Medicaid Expansion States Research Articles

The Relationship Between Coronavirus Disease 2019 (COVID-19) Pandemic-linked Job Losses and Health Care Access and Household Financial Health in Medicaid Expansion and Nonexpansion States.

Unemployment associated with the coronavirus disease 2019 (COVID-19) pandemic was linked to financial insecurity and disruptions in access to health care. To explore whether expanded access to Medicaid mitigated the likelihood of health and non-health financial hardship associated with pandemic-linked job loss. We estimate linear regression models comparing differences in the levels of outcomes attributable to pandemic-linked joblessness in Medicaid expansion and nonexpansion states. A total of 20,281 adults aged 19-64 were in the 2021 National Financial Capability Study. Our key exposure was job loss, layoffs, and furloughs, attributable to the COVID-19 pandemic. Outcomes under evaluation include indicators of health care access and household financial health. Relative to persons reporting pandemic-linked unemployment in nonexpansion states, adults experiencing pandemic-linked job loss in expansion states were less likely to report as uninsured [-6.2 percentage points (PPs); 95% CI: -10.8, -1.6; P < 0.01], having unpaid medical bills (-4.3 PP; 95% CI: -8, -0.6; P < 0.05), having unmet medical needs due to cost (-5.3 PP; 95% CI: -10.1, -0.5; P < 0.05), and having calls from debt collection agencies (-6.9 PP; 95% CI: -10.6, -3.1; P < 0.01). Patterns consistent with Medicaid acting as a safety net for the adverse financial effects of job loss were more pronounced for middle-income households. In economic downturns, such as the COVID-19 crisis, Medicaid can help insulate households from diminished health care access and financial distress associated with job loss.

Aging Out of Dependent Coverage and Health Insurance Trends, 2014–2019

ObjectiveTo examine changes in health insurance coverage when adults age out of dependent coverage at age 26 after the implementation of most Affordable Care Act (ACA) provisions. Our analysis also documented differences by sex, race and ethnicity, and state Medicaid expansion status. MethodsWe used a regression discontinuity design and the 2014–2019 American Community Survey to estimate coverage changes (uninsured, any private, employer-sponsored coverage, direct purchase, and Medicaid) at age 26. Our main sample consisted of adult citizens aged 22–29 years. ResultsUninsurance increased by 2.7% points [95% CI; 1.8–3.4] at age 26, which was driven by a significant decline in any private insurance (3.7% point decrease). Young adults experienced a smaller increase in the uninsured rate on turning age 26 in states that expanded in 2014 compared to nonexpansion states (2.2% and 3.2% point increases, respectively), but the difference was not significant (P = .07). Changes in the uninsured rate at age 26 did not differ significantly by sex or race and ethnicity. ConclusionsThe 2010 dependent coverage provision led to more coverage options among young adults and in turn the uninsured rate declined among a population historically among the most likely to lack coverage. The 2014 Medicaid and Marketplace expansions reduced the uninsured rate even further among young adults. Despite important progress, our findings for 2014–2019 were similar to previous studies using pre-ACA data suggesting that coverage loss remains a risk when adults age out of dependent coverage at age 26.

Medicaid Expansions and Access to Substance Abuse Treatment Services Among Limited English Proficiency Populations.

Although the myriad of provisions under the Affordable Care Act (ACA) have generally increased coverage and financial access to the health systems, language barriers represent a serious challenge to access to care among Limited English Proficiency (LEP) populations. The aim of this study was to examine the effect of Medicaid expansions under the ACA on the availability of language services and Medicaid acceptance in substance abuse treatment (SAT) facilities. A quasi-experimental difference-in-differences design with multiple time periods was used to compare changes in the availability of language services and Medicaid as a payment source between Medicaid expansion and nonexpansion states. Facility-level observational data in the National Survey of Substance Abuse Treatment Services 2010-2019 was included. Availability of LEP services and Medicaid acceptance in the SAT facilities. The proportion of SAT facilities that provide LEP services increased from 40% in 2013 to 53% in 2019. The proportions by state are heterogeneous, ranging from approximately 20% to 70%. The ACA Medicaid expansions are not associated with changes in the availability of LEP services in the facilities. Moreover, Medicaid acceptance in the expansion states increased gradually following the expansion; however, the estimates are not statistically significant. The ACA Medicaid expansion had no impact on the availability of LEP services and the acceptance of Medicaid as a payment source in the SAT facilities.

Medicaid Expansion Lowered Uninsurance Rates Among Nonelderly Adults In The Most Heavily Redlined Areas.

Medicaid expansion narrowed racial and ethnic disparities in health coverage, but few studies have explored differential impact by exposure to structural racism. We analyzed data on historical residential redlining in US metropolitan areas from the Mapping Inequality project, along with data on uninsurance from the American Community Survey, to test whether Medicaid expansion differentially reduced uninsurance rates among nonelderly adults exposed to historical redlining. Our difference-in-differences analysis compared uninsurance rates in Medicaid expansion and nonexpansion states both before (2009-13) and after (2015-19) the state option to expand Medicaid pursuant to the Affordable Care Act took effect in 2014. We found that Medicaid expansion had the greatest impact on lowering uninsurance rates in census tracts with the highest level of redlining. Within each redline category, there were no significant differences by race and ethnicity. Our results highlight the importance of considering contextual factors, such as structural racism, when evaluating health policies. States that opt not to expand Medicaid delay progress toward health equity in historically redlined communities.

Challenging Health Inequities in Incarceration: a Call for Equitable Care for Kidney Disease and Hypertension.

To review the current literature on care of hypertension and chronic kidney disease for people who are currently and formerly incarcerated, and to make recommendations for improving outcomes. There is a growing body of literature describing care for kidney disease and hypertension for incarcerated and formerly incarcerated individuals that documents the provision of care itself, notably that many jails contract with private companies; the system is not designed to provide sustained, chronic disease care; and the transition from incarceration to community is fraught with gaps in care. However, deficiencies in data collection and regulation still limit our understanding of the quality of care provided in jails and prisons. Furthermore, more data is needed to understand the impact of structural racism in the criminal legal system on overall disparities in care for hypertension and kidney disease. Insurance coverage rates for people who were formerly incarcerated continue to be lower than the general population despite Medicaid expansion in many states. There is little recent data regarding kidney replacement therapy for this population despite known variation in dialysis modalities and transplant programs by state. Transitions clinics, which connect people who were formerly incarcerated with care in the community upon release, are growing and are important avenues by which to deliver care. People who are incarcerated are disproportionately affected by hypertension and kidney disease, yet data regarding the extent of these inequities and availability of quality care is lacking. More work is needed to understand the care of individuals with kidney disease and hypertension in prisons and to improve outcomes for these common chronic conditions. Both providing effective treatment of kidney disease and hypertension in prisons and jails and providing coordinated, quality transition to community care upon release represents an important opportunity for reform in care for a marginalized population.

Association of Managed Medicaid Plans and Cancer Stage at Diagnosis

Managed care organizations provide insurance to many Medicare (Advantage) and Medicaid beneficiaries and seek to maintain quality while controlling provider networks, utilization, and costs. In prior research, patients with Medicare Advantage plans had restricted access to care, including at cancer centers, and had higher mortality after cancer surgery than patients with traditional Medicare. Over 80% of Medicaid patients nationally are enrolled in managed care plans; despite their prevalence, there is a paucity of evidence regarding the quality of cancer care provided by these plans. We examined associations of state-level managed Medicaid rates and cancer stage at diagnosis. Adults ages 18-64 years with Medicaid coverage diagnosed with cancer from 2007-2016 were identified from Surveillance, Epidemiology, and End Results program data covering 12 states. Note that 2016 was the last year with unsuppressed insurance status data. Year-varying state-level rates of types of managed Medicaid plans (comprehensive risk-based managed care, limited benefit plans, and primary care case management) were obtained from the Medicaid and CHIP Payment and Access Commission and categorized in quartiles. The association of state levels of each type of managed Medicaid plan with localized stage diagnoses was evaluated using multivariable linear probability models with cluster-robust standard errors (state clusters) accounting for state fixed effects, year fixed effects, age, sex, race, metropolitan residence, marital status, county-level income and education, state Medicaid expansion status, and cancer type. A total of 229,227 Medicaid patients were identified. The average state-level rates of comprehensive managed care, limited benefit, and primary care case management plans were 47%, 47%, and 5.6%, respectively. In adjusted analyses, relative to states with <20% of Medicaid recipients enrolled in comprehensive managed care plans, states with 40-80% (-2.07 percentage points, 95% CI = -3.31 to -0.83, P = .001) and >80% (-1.49, 95% CI = -2.49 to -0.50, P = .003) had fewer localized stage diagnoses. States with >2% relative to 0-1% of recipients enrolled in primary care case management plans had more localized stage diagnoses (1.02, 95% CI = 0.27 to 1.77, P = .008). States with higher levels of limited benefit plans had more localized stage diagnoses (P = .011), though associations were attenuated with increasing levels (20-40%: 1.22; 40-80%: 0.53; >80%: 0.40). Patterns were similar across most cancer types. The prevalence and type of Medicaid managed care plans are associated with early-stage cancer diagnoses. Higher levels of comprehensive managed care plans were associated with fewer early diagnoses, raising concerns about barriers to symptom evaluation and diagnostic workup. In contrast, higher levels of primary care case management plans were associated with more early diagnoses, potentially through streamlined care coordination.

State Mandatory Paid Family Leave and Survival among Children with Cancer

Childhood cancer treatment is often costly and time intensive and may require parents/caregivers to stop working. Since 2012, several states have introduced mandatory paid family leave policies. We hypothesized that such policies, whether by reducing financial toxicity or by providing parents greater flexibility to care for their sick children, would improve outcomes among children with cancer. Children ages 0-18 years diagnosed with cancer between 2010 and 2019 were identified from the Surveillance, Epidemiology, and End Results program (SEER) database. The primary outcome was overall survival (OS). The exposure of interest was state mandatory paid family leave. Difference-in-differences (DID) analyses with additive hazards regression models were utilized to compare changes in OS from pre- to post- mandatory paid sick leave policy implementation in states with vs. without paid sick leave policies. The models were adjusted for year fixed effects, state fixed effects, state Medicaid expansion status, age, race, sex, metropolitan residence status, county-level income and education, cancer site, cancer stage, and insurance status. Clustered standard errors by state were achieved via the cluster bootstrap. The plausibility of the common trends assumption was tested using event study analyses and was satisfied for all analyses. A total of 38,053 children with cancer were identified. In adjusted difference-in-differences analyses, there was no significant change in OS in states with vs. without state mandatory paid family leave policies after policy enactment (hazard difference: 0.0001, 95% CI = -0.0002 to 0.0016, P = .47). However, among non-metropolitan residents, 1-year OS improved from 93.0% to 95.5% (2-year OS: 88.6% to 93.4%) in states with mandatory paid family leave policies compared to 92.7% to 92.5% (2-year OS: 88.0% to 87.7%) in states without such policies after policy enactment. This translates to a 2.7% improvement in 1-year OS (5.2%, 2-year OS) (hazard difference: -0.0021, 95% CI = -0.0034 to -0.0005, P = .037). There was no corresponding change for metropolitan residents (hazard DID = 0.0001, P = .47). By cancer site, the largest policy-associated improvements in survival were observed for rhabdomyosarcoma (hazard DID = -0.0037, P = .11), osteosarcoma (hazard DID = -0.0036, P<.001), and Intracranial and intraspinal embryonal tumors (hazard DID = -0.0026, P = .061). State mandatory paid family leave policies were associated with improved survival for some children with cancer, most notably for those residing in non-metropolitan areas. The improvements for non-metropolitan residents may be related to alleviating otherwise increased travel burdens for cancer treatment if treatment occurs out-of-town, where working while taking care of a child is less feasible. These data also suggest a slight narrowing in rural-urban-metropolitan childhood cancer disparities associated with paid family leave policies.

Association of state Medicaid expansion policies with pediatric liver transplant outcomes

Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.

Utilization of access to colorectal cancer screening modalities in low-income populations after medicaid expansion.

Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA's Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants. To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States. This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status. A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55). Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across all low-income populations, but not all races or levels of education.

Cost of Public Health Insurance for US-Born and Immigrant Adults

The immigrant population in the US has low health insurance coverage. Surveys find that approximately one-half of the US population is opposed to public health insurance of immigrants, and there is a widely held belief that immigrants are a state fiscal liability. To estimate the cost of providing public health insurance to immigrants in the US. This serial cross-sectional study used restricted data from the 2011 to 2019 Medical Expenditure Panel Survey (and data from 2011-2020 in supplemental analyses). The data are nationally representative of the US civilian noninstitutionalized population. Participants included adults aged 19 to 64 years with family incomes below 138% of the Federal Poverty Level, the population that benefited from the Medicaid expansions. Data analysis was performed from November 2022 to August 2023. State Medicaid expansion. The primary outcomes were insurance coverage, total health care expenditures, expenditures categorized by payment source (paid by self or family and paid by others), expenditures by major health care type (office based, inpatient, and prescription), and health care utilization (number of office-based visits, outpatient facility visits, emergency department visits, hospital discharges, dental care visits, home health clinician days, and prescription medicine refills). A difference-in-differences method was used to compare the health care cost and utilization by low-income, working-age US-born and immigrant adults in states that adopted the Patient Protection and Affordable Care Act (ACA) Medicaid expansions with the corresponding change in nonexpansion states before and after the policy implementation. Among the study sample of 44 482 individuals (mean [SD] age, 38.5 [14.0] years; 25 221 female individuals [56.7%]; 34 052 [76.6%] US born), 46% of immigrant adults (1953 participants) and 70% of US-born adults (9396 participants) had insurance coverage in the pre-ACA period. Medicaid expansions increased insurance coverage of both groups by 7 percentage points (95% CI, 3 to 11 percentage points). The resulting change in health care increased total expenditures (self-paid plus insurer paid) by $660 (95% CI, $79 to $1242) and insurer-paid expenditures by $745 (95% CI, $141 to $1350) per US-born adult. For immigrant adults, the corresponding changes in total ($266; 95% CI, -$348 to $880) and insurer-paid ($308; 95% CI, -$352 to $968) expenditures were small and not statistically significant. Estimates suggest that providing insurance to immigrants costs the health care system approximately $3800 per person per year, less than one-half the corresponding cost ($9428 per person per year) for US-born adults. These findings suggest that the direct cost of providing public health insurance to immigrants is less than that for the US born, and immigrants' health care utilization, upon coverage, remains comparatively modest, thus refuting the notion that providing insurance to immigrants imposes a heavy fiscal burden.

Effect of Medicaid Expansion in Reducing Racial Disparities in Early Onset Colorectal Cancer.

The burden of early onset colorectal cancer (EOCRC) falls disproportionately on minorities and individuals in specific geographic regions. While these disparities are likely multi-factorial, access to high-quality health care plays a significant role. We sought to determine if Medicaid expansion is associated with reducing racial disparities in EOCRC detection in Hispanics and non-Hispanic Blacks (NHB), compared to non-Hispanic Whites (NHW). Analysis of data from National Cancer Database was undertaken to compare incidence of EOCRC among those aged 40-49 between Medicaid expansion states (ES) and non-expansion states (NES) by racial/ethnic groups. Data was classified by race (NHW, NHB, or Hispanic), state of residence (ES or NES), and time (pre- or post-expansion). The primary outcome was change in incidence rate of EOCRC among racial/ethnic groups, according to whether patients resided in Medicaid expansion or non-expansion states. Among Hispanics, the ES showed a significant increase in EOCRC incidence post expansion as compared to NES (p = 0.03). The rate of increase in annual incidence of EOCRC among Hispanics was 4.3% per year (pre-expansion) and 9.8% (post-expansion) for ES; and 6.4% (pre-expansion) and 1% (post-expansion) in NES. However, no difference was noted among NHB (p = 0.33) and NHW (p = 0.94). Medicaid expansion has improved detection rates of EOCRC in ES especially in Hispanic population. This is the first study to demonstrate the effect of Medicaid expansion on the incidence of EOCRC. Based on our study findings we suggest that racial and ethnic disparities should be considered in the earlier CRC screening debates.

Impacts of the Affordable Care Act Medicaid Expansion on Mental Health Treatment Among Low-income Adults Across Racial/Ethnic Subgroups, 2010-2017.

This study examines whether the Affordable Care Act (ACA) Medicaid expansion (ME) was associated with changes in racial/ethnic disparities in insurance coverage, utilization, and quality of mental health care among low-income adults with probable mental illness using the National Survey on Drug Use and Health with state identifiers. This study employed difference-in-difference models to compare ME states to non-expansion states before (2010-2013) and after (2014-2017) expansion and triple difference models to examine these changes across non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino racial/ethnic subgroups. Insurance coverage increased significantly for all racial/ethnic groups in expansion states relative to non-expansion states (DD: 9.69; 95% CI: 5.17, 14.21). The proportion low-income adults that received treatment but still had unmet need decreased (DD: -3.06; 95% CI: -5.92, -0.21) and the proportion with unmet need and no mental health treatment increased (DD: 2.38; 95% CI: 0.03, 4.73). ME was not associated with reduced disparities.

Community- and Program-Level Predictors of Funding Streams Used by Coordinated Specialty Care Programs.

Although coordinated specialty care (CSC) is an effective service model to address first-episode psychosis, CSC is not widely accessible in the United States, and funding for this service model often remains challenging. The authors examined whether community- or program-level factors predict the use of public and private funding streams in a national sample of 34 CSC programs in 22 U.S. states and territories. As part of a larger mixed-methods study, CSC program leaders completed a brief questionnaire regarding funding sources. Statistical modeling was used to examine program- and community-level predictors of the use of funding sources. Most CSC programs (20 of 34, 59%) reported that Mental Health Block Grant (MHBG) set-aside funds accounted for more than half of their total funding, and 11 of these programs reported that these funds contributed to >75% of their funding. Programs ≤5 years old were more likely to rely on MHBG set-aside funds. Programs in Medicaid expansion states were more likely to rely on Medicaid funding than programs in nonexpansion states. Programs in higher-income service catchment areas used more state funds than did those in lower-income areas, and among programs in lower-income service catchment areas, those that were >4 years old were more likely than those ≤4 years old to rely on state funds other than Medicaid. CSC programs remain largely dependent on MHBG set-aside funding. Some programs have diversified their funding streams, most notably by including more Medicaid and other state funding. A more comprehensive funding approach is needed to reduce reliance on the MHBG set-aside funds.

Inequities in Patient Access to Care Among Asian American, Native Hawaiian, and Pacific Islander Adults in Medicaid.

Despite decades of advocacy for disaggregated data collection and reporting for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) people, significant gaps remain in our ability to understand AA and NHPI individuals' access to care. We assess inequities in access to care measures between non-Hispanic White and AA and NHPI adult Medicaid enrollees. We used the 2014-15 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems, the first-and-only nationally representative sample of Medicaid enrollees. Our main outcomes were access to needed care, access to a personal doctor, timely access to a checkup, and timely access to specialty care. Using multivariable linear probability models, we assessed the relationship between racial/ethnic group and our outcomes, both in the aggregate and disaggregated into ten racial/ethnic groups, and adjusted for enrollee-level sociodemographic characteristics, health status, and state-level Medicaid expansion status. In aggregate, AA and NHPI enrollees reported worse access to care than White enrollees on all four metrics (p < 0.001). The magnitude of disparities varied across the ten AA and NHPI ethnic groups. Disparities relative to White enrollees were particularly large in magnitude, roughly 1.5 to 2 times greater, for Chinese, Korean, and Vietnamese enrollees than for the aggregated AA and NHPI group. Despite comparable insurance coverage, there were inequities in multiple access to care metrics between non-Hispanic White and AA and NHPI Medicaid enrollees. Collection of disaggregated health data on AA and NHPI patients reveals important variation in access to care by ethnic group.

Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012–2015

BackgroundWhile the Affordable Care Act’s Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers.MethodsPrespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012–2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance.ResultsWe identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012–2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5–31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9–5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1–7.5, p = 0.009).ConclusionsFollowing Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.

Residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling by adults with lower incomes: Is increased access to primary care enough?

We investigate whether living in a state that expanded Medicaid eligibility is associated with receiving alcohol screening and brief counseling among nonelderly, low-income adults and a subgroup with chronic health conditions caused or exacerbated by alcohol use. Data are from the 2017 and 2019 Behavioral Risk Factor Surveillance System (N = 15,743 low-income adults; n = 7062 with a chronic condition). We used propensity score-weighted, covariate-adjusted, modified Poisson regression to estimate associations between residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling. Models estimated associations in the overall sample and chronic conditions subsample, as well as differential associations across sex, race, and ethnicity using interaction terms. Living in a state that expanded Medicaid eligibility was associated with being asked whether one drank (prevalence ratio (PR) = 1.15, 95% confidence interval (CI) = 1.08, 1.22), but not with further alcohol screening, guidance about harmful drinking, or advice to reduce drinking. Among individuals with alcohol-related chronic conditions, expansion state residence was associated with being asked about drinking (PR = 1.13, 95% CI = 1.05, 1.20) and, among past 30-day drinkers with chronic conditions, being asked how much one drank (PR = 1.28, 95% CI = 1.04, 1.59) and about binge drinking (PR = 1.43, 95% CI = 1.03, 1.99). Interaction terms suggest that some associations differ by race and ethnicity. Living in a state that expanded Medicaid is associated with a higher prevalence of receiving some alcohol screening at a check-up in the past 2 years among low-income residents, particularly among individuals with alcohol-related chronic conditions, but not with the receipt of high-quality screening and brief counseling. Policies may have to address provider barriers to delivery of these services in addition to access to care.

The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities.

While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities. Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre-and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states. Among 33,764 patients who underwent resection of PDAC, 19.1% (n=6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p<0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p=0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p=0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p=0.022). Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.

Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-to-Implant Trends.

Direct-to-implant breast reconstruction is an attractive choice for appropriately selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value health care, therefore, it is important to investigate use of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis. This was a retrospective investigation of direct-to-implant reconstruction between 2010 and 2018 in the United States, using the National Inpatient Sample database. All study analyses were undertaken using Stata version 15.0. The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010 and 2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures increased significantly ( P = 0.03), relative to staged and delayed implant-based procedures. Although direct-to-implant patients were younger and more likely to be White and privately insured, the proportion of non-White, publicly insured patients undergoing direct-to-implant reconstruction increased significantly by 2018 ( P < 0.05). Furthermore, direct-to-implant use among Medicaid patients was 2.2 times the rate in Medicaid expansion states compared with nonexpansion states. Direct-to-implant patients had significantly higher All Patient Refined Diagnosis Related Group risk scores in 2018 than in 2010 ( P = 0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures ( P = 0.03), when considering expander placement and expander-to-implant exchange. Overall, use of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate. Therapeutic, III.

Medicaid Expansion and Racial Disparity in Timely Multidisciplinary Treatment in Muscle Invasive Bladder Cancer.

Multidisciplinary cancer care (neoadjuvant chemotherapy+radical cystectomy (NAC+RC) or trimodality treatment (TMT)) is crucial for outcome of muscle invasive bladder cancer (MIBC), a potentially curable illness. Medicaid expansion through Affordable Care Act (ACA) increased insurance coverage especially among patients of racial minorities. This study aims to investigate the association between Medicaid expansion and racial disparity in timely treatment in MIBC. This quasi-experimental study analyzed 18-64-year-old Black and White people with stage II&III bladder cancer treated with NAC+RC or TMT from National Cancer Database 2008-2018. Primary outcome was timely treatment started within 45 days following cancer diagnosis. Racial disparity is the percentage-point difference between Black and White patients. Patients in expansion and nonexpansion states were compared using difference-in-differences (DID) and difference-in-difference-in-differences (DDD) analyses, controlling for age, sex, area level income, clinical stage, comorbidity, metropolitan status, treatment type, and year of diagnosis. The study included 4991 patients (92.3% White, N = 4605; 7.7% Black, N = 386). Percent of Black patients received timely care increased following the ACA in Medicaid expansion states (54.5% pre-ACA vs 57.4% post-ACA) whereas decreased in non-expansion states (69.9% pre-ACA vs 53.7% post-ACA). After adjusting covariates, Medicaid expansion was associated with a net 13.7 percentage-point reduction of Black-White disparity in timely receipt of MIBC treatment (95%CI: 0.5%-26.8%; p < .01). Medicaid expansion was associated with statically significant reduction in racial disparity between Black and White patients in timely multidisciplinary treatment for MIBC.

Association of Medicaid expansion with dental emergency department visits overall and by states’ Medicaid dental benefits provision

BackgroundEvidence on the association of Medicaid expansion with dental emergency department (ED) utilization is limited, while even less is known on policy-related changes in dental ED visits by Medicaid programs’ dental benefits generosity. The objective of this study was to estimate the association of Medicaid expansion with changes in dental ED visits overall and by states’ benefits generosity.MethodsWe used the Healthcare Cost and Utilization Project’s Fast Stats Database from 2010 to 2015 for non-elderly adults (19 to 64 years of age) across 23 States, 11 of which expanded Medicaid in January 2014 while 12 did not. Difference-in-differences regression models were used to estimate changes in dental-related ED visits overall and further stratified by states’ dental benefit coverage in Medicaid between expansion and non-expansion States.ResultsAfter 2014, dental ED visits declined by 10.9 [95% confidence intervals (CI): -18.5 to -3.4] visits per 100,000 population quarterly in states that expanded Medicaid compared to non-expansion states. However, the overall decline was concentrated in Medicaid expansion states with dental benefits. In particular, among expansion states, dental ED visits per 100,000 population declined by 11.4 visits (95% CI: -17.9 to -4.9) quarterly in states with dental benefits in Medicaid compared to states with emergency-only or no dental benefits. Significant differences between non-expansion states by Medicaid’s dental benefits generosity were not observed [6.3 visits (95% CI: -22.3 to 34.9)].ConclusionsOur findings suggest the need to strengthen public health insurance programs with more generous dental benefits to curtail costly dental ED visits.