Medicaid Recipients Research Articles

Changes in healthcare costs and utilization for Medicaid recipients who received supportive housing through a payer-community-based housing partnership.

To evaluate healthcare cost and utilization changes among Medicaid and dually eligible participants of a supportive housing program implemented by a managed care organization and community-based organization. Healthcare claims were reviewed retrospectively for 80 program participants in one urban Pennsylvania county between 1/1/2018 and 9/28/2023 who had ≥6 months of claims data in both pre- and post-housing periods. Eligibility included age >18 years, Medicaid/Special Needs Plan enrollment, and housing need. Due to limited housing units, potential participants were prioritized by medical need and history of unplanned care. Healthcare cost and utilization were compared during pre- (i.e., 12 months before housing initiation) and post-periods (i.e., 12 months after housing initiation). Compared to the pre-period, significantly lower medical (-40.4%, p = 0.004), emergency department (-62.7%, p = 0.02), and total (-33.3%, p = 0.02) costs of care were observed in the post-period. Significantly lower primary care (-50.0%, p = 0.0003), specialist (-31.3%, p = 0.02), and emergency department (-50.0%, p = 0.03) utilization were also observed. Healthcare cost and utilization among medically complex individuals were lower with supportive housing. Future evaluations with randomized designs can address the potential causal impact of supportive housing as a healthcare intervention on specific outcomes.

Leveraging Quality Improvement and Shared Learning to Improve Infant Well-Child Visit Rates in Texas.

Texas Medicaid improved infant well-child visit rates by participating in a national learning collaborative. The two-year program encouraged creativity and innovation in care for Medicaid recipients through partnerships with managed care organizations (MCOs). The MCO projects discovered valuable practices in member outreach and were disseminated in shared learning experiences. At the completion of the learning collaborative, Texas Medicaid surveyed the MCO participants to assess the impact of their projects on Medicaid beneficiaries in Texas as well as the quality improvement project format. Collectively, the MCOs raised the infant well-child visit rate year-over-year. All of the partner MCOs stated they plan to continue focused work on improving infant well-child visit rates after the learning collaborative.

79 - Study Design and Baseline Characteristics of Older Medicaid Recipients Enrolled in the Incontinence Helping Others Manage at Home (Incon@Home) Implementation Study

79 - Study Design and Baseline Characteristics of Older Medicaid Recipients Enrolled in the Incontinence Helping Others Manage at Home (Incon@Home) Implementation Study

Elucidating disparities in sunscreen coverage among state Medicaid preferred drug lists.

Regular application of over-the-counter (OTC) sunscreen is considered the foundation of skin cancer prevention, yet OTC sunscreen is not eligible for reimbursement in almost all state Medicaid benefit plans. On review of 111 Medicaid preferred drug lists (PDLs) across 50 states and the District of Columbia (DC), only five plans were identified that incorporate coverage of sunscreen. Thus, many recipients of Medicaid, the majority of whom are individuals and families of lower socioeconomic status, may encounter financial difficulty and thus forego utilizing sun protective measures due to financial constraints. Here, we compare current Medicaid coverage of OTC sunscreen and discuss calculated and theoretical annual costs of this skin cancer prevention method.

Abstract B058: Preliminary findings of a multilevel community-based clinical trials and genomic navigation program implemented in the southern United States

Abstract Introduction: Advances in genomics have increased our understanding of the interplay between genetics, environment, behavior, and disease. However, these scientific advances are hampered by the inadequate representation of African American (AA) and Hispanic populations in genomic studies and clinical trials; thus, it is important to identify effective engagement and navigation strategies. The goal of the MSM/TU/UAB OCCC Partnerships to Advance Cancer Health Equity (PACHE) Outreach Core is to implement and evaluate an evidence-based, theory-informed, multi-level, clinical trial and cancer genomics education program (CTC-GEP) to address the determinants for AA and Hispanic participation in clinical trials and genomic research. The program consists of a clinical and genomic navigator and a high and low-tech toolkit. We will present preliminary data characterizing the feasibility phase of this two-arm behavioral trial. Methods: The Attitudes and Intentions to Enroll in a Therapeutic Trial (AIET) questionnaire and a culturally tailored social and demographic questionnaire were used by navigators to obtain participants information. Cumulative logistic regression was used to assess the correlation of age, race, education, and type of health insurance with attaining a higher score on the Likert scale used in AIET survey questions at pre- and post-test. Results: Younger participants (18-49 years) were significantly more likely than older participants (ages 50 and above) to hold several positive views about participating in clinical trials. Specifically, they were 3.6 times as likely to believe that participating in a clinical trial could help advance science to improve community health (P-value = 0.0393); 4.6 times as likely to think there are benefits for others like them (P-value = 0.25); 5.6 times as likely to trust that clinical trial centers have rules to protect their records (P-value = 0.024); and 3.9 times as likely to trust health workers (P-value = 0.002). Additionally, participants with a high school education or less were 3.2 times as likely to consider themselves at risk of cancer compared to those with a college education or higher (P- value = 0.0015). Medicare & Medicaid recipients, compared to those with private insurance, viewed privacy as a major concern when participating in research (P-value = 0.008). Furthermore, Black/AA participants were more likely than White participants to believe that Blacks are used in research without their knowledge (P-value = 0.005). Conclusions: CTC- GEP was demonstrated to be feasible and acceptable among study participants. Findings from the AIET survey highlight privacy concerns are more pronounced among Medicare & Medicaid recipients, indicating a need for better communication about privacy protections. As well, age and racial disparities exist in trust regarding the ethical conduct of research, with older and AA participants expressing significant concern about being used in research inappropriately and without their knowledge. Citation Format: Mohamed Mubasher, Osato Eke, Victoria Churchill, Vivian Carter, Yu-Mei Schoenberger, Desiree Rivers, Jamirah Chevrin, Stephen Sodeke, Christina Wilkerson, Makeeta Rayton, Teresa Hall, Illeana Barrios Zermeno, Angela Morris, Jennifer Culbertson, Roland Matthews, Brian Rivers. Preliminary findings of a multilevel community-based clinical trials and genomic navigation program implemented in the southern United States [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B058.

Emergency Department Visits Among Adolescents for Intentional Assault, Firearm, Poison, and Self-Harm Injuries Before and During the COVID-19 Pandemic in the United States.

Purpose This study aimed to examine changes in adolescent emergency department (ED) visits for firearm, poison, self-harm, and intentional assault injuries before and during the COVID-19 pandemic and to identify sociodemographic factors influencing these variations. Methods Utilizing the Nationwide Emergency Department Sample (NEDS), the study analyzes data for intentional self-harm, poison-related, intentional assaults, and firearm injuries from 2019 to 2021 in adolescents aged 10 to 18 years. A difference-in-differences analysis was conducted to investigate the potential impacts of COVID-19 on injury-associated ED visits, accounting for adjustments related to year, patient factors, and hospital characteristics. Results There was a substantial decline in the number of all ED visits from pre-COVID to during the COVID, but we observed increases in the volume of ED visits for firearm-related injuries (13,248 to 20,611; p-value < 0.0001), poison-related injuries (147,812 to 213,753; p-Value < 0.0001), and intentional self-harm-related injuries (153,297 to 229,591; p-value < 0.0001). Conversely, intentional assault-related injuries decreased (167,614 to 154,940; p-value < 0.0001). During the COVID-19 pandemic, ED visits for intentional self-harm increased by 15% (95% CI = 1.09-1.21), intentional assault by 6% (95% CI = 1.02-1.09), and poison-related injuries by 17% (95% CI = 1.11-1.21) compared to pre-pandemic levels. Racial disparities were observed, with Black individuals having lower odds of self-harm (aOR = 0.63) and poison-related visits (aOR = 0.69) but higher odds of assault-related visits (aOR = 1.40) compared to Whites. Hispanic individuals had fewer ED visits across all injury types, while Native Americans had higher odds across all injury types. Disparities between Black and White individuals in assault-related visits narrowed during the pandemic (aOR = 1.40 to 0.94), but disparities for Native Americans in assault-related injuries widened. Insurance status influenced ED visits, with Medicaid recipients having higher odds of self-harm (aOR = 1.11) but lower odds of assault visits (aOR = 0.82) compared to those with private insurance. Uninsured adolescents had lower odds of self-harm (aOR = 0.85) and poison-related visits (aOR = 0.95), but higher odds of assault-related visits (aOR = 1.17). Gender disparities persisted, with females having higher odds of self-harm (aOR = 1.66) and poison-related visits (aOR = 1.42) but lower odds of assault-related visits (aOR = 0.91) compared to males, with these disparities widening for self-harm and poison-related visits during the pandemic. Conclusions The findings underscore the heightened vulnerability of adolescents to certain injuries during the COVID-19 pandemic. Targeted interventions and policies to support mental health, firearm safety measures, and strategies to prevent poisoning are recommended. Addressing socioeconomic disparitiesis necessary to mitigate the impact of intentional injuries among racially/ethnically diverse adolescents during future pandemics.

Patient- and Provider-Level Factors Associated with Patient Portal Usage Among Medicaid Recipients.

Background: Patient portals can improve access to electronic health information and enhance patient engagement. However, disparities in patient portal utilization remain, affecting disadvantaged communities disproportionately. This study examined patient- and provider-level factors associated with portal usage among Medicaid recipients in a large federally qualified health center (FQHC) network in Texas. Methods: Deidentified electronic medical records of patients 18 years or older from a large Texas FQHC network were analyzed. The dependent variable was a binary flag indicating portal usage during the study period. Independent variables included patient- and provider-level factors. Patient-level factors included sociodemographic, geographic, and clinical characteristics. Provider characteristics included primary service line, provider type, provider language, and years in practice. Because the analysis was at the individual level, a multivariable logistic regression model focused on adjusted associations between independent variables and portal usage. Results: The analytic sample consisted of 9,271 individuals. Compared with individuals 18-39 years, patients 50 years and older had lower odds (50-64 OR: 0.60, p < 0.001; 65+ OR: 0.51, p < 0.001) of portal usage. Males were less likely to use portals (OR: 0.44, p = 0.03), and compared to Non-Hispanic Whites, Non-Hispanic Black (OR: 0.86, p = 0.02) and Hispanics (OR: 0.83, p < 0.001) were significantly less likely to use portals. Individuals with 1 or more telemedicine consults had a two-times greater odds of portal usage (OR: 1.97, p < 0.001). Compared to individuals who had clinic visits in December 2018, portal usage was significantly higher in the pandemic months (March 2020-November 2020, all p's < 0.01). Importantly, the behavioral health service line had the greatest odds (OR: 1.52, p < 0.001), whereas the dental service line had the lowest odds (OR: 0.69, p = 0.01) compared to family practice. No other provider characteristics were significant. Conclusion: Our finding of significant patient-level factors is important and can contribute to developing appropriate patient-focused health information technology approaches to ensure equitable access and maximize the potential benefits of patient portals in health care delivery.

Prenatal exposure to greenspace and risk of children’s neurodevelopmental disease: a national cohort study of Medicaid recipients

Prenatal exposure to greenspace and risk of children’s neurodevelopmental disease: a national cohort study of Medicaid recipients

Prenatal exposure to fine particulate matter (PM2.5) and risk of neurodevelopmental delays: a national cohort study of Medicaid recipients

Prenatal exposure to fine particulate matter (PM2.5) and risk of neurodevelopmental delays: a national cohort study of Medicaid recipients

The TBI Model Systems Neighborhood Socioeconomic Disadvantage Index (TBIMS-NSDI): Development and Comparison to Individual Socioeconomic Characteristics.

To create a census-based composite neighborhood socioeconomic deprivation index (NSDI) from geocoded residential addresses and to quantify how NSDI aligns with individual-level socioeconomic factors among people with traumatic brain injury (TBI). Community. People enrolled in the TBI Model Systems National Database (TBIMS NDB). Secondary analysis of a longitudinal cohort study. The TBIMS-NSDI was calculated at the census tract level for the United States population based on a principal components analysis of eight census tract-level variables from the American Community Survey. Individual socioeconomic characteristics from the TBIMS NDB were personal household income, education (years), and unemployment status. Neighborhood:Individual NSDI residuals represent the difference between predicted neighborhood disadvantage based on individual socioeconomic characteristics versus observed neighborhood disadvantage based on the TBIMS-NSDI. A single principal component was found to encompass the eight socioeconomic neighborhood-level variables. It was normally distributed across follow-up years 2, 5, and 10 post-injury in the TBIMS NDB. In all years, the TBIMS-NDSI was significantly associated with individual-level measures of household income and education but not unemployment status. Males, persons of Black and Hispanic background, Medicaid recipients, persons with TBI caused by violence, and those living in urban areas, as well as in the Northeast or Southern regions of the United States, were more likely to have greater neighborhood disadvantage than predicted based on their individual socioeconomic characteristics. The TBIMS-NSDI provides a neighborhood-level indicator of socioeconomic disadvantage, an important social determinant of outcomes from TBI. The Neighborhood:Individual NSDI residual adds another dimension to the TBIMS-NSDI by summarizing how a person's socioeconomic status aligns with their neighborhood socioeconomics. Future studies should evaluate how both measures affect TBI recovery and life quality. Research studying neighborhood socioeconomic disadvantage may improve our understanding of how systemic adversity influences outcomes after TBI.

Twelve-Month Contraceptive Supply Policies and Medicaid Contraceptive Dispensing

Nineteen states have passed legislation requiring insurers to cover the dispensation of a 12-month supply of short-acting, hormonal contraception. To determine whether 12-month contraceptive supply policies were associated with an increase in the receipt of 12-month or longer supply of contraception. This retrospective cohort study included data from all female Medicaid enrollees aged 18 to 44 years who used short-acting hormonal contraception (ie, pill, patch, or ring) from 2016 to 2020. Eleven treatment states where legislation required insurers to cover a 12-month supply of contraception to continuing users and 25 comparison states without such legislation prior to December 2020. Proportion of contraception months received via a single 12-month or longer fill. This study included 48 255 512 months of dispensed oral pill, patch, and ring contraception prescription supply among 4 778 264 female Medicaid enrollees. The majority of months of supplied contraception were for the contraceptive pill rather than the patch or ring. In a staggered difference-in-differences model, the 12-month supply policy was associated with an estimated 4.39-percentage point (pp) increase (95% CI, 4.38 pp-4.40 pp) in the proportion of contraception dispensed as part of a 12-month or longer supply, from a mean of 0.11% in treatment states during the first quarter of the study period. Investigating the heterogeneity in policy association across states, California stood out with a 7.17-pp increase (95% CI, 7.15 pp-7.19 pp) in the proportion of contraception dispensed as a 12-month or longer supply; in the other 10 treatment states, the policy association was less than 1 pp. In this cohort study of Medicaid recipients using short-acting hormonal contraception, the passage of a 12-month contraceptive supply policy was associated with a minimal increase in the proportion of contraception dispensed through a 12-month or longer supply.

Intimate Partner Violence and Antenatal Depression Among Underserved Pregnant Women.

Introduction: Few studies have examined the associations of intimate partner violence (IPV) exposure during pregnancy and types of IPV with antenatal depression among underserved pregnant women. Methods: Data came from participants from a Healthy Start program in South Carolina between 2015 and 2019 (n = 1,629). The first two questions in the Woman Abuse Screening Tool (WAST) were used to measure IPV exposure, that is, having a problematic relationship with their partner. Those who had IPV exposure were assessed with six additional questions of the WAST. Principal component analysis was conducted on the 8-item WAST data to identify underlying types of IPV exposure. Antenatal depression was defined as the Center for Epidemiologic Studies Depression scores ≥16. Results: Participants were racially diverse (71% black, 21% white) with 85% Medicaid recipients. Nearly 12% of participants reported IPV exposure and 30% reported antenatal depression. The odds of having IPV exposure were higher among unmarried women, those with less than a high school education, and those who lacked family support. The odds of having antenatal depression were 2.5 times higher (95% CI: 1.9-3.5) among women with IPV exposure. After controlling for covariates, a one-point increase in the scores for psychological IPV (Factor 1) or a problematic relationship (Factor 3) was associated with increased odds of antenatal depression. Conclusion: This is one of the first studies to estimate the prevalence of IPV exposure using a proxy measure (a problematic relationship) among underserved U.S. pregnant women. Its positive association with antenatal depression suggests the utility of screening for a problematic relationship using a two-item WAST and providing assistance to those with IPV exposure.

Access to Dermatological Appointments Based on Insurance Types in Hawai'i.

Although there is evidence that Medicaid beneficiaries in the continental United States experience barriers to accessing dermatological care, limited data exists on whether these same barriers exist in Hawai'i. Using a secret shopper study design, a total of 46 dermatology offices were contacted, 41 (89%) of which were accepting new patients. Thirty (73%) offices were located on O'ahu, and the remaining 11 (27%) were distributed among the neighboring islands (Hawai'i Island, Kaua'i, Maui). Overall, the acceptance rate for Medicaid (n=14) was 34%, which was significantly lower (P<.0001) than private insurance (n=39 (95%)) and Medicare (n=38 (93%)). The acceptance rate for patients with Medicaid insurance was lower for O'ahu offices (27%) than for neighboring islands' offices (55%), but the difference was not statistically significant (P=.095). Differences in average wait times were not statistically significant among insurance types or between O'ahu and neighboring islands. Overall, these results suggest that Medicaid recipients compared to those with private insurance or Medicare might experience difficulty in accessing dermatological care in Hawai'i.

Medicaid Expansion and Restriction Policies for Hepatitis C Treatment

Hepatitis C can be cured with direct-acting antivirals (DAAs), but Medicaid programs have implemented fibrosis, sobriety, and prescriber restrictions to control costs. Although restrictions are easing, understanding their association with hepatitis C treatment rates is crucial to inform policies that increase access to lifesaving treatment. To estimate the association of jurisdictional (50 states and Washington, DC) DAA restrictions and Medicaid expansion with the number of Medicaid recipients with filled prescriptions for DAAs. This cross-sectional study used publicly available Medicaid documents and claims data from January 1, 2014, to December 31, 2021, to compare the number of unique Medicaid recipients treated with DAAs in each jurisdiction year with Medicaid expansion status and categories of fibrosis, sobriety, and prescriber restrictions. Medicaid recipients from all 50 states and Washington, DC, during the study period were included. Multilevel Poisson regression was used to estimate the association between Medicaid expansion and DAA restrictive policies on jurisdictional Medicaid DAA prescription fills. Data were analyzed initially from August 15 to November 15, 2023, and subsequently from April 15 to May 9, 2024. Jurisdictional Medicaid expansion status and fibrosis, sobriety, and prescriber DAA restrictions. Number of people treated with DAAs per 100 000 Medicaid recipients per year. A total of 381 373 Medicaid recipients filled DAA prescriptions during the study period (57.3% aged 45-64 years; 58.7% men; 15.2% non-Hispanic Black and 52.2% non-Hispanic White). Medicaid nonexpansion jurisdictions had fewer filled DAA prescriptions per 100 000 Medicaid recipients per year than expansion jurisdictions (38.6 vs 86.6; adjusted relative risk [ARR], 0.56 [95% CI, 0.52-0.61]). Jurisdictions with F3 to F4 (34.0 per 100 000 Medicaid recipients per year; ARR, 0.39 [95% CI, 0.37-0.66]) or F1 to F2 fibrosis restrictions (61.9 per 100 000 Medicaid recipients per year; ARR, 0.62 [95% CI, 0.59-0.66]) had lower treatment rates than jurisdictions without fibrosis restrictions (94.8 per 100 000 Medicaid recipients per year). Compared with no sobriety restrictions (113.5 per 100 000 Medicaid recipients per year), 6 to 12 months of sobriety (38.3 per 100 000 Medicaid recipients per year; ARR, 0.65 [95% CI, 0.61-0.71]) and screening and counseling requirements (84.7 per 100 000 Medicaid recipients per year; ARR, 0.87 [95% CI, 0.83-0.92]) were associated with reduced treatment rates, while 1 to 5 months of sobriety was not statistically significantly different. Compared with no prescriber restrictions (97.8 per 100 000 Medicaid recipients per year), specialist consult restrictions was associated with increased treatment (66.2 per 100 000 Medicaid recipients per year; ARR, 1.05 [95% CI, 1.00-1.10]), while specialist required restrictions were not statistically significant. In this cross-sectional study, Medicaid nonexpansion status, fibrosis, and sobriety restrictions were associated with a reduction in the number of people with Medicaid who were treated for hepatitis C. Removing DAA restrictions might facilitate treatment of more people diagnosed with hepatitis C.

The Value of Health Insurance during a Crisis: Effects of Medicaid Implementation on Pandemic Influenza Mortality

Abstract This paper studies how better access to public health insurance affects infant mortality during pandemics. The analysis combines cross-state variation in mandated eligibility for Medicaid with two influenza pandemics that arrived shortly before and after the program’s introduction in 1965. We find that better access to public health insurance in high-eligibility states substantially reduced pandemic infant mortality. The reductions in pandemic infant mortality are too large to be attributable solely to new Medicaid recipients, suggesting that expanded access to public health insurance helped mitigate disease transmission among the broader population.

Mandating work, commanding health, and managing risk: the (bio)politics of Medicaid reform

ABSTRACT In this article, I analyze proposed Medicaid work requirements to argue that gendered and racialized discourses of poverty and ableist constructs of employability present “able-bodied” Medicaid recipients as a financial and health risk. Focusing on the co-constitution of rhetoric and policy, I trace the ways in which imaginaries of dependency and irresponsibility contribute to the construction and behavioral regulation of the unproductive and unfit bio-Other. I contend that the regulatory machinations of workfare and healthfare compound structural inequities in the labor market, diminish government-funded healthcare provision, and enhance biometric surveillance of Medicaid recipients.

Medicaid Enrollment and Intergenerational Transfers of Wealth Among Older Adults.

Medicaid look-back periods are meant to prevent Medicaid applicants from gifting assets to meet eligibility requirements. These policies have the potential to affect families across generations given their ability to restrict the transfer of assets between parent and child. Using 2008-2018 data from the Health and Retirement Study, this study analyzed the estate planning and familial wealth transfer behaviors of a cohort of older adults aged 65 and older who became Medicaid recipients during a 10-year period. There were 8,347 respondents aged 65 and older in 2008 and 11.96% of respondents who were not Medicaid recipients at baseline became recipients over the study period. A little more than one third (36.47%) of Medicaid recipients participated in estate planning and asset transfer prior to becoming a recipient, with significant differences among select demographic characteristics. Married recipients were more likely to transfer money compared to their widowed counterparts (51.69% compared to 36.44%; p < .001) and transferred larger amounts compared to those unmarried ($16,286.94 compared to 5,379.13). White, well-educated, married, men participated in higher rates of estate planning, likely a reflection of who has access to resources to make necessary arrangements early. This analysis concludes that more structurally advantaged groups are more likely to engage in estate planning prior to Medicaid enrollment. This analysis demonstrates that some individuals may circumvent Medicaid policies like look-back periods and estate recovery, while others cannot. Policymakers should consider policies that promote the financial health of low-income families.

Decomposition analysis of racial and ethnic differences in receipt of immediate postpartum, long-acting, reversible, and permanent contraception

ObjectivesThis study aimed to determine the factors contributing to racial and ethnic disparities in the use of immediate postpartum, long-acting reversible contraception (IPP LARC) and permanent contraception among Medicaid recipients. Study designWe conducted a cross-sectional study using 3 years of national Medicaid claims data to examine the rates of IPP LARC use alone and a composite measure of postpartum permanent contraception and IPP LARC within 7 days of delivery by race and ethnicity. We used a Blinder–Oaxaca model to quantify the extent to which medical complexity, age, rurality, mode of delivery, and year explained differences in outcomes among different minoritized groups in comparison to non-Hispanic White women. ResultsOur study sample contained 1,729,663 deliveries occurring from 2016 through 2018 among 1,605,199 people living in 16 states. IPP LARC use rates were highest among Black (2.2%), followed by American Indian and Alaska Native at 2.1% and Hawaiian/Pacific Islander beneficiaries at 1.9%, Hispanic (all races) at 1.2%, and Asian at 1.0%. IPP LARC was lowest among White beneficiaries (0.8%). Medical complexity, age, rurality, year, and mode of delivery explained only 12.3% of the difference in IPP LARC rates between Black and White beneficiaries. Postpartum permanent contraception was highest among White (7.6%), Hispanic (7.2%), and American Indian and Alaska Native (6.8%), followed by Black (6.3%), Hawaiian/Pacific Islander (5.1%) and lowest among Asian women (4.1%). When we examined the use of IPP LARC or postpartum permanent contraception together, these same factors explained 94.4% of the differences between Black and White beneficiaries. ConclusionsWhile differences in the use of IPP LARC by race and ethnicity were identified, our findings suggest that overall use of inpatient highly effective contraception are similar across racial and ethnic groups. ImplicationsWhen IPP LARC and postpartum permanent contraception are examined jointly, their use is similar across racial and ethnic groups.

The association of short-term increases in ambient PM2.5 and temperature exposures with stillbirth: racial/ethnic disparities among Medicaid recipients.

Racial/ethnic disparities in the association between short-term (eg, days, weeks), ambient fine particulate matter (PM2.5) and temperature exposures and stillbirth in the United States have been understudied. A time-stratified, case-crossover design using a distributed lag nonlinear model (0- to 6-day lag) was used to estimate stillbirth odds due to short-term increases in average daily PM2.5 and temperature exposures among 118 632 Medicaid recipients from 2000 to 2014. Disparities by maternal race/ethnicity (Black, White, Hispanic, Asian, American Indian) and zip code-level socioeconomic status (SES) were assessed. In the temperature-adjusted model, a 10μg m-3 increase in PM2.5 concentration was marginally associated with increased stillbirth odds at lag 1 (0.68%; 95% CI, -0.04% to 1.40%) and lag 2 (0.52%; 95% CI, -0.03 to 1.06) but not lag 0-6 (2.80%; 95% CI, -0.81 to 6.45). An association between daily PM2.5 concentrations and stillbirth odds was found among Black individuals at the cumulative lag (0-6days: 9.26% 95% CI, 3.12%-15.77%) but not among other races or ethnicities. A stronger association between PM2.5 concentrations and stillbirth odds existed among Black individuals living in zip codes with the lowest median household income (lag 0-6: 14.13%; 95% CI, 4.64%-25.79%). Short-term temperature increases were not associated with stillbirth risk among any race/ethnicity. Black Medicaid enrollees, and especially those living in lower SES areas, may be more vulnerable to stillbirth due to short-term increases in PM2.5 exposure. This article is part of a Special Collection on Environmental Epidemiology.

Risk of Hospitalization Associated with Use of Consumer-Directed Attendant Care

ABSTRACT Older people with disabilities living independently often use attendant care, also known as Personal Assistive Services (PAS). The aides providing care can come from a home health agency contracted by the state Medicaid authority, known as agency-directed PAS, or the Medicaid recipient can receive a monthly budget and arrange their own care, known as consumer-directed care. Consumer-directed care is hypothesized to have some possible benefits but could also potentially lead to health hazards. This study examined whether people receiving consumer-directed PAS versus people receiving agency-directed PAS faced a higher risk of hospitalization. The data for this study came from Pennsylvania Medicaid claims, enrollment files, standardized assessments, and hospitalization claims from Medicare and Medicaid. The analysis used two-stage least square regression, with the percentage of people in a county using consumer-directed care as an instrument for the type of PAS. People using consumer-directed care did not have a statistically significant difference in risk for hospitalization compared to people using agency-directed PAS (p = .976). Risk of hospitalization was not different for people using consumer-directed care compared to people using agency-directed care.