $39.199 [IQR, 60,142]; P < .001). In regression analyses, the post-ACA relative risk (RR) of undergoing surgery in the West versus South for Medicaid patients demonstrated a higher proportion undergoing surgery on DiD for carotid endarterectomy (adjusted RR [aRR] 2.37 [standard error, 0.05]; P < .001), mAMP (aRR, 1.17 [standard error, 0.03]; P < .001) and TEVAR (aRR, 1.35 [standard error, 0.17]; P = .008), but the RR decreased on DiD for arteriovenous fistula/graft creation (aRR, 0.49 [standard error, 0.04]; P < .001) and peripheral vascular intervention (aRR, 0.85 [standard error, 0.03]; P < .001). There were no significant differences post-ACA implementation for AAA (P = .36), carotid artery stenting (P = .49), EVAR (P = .18), lower extremity revascularization (P = .23), and AMP (P = .59) (Table). Implementation of the ACA’s Medicaid expansion was associated with significant transformation in payer mix for vascular surgery and reduction in the median charges per patient; however, improving access to limb revascularization and reducing amputations continues to lag for Medicaid patients. Future research is needed to understand the impact of Medicaid expansion on individual patient level outcomes and population health measures.TableGeneralized linear model with modified Poisson regression comparing the likelihood of a Medicaid patient undergoing a given vascular procedure in the Western versus Southern Region (referent) stratified by pre-Affordable Care Act (ACA) implementation vs post-ACA implementation and adjusted for gender and race/ethnicityWestern regionSouthern regionPre versus Post DiDP valueINTERPRETATIONAdjusted RR post-ACASEP valueAdjusted RR post-ACASEP valueAAA0.950.11.640.800.09.01.36No significant differences in AAA occurrence post-ACAAVF/AVG0.490.04<.0010.510.04<.001<.001Significantly larger decrease in AVF/AVG in the West post-ACACEA2.370.05<.0011.440.04<.001<.001Significantly greater increase in CEA in the West post-ACACAS1.350.11.0051.170.09.06.49No significant differences in CAS occurrence post-ACAEVAR3.460.13<.0014.770.09<.001.18No significant difference in the increase of EVAR post-ACALER0.970.05.461.010.03.71.23No significant differences in LER occurrence post-ACAMinor AMP1.170.03<.0010.880.03<.001<.001Significantly greater increase in minor AMP in the West post-ACAMajor AMP1.030.04.430.790.03<.001.58No significant changes in major AMP post-ACAPVI0.850.03<.0011.240.02<.001<.001PVI decreased in the West but increased in the South post-ACATEVAR1.350.17.071.450.14.009.008Significantly greater increase in TEVAR in the West post-ACAAAA, Abdominal aortic aneurysm; AMP, amputation; AVF, arteriovenous fistula; AVG, arteriovenous graft; CAS, carotid artery stenting; CEA, carotid endarterectomy; DiD, difference-in-difference; EVAR, endovascular aortic aneurysm repair; LER, lower extremity revascularization; PVI, peripheral vascular intervention; RR, relative risk; TEVAR, thoracic endovascular aortic repair.ARR of undergoing the procedure in the West compared to the South and least squares means estimates describing difference-in-differences for Medicaid patients pre- and post-ACA expansion are reported. Open table in a new tab

How the COVID-19 Recession Could Affect Health Insurance Coverage

Thirty million workers filed initial unemployment claims between March 15 and April 25. As workers lose their jobs, many will also lose their employer-sponsored health insurance (ESI), as will their dependents. Some of these workers and dependents will qualify for Medicaid coverage, particularly in states that expanded Medicaid eligibility under the Affordable Care Act (ACA). Others will purchase individual coverage on the health insurance Marketplaces, possibly with a subsidy to offset the premium cost. And many will be unable to replace their ESI coverage and become uninsured. In this brief, we estimate how health insurance coverage could change as millions of workers lose their jobs during the COVID-19 recession. We present national and state-level estimates of coverage changes if unemployment rates rise from precrisis levels (around 3.5 percent nationally) to 15 percent, 20 percent, or 25 percent. For each unemployment level, we provide a base case scenario of coverage changes and a high scenario, derived from two different estimation methods. In our base scenario, we estimate that at 20 percent unemployment, approximately 25 million people will lose ESI coverage, and of them, 12 million would gain Medicaid coverage, 6 million would gain Marketplace or other private coverage, and 7 million would become uninsured. In the high scenario, we estimate that 43 million people would lose ESI coverage. The increase in Medicaid coverage and uninsurance rates will be uneven across the country, with a greater share of those estimated to lose ESI gaining Medicaid coverage and a lower share becoming uninsured in states that expanded Medicaid under the ACA.

Medicaid Utilization and Spending among Homeless Adults in New Jersey: Implications for Medicaid-Funded Tenancy Support Services.

Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending. Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries. More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups. A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.

Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study.

It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions. Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being. Mixed-methods study including a telephone survey and semi-structured interviews. Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP). 4090 survey respondents (response rate 54%) with ≥ 12months HMP enrollment and 67 interviewees with ≥ 6months enrollment. Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status. Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health. Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.

Impact of Health Insurance on Stage at Cancer Diagnosis Among Adolescents and Young Adults

Uninsured adolescents and young adults (AYAs) and those with publicly funded health insurance are more likely to be diagnosed with cancer at later stages. However, prior population-based studies have not distinguished between AYAs who were continuously uninsured from those who gained Medicaid coverage at the time of cancer diagnosis. AYA patients (ages 15-39 years) with nine common cancers diagnosed from 2005 to 2014 were identified using California Cancer Registry data. This cohort was linked to California Medicaid enrollment files to determine continuous enrollment, discontinuous enrollment, or enrollment at diagnosis, with other types of insurance determined from registry data. Multivariable logistic regression was used to evaluate factors associated with later stages at diagnosis. The majority of 52 774 AYA cancer patients had private or military insurance (67.6%), followed by continuous Medicaid (12.4%), Medicaid at diagnosis (8.5%), discontinuous Medicaid (3.9%), other public insurance (1.6%), no insurance (2.9%), or unknown insurance (3.1%). Of the 13 069 with Medicaid insurance, 50.1% were continuously enrolled. Compared to those who were privately insured, AYAs who enrolled in Medicaid at diagnosis were 2.2-2.5 times more likely to be diagnosed with later stage disease, whereas AYAs discontinuously enrolled were 1.7-1.9 times and AYAs continuously enrolled were 1.4-1.5 times more likely to be diagnosed with later stage disease. Males, those residing in lower socioeconomic neighborhoods, and AYAs of Hispanic or black race and ethnicity (vs non-Hispanic white) were more likely to be diagnosed at a later stage, independent of insurance. Our findings suggest that access to continuous medical insurance is important for decreasing the likelihood of late stage cancer diagnosis.

The effect of the affordable care act Medicaid expansions on financial wellbeing

We examine the effect of the Medicaid expansions under the 2010 Patient Protection and Affordable Care Act (ACA) on consumer financial outcomes using data from a major credit reporting agency for a large, national sample of adults. We employ the synthetic control method to compare individuals living in states that expanded Medicaid to those that did not. We find that the Medicaid expansions significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies among those residing in zip codes with the highest share of low-income, uninsured individuals. Our estimates imply a reduction in collection balances of approximately $1140 among those who gain Medicaid coverage due to the ACA. Our findings suggest that the ACA Medicaid expansions had important financial impacts beyond increasing health care use.

Gaining Medicaid Coverage During ACA Implementation: Effects on Access to Care and Preventive Services

The continued expansion of Medicaid is under debate; it is critical to evaluate the effect of obtaining Medicaid on access to preventive care. We analyzed longitudinal data from the 2013-2014 Medical Expenditure Panel Survey and applied a difference-in-differences approach. Our treatment group included low-income, non-pregnant, non-disabled adults aged 18-64 with no insurance in 2013 who received Medicaid in 2014; the comparison group included individuals who did not have insurance in either year. Gaining Medicaid increased the likelihood of having a usual source of care, at least one office visit, annual checkup, annual cholesterol and blood pressure tests by 13 (CI: 2-24), 14 (CI: 2-27), 11 (CI: 1-21), 29 (CI: 20-39), and 13 (CI: 1-25) percentage points, respectively. Receipt of flu vaccine increased by eight (CI: -3-19) percentage points (insignificant). Medicaid coverage improved use of evidence-based preventive services at a national level among uninsured, non-pregnant, low-income adults.

Medicaid's Impact on Chronic Disease Biomarkers: A Cohort Study of Community Health Center Patients.

Understanding the impact of health insurance is critical, particularly in the era of Affordable Care Act Medicaid expansion. The electronic health record (EHR) provides new opportunities to quantify health outcomes. To assess changes in biomarkers of chronic disease among community health center (CHC) patients who gained Medicaid coverage with the Oregon Medicaid expansion (2008-2011). Prospective cohort. Patients were followed for 24months, and rate of mean biomarker change was calculated. Time to a controlled follow-up measurement was compared using Cox regression models. Using EHR data from OCHIN (a non-profit network of CHCs) linked to state Medicaid data, we identified three cohorts of patients with uncontrolled chronic conditions (diabetes, hypertension, and hyperlipidemia). Within these cohorts, we included patients who gained Medicaid coverage along with a propensity score-matched comparison group who remained uninsured (diabetes n = 608; hypertension n = 1244; hyperlipidemia n = 546). Hemoglobin A1c (HbA1c) for the diabetes cohort, systolic and diastolic blood pressure (SBP and DBP, respectively) for the hypertension cohort, and low-density lipoprotein (LDL) for the hyperlipidemia cohort. All cohorts improved over time. Compared to matched uninsured patients, adults in the diabetes and hypertension cohorts who gained Medicaid coverage were significantly more likely to have a follow-up controlled measurement (hazard ratio [HR] =1.26, p = 0.020; HR = 1.35, p < 0.001, respectively). No significant difference was observed in the hyperlipidemia cohort (HR = 1.09, p = 0.392). OCHIN patients with uncontrolled chronic conditions experienced objective health improvements over time. In two of three chronic disease cohorts, those who gained Medicaid coverage were more likely to achieve a controlled measurement than those who remained uninsured. These findings demonstrate the effective care provided by CHCs and the importance of health insurance coverage within a usual source of care setting. NCT02355132 [ https://clinicaltrials.gov/ct2/show/NCT02355132 ].

Gaining Coverage In 2014: New Estimates Of Marketplace And Medicaid Transitions.

We used data from the Medical Expenditure Panel Survey-Household Component to examine coverage transitions for nonelderly US adults. We found that 71.5percent of Marketplace enrollees in 2014 had some period of uninsurance before enrollment. In Medicaid expansion states, 17.4percent of adults who were uninsured throughout 2013 gained Medicaid coverage in 2014, compared with only 5.6percent in those states between 2012 and 2013.

United States Health Care Reform: Progress to Date and Next Steps.

The Affordable Care Act is the most important health care legislation enacted in the United States since the creation of Medicare and Medicaid in 1965. The law implemented comprehensive reforms designed to improve the accessibility, affordability, and quality of health care. To review the factors influencing the decision to pursue health reform, summarize evidence on the effects of the law to date, recommend actions that could improve the health care system, and identify general lessons for public policy from the Affordable Care Act. Analysis of publicly available data, data obtained from government agencies, and published research findings. The period examined extends from 1963 to early 2016. The Affordable Care Act has made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care. Since the Affordable Care Act became law, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, primarily because of the law's reforms. Research has documented accompanying improvements in access to care (for example, an estimated reduction in the share of nonelderly adults unable to afford care of 5.5 percentage points), financial security (for example, an estimated reduction in debts sent to collection of $600-$1000 per person gaining Medicaid coverage), and health (for example, an estimated reduction in the share of nonelderly adults reporting fair or poor health of 3.4 percentage points). The law has also begun the process of transforming health care payment systems, with an estimated 30% of traditional Medicare payments now flowing through alternative payment models like bundled payments or accountable care organizations. These and related reforms have contributed to a sustained period of slow growth in per-enrollee health care spending and improvements in health care quality. Despite this progress, major opportunities to improve the health care system remain. Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation's most complex challenges.

Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study.

Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population. We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers. Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data. Cohort of patients who smoke and who gained Medicaid coverage in 2008-2011 after ≥ 6months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n = 4140 matched pairs; 8280 patients). Gaining Medicaid after being uninsured for ≥ 6months. 'Quit' smoking status (baseline smoking status was 'current every day' or 'some day' and status change to 'former smoker' at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period. The newly insured had 40% increased odds of quitting smoking (aOR = 1.40, 95% CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR = 2.94, 95% CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR = 2.12, 95% CI:1.94, 2.32) compared to their uninsured counterparts. Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation.

The Role of Public Health Insurance in Reducing Child Poverty

Over the past 30 years, there have been major expansions in public health insurance for low-income children in the United States through Medicaid, the Children's Health Insurance Program (CHIP), and other state-based efforts. In addition, many low-income parents have gained Medicaid coverage since 2014 under the Affordable Care Act. Most of the research to date on health insurance coverage among low-income populations has focused on its effect on health care utilization and health outcomes, with much less attention to the financial protection it offers families. We review a growing body of evidence that public health insurance provides important financial benefits to low-income families. Expansions in public health insurance for low-income children and adults are associated with reduced out of pocket medical spending, increased financial stability, and improved material well-being for families. We also review the potential poverty-reducing effects of public health insurance coverage. When out of pocket medical expenses are taken into account in defining the poverty rate, Medicaid plays a significant role in decreasing poverty for many children and families. In addition, public health insurance programs connect families to other social supports such as food assistance programs that also help reduce poverty. We conclude by reviewing emerging evidence that access to public health insurance in childhood has long-term effects for health and economic outcomes in adulthood. Exposure to Medicaid and CHIP during childhood has been linked to decreased mortality and fewer chronic health conditions, better educational attainment, and less reliance on government support later in life. In sum, the nation's public health insurance programs have many important short- and long-term poverty-reducing benefits for low-income families with children.

Receipt of Preventive Services After Oregon's Randomized Medicaid Experiment.

It is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S., primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon's 2008 randomized Medicaid expansion ("Oregon Experiment") on receipt of 12 preventive care services in community health centers using electronic health record data. Demographic data from adult (aged 19-64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008-2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012-2014; analysis performed in 2014-2015). Intent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for 8 of 12 assessed preventive services. In intent-to-treat analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography). Rates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations.

Community Health Center Use After Oregon's Randomized Medicaid Experiment.

There is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment"). We probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008-2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging. The intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05-1.55) for laboratory tests to 1.58 (95% CI, 1.10-2.28) for referrals. Our results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.