Medicaid Policy Research Articles

Screening for Sexually Transmitted Infections After Cervical Cancer Screening Guideline and Medicaid Policy Changes: A Population-based Analysis.

Sexually transmitted infection (STI) screening prevents complications and is cost-effective. Annual screening is recommended in sexually active women below 25 years and older women at increased risk. Cervical cancer (CC) screening guideline changes in 2009 and 2012 recommended less frequent screening, causing concern that STI screening would decrease. Pennsylvania Medicaid implemented a family planning program in 2007 which covered women's health services (including STI testing) for uninsured women. It is unclear how STI screening was affected by these countervailing forces. The main objective of this study was to assess STI screening before and after CC screening guideline changes and family planning program implementation, and to determine factors associated with STI screening. This study was an observational cross-sectional study of Pennsylvania Medicaid administrative claims from 2007 to 2013. Sixteen-year-old to 30-year-old women enrolled in Pennsylvania Medicaid. Annual STI screening, defined as receipt of ≥1 STI test in respective 1-year periods. Our population included 1,226,079 women-years for 467,143 women. STI screening increased by 48% between 2007 and 2011, and stabilized by 2013. Odds for STI screening were higher among black compared with white women [adjusted odds ratio (AOR), 2.56; 95% confidence interval (CI), 2.60-3.10]; Hispanic compared with non-Hispanic women (AOR, 1.42; 95% CI, 1.39-1.46); family planning program enrollees (AOR, 1.42; 95% CI, 1.40-1.45); and urban compared with rural residents (AOR, 1.05; 95% CI, 1.03-1.06). STI screening dramatically increased between 2007 and 2011. Potential reasons are family planning program implementation, increased urine/vaginal testing, and reporting improvements. It is reassuring that STI screening did not decrease despite CC screening guideline changes. Between 2011 and 2013, rates stabilized at 45% among all women and 60% among sexually active women below 25 years, suggesting opportunities for improvement.

Abstract PR07: Primary care utilization, late-stage diagnosis, and timeliness of treatment among Medicaid cancer patients: Early signals following the ACA expansion

Abstract Background: Low-income and racial/ethnic minority cancer patients in the United States, particularly those with Medicaid coverage, are more likely to be diagnosed with later-stage cancer and experience worse survival compared to other groups. Recent national and state Medicaid policy initiatives, including the Medicaid eligibility expansion, aim to increase access to care, improve quality, and reduce costs. It is unclear, however, whether these non-cancer specific system-level efforts will have an impact on cancer care quality for Medicaid-insured patients. Currently, few cancer-specific analyses are available from early Medicaid redesign implementation periods (2012 and beyond) to inform possible care improvement strategies for vulnerable cancer patients. Methods: Through a recent linkage of New Jersey State Cancer Registry (NJSCR), one of twenty SEER regions, and Medicaid claims/encounter/enrollment data, we examined the effect of primary care (PC) utilization on late-stage diagnosis (stage III/IV) and treatment delays for breast (BC), colorectal (CRC), or invasive cervical cancer (ICC) diagnosed from 2012-2014. We compared late-stage diagnosis and treatment delays (> 90 days) by PC utilization (one or more visits 2-12 months prior to diagnosis), Medicaid-related factors (eligibility category, enrollment days prediagnosis, coverage gaps, managed care enrollment), and tumor and demographic characteristics. Adjusted logistic regression models were used to identify factors independently associated with improved timeliness of treatment and late-stage disease. Results: A total of 1,919 BC, 1,068 CRC, and 256 ICC non-elderly, Medicaid-insured adults were identified in the linked dataset. Nearly half of cancer patients (49%) in the linked cohort were African American or Hispanic. Compared to non-Medicaid cases, significantly higher proportions of linked Medicaid cases were diagnosed with later-stage disease (BC: 21% vs. 10%, p<0.001; CRC: 49% vs. 42%, p<0.001; ICC: 40% vs. 28%, p 0.04) and experienced longer than 90 days to first treatment (All cases: 22% vs 16%, p< 0.001). For patients enrolled in a managed care plan (67%), the proportion of late-stage cases varied significantly from 38% to 54% by plan (p<0.001). Only 26% of Medicaid cancer patients had 1 or more PC visits prediagnosis. In adjusted models, Medicaid patients with no PC visits (OR 2.13, 95% CI 1.63-2.77), enrolled in Medicaid ≤ 3 months prediagnosis (OR 1.50, 95% CI 1.20-1.88), or were FFS for the majority of their enrolled days in the year prior to diagnosis were more likely to have late-stage cancer. In cancer site-specific models, Medicaid patients diagnosed with CRC during the expansion year (2014 vs 2012-2013) were more likely to have late-stage disease (OR 2.05, 95% CI 1.42-2.93). Not having a PC visit was also significantly associated with treatment delays (OR 2.71, 95% CI 1.67-4.40). Conclusions: These findings indicate that Medicaid cancer patients diagnosed in the early ACA implementation period continue to be composed of significantly higher proportions of later-stage cases, thus requiring more aggressive treatment, leading to potential complications, worse outcomes, and higher overall costs of care. Targeted strategies to improve continuity of care and access to primary care within safety-net settings prior to a cancer diagnosis are needed to reduce late-stage cancer burden in this population. More detailed monitoring of cancer-related quality metrics across managed care organizations may also be warranted. Cancer care providers must also plan for high levels of late-stage diagnosis among newly enrolled Medicaid patients with cancer. Citation Format: Jennifer Tsui, Derek DeLia, Jose Nova, Rotter David, Kulkarni Aishwarya, Demissie Kitaw, Stroup Antoinette, Joel C. Cantor. Primary care utilization, late-stage diagnosis, and timeliness of treatment among Medicaid cancer patients: Early signals following the ACA expansion [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR07.

Cost-effectiveness of Treating Severe Childhood Caries under General Anesthesia versus Conscious Sedation.

Two common methods of treating pediatric dental patients with severe early childhood caries (S-ECC) are general anesthesia (GA) and conscious sedation (CS). We sought to first evaluate the cost-effectiveness of treating S-ECC with GA versus CS and then compare the cost-effectiveness at 2 time points: 2011 and 2015. We used a decision tree model to produce 2-y estimates of costs and outcomes from the Medicaid perspective. The model cohort consisted of healthy 3-y-olds with S-ECC in need of a theoretical set of dental treatments to be performed under either a single GA visit or 3 CS visits. Outcomes were measured in caries-free months. Costs were evaluated in 2015 US dollars. Costs, probabilities, and outcomes were estimated from published data, expert opinion, and Medicaid billing at an academic health center. One-way and probabilistic sensitivity analyses were performed. As compared with CS, GA resulted in 4 additional caries-free months per child. The cost of a caries-free month for GA versus CS rose from $596 in 2011 to $881 in 2015. These findings were sensitive to loss to follow-up for subsequent CS visits and total cost of GA. Comprehensive S-ECC treatment had better outcomes when performed under GA versus CS. However, GA was not cost saving when compared with CS. While the cost of dental treatment increased for both GA and CS from 2011 to 2015, the cost rose faster for GA. These results have important implications due to the increasing cost to Medicaid insurance and the rising number of young children being treated for S-ECC under GA. Medicaid policy makers can use the results of this study to evaluate the cost-effectiveness of dental treatment for young children with S-ECC at 2 time points: 2011 and 2015. Compared with CS, GA resulted in a longer amount of time during which children were free from dental caries but at a higher cost. The cost difference rose from 2011 to 2015.

MEDICAID AND THE LABOR SUPPLY OF SINGLE MOTHERS: IMPLICATIONS FOR HEALTH CARE REFORM

AbstractThe Medicaid expansions and health insurance subsidies of the Affordable Care Act (ACA) change work incentives for single mothers. To evaluate the employment effects of these policies ex ante, I estimate a model of labor supply and health insurance choice exploiting variation in pre‐ACA Medicaid policies. Simulations show that single mothers increase their labor supply at the extensive and intensive margin by 12% and 7%, respectively, uninsurance rates decline by up to 40%, and an average family's welfare improves by 1,600 dollars per year. Health insurance subsidies and not Medicaid expansions mostly drive these effects.

Acceptability of Postpartum No-Cost LARC Among Women Using Emergency Medicaid for Labor and Delivery [19F

INTRODUCTION: In 2012, South Carolina (SC) instituted a Medicaid policy allowing full reimbursement for inpatient post-partum long acting reversible contraceptives (LARC) and related services; however, the policy does not apply when delivery costs are covered by Emergency Medicaid. This study evaluated the acceptability of inpatient postpartum no-cost LARC for women with Emergency Medicaid coverage. METHODS: This cross-sectional study enrolled participants following delivery in three teaching hospitals in SC between November 2016 and May 2017. Eligible women were at least 18 years old and qualified for Emergency Medicaid coverage. Data were collected through patient interviews and chart abstraction. Each site provided LARC at no cost regardless of study enrollment. RESULTS: Among the 220 women enrolled, 89 women (40%) left with either the implant (n=57) or an IUD (n=32). Among those women, 79% were “very satisfied” with the insertion. When comparing pre-delivery documented contraception plans with method recorded at discharge, we found an increase in those choosing implant (pre= 18%, postpartum=26%) and a decrease in no method (pre= 26%, postpartum=15%) and IUD (pre=17%, postpartum= 15%,). Contraceptive counseling was recorded in most inpatient records (81%) and prenatal records (76%). Few participants reported receiving the information they needed about the IUD (36%) or implant (38%). Though 89% of participants planned to breastfeed, only 70% and 6% received information about breastfeeding while using implants and IUDs, respectively. CONCLUSION: LARC methods were commonly selected postpartum among this population. Despite counseling documented by providers, patients receive insufficient information about specific LARC methods and their use while also breastfeeding.

Pediatric Lead Testing: A Provider Survey

Background: Medicaid-enrolled children are considered at high risk for exposure to lead. Michigan Medicaid policy requires that all Medicaid-enrolled children be tested for lead at 12 and 24 months of age, or between 36-72 months of age if not already tested. The Michigan Department of Health and Human Services Lead Poisoning Prevention Program publishes monthly blood lead testing reports. Data from July 2016 reveal that statewide 76% of children enrolled in Medicaid had at least one blood lead level measured on or before their third …

Policies Affecting Medicaid Beneficiaries' Smoking Cessation Behaviors.

Smoking rates for Medicaid beneficiaries have remained flat in recent years. Medicaid may support smokers in quitting by covering a broad array of tobacco cessation services without barriers such as copays. This study examines the impact of increasing generosity in Medicaid tobacco cessation coverage policies on smoking and cessation behaviors. We used 2010 and 2015 National Health Interview Survey data merged with information on state tobacco, Medicaid cessation, and Medicaid eligibility policies to estimate state fixed effects models of cessation medication use, counseling use, quit attempts, and current smoking. Smokers living in states that cover cessation medications but not counseling services were less likely to use counseling. Smokers were more likely to report having tried to quit in states with higher rates of use of cessation medications among Medicaid beneficiaries. We found no impact of Medicaid policies on use of cessation medications. States that impose copays had higher rates of smoking, while those that require counseling as a condition of receiving medication had lower rates of smoking. Additionally, we found that expanding Medicaid eligibility under the Affordable Care Act is associated with decreased smoking prevalence among Medicaid beneficiaries. Covering cessation counseling may encourage smokers that want to quit to use this service. Promoting the use of cessation medications may improve the likelihood that smokers try to quit. Medicaid coverage of cessation services is an important but incomplete strategy in addressing smoking among low-income populations. States may be able to improve utilization of cessation counseling by providing Medicaid reimbursement for this service. Encouraging utilization of tobacco cessation medications may help more smokers quit. States should consider how to promote effective cessation methods among clinicians and patients.

Moral Distress with Obstacles to Hepatitis C Treatment: A Council of Academic Family Medicine Educational Research Alliance (CERA) Study of Family Medicine Program Directors.

To determine whether family medicine program directors (PDs) experienced moral distress due to obstacles to Hepatitis C virus (HCV) treatment, and to explore whether they found those obstacles to be unethical. An omnibus survey by the Council of Academic Family Medicine's Educational Research Alliance was administered to 452 and completed by 273 US-based PDs. The survey gauged attitudes and opinions regarding ethical dilemmas in patient access to HCV treatment. Most of the respondents were male. Sixty-four percent of respondents believed that treatment should be an option for all patients regardless of cost. Forty-one percent believed that it was unethical to deny treatment based on past or current substance use, and 38% believed treatment should be offered to patients who were substance abusers. Moral distress was reported by 61% (score >3) of participants when they were unable to offer treatment to patients due to the patient's failure to meet eligibility criteria. In addition, PDs reporting moderate-to-high levels of moral distress were also likely to report the following opinions: 1) treatment should be offered regardless of cost, 2) it is unethical to deny treatment based on past behavior, 3) substance abusers should be offered treatment, 4) it is unethical for medicine to be prohibitively expensive, and 5) Medicaid policy that limits treatment will worsen racial and ethnic disparities. Currently, important ethical dilemmas exist in the access and delivery of HCV therapy. Although a diversity of opinions is noted, a significant proportion of PDs are concerned about patients' inability to avail equitable care and experience distress. In some cases, this moral distress is in response to, and in conflict with, current guidelines.

Changes in Health Insurance Coverage Associated With the Affordable Care Act Among Adults With and Without a Cancer History: Population-based National Estimates.

The Affordable Care Act (ACA) improved health care coverage accessibility by expanding Medicaid eligibility, creating insurance Marketplaces, and subsidizing premiums. We examine coverage changes associated with ACA implementation, comparing adults with and without a cancer history. We included nonelderly adults from the 2012 to 2015 National Health Interview Survey. Using information on state Medicaid policies (2013), expansion decisions (2015), family structure, income, insurance offers, and current coverage, we assigned adults in all 4 years to mutually exclusive eligibility categories including: Medicaid-eligible pre-ACA; expansion eligible for Medicaid; and Marketplace premium subsidy eligible. Linear probability regressions estimated pre-post (2012-2013 vs. 2014-2015) coverage changes by eligibility category, stratified by cancer history. The uninsured rate for cancer survivors decreased from 12.4% to 7.7% (P<0.001) pre-post ACA implementation. Relative to income >400% of the federal poverty guideline, the uninsured rate for cancer survivors decreased by an adjusted 8.4 percentage points [95% confidence interval (CI), 1.3-15.6] among pre-ACA Medicaid eligible; 16.7 percentage points (95% CI, 9.0-24.5) among expansion eligible, and 11.3 percentage points (95% CI, -0.8 to 23.5, with a trend P=0.069) for premium subsidy eligible. Decreases in uninsured among expansion-eligible adults without a cancer history [9.7 percentage points (95% CI, 7.4-12.0), were smaller than for cancer survivors (with a trend, P=0.086)]. Despite coverage gains, ∼528,000 cancer survivors and 19.1 million without a cancer history remained uninsured post-ACA, yet over half were eligible for Medicaid or subsidized Marketplace coverage. ACA implementation was associated with large coverage gains in targeted expansion groups, including cancer survivors, but additional progress is needed.

Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception

ContextLong-acting reversible contraception (LARC) is the most effective reversible method to prevent unplanned pregnancies. Variability in state-level policies and the high cost of LARC could create substantial inconsistencies in Medicaid coverage, despite federal guidance aimed at enhancing broad access. This study surveyed state Medicaid payment policies and outreach activities related to LARC to explore the scope of services covered. MethodsUsing publicly available information, we performed a content analysis of state Medicaid family planning and LARC payment policies. Purposeful sampling led to a selection of nine states with diverse geographic locations, political climates, Medicaid expansion status, and the number of women covered by Medicaid. ResultsAll nine states' Medicaid programs covered some aspects of LARC. However, only a single state's payment structure incorporated all core aspects of high-quality LARC service delivery, including counseling, device, insertion, removal, and follow-up care. Most states did not explicitly address counseling, device removal, or follow-up care. Some states had strategies to enhance access, including policies to increase device reimbursement, stocking and delivery programs to remove cost barriers, and covering devices and insertion after an abortion. ConclusionsAlthough Medicaid policy encourages LARC methods, state payment policies frequently fail to address key aspects of care, including counseling, follow-up care, and removal, resulting in highly variable state-level practices. Although some states include payment policy innovations to support LARC access, significant opportunities remain.

Understanding The Relationship Between Medicaid Expansions And Hospital Closures.

Decisions by states about whether to expand Medicaid under the Affordable Care Act (ACA) have implications for hospitals' financial health. We hypothesized that Medicaid expansion of eligibility for childless adults prevents hospital closures because increased Medicaid coverage for previously uninsured people reduces uncompensated care expenditures and strengthens hospitals' financial position. We tested this hypothesis using data for the period 2008-16 on hospital closures and financial performance. We found that the ACA's Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion. Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

State Medicaid Expansions for Parents Led to Increased Coverage and Prenatal Care Utilization among Pregnant Mothers.

To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant. Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System. The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents. I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion. I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization. Expanded Medicaid coverage for low-income adults has the potential to increase a woman's health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy.

Variation in outpatient emergency department utilization in Texas Medicaid: a state-level framework for finding \u201csuperutilizers\u201d

BackgroundVery frequent outpatient emergency department (ED) use—so called “superutilization”—at the state level is not well-studied. To address this gap, we examined frequent ED utilization in the largest state Medicaid population to date.MethodsUsing Texas Medicaid (the third largest in the USA) claims data, we examined the variability in expenditures, sociodemographics, comorbidities, and persistence across seven levels of ED utilization/year (i.e., 1, 2, 3–4, 5–6, 7–9, 10–14, and ≥ 15 visits). We classified visits into emergent and non-emergent categories using the most recent New York University algorithm.ResultsThirty-one percent (n = 346,651) of Texas Medicaid adult enrollees visited the ED at least once in 2014. Enrollees with ≥ 3 ED visits accounted for 8.5% of all adult patients, 60.4% of the total ED visits, and 62.1% of the total ED expenditures. Extremely frequent ED users (≥ 10 ED visits) represented < 1% of all users but accounted for 15.5% of all ED visits and 17.4% of the total ED costs. The proportions of ED visits classified as non-emergent or emergent, but primary care treatable varied little as ED visits increased. Overall, approximately 13% of ED visits were considered not preventable or avoidable.ConclusionsThe Texas Medicaid population has a substantial burden of chronic disease with only modest increases in substance use and mental health diagnoses as annual visits increase. Understanding the characteristics that lead to frequent ED use is vital to developing strategies and Medicaid policy to reduce high utilization.

Factors Influencing Receipt of Mental Health Services Among Medicaid Beneficiaries With Breast Cancer.

This study examined associations of state-level Medicaid reimbursement and other policies and patient characteristics with receipt of mental health diagnostic and treatment services for beneficiaries with cancer. Data (2006-2008) from Medicaid beneficiaries with breast cancer were analyzed to examine predictors of receiving mental health diagnostic services and mental health treatment services. Independent variables included state-level Medicaid policies for reimbursements for mental health services and consultations (requests from one health care provider to another for advice regarding evaluation or management of a specific problem), required patient copayments, and requirements governing the timing of Medicaid eligibility recertification (eligibility recertification period). Generalized estimating equations were used to assess factors influencing receipt of mental health services while controlling for clustering by state. The analysis of diagnostic services included 7,441 Medicaid beneficiaries, and the analysis of treatment services included 7,511 beneficiaries. Medicaid reimbursements for mental health services were not associated with receiving these services. However, increased Medicaid reimbursement for consultations significantly increased the likelihood of receiving mental health diagnostic and treatment services. Increased comorbidities were also associated with increased likelihood of receiving mental health services. The association of higher Medicaid reimbursements for consultations with receipt of mental health services suggests that consultation reimbursement has a "gatekeeper" effect-after a patient received an initial consultation, lower reimbursements for mental health services were not barriers to subsequent mental health care. Increased Medicaid reimbursement for consultations with a mental health professional may increase willingness of health care providers to provide mental health care services for Medicaid beneficiaries.

Medicaid Prior Authorization Policies for Medication Treatment of Attention-Deficit/Hyperactivity Disorder in Young Children, United States, 2015.

In 2011, the American Academy of Pediatrics updated its guidelines for the diagnosis and treatment of children with attention-deficit/hyperactivity disorder (ADHD) to recommend that clinicians refer parents of preschoolers (aged 4-5) for training in behavior therapy and subsequently treat with medication if behavior therapy fails to sufficiently improve functioning. Data available from just before the release of the guidelines suggest that fewer than half of preschoolers with ADHD received behavior therapy and about half received medication. About half of those who received medication also received behavior therapy. Prior authorization policies for ADHD medication may guide physicians toward recommended behavior therapy. Characterizing existing prior authorization policies is an important step toward evaluating the impact of these policies on treatment patterns. We inventoried existing prior authorization policies and characterized policy components to inform future evaluation efforts. A 50-state legal assessment characterized ADHD prior authorization policies in state Medicaid programs. We designed a database to capture data on policy characteristics and authorization criteria, including data on age restrictions and fail-first behavior therapy requirements. In 2015, 27 states had Medicaid policies that prevented approval of pediatric ADHD medication payment without additional provider involvement. Seven states required that prescribers indicate whether nonmedication treatments were considered before Medicaid payment for ADHD medication could be approved. Medicaid policies on ADHD medication treatment are diverse; some policies are tied to the diagnosis and treatment guidelines of the American Academy of Pediatrics. Evaluations are needed to determine if certain policy interventions guide families toward the use of behavior therapy as the first-line ADHD treatment for young children.

Prolonged Hospital Discharge for Children with Technology Dependency: A Source of Health Care Disparities.

Children with ventilator assistance have been supported in living at home since 1981 when parental advocacy ushered in a change to Medicaid policy. As the population of children who use medical technology such as long-term ventilation increases, we must critically evaluate our systems for preparing families for home life. Discharge delays persist in the modern era because of fragmentation between hospital and home systems. These discharge delays result in children spending time in less developmentally rich environments, further exacerbating the health and development disparities of children with complex disabilities. In this article, we discuss the complication of hospital discharge and how it contributes to health and developmental disparities. We also describe a hospital-to-home transitional care model, which presents a home-like environment to provide developmental support while focusing on parental training, home nursing, and public-funding arrangements. [Pediatr Ann. 2017;46(10):e365-e370.].

Impact of Medicaid prescription copayments on use of antipsychotics and other medications in patients with schizophrenia

Objective: To assess the impact of Medicaid prescription copayment policies on anti-psychotic and other medication use among patients with schizophrenia.Method: The study sample included fee-for-service adult Medicaid patients with schizophrenia. Medicaid claims records from 2003–2005 from 42 states and D.C. were linked with county-level data from the Area Resource File and findings from a state Medicaid policy survey. Patient-level fixed-effects regression models examined the impact of increases in generic copayments and generic/brand copayment differentials on monthly use of anti-psychotic (overall and by generic/brand status) and other non-antipsychotic medications. Medications for hypertension, hyperlipidemia, and diabetes in sub-groups of patients with these comorbidities were also examined.Results: Prescription copayment changes had a statistically significant but small impact on anti-psychotic use. For instance, for every $1 increase in the minimum or generic copayment per prescription, there was a reduction of 1.4 anti-psychotic drug fills per 100 patient months (relative reduction = 1.9%). The generic/brand copayment differential increases also had a minimal impact in changing utilization of first-generation (generic) and second-generation (brand) anti-psychotics. Effects of copayment changes on non-anti-psychotic medication use were substantially higher; for each $1 generic copayment increase, there was a reduction of 23 non-anti-psychotic drug fills per 100 patient months (relative reduction = 10.1%). Similarly, for each $1 increase in the generic/brand copayment differential, there was a reduction of 15 non-anti-psychotic drug fills (relative reduction = 5.6%). Reductions in the number of prescriptions filled for antidiabetics, antihypertensives, and lipid-lowering agents were 4–11-fold higher than corresponding reductions for anti-psychotics.Limitations: Because federal law requires pharmacists to fill medications for Medicaid patients regardless of the ability to pay, these results may under-estimate the true impact of copayment increases.Conclusions: Medicaid prescription copayment increases resulted in only a minimal decline in anti-psychotic medication use, but much larger reductions in use of other medications, particularly cardiometabolic medications.

Medicaid Beneficiaries' Access to Residential Care Settings

ABSTRACTResidential care settings (RCSs) are community-based housing and supportive services providers. Medicaid beneficiaries' access to RCSs is of concern to policymakers and other stakeholders because most people prefer community-based to institutional services and RCSs are generally less expensive than nursing homes. To better understand Medicaid beneficiaries' access to state-licensed RCSs, we examined Medicaid policies in 50 states and the District of Columbia, interviewed seven subject-matter experts, and conducted four state case studies informed by reviews of state policies and interviews with 27 stakeholders. Factors identified as influencing Medicaid beneficiaries' access to RCSs include Medicaid reimbursement rates for RCS services, the supply of Medicaid-certified RCSs and RCS beds, and policies that affect RCS room and board costs for Medicaid beneficiaries. Shifting Medicaid spending toward community-based instead of institutional care may require attention to these interrelated issues of RCS payment, supply, and room and board costs.

Worth the Wait? The Effect of Early Term Birth on Maternal and Infant Health

Early term birth is defined as birth at 37 or 38 weeks gestation. While infants born early term are not considered premature, the medical literature suggests that they have an increased risk of serious adverse health outcomes compared to infants born at term (39 or 40 weeks). Despite these known harms, we document a rise in early term births in the United States from 1989 to the mid-2000s, followed by a decline in recent years. We posit that the recent decline in early term births has been driven by changes in medical practice advocated by the American College of Obstetricians and Gynecologists, programs such as the March of Dimes’ "Worth the Wait" campaign, and by Medicaid policy. We first show that this pattern cannot be attributed to changes in the demographic composition of mothers, and provide some evidence that efforts to reduce early term elective deliveries (EEDs) through Medicaid policy were effective. We next exploit county-level variation in the timing of these changes in medical practice to examine the effect of early term inductions (our proxy for EEDs) on infant and maternal health. We find that early term inductions lower birth weights and increase the risks of precipitous labor, birth injury, and required ventilation. Our results suggest that reductions in early term inductions can explain about one-third of the overall increase in birth weights between 2010 and 2013 for births at 37 weeks gestation and above.

State HCV Incidence and Policies Related to HCV Preventive and Treatment Services For Persons Who Inject Drugs — United States, 2015–2016

Hepatitis C is associated with more deaths in the United States than 60 other infectious diseases reported to CDC combined. Despite curative hepatitis C virus (HCV) therapies and known preventive measures to interrupt transmission, new HCV infections have increased in recent years (1,2). Injection drug use is the primary risk factor for new HCV infections (2). One potential strategy to decrease the prevalence of HCV is to create and strengthen public health laws and policies aimed specifically at reducing transmission risks among persons who inject drugs. To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.