State Medicaid Programs Research Articles

The Medicaid expansion of the Affordable Care Act and participation of patients with Medicaid in cancer clinical trials.

6505 Background: The Affordable Care Act (ACA) Medicaid Expansion (ME) resulted in increased use of Medicaid insurance nationwide. However, the impact of the ACA ME on access to clinical trials has not been examined. Methods: We examined the number and proportion of patients insured by Medicaid at enrollment over time using data from the SWOG Cancer Research Network. We examined all patients 18-64 years old enrolled to treatment trials between April 1, 1992 to February 28, 2020 using Medicaid vs. private insurance. Interrupted time-series analysis was used; first implementation of the ACA ME (in 2014) was the independent exposure variable. Segmented logistic regression was used to estimate the difference between actual enrollment of patients using Medicaid to the expected rate had the ACA ME not been implemented. To account for secular trends related to economic conditions, we adjusted for the monthly unemployment rate using data from the Bureau of Labor Statistics. Indicator variables to reflect administrative differences in Medicaid by presidential administration were included. Results: In total, 47,042 patients age < 65 years were analyzed, including 31,565 (67.1%) females, 18,987 (40.4%) age < 50 years, and 4,709 (10.0%) with Medicaid coverage. Overall, a 20% (OR = 1.20, 95% CI, 1.11-1.30, p <.001) increase per year in the odds of patients using Medicaid was detected following the ACA ME. Based on pre-ACA patterns, the proportion of patients using Medicaid decreased during periods of economic growth and low unemployment; thus, the model-based estimate of the proportion of patients with Medicaid insurance had the ACA ME not occurred was only 7.4% (95% CI, 4.8%-9.5%) at the end of the study period (February 2020), when national unemployment was low (3.5%). In contrast, the actual rate was 20.8% (95% CI, 17.1%-25.0%). Patterns were consistent by age but not by sex, with a stronger 29% (OR = 1.29, 95% CI, 1.17-1.42, p <.001) annual increase in the proportion of Medicaid use for female patients compared to only 7% (OR = 1.07, 95% CI, 0.94-1.23, p =.26) for males. The increase per year of Medicaid use for patients from states that implemented the ME in 2014 or 2015 was 27% (OR = 1.27, 95% CI, 1.16-1.41, p <.001) compared to 7% for patients from other states (OR = 1.07, 95% CI, 0.94-1.22, p =.28). Conclusions: The implementation of the ACA ME was associated with nearly a threefold increase (20.8% vs. 7.4%) in the proportion of patients using Medicaid in cancer clinical trials by early 2020. Improved access to clinical trials for more vulnerable patients is critical for improving confidence that trial findings apply to the general cancer population. These findings suggest that the recently enacted Cancer Treatment Act – which mandates that state Medicaid programs cover the routine care costs of clinical trial participation – may continue to improve access to clinical trials for those with Medicaid insurance.

Association between dispensing of low-value oral albuterol and removal from Medicaid preferred drug lists

BackgroundOral albuterol has worse efficacy and side effects compared with inhaled albuterol, and thus its use has been discouraged for decades. Drug inclusion or exclusion on formularies have been associated with reductions in low-value care. This study examines dispensing of oral albuterol and inclusion of oral albuterol on state Medicaid drug formularies--Preferred Drug Lists (PDLs). It also evaluates the association between removal of oral albuterol from the PDL and dispensing levels.MethodsThis quasi-experimental study determined oral albuterol inclusion on PDLs and dispensing between 2011 and 2018, using Medicaid program websites and the State Drug Utilization Database. Using a difference-in-differences model, we examine the association between removal of oral albuterol from Arkansas’ Medicaid PDL in 2014 and dispensing of this drug through Medicaid, with Iowa as a control state. The outcome measure was the percent of all albuterol prescriptions that were for oral albuterol.ResultsA total of 28 state Medicaid PDLs included at least one formulation of oral albuterol in 2018. In 2018, 179,446 oral albuterol prescriptions were dispensed to Medicaid beneficiaries nationally. Medicaid programs paid approximately $3.0 million for oral albuterol prescriptions in 2018. Removal of oral albuterol syrup from the Arkansas PDL in March 2014 was associated with a more rapid decline in dispensing compared with Iowa which maintained this medication on their PDL.ConclusionsFindings suggest that removal of low-value medications, such as oral albuterol, from PDLs may be one avenue by which state Medicaid programs can reduce wasteful spending while improving guideline-based care.

Recreational cannabis legalizations associated with reductions in prescription drug utilization among Medicaid enrollees.

The potential substitution of cannabis for prescription medication has attracted a substantial amount of attention within the context of medical cannabis laws (MCLs). However, much less is known about the association between recreational cannabis laws (RCLs) and prescription drug use. With recent evidence supporting substitution of cannabis for prescription drugs following MCLs, it is reasonable to ask what effect RCLs may have on those outcomes. We use quarterly data for all Medicaid prescriptions from 2011 to 2019 to investigate the effect of state-level RCLs on prescription drug utilization. We estimate this effect with a series of two-way fixed effects event study models. We find significant reductions in the volume of prescriptions within the drug classes that align with the medical indications for pain, depression, anxiety, sleep, psychosis, and seizures. Our results suggest substitution away from prescription drugs and potential cost savings for state Medicaid programs.

Changes in predicted opioid overdose risk over time in a state Medicaid program: a group-based trajectory modeling analysis.

The time lag encountered when accessing health-care data is one major barrier to implementing opioid overdose prediction measures in practice. Little is known regarding how one's opioid overdose risk changes over time. We aimed to identify longitudinal patterns of individual predicted overdose risks among Medicaid beneficiaries after initiation of opioid prescriptions. A retrospective cohort study in Pennsylvania, USA among Pennsylvania Medicaid beneficiaries aged 18-64 years who initiated opioid prescriptions between July 2017 and September 2018 (318 585 eligible beneficiaries (mean age = 39 ± 12 years, female = 65.7%, White = 62.2% and Black = 24.9%). We first applied a previously developed and validated machine-learning algorithm to obtain risk scores for opioid overdose emergency room or hospital visits in 3-month intervals for each beneficiary who initiated opioid therapy, until disenrollment from Medicaid, death or the end of observation (December 2018). We performed group-based trajectory modeling to identify trajectories of these predicted overdose risk scores over time. Among eligible beneficiaries, 0.61% had one or more occurrences of opioid overdose in a median follow-up of 15 months. We identified five unique opioid overdose risk trajectories: three trajectories (accounting for 92% of the cohort) had consistent overdose risk over time, including consistent low-risk (63%), consistent medium-risk (25%) and consistent high-risk (4%) groups; another two trajectories (accounting for 8%) had overdose risks that substantially changed over time, including a group that transitioned from high- to medium-risk (3%) and another group that increased from medium- to high-risk over time (5%). More than 90% of Medicaid beneficiaries in Pennsylvania USA with one or more opioid prescriptions had consistent, predicted opioid overdose risks over 15 months. Applying opioid prediction algorithms developed from historical data may not be a major barrier to implementation in practice for the large majority of individuals.

Stakeholder Engagement: Bridging Research and Policy to Improve Measurement and Dental Care for Children in Medicaid.

Stakeholder Engagement: Bridging Research and Policy to Improve Measurement and Dental Care for Children in Medicaid.

OP058: 2021 genetics policies in state Medicaid programs

The Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services supports the National Coordinating Center for the Regional Genetics Networks (NCC) to improve access to underserved populations throughout the US. As the National Coordinating Center for the RGN system, NCC is tasked with tracking and reporting information on genetics policy, including coverage of genetic services in Medicaid.

Translating Medicaid policy into practice: policy implementation strategies from three US states\u2019 experiences enhancing substance use disorder treatment

BackgroundDespite the important upstream impact policy has on population health outcomes, few studies in implementation science in health have examined implementation processes and strategies used to translate state and federal policies into accessible services in the community. This study examines the policy implementation strategies and experiences of Medicaid programs in three US states that responded to a federal prompt to improve access to evidence-based practice (EBP) substance use disorder (SUD) treatment.MethodsThree US state Medicaid programs implementing American Society of Addiction Medicine (ASAM) Criteria-driven SUD services under Section 1115 waiver authority were used as cases. We conducted 44 semi-structured interviews with Medicaid staff, providers and health systems partners in California, Virginia, and West Virginia. Interviews were triangulated with document review of state readiness and implementation plans. The Exploration, Preparation, Implementation, Sustainment Framework (EPIS) guided qualitative theme analysis. The Expert Recommendations for Implementing Change and Specify It criteria were used to create a taxonomy of policy implementation strategies used by policymakers to promote providers’ uptake of statewide EBP SUD care continuums.ResultsFour themes describe states’ experiences and outcomes implementing a complex EBP SUD treatment policy directive: (1) Medicaid agencies adapted their inner/outer contexts to align with EBPs and adapted EBPs to fit their local context; (2) enhanced financial reimbursement arrangements were inadequate bridging factors to achieve statewide adoption of new SUD services; (3) despite trainings, service providers and managed care organizations demonstrated poor fidelity to the ASAM Criteria; and (4) successful policy adoption at the state level did not guarantee service providers’ uptake of EBPs. States used 29 implementation strategies to implement EBP SUD care continuums. Implementation strategies were used in the Exploration (n=6), Preparation (n=10), Implementation (n=19), and Sustainment (n=6) phases, and primarily focused on developing stakeholder interrelationships, evaluative and iterative approaches, and financing.ConclusionsThis study enhances our understanding of statewide policy implementation outcomes in low-resource, public healthcare settings. Themes highlight the need for additional pre-implementation and sustainment focused implementation strategies. The taxonomy of detailed policy implementation strategies employed by policymakers across states should be tested in future policy implementation research.

Evidenced-Based Approaches States and Territories Can Implement to Advance Adult Immunization Uptake During the COVID-19 Pandemic and Beyond.

Evidenced-Based Approaches States and Territories Can Implement to Advance Adult Immunization Uptake During the COVID-19 Pandemic and Beyond.

Association between treatment setting and outcomes among oregon medicaid patients with opioid use disorder: a retrospective cohort study

BackgroundResidential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment.MethodsA retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes.ResultsOf 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73–2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80–1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23–0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32–2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56–2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46–1.29; interaction p = 0.001).ConclusionsRelative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

Coverage of genetic therapies for spinal muscular atrophy across fee-for-service Medicaid programs.

BACKGROUND: Genetic therapies are a promising treatment for children born with spinal muscular atrophy (SMA); however, their high price tags can evoke coverage restrictions. OBJECTIVE: To assess variation in coverage guidelines across fee-for-service state Medicaid programs for 2 novel genetic therapies, nusinersen and onasemnogene abeparvovec, that treat SMA. We also assessed the association of these coverage guidelines with use of the 2 genetic therapies. METHODS: We evaluated fee-for-service Medicaid coverage policies for nusinersen and onasemnogene abeparvovec from publicly available websites for the period February 2020-March 2020. We then documented areas of agreement and disagreement across 4 key coverage domains. We used 2018 and 2019 state Medicaid drug utilization data to calculate the use of nusinersen across Medicaid programs and assessed that use against the restrictiveness of the coverage guidelines. RESULTS: We identified 19 state Medicaid coverage guidelines for nusinersen. Most states agreed on diagnostics requirements; however, there were disagreements based on ventilator status. We identified 17 state Medicaid coverage guidelines for onasemnogene abeparvovec. There was more discordance in these coverage guidelines compared with nusinersen, notably in domains of SMN2 gene count and ventilator status. When comparing utilization of nusinersen with coverage restrictions, we found that the more restrictive states had considerably lower utilization of nusinersen. CONCLUSIONS: There was significant variation across fee-for-service Medicaid coverage policies for nusinersen and onasemnogene abeparvovec. Although states can impose individual coverage guidelines for each drug, we presented policy options that could reduce variation and potentially decrease the cost burden of these drugs. DISCLOSURES: This study was funded by Arnold Ventures. The authors have no conflicts of interest to disclose.

Abstract PO-207: Impact of Medicaid expansion on stage at diagnosis for US adults with pancreatic cancer: A population-based study

Abstract Introduction: We evaluated whether expansion of state Medicaid programs is associated with earlier-stage at diagnosis for pancreatic cancer among those under the age of 65, before and after Medicaid expansion considering key demographic, clinical, and geographic covariates. Methods: We obtained Surveillance, Epidemiology, and End-Results (SEER-18) data on individuals under 65 years of age diagnosed with pancreatic cancer from 2007-2016, including Urban Influence Code (UIC) and Social Deprivation Index (SDI) data. We defined early stage as either local or regional disease (versus advanced disease). To estimate the effect of Medicaid expansion on stage at diagnosis, we used a Difference-in-Differences (DD) model, at the individual level, comparing those from early-adopting states in 2014 to non-early-adopting states. We utilized cluster-robust standard errors and explored the role of covariates including demographic factors (race, sex, insurance coverage at diagnosis), clinical indicators (disease located in the head of the pancreas), and county characteristics (UIC and SDI). Results: The probability of early-stage disease at diagnosis increased by 3.9 percentage points (ppt) for those from Medicaid expansion states post-expansion (n=36,609). After adjustment for key covariates, the ppt was attenuated to 2.7. Of note, we observed evidence of interactions with sex and race. Indeed, the beneficial effect of living in an expansion state on stage at diagnosis was less pronounced for men (increase in the probability of early stage at diagnosis by 2.1ppt) than women (3.6ppt) and non-existent for blacks (-3.1ppt) compared to whites (4.9ppt) and other races (4.8ppt). Redefining early stage to only local stage attenuated the beneficial effect for all groups and increased the negative effect for blacks. Conclusion: Medicaid expansion is associated with earlier stage at diagnosis for pancreatic cancer; however, this beneficial effect is not uniform across sex and race. This underscores the need to investigate the impact of policy changes and implementation strategies on disparities in pancreatic cancer survival. Citation Format: Erin M. Mobley, Christina Guerrier, Ian Tfirn, Michael S. Gutter, Kimberly Vigal, Keouna Pather, Brett Baskovich, Ziad Awad, Alexander S Parker. Impact of Medicaid expansion on stage at diagnosis for US adults with pancreatic cancer: A population-based study [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-207.

Trends in quality of care among children with sickle cell anemia.

For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke. We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures. Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011-2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models. A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05). Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

Projection of net savings to U.S. state Medicaid programs from reduced nursing home utilization due to an Alzheimer’s treatment

AbstractBackgroundThe approval of a disease‐modifying Alzheimer’s treatment could provide relief to U.S. state budgets that were hit hard by the COVID‐19 pandemic, as mostly Medicare would cover treatment cost, whereas Medicaid would see savings from reduced nursing home utilization.MethodWe project savings from 2021 to 2040 with a simulation model.ResultTreatments would avoid payments of up to $186 billion for around 1.1 million nursing home patient‐years, an average 5.06% relative reduction of Medicaid spending on nursing home care. Higher per capita savings were projected for older states, those with higher Medicaid payment rates, those with more nursing home residents covered by Medicaid, and those with a lower federal contribution (Figure).ConclusionTreatments would avoid payments of up to $186 billion for around 1.1 million nursing home patient‐years, an average 5.06% relative reduction of Medicaid spending on nursing home care. Higher per capita savings were projected for older states, those with higher Medicaid payment rates, those with more nursing home residents covered by Medicaid, and those with a lower federal contribution.

Changing Pediatric Hospice and Palliative Care Through Medicaid Partnerships.

Since its inception in 2010, the Concurrent Care for Children Provision of the Affordable Care Act has enabled seriously ill pediatric patients and their families to access comprehensive, supportive hospice services while simultaneously receiving ongoing treatment-directed therapies. Although this groundbreaking federal legislation has resulted in improvements in care for vulnerable pediatric patients, the implementation of the law has varied from state to state through Medicaid programming. The pediatric professional community is called to consider how Medicaid services can more effectively be delivered by leveraging legislative mandates and collaborative relationships between clinicians, Medicaid administrators, and policy makers. In this article, we examine ways concurrent care has been executed in 3 different states and how key stakeholders in care for children with serious illness advocated to ensure effective implementation of the legislation. The lessons learned in working with state Medicaid programs are applicable to any advocacy issue impacting children and families .

The Association Between Medicaid Adult Dental Coverage And Children's Oral Health.

Although all state Medicaid programs cover children's dental care, Medicaid-eligible children are more likely to experience tooth decay than children in higher-income families. Using data from the 1999-2016 National Health and Nutrition Examination Survey and the 2003, 2007, and 2011-12 waves of the National Survey of Children's Health, we examined the association between Medicaid adult dental coverage (an optional benefit) and children's oral health. Adult dental coverage was associated with a statistically significant 5-percentage-point reduction in the prevalence of untreated caries among children after Medicaid-enrolled adults had access to coverage for at least one year. These policies were also associated with a reduction in parent-reported fair or poor child oral health with a two-year lag between the onset of the policy and the effect. Effects were concentrated among children younger than age twelve. We estimated declines in poor oral health among all racial and ethnic subgroups, although there was some evidence that non-Hispanic Black children experienced larger and more persistent effects than non-Hispanic White children. Future assessments of the costs and benefits of offering adult dental coverage may consider potential effects on the children of adult Medicaid enrollees.

Navigating the Continuum of Ethical Billing

Clinical nutrition services improve conditions such as diabetes, heart disease, and hypertension and support value-based care, focusing on optimizing cost, quality, and the patient’s care experience. Many registered dietitian nutritionists (RDNs) work to treat and prevent disease by providing medical nutrition therapy (MNT), which is covered by the Medicare Part B program, numerous commercial insurance plans, and many state Medicaid programs. Notably, the US health care system continues to witness changes related to payment for medical and nutrition services.

Contraceptive Use and Pregnancy Outcomes Among Women Enrolled in South Carolina Medicaid Programs.

State medicaid programs provide access to effective contraception for people with lower incomes. This study examined contraception use and pregnancy among reproductive-age women enrolled in the South Carolina Medicaid, by eligibility program and socio-demographic sub-groups. A retrospective cohort of women aged 15-45 who were newly eligible for South Carolina Medicaid from 2012 to 2016 was examined. Log-binomial regression and average marginal effects assessed relationships between contraception use and pregnancies ending in live and non-live births. Contraception was categorized as permanent, long acting reversible contraception (LARC), short-acting hormonal contraception (SAC), or no contraceptive claims. Women with family planning or full-benefit medicaid coverage were included. Approximately 11% of women used LARC methods, 41% used SAC methods, and 46% had no evidence of contraceptive claims. Method utilization varied by eligibility program, race/ethnicity and age. The likelihood of pregnancy was lower among SAC users and lowest among LARC users compared to women with no evidence of contraception across all three programs (family planning APR = 0.44; 95% CI 0.41-0.49 and APR = 0.13, 95% CI 0.10-0.17; Low income families APR = 0.82; 95% CI 0.77-0.88 and APR = 0.33, 95% CI 0.28-0.38; Partners for Healthy Children APR = 0.72; 95% CI 0.68-0.77 and APR = 0.35, 95% CI 0.30-0.43, respectively). Non-Hispanic Black and Hispanic teens were less likely to experience a pregnancy than non-Hispanic white teens. The likelihood of pregnancy was lower among women using SAC methods and markedly lower among women using LARC. Variation in contraceptive use among racial/ethnic groups was noted despite Medicaid coverage. As new policies and initiatives emerge, these findings provide important context for understanding the role of Medicaid programs in reducing financial barriers to contraceptive services and ensuring access to effective contraception, while fostering reproductive health autonomy among women.

Recent Trends in Medicaid Spending and Use of Drugs With US Food and Drug Administration Accelerated Approval

State Medicaid programs have reported concerns about rising drug prices and spending, particularly regarding drugs entering the market through the accelerated approval program under the US Food and Drug Administration (FDA). The accelerated approval program enables the FDA to approve drugs on the basis of unverified surrogate end points, meaning that clinical benefits for these products are uncertain at the time of approval. However, state Medicaid programs are legally required to cover these drugs. Little is known about the set of products with accelerated approval over time, their use among Medicaid beneficiaries, or the magnitude of their financial influence on state Medicaid programs. To identify the number and class of drugs approved through the FDA's accelerated approval pathway and analyze state Medicaid programs' use and spending on these drugs from 2015 through 2019. In this cross-sectional study, biannual FDA reports were used to identify products granted accelerated approval and their associated indications approved between December 1992 and December 2020. State Medicaid Drug Utilization Data files available for 1992 through 2019 were used to estimate national totals for spending and use of outpatient drugs. National Medicaid use and gross and net spending on drugs with accelerated approval from 2015 through 2019. Since the inception of the FDA's accelerated approval pathway in 1992 through 2020, 216 product-indication pairs granted accelerated approval were identified, comprising 149 unique products. The composition of drugs approved through the pathway has changed over time, with 28 of 30 (93.3%) product-indication pairs receiving accelerated approval in 2020 being indicated for cancer. Relative to all outpatient prescription drugs paid for by Medicaid, products with accelerated approval ranged from 0.2% to 0.4% of use (1.3-2.4 million prescriptions annually). Despite their infrequent use, drugs with accelerated approval represented a minimum annual net spending on all drugs covered by Medicaid of 6.4% ($2.2 billion of $34.6 billion) in 2015 and a maximum of 9.1% ($2.5 billion of $27.6 billion) in 2018. Estimated annual gross spending on drugs with accelerated approval ranged from $4.2 billion to $4.9 billion over 2015 through 2019, and estimated net spending from $2.2 billion to $2.6 billion. In this cross-sectional study of 216 drugs granted accelerated approval, state spending on drugs approved through the FDA's growing accelerated approval program represented an outsized amount of spending relative to use. Because drugs with accelerated approval have come to market on the basis of trials using surrogate end points, considerable amounts of this spending may have been attributable to products with unproven clinical benefits.

Racial Disparities in Children, Adolescents, and Young Adults with Hodgkin Lymphoma Enrolled in the New York State Medicaid Program.

Background: We examined the impact of race/ethnicity and age on survival in a publicly insured cohort of children and adolescent/young adults (AYA; 15-39 years) with Hodgkin lymphoma, adjusting for chemotherapy using linked Medicaid claims. Materials and Methods: We identified 1231 Medicaid-insured patients <1-39 years diagnosed with classical Hodgkin lymphoma between 2005 and 2015, in the New York State Cancer Registry. Chemotherapy regimens were based on contemporary therapeutic regimens. Cox proportional hazards regression models quantified associations of patient, disease, and treatment variables with overall survival (OS) and disease-specific survival (DSS), and are presented as hazard ratios (HR) with confidence intervals (95% CIs). Results: At median follow-up of 6.6 years, N = 1108 (90%) patients were alive; 5-year OS was 92% in children <15 years. In multivariable models, Black (vs. White) patients had 1.6-fold increased risk of death (HR: 1.58, 95% CI: 1.02-2.46; p = 0.042). Stage III/IV (vs. I/II) was associated with 1.9-fold increased risk of death (HR: 1.86, 95% CI: 1.25-2.78; p = 0.002) and treatment at a non-National Cancer Institute (NCI) affiliate was associated with worse DSS (HR: 2.71, 95% CI: 1.47-4.98; p = 0.001). Conclusions: In this Medicaid-insured cohort of children and AYAs with Hodgkin lymphoma, Black race/ethnicity remained associated with inferior OS in multivariable models adjusted for disease, demographic, and treatment data. Further work is needed to identify dimensions of health care access not mediated by insurance, as findings suggest additional factors are contributing to observed cancer disparities in vulnerable pediatric and AYA populations.

Impact of Medicaid expansion and methadone coverage as a medication for opioid use disorder on foster care entries during the opioid crisis

Between 2012 and 2018, incidents of opioid-involved injuries surged and the number of children in foster care due to parental drug use disorder increased. Treatments for opioid use disorder (OUD) might prevent or reduce the amount of time that children spend in the child welfare system. Using administrative data, we examined the impact of Medicaid expansion and state support for methadone as a medication for opioid use disorder (MOUD) on first-time foster care placements. Results show that first-time foster care entries due to parental drug use disorder experienced a reduction of 28 per 100,000 children in Medicaid expansion states with methadone MOUD covered by their state Medicaid programs. The largest reduction was found among non-Hispanic Black children and the youngest children (age 0–1 years). Policies that increase OUD treatment access may reduce foster care placements by reducing parents’ drug use, a risk factor for child abuse/neglect and subsequent home removal.