Public Insurance Programs Research Articles

Do Older Mexican Americans With Dementia Benefit From Living Closer to the Border? Evidence From the HEPESE

This paper explores disparities in health outcomes among Hispanic older adults living near the United States (U.S.)-Mexico border. Hispanic older adults face significant barriers to healthcare access, stemming from multiple factors: limited income, high medical costs, elevated rates of chronic disease and dementia, and greater reliance on public insurance programs, relative to other racial, ethnic, and age groups. Likewise, Hispanic older adults diagnosed with dementia near the U.S.-Mexico border face documented barriers to healthcare, including higher costs, fewer adult day care centers, and a lack of health insurance. We use a health disparities and dementia care conceptual framework to explore the interactions of these social determinants of health for the older Hispanic American population. Using data from the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE, waves 8–9, 2012–2013 and 2016), complemented by the American Community Survey (ACS, 2011–2022), we conduct descriptive and regression model analyses to explore the relationship between living in U.S. counties and states that border Mexico and health outcomes such as mobility difficulties, self-care, self-reported health, and issues with activities of daily living (ADL) and instrumental activities of daily living (iADL). We control for demographic, health, and social support characteristics to account for individual level differences. We also examine how proximity to the border and caregiver and community resources affect outcomes for Mexican American older adults aged 80 and older—a growing demographic with limited data and a higher risk of health disparities. Our findings show that Hispanic older adults who reside closer to the border rely more on caregivers for instrumental and emotional support, report worse self-reported health, experience more difficulty paying bills, report lower independence in both ADL and iADL measures, and face an increased risk of dementia diagnosis, relative to their counterparts further from the border. Our findings suggest the urgency for better policies to address the needs of older Hispanic Americans with dementia in the border region. These policies require a focus on primary care, benefits counseling, and assistance in locating and accessing community services. The long-term focus should be to support flexible caregiving arrangements that increase the autonomy of both the care recipient and caregiver, community support, culturally competent caregiving, infrastructural improvements, and in-home support services for families coping with a dementia patient.

Impacto de um mecanismo de seguro agrícola no crédito na agricultura familiar: evidência do “Proagro Mais” no Paraná

Abstract This research analyzes a public compulsory crop-credit public insurance program, Proagro Mais, which is one of the largest agricultural risk management programs in Brazil and is also focused on smallholder producers. In particular, this study assesses the influence of the program on the amount of credit obtained per hectare by smallholder corn producers in the state of Paraná, Brazil. The primary dataset is a comprehensive database of agricultural credit borrowers comprising 93.303 individuals. The methodology incorporates the propensity score matching (PSM) at the endline year, employing three distinct matching algorithms, and PSM at the baseline, coupled with the difference-in-differences method. The results indicate that the treatment had ambiguous effect on the treated, with reduced impacts when compared with the outcome variable means. This suggests that the control group may have employed agricultural risk management tools other than Proagro Mais to mitigate the effects of low production on the average credit per hectare. It should be noted that this research represents one of the few impact evaluation studies on crop insurance in Latin America.

Beyond the operating room: Comparing surgical outcomes of a public insurance programme in Khyber Pakhtunkhwa

Objective: To estimate the utilization of public insurance for surgical interventions in Khyber Pakhtunkhwa, Pakistan, andcompare surgical outcomes between insured and uninsured patients. Methods: We retrospectively extracted data from one public and three private tertiary hospitals of Khyber Pakhtunkhwa(KP) that are empanelled under the Sehat Card Plus (SCP) Programme. Secondary Data was collected for a period of 16months, from 1st June 2021 to 30th September 2022 both electronically and manually. The data collection process tookplace from October 2022 to December 2022. Patients undergoing exploratory laparotomy, lower (uterine) segmentcaesarean section (LSCS), or open reduction internal fixation (ORIF) of fractures were included. Extracted data includeddemographic details, payment status (SCP user/non-user), and surgical outcomes [in-hospital mortality, length of stay (LOS),14- and 30-day readmission]. Multivariable regression models were created to determine the association of SCP use withsurgical outcomes. Results: Records of 1,853 patients were analysed. The mean age was 28.74±12.75 years. A total of 582 (31.41%) patientsutilized SCP for their treatment,429 (73.71%) of whom underwent LSCS. Overall mortality rate was 17 (0.92%). Comparedwith SCP non-users, SCP users had a significantly higher LOS (standardised beta: 0.52, 95% CI: 0.08-0.97) and lower 14-dayreadmission rate (OR: 0.64, 95% CI: 0.41-1.00). However, no significant difference was observed for 30-day readmission. Conclusion: Significantly prolonged LOS in SCP users can lead to over-utilisation of available assets. However, a lower 14-day readmission rate was also noted among the SCP users. To ensure optimal outcomes among patients and adequate useof resources, continuous monitoring and changes are required for such public insurance programmes in low-resourcesettings. Keywords: Health insurance, National health programs, Universal health insurance, Treatment outcome

The impact of health insurance integration on patient choice of providers in China

ABSTRACT This paper utilizes a nationwide integration reform of two public health insurance programmes in China to examine the impact of health insurance integration on patient choice of medical providers. Using a dataset that combines longitudinal survey data and government regulations data, we find that the integration leads to an increasing probability of outpatients in nearby primary care facilities and decreased outpatient visits to public healthcare providers. Moreover, the effects of integration vary with patient demographics, the type of healthcare, and the model of insurance management. No significant evidence suggests that the integration affects health behaviours or health status in the short term. These findings provide empirical evidence on the effects of insurance integration and policy implications for building an efficient hierarchical healthcare system.

Validation Study of the Claims-Based Algorithm Using the International Classification of Diseases Codes to Identify Patients With Coronavirus Disease in Japan From 2020 to 2022: The VENUS Study.

We validated claims-based algorithms using the International Classification of Diseases, Tenth Revision (ICD-10) to identify patients with the first-ever coronavirus disease (COVID-19) onset between May 2020 and August 2022. The study cohort was comprised of residents of one municipality enrolled in a public insurance program. This study used data provided by the municipality, including residents' insurer-based medical claims data linked to the Health Center Real-time Information-Sharing System (HER-SYS). The HER-SYS data included positive results from COVID-19 tests and were used as reference standards. Claims-based algorithms #1 and #2 were U07.1, B34.2, with and without suspicious diagnoses, respectively. Claims-based algorithms #3 and #4 were U07.1 with and without suspicious diagnoses, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each algorithm. The study cohort included 165 038 residents, including 13 402 residents were the reference standard. For the entire period, the sensitivity, specificity, PPV, and NPV were 55.7% (95% confidence interval: 54.8%-56.5%), 65.4% (65.2%-65.6%), 11.5% (11.3%-11.8%), and 98.9% (98.8%-99.0%) for Algorithm #1, and 67.0% (66.2%-67.8%), 88.1% (87.9%-88.3%), 31.6% (31.1%-32.2%), and 97.8% (97.7%-97.8%) for Algorithm #2, and 52.9% (52.0%-53.7%), 67.1% (66.9%-67.3%), 11.5% (11.2%-11.8%), and 98.3% (98.3%-98.4%) for Algorithm #3, 62.6% (61.8%-63.4%), 88.5% (88.3%-88.7%), 30.9% (30.3%-31.4%), and 97.3% (97.2%-97.4%) for Algorithm #4, respectively. Our study showed that the validity of claims-based algorithms consisting of COVID-19-related ICD-10 codes to identify patients with first-onset COVID-19 is limited.

Abstract B139: Redlining bias and progression of chronic health conditions in survivors of childhood cancer: A report from the St. Jude lifetime cohort study

Abstract Background/Aims: Racial health disparities have been linked to racial and residential segregation. Redlining bias is a special form of racial and residential segregation involving the systematic denial of mortgages, insurance, and other financial services to racial/ethnic minorities. This study examined associations between redlining bias and the progression of chronic health conditions (CHCs) in adult survivors of childhood cancer. Methods: We included 1,670 adult survivors of childhood cancer from the St. Jude Lifetime Cohort Study who had undergone two or more clinical assessments. Over 200 individual CHCs were graded using a modified CTCAE version and aggregated to determine the global CHC burden. CHC progression from baseline to follow-up evaluation was classified as either worsening over time (from Grade 2 to 3-5 or from Grade 3 to 4-5) or new-onset (from Grades 0-1 to 2-5). Survivors' home addresses at baseline (2007-2020) were linked to contemporary redlining bias data (2010-2017) created by Beyer et al. (J Clin Oncol, 2021). Redlining bias was defined as the odds ratio of a mortgage application denial for properties in a local area versus all metropolitan statistical areas and further classified as high (≥2.0), moderate (1.0-1.9), low (0.5-0.9), or least bias (<0.5). Multivariable logistic regression tested associations of risk for worsening/new-onset CHCs (vs. no progression) with redlining bias (high vs. moderate/low/least bias), adjusting for age, sex, treatment factors, personal socioeconomic status (SES; education and health insurance), and lifestyle factors. Joint effects of redlining bias and personal SES on CHC progression were also evaluated. Results: Survivors’ mean±SD age at baseline was 31.7±8.3 years; 17.5% lived in high and 19.5% in moderate redlining neighborhoods. The bivariate analysis found that living in a neighborhood classified as having high redlining bias (vs. moderate/low/least bias) increased the risk of progression of the global burden of CHCs (OR=1.32, 95% CI: 1.02-1.70). Multivariable analysis found significant associations of redlining bias with the risk of worsening/new-onset of individual CHCs such as cardiomyopathy (OR=1.63, 95% CI: 1.07-2.48), peripheral motor neuropathy (OR=1.56, 95% CI: 1.00-2.44), asthma (OR=1.85, 95% CI: 1.04-3.32), and restrictive pulmonary deficit (OR=1.79, 95% CI: 1.05-3.04). Considering joint effects, survivors enrolled in public insurance programs and living in a high redlining area had a higher risk of progression of the global burden of CHCs (OR=1.73, 95% CI: 1.05-2.87) and of worsening/new-onset in peripheral motor neuropathy (OR=3.18, 95% CI: 1.57-6.42) and restrictive pulmonary deficit (OR=5.29, 95% CI: 2.46-11.37) CHCs. Conclusions: The significant associations of redlining bias with the progression of CHCs among adult survivors of childhood cancer suggest an urgent need for interventions (typically social or healthcare policies) targeting neighborhoods with high discriminatory exposures to prevent CHC burden in this population. Citation Format: Jaesung Choi, Madeline R. Horan, Nickhill Bhakta, Deo Kumar Srivastava, Kirsten K. Ness, Gregory T. Armstrong, Melissa M. Hudson, I-Chan Huang. Redlining bias and progression of chronic health conditions in survivors of childhood cancer: A report from the St. Jude lifetime cohort study [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 B139.

Navigating the 24-Hour Home Care Market: Infrastructure as the Key to Social Care in Japan

Background: Long-term care insurance in Japan is a public insurance program. However, all home care service designs are based on the business market. The purpose of the present research is to examine the difficulties of 24-hour home care offered by private care providers, to clarify family styles and family care, and to consider how to build a 24-hour home care platform with private care companies, taking cues from Denmark.

Prevalence and incidence measures for schizophrenia among commercial health insurance and medicaid enrollees

Given the chronic nature of schizophrenia, it is important to examine age-specific prevalence and incidence to understand the scope of the burden of schizophrenia across the lifespan. Estimates of lifetime prevalence of schizophrenia have varied widely and have often relied upon community-based data estimates from over two decades ago, while more recent studies have shown considerable promise by leveraging pooled datasets. However, the validity of measures of schizophrenia, particularly new onset schizophrenia, has not been well studied in these large health databases. The current study examines prevalence and validity of incidence measures of new diagnoses of schizophrenia in 2019 using two U.S. administrative health databases: MarketScan, a national database of individuals receiving employer-sponsored commercial insurance (N = 16,365,997), and NYS Medicaid, a large state public insurance program (N = 4,414,153). Our results indicate that the prevalence of schizophrenia is over 10-fold higher, and the incidence two-fold higher, in the NYS Medicaid population compared to the MarketScan database. In addition, prevalence increased over the lifespan in the Medicaid population, but decreased in the employment based MarketScan database beginning in early adulthood. Incident measures of new diagnoses of schizophrenia had excellent validity, with positive predictive values and specificity exceeding 95%, but required a longer lookback period for Medicaid compared to MarketScan. Further work is needed to leverage these findings to develop robust clinical outcome predictors for new onset of schizophrenia within large administrative health data systems.

(265) BARRIERS TO FERTILITY PRESERVATION: THE ROLE OF HEALTH POLICY, COST, AND ACCESS TO SPECIALIZED CARE

Abstract Introduction Iatrogenic infertility, arising from necessary medical interventions such as gonadotoxic chemotherapy, radiation therapy, certain surgeries, biologic treatments for autoimmune conditions, and hormone therapy, presents significant reproductive challenges. Fertility preservation techniques-including the cryopreservation of embryos, oocytes, ovarian tissue, sperm, or testicular tissue-provide critical options for patients seeking to maintain their reproductive potential. Despite growing awareness and increased referrals for individuals at risk, numerous barriers impede access to fertility preservation services. Objective This study aims to identify and analyze the obstacles that patients face in accessing fertility preservation services in the context of iatrogenic infertility. Methods A comprehensive literature review was conducted using PubMed, with a focus on the terms “iatrogenic infertility,” “fertility preservation,” and “health policy.” Relevant articles were systematically reviewed and categorized by three reviewers to ensure thoroughness and accuracy in identifying key barriers. Results Key barriers to fertility preservation identified include prohibitive costs, limited access to specialized care, and inconsistent insurance coverage. The financial burden for fertility preservation ranges from $2,500 to $20,000 for initial processing and storage, with significant variability based on state and insurance policy. Additional challenges include a lack of standardized guidelines to inform policymaking, difficulties in policy implementation at the state level, and insufficient coverage in public insurance programs, including Medicaid. Conclusions The lack of attention to fertility preservation before fertility-compromising treatments can significantly impact patients' well-being and quality of life. Urologists and other healthcare providers can play a crucial role in improving patient care through advocacy, policy initiatives, and clinical practices. Future directions include advocating for policy changes at multiple levels, increasing access to specialized fertility care, and leveraging technological advancements to reduce costs. Disclosure No.

Health-related quality of life at age 10 years in children born extremely preterm.

To evaluate the association between prenatal maternal health and socioeconomic status (SES) and health-related quality of life (QoL) among 10-year-old children born extremely preterm. Retrospective analysis of the Extremely Low Gestational Age Newborns (ELGAN) Study cohort of infants born < 28 weeks gestational age. QoL was assessed at 10 years of age using the Pediatric Quality of Life Inventory. Multivariate regression models were used for analyses. Of 1198 participants who survived until 10 years of age, 889 (72.2%) were evaluated. Lower maternal age, lack of college education; receipt of public insurance and Supplemental Nutrition Assistance Program (SNAP) were associated with lower QoL scores. Specific maternal health factors were also associated with lower child QoL scores. Specific, potentially modifiable, maternal health and social factors are associated with lower scores on a measure of parent-reported child QoL across multiple domains for children born extremely preterm.

Incentivizing dental services in healthy behaviour Medicaid waivers.

In the United States, adult dental benefits are optional in the state-managed, public insurance program, Medicaid. States also have the option to adapt their Medicaid program via waivers which pair healthy behaviour incentives (HBI) with cost-sharing. These waivers have proven ineffective, but the empirical evidence has ignored differences between states. This study aims to evaluate the impact of four state's HBI Medicaid waiver on dental visits among low-income adult population subject to incentives and cost-sharing requirements by the HBI waiver. Analysing biannual data from the Behavioural Risk Factor Surveillance System's Oral Health module (2008-2018) with a Difference-in-Differences design, this study estimated the effect of a Healthy Behaviour Incentive waiver on the probability of visiting the dentist in the past year. The three states that implemented an HBI Waiver (Indiana, Michigan and Wisconsin) were analysed separately. Secondary outcomes included being uninsured and having all teeth extracted. Matrix Completion methods accounted for dynamic treatment and tested for non-common trends. Inference was based on randomization inference tests. Only in Michigan was an HBI waiver consistently associated with a significant increase in the probability of a dental visit (Est. = 5.6%-points, p = .01). There was little convincing evidence that HBI waivers were associated with being uninsured or having all teeth extracted. Between 2010 and 2019, many states have implemented an HBI waiver, each with a different approach to incentivizing dental visits. These implementation differences may explain the heterogeneous effects by state. More work is needed to evaluate how Medicaid waivers impact health outcomes in low-income populations.

Patient experiences with prenatal cell-free DNA screening in a safety net setting.

Thirty-five states, including Florida, now cover cell-free DNA (cfDNA) screening of fetuses for all pregnant patients enrolled in state public insurance programs. We interviewed Black and Hispanic obstetric patients at a safety net clinic in Florida shortly after the state rolled out cfDNA as a first-tier screening method for publicly insured patients. Black and Hispanic patients receiving prenatal care from a prenatal or maternal fetal medicine clinic at a federally qualified health center in Jacksonville, FL were invited to participate in a qualitative interview in English or Spanish to explore experiences and perceptions of prenatal cfDNA screening. Participants were recruited following their first prenatal visit when cfDNA is typically introduced. Interview transcripts were qualitatively analyzed for iterative themes based on principles of grounded theory. One hundred Black and Hispanic patients (n=51 non-Hispanic Black, n=43 Hispanic, n=3 Hispanic Black, n=3 Not Reported/Other) completed an interview. Participants described minimal opportunity for pre-screening counseling and limited health literacy about cfDNA or its uses. Some believed that cfDNA could positively impact pregnancy health. Many were unsure if they had received cfDNA even though they were aware of the information provided by it. Most participants expressed an interest in cfDNA as a means for early detection of fetal sex and as an additional indication of general fetal health. Patient experiences indicate limited informed consent and decision-making for cfDNA, discordant with professional guidelines on pre-screen counseling. Our findings suggest that there should be additional investment in implementing cfDNA in safety net settings to ensure that patients and providers receive the support necessary for effective patient counseling and follow-on care for the ethical implementation of cfDNA.

Interruptions in Insurance Coverage and Prescription Drug Utilization: Evidence from Kentucky.

This study examined how interruptions in insurance coverage affect purchases of prescription drugs for young adults. It used data spanning 2014 to 2018 from Kentucky's prescription drug monitoring program, which tracked the universe of federally-regulated (Schedule II-V) prescription drugs dispensed in the state. The study employed a regression discontinuity design based on the age limit at 26 for dependent insurance coverage for children. At age 26, the probability of purchasing a prescription decreased by 5%, with all subcategories of prescriptions affected. The share of generic prescriptions increased for stimulants (the only category observed with substantial branded prescriptions). By age 27, prescription purchases returned to levels observed at 25, but the share purchased with public insurance and the generic share for stimulants remained higher. The findings suggest that interruptions in insurance coverage decrease prescription drug utilization by young adults and that public insurance programs such as Medicaid are important for resuming treatment.

Evaluation of longer- vs short-term use of patiromer on health care resource utilization in the patiromer longer-term use evaluation (VALUE) study.

Studies suggest that continuous long-term use of patiromer by patients with hyperkalemia is associated with less health care resource utilization compared with not using potassium binders. To retrospectively evaluate health care resource utilization and costs with longer-term adherent vs short-term use of patiromer. Time-restricted extracts from Optum's de-identified Clinformatics® Data Mart Database (CDM; January 2016-May 2019) and Symphony Health (SHA; January 2016-September 2018) deidentified databases were analyzed. Both include participants enrolled in commercial and privatized public insurance programs (SHA includes some government programs). Both integrate health care claims data from medical and pharmacy claims. Patients aged 18 years or older with hyperkalemia and an index patiromer prescription were selected. Patiromer use was identified as short-term (<2 months) and any fill quantity or adherent longer-term with claims for at least 2 consecutive months and fill quantities of at least 80% of the total days. Groups were matched on multiple categorical covariates to control for demographic variables, baseline characteristics, and markers of disease severity. Random sampling without replacement was performed 50 times to identify 50 sets of patients matched from the short-term cohort to the longer-term cohort. Health care costs/charges and encounters were compared for a 6-month post-index period using t-tests. Of the CDM patients, 1,267 (40.2%) vs 1,887 (59.8%) and of the SHA patients, 2,234 (35.1%) vs 4,132 (64.9%) experienced longer-term vs short-term patiromer use, respectively. Patient sampling selected 242 and 485 patient-matched pairs from CDM and SHA databases, respectively. At 6 months post-index in longer-term vs short-term patiromer groups (P < 0.0001 for all differences shown), respective mean medical and prescription costs/charges were $42,000 vs $54,311 (-$12,311) and $6,816 vs $4,786 (+$2,030), respectively, for CDM patients and $75,147 vs $84,414 (-$9,267) and $4,689 vs $3,736 (+$953) for SHA patients. In the CDM database, medical costs were lower for longer-term vs short-term cohorts for end-stage renal disease services charges ($10,342 vs $14,976 [-$4,634]), inpatient charges ($15,789 vs $21,473 [-$5,684]), and office visit charges ($10,152 vs $13,152 [-$3,000]). Patient out-of-pocket costs ($658 vs $420 [+$238]) and total prescription charges ($6,158 vs $4,366 [+$1,792]) were higher for the longer-term cohort of CDM patients, with similar findings in the SHA dataset. Adherent, longer-term use of patiromer is associated with significantly lower medical costs offsetting higher prescription costs, driven by the largest changes in inpatient and clinic services at CDM and SHA, respectively. This illustrates an economic value of longer-term adherence to patiromer.

Dynamic Effects of Long-Term Care Insurance on Healthcare Expenditures: Evidence from South Korea

Long-term care expenses pose a large financial risk to the elderly. In 2008, South Korea introduced a public long-term care insurance (LTCI) program for individuals older than 65. We study the dynamic effects of the LTCI on various healthcare expenditures. We find that after the implementation of the LTCI, average prescription drug and outpatient expenditures of the elderly increased. Dynamically, we observe that the growth in these expenditures moderates. We also find suggestive evidence that after the introduction of the LTCI, the elderly may utilize LTC hospitals instead of inpatient hospital services. These findings underscore the importance of understanding the long-term effects of LTCI on health and healthcare expenditures of the elderly and the need to account for interactions between LTC and other types of healthcare services in policy design.

Controlling Spending For Health Care And Long-Term Care: Japan's Experience With A Rapidly Aging Society.

As the Japanese population has aged rapidly, Japan's experience has implications for other high-income countries, including the United States. The aging of Japan's population, coupled with the government's decision to implement a public long-term care insurance program in 2000, has increased the nation's expenditures. In acute care, costs have been relatively contained by biennially revising the fee schedule for all physician and hospital services and by lowering pharmaceutical prices. The fee schedule not only sets prices but also controls volume by setting the conditions of billing for each item. This fee schedule is applied to all social health insurance plans (which enroll all permanent residents of Japan) and to virtually all providers. In contrast, despite the use of a similar fee schedule, spending in long-term care insurance has increased more than spending in health care. This is both because long-term care became an entitlement and because aging has had a greater impact on long-term care insurance spending than on health insurance spending. In this article we analyze Japanese expenditure data to provide essential information to the US as the percentage of its population ages sixty-five and older continues to rise. A key lesson that the US can learn from Japan's experience is that as its population ages, the need for long-term care will increase, necessitating better control of acute care spending.

National trends in psychotropic medication prescribing before and during the COVID-19 pandemic

The early months of the COVID-19 pandemic saw a decline in psychotropic medication use; however, little is known about how this trend evolved as the pandemic progressed and how it varied across different payers in the United States. Using a national multi-payer pharmacy claims database and adopting a quasi-experimental research design, this study examines trends in psychotropic medication prescriptions dispensed from July 2018 - June 2022. The study finds that the number of patients with dispensed psychotropic medications and the number of psychotropic medications dispensed declined during the early months of the pandemic but experienced a statistically significant growth in later periods compared to the pre-pandemic rate. Average days supply of psychotropic medications dispensed increased significantly throughout the pandemic. Commercial insurance remained the primary payer for psychotropic medication during the pandemic, but there was a significant increase in the number of prescription fills covered under Medicaid. This implies that public insurance programs played an increasing role in financing psychotropic medication use during the COVID-19 pandemic.

Access to dental insurance and oral health inequities in the United States.

While the oral health status of the United States (U.S.) population has improved over the years, racial/ethnic inequities are pervasive with Black Americans carrying a greater burden of oral diseases in most measured outcomes. Access to dental care is a major structural and societal determinant of oral health inequities rooted in structural racism. From post-Civil War-era to present day, this essay presents a series of examples of racist policies that have shaped access to dental insurance for Black Americans both directly and indirectly. Additionally, this essay explains the unique challenges of Medicare and Medicaid highlighting the specific disparities that these public insurance programs face, and proposes policy recommendations aimed to reduce racial/ethnic inequities in dental coverage and access to advance the nation's oral health with comprehensive dental benefits in public insurance programs.

Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy

BackgroundOpioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder. Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited.MethodsWe conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights.ResultsThe data source for the study consisted of 2,548,372 pregnancies that ended in live births. In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery). Neonatal abstinence syndrome occurred in 52.0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0.73; 95% confidence interval [CI], 0.71 to 0.75). Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of those exposed to methadone (adjusted relative risk, 0.58; 95% CI, 0.53 to 0.62); small size for gestational age in 12.1% and 15.3%, respectively (adjusted relative risk, 0.72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0.63). Delivery by cesarean section occurred in 33.6% of pregnant persons exposed to buprenorphine in early pregnancy and 33.1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3.5%, respectively (adjusted relative risk, 0.91; 95% CI, 0.74 to 1.13). Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy.ConclusionsThe use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on Drug Abuse.)

Public drug insurance, moral hazard and children's use of mental health medication: Latent mental health risk-specific responses to lower out-of-pocket treatment costs.

Studies have shown that reducing out-of-pocket costs can lead to higher medication initiation rates in childhood. Whether the cost of such initiatives is inflated by moral hazard issues remains a question of concern. This paper looks to the implementation of a public drug insurance program in Québec, Canada, to investigate potential low-benefit consumption in children. Using a nationally representative longitudinal sample, we harness machine learning techniques to predict a child's risk of developing a mental health disorder. Using difference-in-differences analyses, we then assess the impact of the drug program on children's mental health medication uptake across the distribution of predicted mental health risk. Beyond showing that eliminating out-of-pocket costs led to a 3 percentage point increase in mental health drug uptake, we show that demand responses are concentrated in the top two deciles of risk for developing mental health disorders. These higher-risk children increase take-up of mental health drugs by 7-8 percentage points. We find even stronger effects for stimulants (8-11 percentage point increases among the highest risk children). Our results suggest that reductions in out-of-pocket costs could achieve better uptake of mental health medications, without inducing substantial low-benefit care among lower-risk children.