Implementation Of Affordable Care Act Research Articles

Effect of the Affordable Care Act on Cervical Cancer Survival Rates in Californian Women [ID 2683402

INTRODUCTION: Following the Affordable Care Act (ACA), insurance coverage among women in California surged. While ACA aimed to boost health care access and utilization, whether this has improved cancer-specific survival rates for cervical cancer patients remains questioned. In the present study, we evaluate the effect of the Affordable Care Act (ACA) on cancer-specific survival rates among women with cervical cancer by comparing pre-ACA (2000–2009) and post-ACA (2010–2020) periods. METHODS: This study utilized data from the Surveillance, Epidemiology, and End Results (SEER) Registry from 2000 to 2020. We bifurcated the study duration into pre-ACA (2000–2009) and post-ACA (2010–2020). The primary outcome investigated was cancer-specific survival between these periods. Our objective was to assess the effect of ACA's implementation on cancer-specific survival among women diagnosed with cervical cancer. Analytical adjustments were made for patient age, race/ethnicity, disease stage at presentation, income, marital status, and metropolitan residence status. We also considered whether cervical cancer was the primary site and incorporated treatment modalities such as curative surgery, radiotherapy, and chemotherapy into our analysis. RESULTS: Of 29,402 cervical cancer patients, 15,962 were diagnosed pre-ACA and 13,440 post-ACA. More women over 50 were diagnosed post-ACA (49.4%) than pre-ACA (44.9%). Late-stage diagnoses rose slightly post-ACA (42.7% versus 40.8%). Curative surgery decreased post-ACA (53.7% from 62.7%), but chemotherapy increased (48.6% from 39.9%). After adjusting for treatment modalities, post-ACA survival rates in California mirrored those of the pre-ACA period (hazard ratio [HR] 1.06; 95% CI, 0.98–1.15). CONCLUSION: The implementation of the ACA led to notable changes in treatment patterns and demographics for cervical cancer patients in California. Although health care access increased, cancer-specific survival rates were similar to the pre-ACA period when adjusting for treatment modalities.

Impact of Medicaid expansion on pregnancy outcomes among women with gestational diabetes.

The Affordable Care Act (ACA) aims to broaden health care access and significantly impacts obstetric practices. Yet, its effect on maternal and neonatal outcomes among women with gestational diabetes across diverse demographics is underexplored. This study examines the impact of the implementation of the ACA on maternal and neonatal health in Maryland with ACA implementation and Georgia without ACA implementation. We used data from the Maryland State Inpatient Database and US Vital Statistics System to assess the ACA's influence on maternal and neonatal outcomes in Maryland, with Georgia serving as a nonexpansion control state. Outcomes compared include cesarean section (CS) rates, low Apgar scores, neonatal intensive care unit (NICU) admissions, and assisted ventilation 7 h postdelivery. We adjusted for factors including women's age, race, insurance type, preexisting conditions, prior CS, prepregnancy obesity, weight gain during pregnancy, birth weight, labor events, and antenatal practices. The study included 52 479 women: 55.8% from Georgia and 44.2% from Maryland. Post-ACA, CS rates were 45.1% in Maryland versus 48.2% in Georgia (P = 0.000). Maryland demonstrated better outcomes, including lower rates of low Agar scores (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.63-0.86]), assisted ventilation (OR, 0.79 [95% CI, 0.71-0.82]), and NICU admissions (OR, 0.76 [95% CI, 0.71-0.82]), but no significant change in CS rates (OR, 0.96 [95% CI, 0.92-1.01]). After ACA implementation, Maryland showed improved maternal and neonatal outcomes compared with Georgia, a nonexpansion state.

The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012–2018

BackgroundPerinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees.MethodsWe applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum.ResultsACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis.ConclusionThe ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

Causal Effects of the Affordable Care Act (ACA) Implementation on Non-Hodgkin's Lymphoma Survival: A Difference-in-Differences Analysis.

Non-Hodgkin's Lymphoma (NHL) accounts for a substantial number of cancer cases in the United States, with a significant prevalence and mortality rate. The implementation of the Affordable Care Act (ACA) has the potential to impact cancer-specific survival among NHL patients by improving access to healthcare services and treatments. This study aims to assess the impact of the implementation of the ACAon cancer-specific survival among patients diagnosed with NHL. In this retrospective analysis, we leveraged data from the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of the ACAon cancer-specific survival among NHL patients. The study covered the years 2000-2020, divided into pre-ACA (2000-2013) and post-ACA (2017-2020) periods, with a three-year washout (2014-2016). Using a Difference-in-Differences approach, we compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014). We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities. Among 74,762 patients, 56.2% were in New Jersey (42,005), while 43.8% were in Georgia (32,757). The pre-ACA period included 32,851 patients (51.7% in Georgia and 56.7% in New Jersey), and 27,447 patients were in the post-ACA period (48.3% in Georgia and 43.4% in New Jersey). The post-ACA period exhibited a 34% survival improvement (OR=0.66, 95% CI 0.58-0.75). ACA implementation was associated with a 16% survival boost among NHL patients in New Jersey (OR=0.84, 95% CI 0.74-0.95). Other factors linked to improved survival included surgery (OR=0.86, 95% CI 0.81-0.91), radiotherapy (OR=0.77, 95% CI 0.72-0.82), and married status (OR=0.67, 95% CI 0.64-0.71). The study underscores the ACA's potential positive impact on cancer-specific survival among NHL patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.

States' racial resentment correlates with administrative distancing and lower rates of health plan selection in affordable care act marketplaces: a cross sectional analysis.

In the United States, the Affordable Care Act (ACA) pursued equity in healthcare access and treatment, but ACA implementation varied, especially limiting African Americans' gains. Marketplaces for subsidized purchase of coverage were sometimes implemented with limited outreach and enrollment assistance efforts. Reflecting state's ACA receptivity or reluctance, state's implementation may rest on sociopolitical stances and racial sentiments. Some states were unwilling to provide publicly supported healthcare to nonelderly, non-disabled adults- "the undeserving poor" -who evoke anti-black stereotypes. The present study assessed whether some states shunned Affordable Care Act (ACA) marketplaces and implemented them less vigorously than other states, leading to fewer eligible persons selecting insurance plans. It assessed if states' actions were motivated by racial resentment, because states connote marketplaces to be government assistance for unworthy African Americans. Using marketplace and plan selection data from 2015, we rated states' marketplace structures along a four-level continuum indicating greater acceptance of marketplaces, ranging from states assuming sole responsibility to minimal responsibility. Using national data from a four-question modern racism scale, state-wide racial resentment estimates were estimated at the state level. Analysis assessed associations between state levels of racial resentment with states' marketplace structure. Further analysis assessed relationships between both state levels of racial resentment and states' marketplace structure with states' consumer plan selection rates-representing the proportion of persons eligible to enroll in insurance plans who selected a plan. Racial resentment was greater in states with less responsibility for the administration of the marketplaces than actively participating states. States higher in racial resentment also showed lower rates of plan selection, pointing to less commitment to implementing marketplace provisions and fulfilling the ACA's coverage-improvement mission. Differences persisted after controlling for differences in conservatism, uninsurance, poor health, and rejection of Medicaid expansion. Resentment of African Americans' purported irresponsibility and entitlement to government assistance may interfere with states structuring and operating marketplaces to maximize health insurance opportunities for everyone available under the ACA. N/A.

Association of the affordable care act with perceived health care quality of cancer survivors

BackgroundThe association between the Patient Protection and Affordable Care Act (ACA) and perceptions of health care quality of cancer survivors is not well established. The purpose of this study was to examine changes in perceived health care quality concurrent with the implementation of the ACA among cancer survivors relative to a non-cancer comparison group. MethodsWe used cross-sectional data from the Health Information National Trends Survey (N = 30,542). Participants were considered cancer survivors if they had a diagnosis greater than five years before the interview. The pre-ACA period included the years 2008 through 2014. The post-ACA period included 2017 through 2020. Using difference-in-differences methods, we estimated the association of ACA implementation with perceived health care quality (measured from excellent to fair/poor) using propensity score-matched cancer survivors (n = 2298) and a non-cancer comparison group (n = 6669) with weighted logistic models. ResultsThere were similar distributions of perceptions of excellent, very good, good, and fair/poor health care quality regardless of cancer status or time-period. The pre–post ACA implementation difference of reporting excellent, very good and good health care quality (odds ratio [OR]: 1.0, 95% confidence interval [CI]: 0.83–1.19; OR: 0.98, 95% CI 0.83–1.19; and OR: 1.05, 95% CI: 0.87–1.28 respectively) compared to fair/poor was similar in cancer survivors relative to the non-cancer comparison group. ConclusionsThe initial implementation of the ACA appeared to have no effect on perceived overall health care quality reported by cancer survivors when compared to individuals without a history of cancer. Health care policies and domains which continue to support better patient-perceived care quality should be assessed in the cancer survivor population.

Disparities in Time to Prostate Cancer Treatment Initiation before and after the Affordable Care Act

Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for men with PCa is unknown. Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis to start of surgery, radiotherapy, or hormonal therapy. Cochran-Armitage test measured annual trends in delays, and join point regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays. Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p<.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p<.001) patients had higher odds of delay. These disparities persisted when analyzing only patients treated after 2014 or for patients who had Medicare or Private insurance. Compared to uninsured patients, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = .31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p<.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p<.001) had lower odds of delay. These disparities persisted when analyzing only patients treated after 2014. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p<.001); 2014 was associated with a significant inflection for increase in rates of major delays. The impact of race and insurance status were independently associated with longer delays to PCa treatment in the US. These disparities were unaffected by implementation of the ACA. In fact, implementation of ACA was associated with increased delays in treatment initiation for all men, regardless of race. As the epidemiology of newly diagnosed prostate cancer in the United States continues to shift due to tempered screening and the COVID pandemic, further work will be needed to increase equity in prostate cancer care.

Impact of the Affordable Care Act on Insurance Status of Patients Newly Diagnosed With Kaposi Sarcoma

Background: The Affordable Care Act (ACA) role in changing the insurance composition of patients diagnosed with many dermatological conditions, such as Kaposi Sarcoma (KS), has not been assessed. Methods: The Surveillance, Epidemiology and End Results (SEER) Program, which captures cancer data from nearly 40% of cases in the US was used to extract cases. Cases were subgrouped by Medicaid expansion and non-expansion states. Standard mean differences were used as the statistical measure with P-value &lt;0.05 used for statistical significance. Results: 2,465 patients met the inclusion criteria. In patients newly diagnosed with Kaposi sarcoma nationally before and after ACA implementation, the analysis showed there was no significant difference in the percentage of uninsured patients, Medicaid-insured patients, or privately insured patients. Pre- and post-ACA sub-analysis of patients newly diagnosed with Kaposi sarcoma in states that expanded Medicaid showed: (1) significant decrease in the percentage of uninsured patients (-5.81% difference, 95% CI -9.58% to -2.04%, P &lt;.05); (2) significant increase in the percentage of Medicaid-insured patients (+9.36% difference, 95% CI +0.35% to +18.37%, P &lt;.05) and (3) no significant difference in the percent of privately insured patients (-3.54% difference, 95% CI -13.74% to +6.64%). Sub-analysis in non-expansion states showed no difference between the insurance subtypes. Conclusion: Medicaid expansion played the largest role in reducing the percentage of uninsured patients newly diagnosed with KS. In states without Medicaid expansion, it is important that public health forces ensure adequate access to medications with services like the Ryan White HIV/AIDS Program

Impact of the Affordable Care Act and Medicaid Expansion on Insurance Coverage and Outcomes in Patients with HIV‐associated Aggressive B‐cell Non‐Hodgkin Lymphomas

Introduction: HIV-associated lymphomas affect a uniquely disadvantaged group of patients, who were often denied insurance based on preexisting conditions until the Affordable Care Act (ACA) was signed in 2010. We investigated the impact of ACA and its Medicaid expansion in 2014 which covered the low-income strata, on outcomes among patients with HIV-associated aggressive B-cell non-Hodgkin lymphomas (HIV-aB-NHL). Methods: We used the National cancer database (NCDB) to identify HIV-associated aB-NHL patients aged 18–64 years from 2004 to 2017. We defined the pre-ACA period up to 2013 and the post-ACA period after 2014. States were grouped as Medicaid expansion adopted or not adopted. To reduce bias from advancements in anti-retroviral and chemo-immuno-therapies, we compared survival outcomes between 2010 to 2013 and 2014 to 2017. Kaplan-Meier method and a parametric Weibull model were used for survival analysis. Results: We identified 10,795 eligible patients with HIV-associated aB-NHL, comprised of 1802 Hispanics (16.7%), 3915 non-Hispanic blacks [NHB (36.3%)], 4727 Non-Hispanic Whites [NHW (43.8%)] and 351 other minorities (3.2%). The predominant diagnoses were diffuse large B-cell lymphoma (63.3%) and Burkitt lymphoma (20.1%). The figure shows the distribution of insurance status at diagnosis in Medicaid expansion (n = 4611) and non-expansion (n = 3091) states before and after the implementation of ACA stratified by race. Hispanics were more likely to be from residential zip codes in the lower educational quartile. A higher proportion of patients were seen at academic medical centers in expansion states across all races, and this further improved post-ACA. There was a significant improvement in survival seen among NHB (p < 0.01) post-ACA though the trend in Hispanics was not significant (P = 0.36). A multivariable survival analysis using the Weibull model adjusting for age, sex, insurance status, Charlson-Deyo comorbidity index, income, race, and Medicaid expansion status found statistically significant improvement in the states that adopted Medicaid expansion (HR 0.88, p < 0.01) though NHB race predicted poor survival (HR 1.49, p < 0.01). Keywords: Aggressive B-cell non-Hodgkin lymphoma, Cancer Health Disparities Conflicts of interests pertinent to the abstract. L. D. Anderson Consultant or advisory role: Celgene, BMS, Amgen, GSK, Janssen, Karyopharm, Beigene, AbbVie, Cellectar, and Sanofi Y. F. Madanat Consultant or advisory role: BluePrint Medicines, GERON, OncLive, Sierra Oncology, Stemline Therapeutics and Novartis G. Kaur Honoraria: BMS and Cellectar F. T. Awan Consultant or advisory role: Genentech, Astrazeneca, Abbvie, Janssen, Pharmacyclics, Gilead sciences, Kite pharma, Celgene, Karyopharm, MEI Pharma, Verastem, Incyte, Beigene, Johnson and Johnson, Dava Oncology, BMS, Merck, Cardinal Health, ADCT therapeutics, Epizyme, Caribou Biosciences, Cellecter Bisosciences Research funding: Pharmacyclics P. Ramakrishnan Geethakumari Consultant or advisory role: Kite Pharma, Bristol Myers Squibb, Rafael Pharma, Pharmacyclics LLC, ADC Therapeutics and Cellectar Biosciences

The association between the Patient Protection and Affordable Care Act and healthcare affordability among US adults with intellectual disability.

Historically, US adults with intellectual disability (ID) experience worse healthcare access than the general population. However, the implementation of the Patient Protection and Affordable Care Act (ACA) may have reduced disparities in healthcare access. Using a pre-ACA 2011-2013 sample and a post-ACA implementation 2014-2016 sample from the National Health Interview Survey data, we examined the association between the ACA's introduction and healthcare access among adults with ID (N=623). Negative binomial regression models were used to test the association between the ACA and the total number of foregone healthcare services. Binary logistic regression was used to explore whether the ACA's implementation was associated with the increased likelihood of possessing health insurance as well as the decreased likelihood of any and particular measures of foregone healthcare services due to cost. The study provides evidence that the ACA's implementation was associated with the decreased likelihood of the total number and any foregone care services owing to cost. Findings also revealed that the ACA's implementation was associated with expansion of health insurance coverage and decreasing instances of foregone care services for medical care, dental care, specialist visit and mental care among adults with ID. However, persons with ID were still at a higher risk of foregone prescription medicines, follow-up medical care and eyeglasses due to cost in the post-ACA years. The study provides evidence that healthcare access among Americans with ID improved after the ACA's implementation. However, challenges in access to follow-up care, eyeglasses and prescription medicines persist and require policy solutions, which extend beyond the ACA's provisions.

Racial Disparities in Treatment Indications and Outcomes for Limb Ischemia

Studies suggest that the Affordable Care Act (ACA) of 2014 has improved access to vascular care and vascular outcomes among patients suffering from peripheral arterial disease (PAD). We sought to examine the racial disparities that exist in patients with PAD who have undergone lower extremity bypass (LEB) or a peripheral vascular intervention (PVI) using the Vascular Quality initiative (VQI) database. The VQI infrainguinal and PVI datasets were queried for patients receiving elective and urgent LEB or PVI between 2016, 2years after ACA implementation, and in 2021. Patients undergoing interventions urgently/emergently or for aneurysm were excluded. The primary outcome was major adverse limb event (MALE-defined as any vascular reintervention or above-ankle amputation) free survival at 1year. Standard statistical methods were utilized as appropriate. A total of 17,455 LEB and 87,475 PVIs were included in this analysis. Black persons present at a younger age when compared to non-Hispanic White persons (NHW) and are more likely to have diabetes, hypertension, end-stage renal disease (ESRD), and higher rates of prior amputation. Black persons are more likely to present with chronic limb-threatening ischemia (CLTI) rather than claudication, and in a more urgent setting. Postoperative outcomes show higher rates of major amputations among racial minorities, specifically Black persons for both LEB (1.8% vs. 0.8% P<0.001) and PVI (20.8% vs. 16.8% P<0.001). Black persons are at higher risk of 1-year MALE for LEB (36.7% vs. 29.9% P<0.001) and PVI (31.0% vs. 21.7%; P<0.001). Even after adjusting for confounding variables, Black persons have a higher risk of 1-year MALE for LEB, with an adjusted hazard ratio (aHR) of 1.15 (95% CI [1.05-1.26], P=0.003) and PVI (aHR 1.18 95% CI [1.12-1.24], P<0.001). Other major determinates of 1-year MALE on multivariate Cox regression included CLTI (LEB aHR 1.57 95% CI [1.43-1.72], P<0.001; PVI aHR 2.29 95% CI [2.20-2.39], P<0.001) and history of prior amputation (LEB aHR 1.35 95% CI [1.17-1.56], P<0.001; PVI aHR 1.5 95% CI [1.4-1.6], P<0.001). Compared to NHW persons, Black persons present with more advanced vascular disease regardless of the operative indication. Black persons are also at significantly higher risk of 1-year MALE. Despite some advances in more accessible care through the ACA of 2014, our observations suggest that Black persons still have significantly worse outcomes due to variety of variables that need further investigation.

Insurance Trends in Patients Diagnosed with Melanoma Before and After the Affordable Care Act: A National Database Study

Background: The Affordable Care Act (ACA) was intended, in part, to reduce the uninsured population. It underwent full implementation in 2014 with optional state Medicaid expansion and health insurance marketplaces. Prior to the ACA, studies show that insurance status affects cancer care, including prevention, diagnosis, stage at diagnosis, and management. ACA impact on malignant melanoma is unknown. In this study, the primary objective is to examine the impact of the ACA on insurance rates among patients diagnosed with malignant melanoma. Survival by insurance type was also assessed. Methods: A retrospective analysis of the Surveillance, Epidemiology and End Results (SEER) cancer registry was performed for malignant melanoma between 2007 (first year of insurance da-ta in SEER) and 2015. Standardized mean differences were used for 2007-2013 and 2014-2015 (after full ACA implementation) for the primary objective. Sub-analysis was performed for Med-icaid expansion and non-expansion states. The impact of insurance type (uninsured, Medicaid, non-Medicaid) on all-cause and cause-specific mortality was assessed via adjusted cox regression models. Results: Nationally, the ACA decreased percentage of uninsured patients (-1.12% to -2.26%, P&lt;0.05) and increased percentage of Medicaid enrollees (+1.53% to +4.02%, P&lt;.005) diagnosed with malignant melanoma. Expansion states showed decreased percentage of uninsured patients (-1.43% to -2.24%, P&lt;0.05) and increased percentage of Medicaid enrollees (+1.66% to +4.84%, P&lt;0.05). Non-expansion states showed no change in percentages of uninsured patients and Medicaid enrollees. All-cause and cause-specific mortality were decreased in uninsured and Medicaid patients diagnosed with malignant melanoma compared to non-Medicaid insured patients (reference group). Discussion: The ACA decreased the rate of patients diagnosed with malignant melanoma with uninsured status, but this was only significant in Medicaid expansion states. Although diagnosis of melanoma is associated with High Socioeconomic Status (SES), Medicaid expansion seems to have increased access to dermatologic care. Increasing the number of states expanding Medicaid may be beneficial. However, Medicaid patient have worse all-cause and cause-specific mortality compared to non-Medicaid insured patients. Addressing these disparities through policy is important to ensure insurance coverage translates to better outcomes.

Reexamining the Impact of Insurance Type on Kidney Transplant Waitlist Status and Posttransplantation Outcomes in the United States After Implementation of the Affordable Care Act.

Using Scientific Registry of Transplant Recipients data, we assessed insurance type of waitlisted candidates pre- (2008-2014) versus post- (2014-2021) KAS/ACA using chi-square tests. Next, we performed a competing risk analysis to study the effect of private versus public (Medicare, Medicaid, or government-sponsored) insurance on waitlist outcomes and a Cox survival analysis to study posttransplant outcomes while controlling for candidate, and recipient and donor variables, respectively. The proportion of overall KT candidates insured by Medicaid increased from pre-KAS/ACA to post-KAS/ACA (from 12 667 [7.3%] to 21 768 [8.8%], P < 0.0001). However, KT candidates with public insurance were more likely to have died or become too sick for KT (subdistribution hazard ratio [SHR] = 1.33, confidence interval [CI], 1.30-1.36) or to receive a deceased donor KT (SHR = 1.57, CI, 1.54-1.60) but less likely to receive a living donor KT (SHR = 0.87, CI, 0.85-0.89). Post-KT, KT recipients with public insurance had greater risk of mortality (relative risks = 1.22, CI, 1.15-1.31) and allograft failure (relative risks = 1.10, CI, 1.03-1.29). Although the implementation of ACA marginally increased the proportion of waitlisted candidates with Medicaid, publicly insured KT candidates remained at greater risk of being removed from the waitlist, had lower probability of living donor kidney transplantation, and had greater probability of dying post-KT and allograft failure. Concerted efforts to address factors contributing to these inequities in future studies are needed, with the goal of achieving equity in KT for all.

Changes in receipt of adjuvant brachytherapy for endometrial cancer patients before and after affordable care act: The impact of Medicaid expansion.

For patients with high-intermediate risk (HIR) endometrial cancer, adjuvant radiation (RT) reduces the risk of recurrence, but many patients do not receive RT. Under the Affordable Care Act (ACA), most states expanded Medicaid coverage. Our hypothesis was patients would be more likely to receive indicated adjuvant RT in states that expanded Medicaid compared with patients in states that did not expand Medicaid. National Cancer Database (NCDB) was used to identify patients aged 40-64 years with HIR endometrial adenocarcinoma, stage IA and grade 3 or stage IB and grade 1 or 2, diagnosed from 2010-2018. We conducted a difference-in-differences (DID) cross-sectional retrospective analysis comparing receipt of adjuvant RT among patients residing in Medicaid expansion and non-expansion states before and after ACA implementation (January 2014). Expansion states had higher rates of adjuvant RT prior to January 2014 compared with non-expansion states (49.21% vs. 36.46%), and the proportion of patients who received adjuvant RT increased over the study period across both Medicaid expansion and non-expansion states. After Medicaid expansion, the non-expansion states had a larger absolute increase in adjuvant radiation resulting in a non-significant change in the difference in adjuvant radiation rates compared with baseline (crude increase: 9.63% vs. 7.45%, adjusted DID: -2.68 [95% CI: -7.12-1.75], p = 0.236). Medicaid expansion is likely not the most significant factor affecting access or receipt of adjuvant RT for HIR endometrial cancer patients. Further study could help inform policy and efforts to ensure all patients have access to guideline-recommended RT.

Changes in coverage among non-elderly adults with chronic diseases following Affordable Care Act implementation.

Changes in insurance coverage after the Affordable Care Act (ACA) among non-elderly adults with self-reported chronic conditions across income categories have not been described. To examine changes in insurance coverage after the ACA among non-elderly adults with chronic conditions across income categories, by geographic region. We compared self-reported access to health insurance pre-ACA (2010-2013) and post-ACA (2014-2017) for individuals 18-64 years of age with ≥ 2 chronic conditions, including hypertension, heart disease/stroke, emphysema, diabetes, asthma, cancer, and arthritis, across regions using a logistic regression approach, adjusted for covariates. We also assessed U.S. Census regional differences in insurance coverage post-ACA using modified Poisson regression models with robust variance and calculated the risk ratio (RR) of being uninsured by region, with the Northeast as the reference category. Within each region, we then examined changes in insurance coverage by income level among non-elderly individuals with any chronic condition. 2010-2017 household component of the nationally representative Medical Expenditure Panel Survey (MEPS). All members of surveyed households during five interviews over a two-year period. Start of insurance coverage expansion under the ACA. Health insurance status. On average nationwide, non-elderly adults with self-reported chronic conditions experienced increased insurance coverage associated with the ACA (diabetes: +6.41%, high-blood pressure: +6.09%, heart disease: +6.50%, asthma: +6.37%, arthritis: +6.77%, and ≥ 2 chronic conditions: +6.39%). Individuals in the West region reported the largest increases (diabetes +9.71%, high blood pressure +8.10%, and heart disease/stroke +8.83 %, asthma +9.10%, arthritis +8.39%, and ≥ 2 chronic conditions +8.58). In contrast, individuals in the South region reported smaller increases in insurance coverage post-ACA among those with diabetes, heart disease/stroke, and asthma compared to the Midwest and West. The Northeast region, which had the highest levels of insurance coverage pre-ACA, exhibited the smallest increase in reported coverage post-ACA. Reported insurance coverage improved across all regions for adults with any chronic condition across income levels, most notably for very low- and low-income individuals. A further cross-sectional comparison after the ACA demonstrated important residual differences in insurance coverage, despite the gains in all regions. When compared to the Northeast, adults with any self-reported chronic conditions living in the South were more likely to report no insurance coverage (diabetes: RR 1.99, p-value <0.001, high blood pressure: RR 2.02, p-value <0.001, heart diseases/stroke: RR 2.55, p-value <0.001, asthma RR 2.21, p-value <0.001, arthritis: RR 2.25, p-value <0.001), and ≥ 2 chronic condition (RR 2.29, p-value <0.001). The ACA was associated with meaningful increases in insurance coverage for adults with any self-reported chronic condition in all US regions, most notably in the West region and among those with lower incomes, suggesting a nation-wide trend to improved access to health insurance following implementation. However, intra-regional comparisons after ACA implementation showed important differences. Individuals with ≥2 chronic conditions in the South were 2.29 times less likely to have insurance coverage in comparison to their peers in the Northeast. Though the post-ACA improvements in reported access to health insurance coverage affected all US regions, the reported experience of those with multiple chronic conditions in the South point to continued barriers for those most likely to benefit from access to health insurance coverage. Medicaid expansion in the South would likely result in increased insurance coverage for individuals with chronic conditions and improve health care outcomes.

Impact of the Affordable Care Act on Presentation, Treatment, and Outcomes of Intrahepatic Cholangiocarcinoma

BackgroundThe Affordable Care Act (ACA) transformed the US healthcare system, expanding healthcare insurance coverage. However, its impact on rare malignancies that lack an established screening strategy such as intrahepatic cholangiocarcinoma (ICC) remains ill-defined. MethodsPatients diagnosed with ICC were identified from the National Cancer Database and divided relative to ACA implementation. Multivariate logistic regression analyses were performed to evaluate association with stage at diagnosis, receipt of surgical and multimodal treatments, and survival. ResultsAmong the 9095 patients, 5636 (62.0%) were diagnosed before and 3459 (38.0%) after the implementation of the ACA. Across US regions, rates of early-stage diagnosis increased in the post-ACA era (Northeast, 62.9% vs. 85.2%; South, 63.7% vs. 78.5%; Midwest, 62.1% vs. 83.4%; West, 55.5% vs. 75.4%; p < 0.001). On multivariate analyses, the post-ACA era was associated with increased early-stage diagnosis (OR = 2.19; 95% CI 1.79–2.69), and receipt of surgical treatment (OR = 1.19, 95% CI 1.03–1.38) (both p < 0.01). Furthermore, the ACA’s Medicaid expansion (ME) was also associated with improved overall survival (HR = 0.89, 95% CI 0.80–0.99, p = 0.038). Of note, although the odds of receiving surgical treatment increased after ACA for non-Hispanic White patients (OR = 1.34; 95% CI 1.20–1.49; p < 0.001), no such effect was observed in non-Hispanic Black (OR = 1.01, 95% CI 0.71–1.45), Hispanic (OR = 1.44, 95% CI 0.99–2.09), or others (OR = 1.43, 95% CI 0.98–2.10) (all p > 0.05). ConclusionsThe implementation of the ACA increased rates of early diagnosis and receipt of surgical treatment. Additionally, ME improved short- and long-term outcomes. However, racial and socioeconomic disparities persist, resulting in inequitable access to care and outcomes for patients with ICC.

Gaps and barriers in drug and alcohol treatment following implementation of the affordable care act

BackgroundThis study examines changes in the substance use disorder (SUD) treatment gap and barriers to treatment for low-income adults following Affordable Care Act (ACA) implementation. MethodsNational Survey on Drug Use and Health (NSDUH) data were pooled to assess pre-ACA (2009–2013) and post-ACA (2015–2019) implementation. The sample (n = 44,622) included respondents 18–64 years old, income <200% federal poverty level, and meeting SUD criteria for abuse or dependence of heroin, powdered cocaine, crack cocaine, marijuana, or alcohol. The primary outcome was NSDUH-defined past-year illicit drug or alcohol treatment gap (needing but not receiving SUD specialty treatment). A secondary analysis assessed barriers to SUD treatment including insurance-related barriers, stigma, barriers to access, priority of treatment, and no interest in stopping substance use. ResultsNinety-three percent of respondents reported a drug or alcohol treatment gap before and after ACA implementation. No interest in stopping use was the greatest barrier (40%), followed by insurance-related barriers (39%) and stigma (20%). After adjusting for covariates, results did not show a significant change in SUD treatment gap post-ACA compared to pre-ACA (adjusted odds ratio [aOR]=1.11, 95% confidence interval [CI]=0.97, 1.28, p = 0.13). Compared to pre-ACA, odds of reporting stigma-related barriers (aOR=1.66, 95% CI=1.17, 2.37, p = 0.01) and access-related barriers (aOR=1.79, 95% CI=1.34, 2.38, p < 0.001) increased post-ACA. ConclusionsThere was no significant change in the prevalence of SUD treatment gap after ACA implementation. Increasing access to SUD treatment for low-income individuals will require intervening at multiple socioecological levels beyond reforming treatment financing.

Inequalities in hospitalizations for ambulatory care sensitive conditions in New York City before and after the affordable care act

AbstractThe Patient Protection and Affordable Care Act (ACA) was signed into law by U.S. President Obama in 2010 and fully implemented in 2014. The ACA expanded health insurance by expanding the Medicaid program, creating health insurance exchanges (now called “marketplaces”) in which people with incomes between 139% and 400% of the federal poverty level, could purchase subsidized insurance coverage, and by regulating health insurance to eliminate practices such as denying coverage to people with pre‐existing conditions, or basing premiums on health status. We investigate the effects of the ACA's implementation on access to ambulatory health services in New York City by comparing rates of hospitalizations for ambulatory care‐sensitive conditions (ACSC) before and after the full implementation of the law. Although the ACA was associated with a significant decrease in the rate of ACSC in NYC, we find that there continue to be systemic inequalities by gender, race, ethnicity, income, and insurance status. We argue that the broader social and economic inequalities at the national and state levels, including tax and spending policies that have led to increased income and wealth inequalities, help explain why we see persistent inequalities in hospitalizations for ACSC.

Medicare Advantage Financing and Quality in Puerto Rico vs the 50 US States and Washington, DC

More than 70% of Medicare beneficiaries in Puerto Rico are enrolled in a Medicare Advantage (MA) plan. Evidence of MA plan payments and quality in Puerto Rico compared with the 50 US states and Washington, DC (hereafter referred to as US mainland), is lacking, notably after implementation of the Patient Protection and Affordable Care Act (ACA). To compare MA plan payments and quality in Puerto Rico with those in the US mainland and to evaluate how differences between MA plans in Puerto Rico and the US mainland changed after ACA implementation. This cohort study used publicly available data on MA plans from January 1, 2006, to December 31, 2019, from the Centers for Medicare & Medicaid Services. Data analysis was performed from October 2019 to February 2022. Medicare Advantage plans in Puerto Rico and implementation of the ACA. Primary outcomes were risk-standardized federal benchmark payments (the amount offered by the federal government for insuring a beneficiary of average risk), risk-standardized plan bids (a plan's asking price for a beneficiary of average risk), and rebates received by plans. Additional outcomes included risk-adjusted benchmarks, risk-adjusted bids, actual plan payment, and aggregate plan quality ratings (star ratings). A difference-in-differences analysis examined differential changes in plan payments in Puerto Rico vs the US mainland after ACA implementation. Before ACA implementation, 211 MA plans in Puerto Rico and 13 899 plans in the US mainland were included. After ACA implementation, 433 MA plans in Puerto Rico and 29 515 plans in the US mainland were included. Before ACA implementation, risk-standardized benchmarks were 33% lower for MA plans in Puerto Rico than plans in the US mainland ($556.73 [95% CI, $551.82-$561.64] vs $831.15 [95% CI, $828.55-$833.75] per beneficiary per month [PBPM]). This gap increased to 38% after ACA implementation ($540.58 [95% CI, $536.86-$544.32] vs $869.31 [95% CI, $868.21-$870.42] PBPM). Risk-standardized plan bids in Puerto Rico were 46% lower before ACA implementation and 43% lower after ACA implementation compared with those in the US mainland. Rebates in Puerto Rico decreased from $168.50 (95% CI, $163.57-$173.42) PBPM before ACA implementation to $93.39 (95% CI, $89.51-$97.27) PBPM after ACA implementation, a decrease of $75.11 PMPM compared with a decrease of $2.05 PMPM in the US mainland. Plans in Puerto Rico received increased quality bonus payments, and the mean (SD) risk score for plans in Puerto Rico increased to 1.55 (0.31) after ACA implementation, which increased risk-adjusted benchmarks and actual plan payments, offsetting the widening payment disparity. This cohort study found that after implementation of the ACA, federal benchmark payment amounts decreased in Puerto Rico compared with the US mainland. Responses by MA plans in Puerto Rico, including increased quality bonus payments and risk scores, offset this payment reduction, although actual plan payments in Puerto Rico were lower than those in the US mainland.

Shoulder MRI lag times after implementation of the Affordable Care Act (ACA): a retrospective review

Background: With the Affordable Care Act (ACA), the challenge of expanding healthcare insurance to Americans without jeopardizing quality of care remains. This study was initiated to evaluate how the timing of MRI completion for shoulder pathology correlates with implementation of the ACA by comparing lag times between the initial visit and the date of MRI completion. In addition, the access to orthopaedic care after ACA implementation was evaluated by comparing shoulder MRI lag times among three cohorts based on insurer status. Methods: All shoulder and proximal upper extremity MRIs between 2009 and 2017 were reviewed, 5 yr before and 3 yr after ACA implementation. Patients were grouped into commercial, Medicare, and Medicaid cohorts. Average lag times for the pre- and post-ACA periods overall and among payor cohorts were calculated. Results: Included were 5900 MRIs, 1997 (33.8%) before and 3903 (66.2%) after ACA implementation. The difference in payor mix before and after ACA implementation was significantly different (P&lt;0.001). Median lag time increased from 23 days pre-ACA to 31 days post-ACA (P&lt;0.001). For commercial insurance, median lag time was 23 days pre-ACA compared with 28 days (P&lt;0.001) post-ACA. Median lag time pre- and post-ACA in the Medicaid cohort was 8 days compared with 30.5 days (P&lt;0.001), respectively. Pre- and post-ACA lag times in the Medicare cohort did not differ significantly (P=0.450). Conclusions: Lag times increased significantly after ACA implementation in patients with commercial and Medicaid insurance. This study provides valuable insight into unintended outcomes associated with the ACA legislation. Level of Evidence: Level III.