Medicaid Eligibility Research Articles

Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents

Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Race and ethnicity. Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

Racial and ethnic differences in lifetime Medicare expenditures for dementia patients

AbstractBackgroundResearch on racial and ethnic disparities in lifetime dementia costs is sparse. We analyzed lifetime Medicare expenditures for dementia patients to identify when during the course of care costs are the highest, and whether these costs differ by race and ethnicity.MethodWe analyzed data from the 2000‐2016 Health and Retirement Survey (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four “phases”: 1) the year before dementia diagnosis; 2) the first year following a dementia diagnosis; 3) ongoing care for dementia after the first year; and 4) the last year of life. We then estimated each patient’s phase‐specific and lifetime Medicare expenditures by using a race‐specific survival model and monthly expenditures adjusted for demographics, socio‐economic status, year of dementia diagnosis, nursing home status, functional limitations, cognitive impairment, comorbidities, and Medicaid eligibility status.ResultAdjusted mean lifetime Medicare expenditures for non‐Hispanic Blacks ($166,548) and Hispanics with dementia ($163,425) exceeded corresponding expenditures for non‐Hispanic whites ($135,648) (Figure). In the year preceding and immediately following an initial dementia diagnosis, mean Medicare expenditures for non‐Hispanic Blacks ($26,384 and $20,824) exceeded expenditures for Hispanics and non‐Hispanic whites (ranging $21,340‐23,379 and 17,382‐18,085). Ongoing care costs for non‐Hispanic Blacks with dementia (mean $1,734/month) exceeded costs for Hispanics ($1,538/month) and non‐Hispanic whites ($1,424/month). Of the four phases, the last year of life was responsible for the greatest cost contribution: $52,003 for non‐Hispanic Blacks, $48,377 for Hispanics, and $39,648 for non‐Hispanic whites.ConclusionsTotal mean Medicare expenditures for non‐Hispanic Black and Hispanic beneficiaries with dementia exceeded corresponding expenditures for non‐Hispanic whites. Expenditures were highest for non‐Hispanic Blacks with dementia in every phase of care. Compared to non‐Hispanic whites, Hispanics had lower expenditures in the first year following dementia diagnosis and similar monthly ongoing care expenditures but much higher expenditures during their last year of life. Research should identify factors contributing to the disparities identified here so that policy makers can address problems adversely affecting disadvantaged populations. Figure: Estimated mean lifetime Medicare expenditures for beneficiaries newly diagnosed with dementia, by phase of care and by race and ethnicity (adjusted)

Geographic variation of prevalence of Alzheimer’s Disease and related dementias in the Central Appalachian region of the United States

AbstractBackgroundAreas within the Appalachian region may have a greater burden of under diagnosed Alzheimer’s disease and related dementias (ADRD). As rural areas have lower reported ADRD prevalence compared to urban areas in spite of lower educational attainment (which should lead to higher ADRD prevalence) this argues that the true burden of ADRD is likely underestimated in areas without adequate detection resources. There is need to understand if ADRD prevalence is truly lower in rural areas, or if this is a disease detection difference. The objective of this proposal is to assess the burden of ADRD in Central Appalachia.MethodsCenters for Medicare and Medicaid Services Public Use Files from 2015‐2018 were used to estimate county‐level ADRD prevalence among all fee‐for‐service beneficiaries in Central Appalachia (Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia). Negative binomial regression was used to estimate prevalence overall, by Appalachian Regional Commission’s Appalachian/non‐Appalachian designation, and by rural/urban (Rural‐Urban Continuum Codes) classification. Models were then adjusted for county‐level demographics including age, gender, Medicaid eligibility, and comorbidities (atrial fibrillation, chronic kidney disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, ischemic heart disease, schizophrenia/other psychotic disorders, and stroke).ResultsThe prevalence of ADRD did not vary over the time period but was higher for Appalachian counties both overall (12.0% vs. 11.6%; p = 0.001; Figure 1) and among both urban (p<0.001) and rural counties (p = 0.024; Figure 2). Urban Appalachian counties had 2‐4% higher prevalence compared to urban non‐Appalachian counties with this difference reaching statistical significance in 2017 and 2018. While a similar trend was observed in rural counties (Appalachian counties having 1‐3% higher prevalence), these yearly ratios did not reach statistical significance. After adjustment, the associations attenuated in urban counties, but over the entire study period, rural Appalachian counties had 2.2% higher prevalence than rural non‐Appalachian counties (Figure 3).ConclusionThere is a consistent difference between Appalachian and non‐Appalachian counties, demonstrated overall and by rural status, with Appalachian counties having ADRD prevalence in the range of 1.0‐4.5% higher than non‐Appalachian counties. However, while county‐level demographics and comorbidities explained the difference in urban counties, the elevated prevalence in rural‐Appalachian counties persisted.

Variation in Procedural Denials of Medicaid Eligibility Across States Before the COVID-19 Pandemic

This cross-sectional study examines denials of Medicaid and Children’s Health Insurance Program coverage due to procedural reasons.

Factors associated with delayed treatment initiation of oral anticoagulants among Medicare patients with atrial fibrillation

Abstract Background Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in the United States (US) and is associated with increased risk of stroke.1 Oral anticoagulants (OACs) are the primary treatment to reduce stroke risk in patients with AF.2,3 However, there is recent evidence of underuse of OAC in AF patients.4 Purpose To identify factors associated with delayed OAC treatment initiation among AF patients in the US clinical practice. Methods Medicare beneficiaries aged ≥65 years with a new diagnosis of AF without moderate-to-severe mitral stenosis or a mechanical heart valve after 1 Oct 2015 were included. Additional inclusion criteria included ≥1 claim for an OAC on or after 1st diagnosis of AF, ≥12 months of continuous Medicare Parts A, and D enrollment, and CHA2DS2-VASc score of ≥2 for males/≥3 for females. Time from 1st AF diagnosis to OAC initiation (index OAC), and demographic, sociodemographic, clinical and index OAC formulary characteristics were described. Delayed initiation was defined as OAC initiation >3 months after and early initiation as OAC initiation 0-3 months after 1st AF diagnosis. Factors associated with delayed OAC initiation were assessed using multivariable logistic regressions. Results A total of 446,441 patients met the inclusion criteria. Time from 1st AF diagnosis to OAC initiation was <1 month for 52.4% of patients, 1–≤3 months for 18.1%, >3–≤6 months for 7.1%, >6–≤12 months for 6.8%, and >12 months for 15.7%. Accordingly, 30% had delayed vs. 70% had early OAC initiation. Median age was 78 years (both), 48% and 47% were male, 87% and 89% were White, and median CHA2DS2-VASc score was 4 (both), respectively, for the delayed and early OAC initiation cohorts (Table 1). Factors associated with delayed OAC initiation included Black race (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.25–1.33), South and West US census regions (OR: 1.22, 95%CI: 1.19–1.24 and OR: 1.29, 95%CI: 1.26–1.32, respectively), dementia (OR: 1.27, 95%CI: 1.23–1.30), congestive heart failure (OR: 1.20, 95%CI: 1.26–1.32), bleeding hospitalization ≤3 months before 1st AF diagnosis (OR: 1.22, 95%CI: 1.18–1.27), prior authorization (OR: 1.69, 95%CI: 1.66–1.71), and tier 4 formulary for index OAC at AF diagnosis (OR: 1.26, 95%CI: 1.22–1.30). Additionally, having low-income subsidy or dual eligibility (for Medicare and Medicaid) was associated with increased odds of delayed OAC initiation (OR: 1.06, 95%CI: 1.02–1.10 and OR: 1.09, 95%CI: 1.05–1.14, respectively; Figure 1). Conclusions In this study on Medicare patients with AF, Black race, low-income subsidy, and dual eligibility were found to be associated with delayed OAC initiation, suggesting potential disparities in the care of AF with timely OAC treatment. Moreover, OAC requiring prior authorization (the strongest predictor) or being on formulary tier 4 were associated with delayed initiation, indicating formulary restrictions may create barriers to timely OAC access for AF patients.Table 1.Patient characteristicsFigure 1.Factors of delayed initiation

Abstract 18023: What is the Relationship Between Summer Ambient Temperatures & Heart Failure Hospitalizations Among Low-Income Older Adults in the US?

Background: A trend of warmer nights and higher daily minimum temperatures (T min ) during summer is a leading indicator of climate change. The impact of increased T min on hospitalizations in low-income older adults with heart failure (HF) remains unknown. Hypothesis: Higher T min increases the risk of HF hospitalization among older adults and low-income patients will be more impacted. Methods: We conducted a time-stratified case-crossover study among older adults (age ≥ 66 years) hospitalized for HF during summer months (May-Sept) between 2008-2019 using 20% Medicare data. We employed bidirectional sampling to select controls. Data on daily T min from the Parameter-elevation Relationships on Independent Slopes Model were linked using patient zip code. The non-linear effect of T min was estimated using conditional logistic regression with a restricted cubic spline in all patients and by Medicaid eligibility. Results: Among 460,072 patients hospitalized for HF (mean age 78 years, 62% female, 86% white), the risk of HF hospitalization increased nearly linearly with higher T min (OR: 74 °F = 1.09 [1.09 - 1.10], 84 °F = 1.18 [1.16 - 1.20]) relative to the median summer T min (64 °F) (Figure 1). Patients with Medicaid dual eligibility experienced greater risk of HF hospitalization than their counterparts (Figure 2). Conclusions: Among older US adults, summer days with higher T min were associated with increased risk of HF hospitalization. Low-income patients were at greater risk, possibly secondary to behavioral differences. This effect may be mediated through physiological stress from warmer nights; increased ambient temperatures are associated with inflammation and myocyte damage.

Rates of Ibrutinib Uptake Among Black Patients with Lymphoma in SEER-Medicare Increased over Time

Introduction Disparities in treatments and survival outcomes have been documented in non-Hodgkin lymphomas (NHL). In the past decade, the Food and Drug Administration (FDA) has approved several new oral therapy options, including ibrutinib, lenalidomide, acalabrutinib, and idelalisib, for the treatment of several NHL subtypes. We hypothesized that racial and socioeconomic disparities would lead to delayed uptake of oral therapy options in older patients with NHL. Methods The Medicare Part D dataset, part of the SEER-Medicare linked dataset, was used to identify claims for ibrutinib, acalabrutinib, idelalisib, and lenalidomide from date of drug approval through 2019. Patients with mantle cell lymphoma (MCL), marginal zone lymphoma (MZL), chronic lymphocytic leukemia (CLL), Waldenstrom's macroglobulinemia (WM), and follicular lymphoma (FL) were included since the four oral drugs were approved for their use. Variables reflecting possibly racial and socioeconomic disparities, including race (White, Black, vs Asian, Pacific Islander, and Native American Indian [Asian/PI/NAI]), ethnicity (Hispanic vs non-Hispanic), % poverty and % urban of census tract, and Medicaid eligibility, were included. Bar plots were generated of number of patients with prescriptions for each of the oral drugs over time to assess for rate of uptake and impact of above variables on uptake rate. Cochran Armitage tests were used to test for trend. Results In total, 43,636 patients were included in this analysis, among whom 4,832 (19.4%) had MCL, 8,447 (33.9%) had CLL, 209 (0.8%) had WM, 11,439 (45.9%) had MZL, and 18,691 (42.8%) had FL. Most were White (92.6%), non-Hispanic (95.0%), and from census tracts with <20% poverty (81.0%). 3% of patients were dual-eligible for Medicaid at time of diagnosis. The percentage of Black patients in the total population was 3.9%, compared to 2.5%, 6%, 2.4%, 4.5%, and 3% among patients with MCL, CLL, WM, MZL, and FL, respectively ( Figure A). The number of ibrutinib prescriptions increased from 66 in 2013 to 5,083 in 2019, corresponding to 41 and 589 patients, respectively. The number of acalabrutinib prescriptions also increased from 7 in 2017 to 590 in 2019, corresponding to 5 and 94 patients, respectively. Prescriptions for lenalidomide also increased from 276 in 2013 to 831 in 2019, corresponding to 79 and 148 patients, respectively. Finally, prescriptions for idelalisib started at 98 in 2014, peaked at 395 in 2016, and dropped to 95 by 2019, corresponding to 38, 78, and 20 patients, respectively. Among patients who received ibrutinib prescriptions, the proportion of Black patients increased from 2.4% in 2013 to 5.8% in 2019. The proportion of Black and Asian/PI/NAI increased from 2.4% in 2013 to 9.5% in 2019 ( P for trend=0.0006) ( Figure B). A similar trend was not seen for any of the other three oral agents related to race, nor were any trends noted among all four oral agents for ethnicity, census tract % poverty, census tract % urban, and Medicaid eligibility across time. Discussion In this SEER-Medicare analysis, we found that race appeared to play a factor in prescriptions of ibrutinib, with prescriptions to Black patients gradually increasing over time, despite starting at a proportion even smaller than the proportion of Black patients in the overall dataset. Limitations of this study include limited sampling in SEER-Medicare of patients of minority races as well as potential for missed prescriptions that were not paid for by Medicare. Additionally, we were limited to an assessment of disease incidence rather than prevalence, which may impact proportions of patients using novel oral agents. Overall, these findings suggest that race may continue to play a role in access to care related to novel agents, while oral agents may offer improved equality related to other variables commonly associated with access to care.

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.

Individual and social determinants of adherence to sodium-glucose cotransporter 2 inhibitor therapy: A trajectory analysis.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are known to improve cardiovascular and renal outcomes in patients with type 2 diabetes (T2D). Understanding the longitudinal patterns of adherence and the associated predictors is critical to addressing the suboptimal use of this outcome-improving treatment. OBJECTIVE: To characterize the distinct trajectories of adherence to SGLT2is in patients with T2D and to identify patient characteristics and social determinants of health (SDOHs) associated with SGLT2i adherence. METHODS: In this retrospective cohort study, we identified patients with T2D who initiated and filled at least 1 SGLT2i prescription according to 2012-2016 national Medicare claims data. The monthly proportion of days covered with SGLT2is for each patient was incorporated into group-based trajectory models to identify groups with similar adherence patterns. A multinomial logistic regression model was constructed to examine the association between patient characteristics and group membership. In addition, the association between context-specific SDOHs (eg, neighborhood median income and neighborhood employment rate) and adherence to an SGLT2i regimen was explored in both the overall cohort and the racial and ethnic subgroups. RESULTS: The final sample comprised 6,719 patients with T2D. Four trajectories of SGLT2i adherence were identified: continuously adherent users (49.6%), early discontinuers (27.5%), late discontinuers (14.5%), and intermediately adherent users (8.4%). Patient age, sex, race, diabetes duration, and Medicaid eligibility were significantly associated with trajectory group membership. Areas with a higher unemployment rate, lower income level, lower high school education rate, worse nutrition environment, fewer health care facilities, and greater Area Deprivation Index scores were found to be associated with low adherence to SGLT2is. CONCLUSIONS: Four distinct trajectories of adherence to SGLT2is were identified, with only half of the patients remaining continuously adherent to their treatment regimen during the first year after initiation. Several contextual SDOHs were associated with suboptimal adherence to SGLT2is.

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.

Racial, Ethnic, Socioeconomic, and Geographic Inequities in Access to Mechanical Circulatory Support

BackgroundHospital admissions for cardiogenic shock have increased in the United States. Temporary mechanical circulatory support (tMCS) can be used to acutely stabilize patients. We sought to evaluate the presence of racial, ethnic, and socioeconomic inequities in access to MCS in the United States among patients with cardiogenic shock. MethodsMedicare data were used to identify patients with cardiogenic shock admitted to hospitals with advanced tMCS (microaxial left ventricular assist device [mLVAD] or extracorporeal membranous oxygenation [ECMO]) capabilities within the 25 largest core-based statistical areas, all major metropolitan areas. We modeled the association between patient race, ethnicity, and socioeconomic status and use of mLVAD or ECMO. ResultsAfter adjusting for age and clinical comorbidities, dual eligibility for Medicaid was associated with a 19.9% (95% CI, 11.5%-27.4%) decrease in odds of receiving mLVAD in a patient with cardiogenic shock (P < .001). After adjusting for age, clinical comorbidities, and dual eligibility for Medicaid, Black race was associated with 36.7% (95% CI, 28.4%-44.2%) lower odds of receiving mLVAD in a patient with cardiogenic shock. Dual eligibility for Medicaid was associated with a 62.0% (95% CI, 60.8%-63.1%) decrease in odds of receiving ECMO in a patient with cardiogenic shock (P < .001). Black race was associated with 36.0% (95% CI, 16.6%-50.9%) lower odds of receiving ECMO in a patient with cardiogenic shock, after adjusting for Medicaid eligibility. ConclusionsWe identified large and significant racial, ethnic, and socioeconomic inequities in access to mLVAD and ECMO among patients presenting with cardiogenic shock to metropolitan hospitals with active advanced tMCS programs. These findings highlight systematic inequities in access to potentially lifesaving therapies.

Patient-level factors associated with hemoglobin A1C testing in Alabama Medicaid beneficiaries with diabetes

AimWe evaluated patient-level factors associated with receipt of hemoglobin A1c (HbA1c) testing among Alabama Medicaid beneficiaries with type 2 diabetes. MethodsWe conducted a retrospective analysis of person-year observations from Medicaid claims data from 2011 to 2020. Adults aged 19–64 years with type 2 diabetes and continuous enrollment in Medicaid for study year and year prior were included. Primary outcomes were ≥ 1 and ≥ 2 HbA1c test(s) per year. We conducted multivariable Poisson regression stratified by Medicaid eligibility reason (disability, poverty) examining the association of study year, demographics, clinical factors, and healthcare utilization with HbA1c testing. ResultsWe analyzed 288,379 observations, 51% with disability-based, 49% poverty-based eligibility. Overall, 57% observations had ≥ 1 HbA1c, 35% had ≥ 2 HbA1c tests. More observations with disability-based than poverty-based eligibility had ≥ 1 (76% vs. 38%) and ≥ 2 HbA1c tests (49% vs. 20%). Patient-level factors were associated with a higher likelihood of having ≥ 1 HbA1c: Black race and older age (disability-based eligibility); year after 2011, female sex, and younger age (poverty-based eligibility); and rurality, insulin use, endocrinology care, diabetes complications, and ambulatory care visits (both groups). ConclusionsJust over one-third of adult Alabama Medicaid beneficiaries with diabetes had ≥ 2 HbA1c tests per year; testing frequency differed by Medicaid eligibility.

Factors in Immigrant Children's Use of Physician and Dentist Visits, Hospital Care, and Prescribed Medication in the United States.

Applying the behavioral model of health services utilization to data from the United States, this study examined immigrant children's use of physician and dentist visits, hospital care, and prescribed medication. We employed data describing 9759 immigrant parents and children who participated in 2021's National Survey of Children's Health. Logistic regression results negatively linked physician visits to child health, child age, Asian children, fathers, lower parent education, lower family income, uninsured children, and parent's U.S. residence under 5 years. Dentist visits were positively associated with child age, girls, Hispanic children, parent education, family income, public/private health insurance coverage, and U.S.-born children, but such use was associated negatively with Asian children. Hospital use was positively associated with poor child health, Black children, children of "other" race/ethnicity, younger parent age, enrolled in health insurance, and parent's U.S. residence under 5 years. The use of prescribed medication was negatively associated with Asian children, younger child age, lower parent education, uninsured child, and lack of English proficiency. The paper's conclusion suggests policymakers expand Medicaid and CHIP eligibility among immigrant children and suggests community education to foster awareness of children's physical and oral health needs and of Medicaid, CHIP, and prescription assistance programs. The conclusion calls for healthcare providers and social workers to accommodate and respect immigrants' traditional health-related beliefs, showing cultural competence.

Economic and Humanistic Burden Among Medicare-Aged Women With Fragility Fracture in the United States.

Describe patient characteristics, health care resource utilization, costs, and humanistic burden of women with Medicare insurance with incident fragility fracture who were admitted to post-acute-care (PAC). Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) data. Community-dwelling female Medicare beneficiaries with incident fragility fracture January 1, 2017, to October 17, 2019, resulting in PAC admission to a skilled nursing facility (SNF), home-health care, inpatient-rehabilitation facility, or long-term acute-care hospital. Patient demographic/clinical characteristics were measured during 1-year baseline. Resource utilization and costs were measured during baseline, PAC event, and PAC follow-up. Humanistic burden was measured among SNF patients with linked Minimum Data Set assessments. Multivariable regression examined predictors of PAC costs after discharge and changes in functional status during SNF stay. A total of 388,732 patients were included. Compared with baseline, hospitalization rates were 3.5, 2.4, 2.6, and 3.1 times higher and total costs 2.7, 2.0, 2.5, and 3.6 times higher for SNF, home-health, inpatient-rehabilitation, and long-term acute-care, respectively, following PAC discharge. Utilization of dual-energy X-ray absorptiometry (DXA) and osteoporosis medications remained low: 8.5% to 13.7% received DXA during baseline vs 5.2% to 15.6% following PAC; 10.2% to 12.0% received osteoporosis medication during baseline vs 11.4% to 22.3% following PAC. Dual eligibility for Medicaid (ie, low income) was associated with 12% higher costs; Black patients had 14% higher costs. Activities of daily living scores improved 3.5 points during SNF stay, but Black patients had 1.22-point lower improvement than White patients. Pain intensity scores showed small improvement (-0.8 points). Women admitted to PAC with incident fracture had high humanistic burden with little improvement in pain and functional status and significantly higher economic burden after discharge compared with baseline. Disparities in outcomes related to social risk factors were observed, with consistently low utilization of DXA and osteoporosis medications even after fracture. Results indicate a need for improved early diagnosis and aggressive disease management to prevent and treat fragility fractures.

Georgia Pathways—Partial Medicaid Expansion With Work Requirements and Premiums

This Viewpoint discusses the Georgia Pathways to Coverage program, which is the first state program that partially expands Medicaid eligibility to low-income adults with work requirements.

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.

Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid.

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

The impact of Medicaid expansion on mental health and substance use related inpatient visits.

Under the Affordable Care Act, many states expanded their Medicaid eligibility, allowing individuals living at or below 138% of the Federal Poverty Level to receive insurance coverage. As a result, forty states and the District of Columbia have expanded Medicaid to date. Although Medicaid expansion is expected to increase access to care in general, it is not evident if it has helped increase access to mental health and substance use-related healthcare, especially in inpatient settings. Therefore, this study examines the impact of Medicaid expansion on mental health and substance use- (MHSU) related inpatient visits and the variation in payer mix. This study utilizes state-level quarterly inpatient visit data from the Healthcare Cost and Utilization Project's Fast Stats Database from 2005 to 2019 and performs difference-in-differences regression analyses to compare MHSU-related inpatient visit data in expansion and non-expansion states for all visits and by payer. Analyses controlled for state-level socio-demographic and health policy variables. Findings indicate that Medicaid expansion did not significantly affect overall MHSU-related inpatient visits. However, Medicaid expansion was associated with 22.74% increase (P < 0.01; 95% CI: 17.76, 27.71) in the Medicaid share of MHSU-related inpatient visits, 18.31% reduction (P < 0.01; 95% CI: -22.54, -14.09) in the uninsured share of MHSU-related inpatient visits, and 4.42% reduction (P < 0.05; 95% CI: -7.83, -1.01) in the privately insured share of MHSU-related inpatient visits in expansion states compared with non-expansion states. Findings show that Medicaid expansion significantly affects the payer mix associated with MHSU-related inpatient visits while it has no significant impact on the overall MHSU-related inpatient visits.

The Effect of Medicaid Eligibility on Utilization of Services and Access to Care among Health Center Patients: A Regression Discontinuity Design

The United States’ Affordable Care Act (ACA) aims to improve access to and quality of care for low-income patients. To do so, it expands Medicaid eligibility from individuals under 100% of the federal poverty level (FPL) to include those under 138% of the FPL. Based on the 2014 Health Center Patient Survey (a nationally representative survey sponsored by the Health Resources and Services Administration (HRSA) (n = 4,380)), this study examined the effects of the Medicaid eligibility on having a usual source of care and the utilization of preventive services among health center patients. A regression discontinuity approach was used to identify the causative impact of Medicaid enrollment on low-income and nonelderly health center patients. Our findings suggest that Medicaid enrollment led to a substantial increase in the probability of both undergoing a routine checkup and having had a fecal occult blood test within the past year. These results indicate that changes to Medicaid policy have the potential to affect vulnerable populations. The evidence we provide supports the importance of maintaining the ACA due to its expanded Medicaid funding.

Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries

Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes. To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees. This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design. Enrollment in MA and dual eligibility for Medicare and Medicaid. Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services. Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility. In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.