Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes

Revealed Comparative Disadvantage of Infants: Exposure to NAFTA and Birth Outcomes

This paper investigates the relationship between regional exposure to trade liberalization under the North American Free Trade Agreement (NAFTA) and infant health outcomes in the U.S., focusing on differences in impact across areas with varying levels of import competition. I explore this question by implementing event studies and difference-in-difference regressions that compare birth outcomes of infants born in different years relative to NAFTA and localities with differential exposure to import competition. Using more than 88M birth records of Natality data, I find significant negative effects on a wide range of birth outcomes. The adverse effects are much larger for infants at the lower tails of birth weight and gestational age distribution. Additional analyses using a wide range of alternative data sources suggest several potential pathways, including reductions in income-employment, decreases in housing wealth, lower health care utilization, lower health insurance use, and lower-quality health insurance.

Reduced odds of severe maternal morbidity associated with the US Affordable Care Act dependent coverage provision

BACKGROUND

Continuous perinatal health insurance coverage is a policy intervention that may help reduce severe maternal morbidity (SMM) and racial and ethnic disparities in SMM in the United States. The Affordable Care Act Dependent Coverage Provision (DCP) allowed young adults to remain on their parent's private health insurance plan until their 26th birthday but its effectiveness in reducing SMM has not been evaluated.

OBJECTIVE

To assess the association of the DCP with SMM during delivery hospitalization.

STUDY DESIGN

Difference-in-differences analysis of US delivery hospitalizations from January 2006 to September 2015, stratified according to maternal race and ethnicity. The outcome was SMM exclusive of blood transfusion only, as defined by the Centers for Disease Control and Prevention criteria. The exposure was maternal age categorized into 21 to 25 years (covered by the DCP) and 27 to 31 years (not covered the DCP). The intervention was the DCP categorized into pre- and post-DCP periods (January 2006-September 2010 and October 2010-September 2015, respectively).

RESULTS

Of the 4,007,937 delivery hospitalizations in the sample, 22,540 (56.2 per 10,000) recorded SMM. For birthing people aged 21 to 25 years (covered by the DCP), the mean SMM rate was 48.9 per 10,000 during the pre-DCP period and 58.2 per 10,000 during the post-DCP period (crude difference: 9.3 per 10,000). For birthing people aged 27 to 31 years (not covered the DCP), the mean SMM rate was 53.4 per 10,000 during the pre-DCP period and 63.6 per 10,000 during the post-DCP period (crude difference: 10.2 per 10,000). Implementation of DCP was associated with a 1.2% (95% CI: -3.6, 1.3) relative decrease in the mean SMM rate (adjusted odds ratio (aOR): 0.988; 95% CI: 0.964, 1.013). For non-Hispanic White people, the DCP was associated with a 10.7% (95% CI: 7.1, 14.2) relative decrease in the mean SMM rate (aOR: 0.893; 95% CI: 0.858, 0.929). The DCP was associated with an increase in the proportion of privately insured (aOR: 1.225; 95% CI: 1.220, 1.231), a decrease in the proportion of Medicaid beneficiaries (aOR: 0.853; 95% CI: 0.849, 0.856), and a decrease in the proportion of uninsured (aOR: 0.807; 95% CI: 0.798, 0.816).

CONCLUSIONS

Maternal health benefit of the DCP appears to be limited to non-Hispanic White birthing people.

Trends and Racial/Ethnic Disparities in Prenatal Care (PNC) Use from 2016 to 2021 in the United States

OBJECTIVES

To investigate the trends and racial/ethnic disparities in adequate prenatal care (PNC) use in the USA.

METHODS

A repeated cross-sectional study was conducted using May 2016-May 2021 data from the Pregnancy Risk Assessment Monitoring System (PRAMS). A primary outcome was the Kotelchuck index, a measure of the adequacy of PNC use, and the year was a key independent variable. Multinomial and binary logistic regression analyses were performed to examine PNC utilization using multiple imputations with chained equations.

RESULTS

Among the 190,262 pregnant individuals, adequate PNC use was largely consistent from 2016 to 2019. However, there was an immediate drop from 77.4-78.3% between 2016 and 2019 to 75.2% in 2020 and 75.8% in 2021. Conversely, both intermediate and inadequate PNC use tended to increase in 2020 and 2021. Adequate PNC use, when compared to inadequate use, showed significantly lower odds in 2020 (adjusted Odds Ratio [aOR] 0.87, 95% CI 0.78-0.96; p = 0.009) and 2021 (aOR 0.87, 95% CI 0.77-0.99; p = 0.033) than in 2016. Notably, Hispanic participants experienced substantial impacts (aOR 0.75, 95% CI 0.64-0.88; p = 0.001 in 2020 and aOR 0.72, 95% CI 0.59-0.89; p = 0.002 in 2021).

CONCLUSIONS

While adequate PNC use was a steady, slightly upward trend before 2020, it had a steep decline afterward. It is worth noting that Hispanic individuals were severely affected. Targeted interventions or policies to address barriers to PNC and foster equitable and sustainable care models are required.

Timing of treatment for opioid use disorder among birthing people

BACKGROUND

The number of pregnant women with opioid use disorder (OUD) has increased over time. Although effective treatment options exist, little is known about the extent to which women receive treatment during pregnancy and at what stage of pregnancy care is initiated.

METHODS

Using a national private health insurance claims database, we identified women aged 13-49 who gave birth in 2006-2019 and had an OUD or nonfatal opioid overdose (NFOO) diagnosis during the year prior to or at delivery. We then identified women who received their first OUD treatment prior to or during pregnancy. In this cross-sectional study, we investigated how rates and timing of the initial OUD treatment changed over time. Furthermore, we examined factors associated with early initiation of OUD treatment among birthing people.

RESULTS

Of the 7057 deliveries from 6747 women with OUD or NFOO, 63.3 % received any OUD treatment. Rates of OUD treatment increased from 42.9 % in 2006 to 69 % in 2019. Of those treated, in 2006, 54.5 % received their first treatment prior to conception and 24.2 % initiated care during the 1st trimester. In 2019, 68.9 % received their first treatment prior to conception, and 15.1 % initiated care during the 1st trimester. The percentage of women who were first treated in the 2nd trimester or later decreased from 21.2 % in 2006 to 16.1 % in 2019. Factors associated with early treatment initiation include being 25 years or older (age 25-34: aOR, 1.51, 95 % CI, 1.28-1.78; age 35-49: aOR, 1.82, 95 % CI, 1.39-2.37), living in urban areas (aOR, 1.28; 95 % CI, 1.05-1.56), having pre-existing behavioral health comorbidities such as anxiety disorders (aOR, 1.8; 95 % CI, 1.40-2.32), mood disorders (aOR, 1.63; 95 % CI, 1.02-2.61), and substance use disorder other than OUD (aOR, 2.56; 95 % CI, 2.03-3.32).

CONCLUSION

Overall, rates of OUD treatment increased over time, and more women initiated OUD treatment prior to conception. Despite these improvements, over one-third of pregnant women with OUD/NFOO either received no treatment or did not initiate care until the 3rd trimester in 2019. Future research should examine barriers to OUD treatment initiation among pregnant women.

Impact of Medicaid expansion on pregnancy outcomes among women with gestational diabetes

INTRODUCTION

The Affordable Care Act (ACA) aims to broaden health care access and significantly impacts obstetric practices. Yet, its effect on maternal and neonatal outcomes among women with gestational diabetes across diverse demographics is underexplored.

OBJECTIVE

This study examines the impact of the implementation of the ACA on maternal and neonatal health in Maryland with ACA implementation and Georgia without ACA implementation.

METHODOLOGY

We used data from the Maryland State Inpatient Database and US Vital Statistics System to assess the ACA's influence on maternal and neonatal outcomes in Maryland, with Georgia serving as a nonexpansion control state. Outcomes compared include cesarean section (CS) rates, low Apgar scores, neonatal intensive care unit (NICU) admissions, and assisted ventilation 7 h postdelivery. We adjusted for factors including women's age, race, insurance type, preexisting conditions, prior CS, prepregnancy obesity, weight gain during pregnancy, birth weight, labor events, and antenatal practices.

RESULTS

The study included 52 479 women: 55.8% from Georgia and 44.2% from Maryland. Post-ACA, CS rates were 45.1% in Maryland versus 48.2% in Georgia (P = 0.000). Maryland demonstrated better outcomes, including lower rates of low Agar scores (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.63-0.86]), assisted ventilation (OR, 0.79 [95% CI, 0.71-0.82]), and NICU admissions (OR, 0.76 [95% CI, 0.71-0.82]), but no significant change in CS rates (OR, 0.96 [95% CI, 0.92-1.01]).

CONCLUSION

After ACA implementation, Maryland showed improved maternal and neonatal outcomes compared with Georgia, a nonexpansion state.

The impact of maternal pertussis vaccination recommendation on infant pertussis incidence and mortality in the USA: an interrupted time series analysis

BACKGROUND

Pertussis is a contagious respiratory disease. Maternal tetanus-diphtheria-acellular pertussis vaccination during pregnancy has been recommended by the United States Centres for Disease Control (US CDC) Advisory Committee on Immunization Practices (ACIP) for unvaccinated pregnant women since October 2011 to prevent infection among infants; in 2012, ACIP extended this recommendation to every pregnancy, regardless of previous vaccination status. The population-level effect of these recommendations on infant pertussis is unknown. This study aimed to examine the impact of the 2011/2012 ACIP pertussis recommendation on pertussis incidence and mortality among US infants.

METHODS

We used monthly data on pertussis deaths among infants aged <1 year between January 2005 and December 2017 in the CDC Death Data and yearly infant pertussis incidence data from the CDC National Notifiable Disease Surveillance System to perform an interrupted time series analysis, accounting for the passage of the Affordable Care Act.

RESULTS

This study included 156 months of data. A potential decline in trend in infant pertussis incidence was noted during the post-recommendations period. No appreciable differences in trend were found in population-level infant pertussis mortality after the guideline changes in both adjusted and unadjusted models. Results were similar for all mortality sensitivity analyses.

CONCLUSIONS

The 2011/2012 ACIP maternal pertussis vaccination recommendations were not associated with a population-level change in the trend in mortality, but were potentially associated with a decrease in incidence in the USA between 2005 and 2017.

The COVID-19 pandemic and non-COVID-19 healthcare utilization in Mexico

OBJECTIVES

This study aimed to analyze the effects of the COVID-19 pandemic on non-COVID-19 healthcare utilization in Mexico, including oral health, mental health, communicable disease visits, health checkups, chronic degenerative disease visits, postpartum care, prenatal care, and family planning visits.

STUDY DESIGN

This was a retrospective ecological analysis during the COVID-19 pandemic. During the pandemic, the Mexican government recommended non-essential consultations be suspended or rescheduled to accommodate the new demand for healthcare services from COVID-19 patients.

METHODS

This study uses administrative data from Mexico's Ministry of Health from January 2017 to December 2022. These data cover 14,299 consultation units and 775 hospitals from the 32 Mexican States, all of which are public institutions. A difference-in-differences strategy and an event study specification are used to study the impacts of the pandemic on non-COVID-19 healthcare utilization.

RESULTS

The findings reveal a decrease in the utilization of all healthcare services: oral health (69%), mental health (27%), communicable diseases (46%), chronic degenerative diseases (36%), health checkups (62%), family planning (45%), prenatal care (36%), and postpartum care (44%). Furthermore, the event study indicates that most services follow a U-shaped trend, although only mental health services clearly return to prepandemic levels. The remainder of services remain below prepandemic levels at the end of 2022.

CONCLUSIONS

The 2020 pandemic had detrimental effects on non-COVID-19 healthcare utilization. The healthcare interruptions will likely impact short- and long-term morbidity and mortality. Programs intended to remediate these negative consequences may be of interest to public health policymakers.

Medicaid expansion and racial disparity in timely multidisciplinary treatment in muscle invasive bladder cancer

BACKGROUND

Multidisciplinary cancer care (neoadjuvant chemotherapy followed by radical cystectomy or trimodality therapy) 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.

METHODS

This quasi-experimental study analyzed Black and White individuals aged 18-64 years with stage II and III bladder cancer treated with neoadjuvant chemotherapy followed by radical cystectomy or trimodality therapy 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 and difference-in-difference-in-differences analyses, controlling for age, sex, area-level income, clinical stage, comorbidity, metropolitan status, treatment type, and year of diagnosis.

RESULTS

The study included 4991 (92.3% White, n = 4605; 7.7% Black, n = 386) patients. Percentage of Black patients who received timely care increased following the ACA in Medicaid expansion states (54.5% pre-ACA vs 57.4% post-ACA) but decreased in nonexpansion 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 patient disparity in timely receipt of MIBC treatment (95% confidence interval = 0.5% to 26.8%; P < .01).

CONCLUSIONS

Medicaid expansion was associated with statically significant reduction in racial disparity between Black and White patients in timely multidisciplinary treatment for MIBC.

Association of the United States Affordable Care Act Dependent Coverage Provision with Labor Neuraxial Analgesia Use

BACKGROUND

Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use.

METHODS

This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate.

RESULTS

Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women.

CONCLUSIONS

Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance.

EDITOR’S PERSPECTIVE

Advocacy in neonatology: current issues and introduction to the series

Advocacy is an increasingly important skill for neonatologists. As social factors play a greater influence on short & long-term newborn outcomes, neonatal physicians must be attentive to policy factors and work to ensure they benefit the health of both patients and the specialty. In this article, we review advocacy issues of current relevance to neonatal practice, including the "Born Alive Executive Order," the "Newborn Screening Saves Lives Act," subspecialty loan repayment and legislation related to donor human milk, as well as introduce topics further discussed as part of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine Advocacy Series.

Effect of covering perinatal health-care costs on neonatal outcomes in Switzerland: a quasi-experimental population-based study

BACKGROUND

Low birthweight and preterm birth are associated with an increased risk of neonatal death and chronic conditions across the life course. Reducing these adverse birth outcomes is a global public health priority and requires strategies to improve health care during pregnancy. We aimed to assess the effect of a Swiss health policy expansion fully covering illness-related costs during pregnancy on health outcomes in newborn babies.

METHODS

We implemented a quasi-experimental difference in regression discontinuity design to assess the effect of expansion of Swiss health insurance (on March 1, 2014), to fully cover health-care costs during pregnancy and 8 weeks postpartum, on neonatal outcomes. Before this reform, only costs specific to the standard monitoring of a normal pregnancy were covered. Babies born before March 1, 2014, and their mothers were assigned to the unexposed group, and babies born on or after March 1, 2014, and their mothers were assigned to the exposed group. We included nearly all children born 2011-19 in Switzerland within a period of 9 months around the date March 1, 2014, and control years 2012, 2016, and 2018. Outcomes were birthweight, low birthweight, very low birthweight, gestational age, preterm or extremely preterm birth, and neonatal death. We estimated the intention-to-treat effect of the policy using parametric regression models.

FINDINGS

61 910 children were born 9 months before and 63 991 were born 9 months after March 1, 2014. 382 861 children were born in the same time period around the three control dates. In the period before policy implementation, mean birthweight was 3289 g, gestational age was 275 days, and 6·5% of children had low birthweight, 1·0% very low birthweight, 7·1% were preterm, 0·4% were extremely preterm, and 0·3% died within the first 28 days of life. After initiation of the policy (vs before) mean birthweight increased by 23 g (95% CI 5 to 40) and the predicted proportion of low birthweight births decreased by 0·81% (0·14 to 1·48) and of very low birthweight births decreased by 0·41% (0·17 to 0·65). The effect on very low birthweight was not robust in sensitivity analyses. The policy had a negligible effect on gestational age (mean difference 1 day, 95% CI 0 to 1) and no clear effects on the other examined outcomes. The change in predicted proportion for preterm births was -0·39% (95% CI -1·2 to 0·38), for extremely preterm births was -0·09% (-0·27 to 0·08), and for neonatal death was -0·07% (-0·2 to 0·07).

INTERPRETATION

Free access to prenatal care in Switzerland reduced the risk of some adverse health outcomes in newborn babies. Expanding health-care coverage is a relevant health system intervention to reduce the risk of adverse health outcomes in the newborn baby and, potentially, across the life course.

FUNDING

Swiss National Science Foundation.

Affordable Care Act (ACA) Implementation and Adolescent Births by Insurance Type: An Interrupted Time Series Analysis of Births between 2009 and 2017 in the United States

BACKGROUND

In 2010, the Affordable Care Act (ACA) was enacted, with full provisions in effect by 2014, including expanded Medicaid coverage, changes to the marketplace, and contraceptive coverage, but its impact on birth trends, particularly adolescent births, is currently unknown.

OBJECTIVES

We sought to determine whether ACA implementation was associated with changes in adolescent births and whether this differed by insurance type (Medicaid or private insurance).

METHODS

We used revised 2009-2017 birth certificate data, restricted to resident women with a Medicaid or privately paid singleton birth (N = 27,748,028). Segmented regression analysis was used to examine births to adolescent mothers (12-19 years old) before and after the ACA.

RESULTS

There were 27,748,028 singleton births (n = 2,013,521 adolescent births) among U.S. residents between 2009 and 2017 in this analytic sample. Adjusted models revealed that the ACA was associated with a 23% significant decrease in odds of an adolescent birth (OR = 0.78; 95% CI, 0.77-0.79) for Medicaid-funded births and a 19% decrease (OR = 0.81; 95% CI, 0.79-0.83) for privately insured births, with a further declining trend. Overall declines in adolescent births among the Medicaid population appear to be driven by states that chose to expand Medicaid.

CONCLUSION

Beyond the declining secular trend already observed in adolescent pregnancy over the last 10 years, the ACA appears to have had a substantial impact on adolescent births, likely due to Medicaid expansion and increased access to affordable contraception. From a population health perspective, efforts to undo the ACA could have important consequences for maternal, infant, and family health in the United States.

Analysis of State Medicaid Expansion and Access to Timely Prenatal Care Among Women Who Were Immigrant vs US Born

IMPORTANCE

Disparities exist in access to timely prenatal care between immigrant women and US-born women. Exclusions from Medicaid eligibility based on immigration status may exacerbate disparities.

OBJECTIVE

To examine changes in timely prenatal care by nativity after Medicaid expansion.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional difference-in-differences (DID) and triple-difference analysis of 22 042 624 singleton births from January 1, 2011, to December 31, 2019, in 31 states was conducted using US natality data. Data analysis was performed from February 1, 2021, to August 24, 2022.

EXPOSURES

Within 16 states that expanded Medicaid in 2014, the rate of timely prenatal care by nativity in years after expansion was compared with the rate in the years before expansion. Similar comparisons were conducted in 15 states that did not expand Medicaid and tested across expansion vs nonexpansion states.

MAIN OUTCOMES AND MEASURES

Timely prenatal care was categorized as prenatal care initiated in the first trimester. Individual-level covariates included age, parity, race and ethnicity, and educational level. State-level time-varying covariates included unemployment, poverty, and Immigrant Climate Index.

RESULTS

A total of 5 390 814 women preexpansion and 6 544 992 women postexpansion were included. At baseline in expansion states, among immigrant women, 413 479 (27.3%) were Asian, 110 829 (7.3%) were Black, 752 176 (49.6%) were Hispanic, and 238 746 (15.8%) were White. Among US-born women, 96 807 (2.5%) were Asian, 470 128 (12.1%) were Black, 699 776 (18.1%) were Hispanic, and 2 608 873 (67.3%) were White. Prenatal care was timely in 75.9% of immigrant women vs 79.9% of those who were US born in expansion states at baseline. After Medicaid expansion, the immigrant vs US-born disparity in timely prenatal care was similar to the preexpansion level (DID, -0.91; 95% CI, -1.91 to 0.09). Stratifying by race and ethnicity showed an increase in the Asian vs White disparity after expansion, with 1.53 per 100 fewer immigrant women than those who were US born accessing timely prenatal care (95% CI, -2.31 to -0.75), and in the Hispanic vs White disparity (DID, -1.18 per 100; 95% CI, -2.07 to -0.30). These differences were more pronounced among women with a high school education or less (DID for Asian women, -2.98; 95% CI, -4.45 to -1.51; DID for Hispanic women, -1.47; 95% CI, -2.48 to -0.46). Compared with nonexpansion states, differences in DID estimates were found among Hispanic women with a high school education or less (triple-difference, -1.86 per 100 additional women in expansion states who would not receive timely prenatal care; 95% CI, -3.31 to -0.42).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that exclusions from Medicaid eligibility based on immigration status may be associated with increased health care disparities among some immigrant groups. This finding has relevance to current policy debates regarding Medicaid coverage during and outside of pregnancy.

Inclusion of Social and Structural Determinants of Health to Advance Understanding of their Influence on the Biology of Chronic Disease

Social Determinants of Health (SDOH) consider social, political, and economic factors that contribute to health disparities in patients and populations. The most common health-related SDOH exposures are food and housing insecurity, financial instability, transportation needs, low levels of education, and psychosocial stress. These domains describe risks that can impact health outcomes more than health care. Epidemiologic and translational research demonstrates that SDOH factors represent exposures that predict harm and impact the health of individuals. International and national guidelines urge health professionals to address SDOH in clinical practice and public health. The further implementation of these recommendations into basic and translational research, however, is lagging. Herein, we consider a precision health framework to describe how SDOH contributes to the exposome and exacerbates physiologic pathways that lead to chronic disease. SDOH factors are associated with various forms of stressors that impact physiological processes through epigenetic, inflammatory, and redox regulation. Many SDOH exposures may add to or potentiate the pathologic effects of additional environmental exposures. This overview aims to inform basic life science and translational researchers about SDOH exposures that can confound associations between classic biomedical determinants of disease and health outcomes. To advance the study of toxicology through either qualitative or quantitative assessment of exposures to chemical and biological substances, a more complete environmental evaluation should include SDOH exposures. We discuss common approaches to measure SDOH factors at individual and population levels and review the associations between SDOH risk factors and physiologic mechanisms that influence chronic disease. We provide clinical and policy-based motivation to encourage researchers to consider the impact of SDOH exposures on study results and data interpretation. With valid measures of SDOH factors incorporated into study design and analyses, future toxicological research may contribute to an evidence base that can better inform prevention and treatment options, to improve equitable clinical care and population health. © 2022 Wiley Periodicals LLC.

Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery

The American Rescue Plan provides a pathway for states to expand postpartum Medicaid coverage for low-income mothers through 12 months after delivery. Data suggests that extension of post-partum Medicaid coverage should improve access to outpatient health care services, increase healthcare utilization, improve chronic disease management for at-risk mothers, and reduce disparities in care for racial/ethnic groups over-represented in Medicaid. Opportunities to provide increased preventive care for perinatal mood disorders and smoking cessation also exist. Further, this policy may reduce the burden of late maternal mortality. While improved access to contraceptive service postpartum provides a potential mechanism by which birth outcomes may improve, the effect of this policy on NICU admission, low birth weight (LBW) infants, and preterm birth is unknown. We discuss possible birth, infant and maternal health outcomes which may result from this expansion, drawing on data from the 2010 Medicaid Expansion via the Affordable Care Act.

Risk Factors for Dual Burden of Severe Maternal Morbidity and Preterm Birth by Insurance Type in California

OBJECTIVES

Among childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type.

METHODS

We estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007-2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics.

RESULTS

Dual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6-10.9) for privately insured to 15.9 (95% CI 9.1-27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7-3.5) for women with Medi-Cal to 5.4 (95% CI 3.5-8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0-8.3) to 19.4 (95% CI 10.3-36.3), respectively, among multiparas.

CONCLUSIONS

Risk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health.

Characterizing Hypertensive Disorders of Pregnancy Among Medicaid Recipients in a Nonexpansion State

Background: The incidence of hypertensive disorders of pregnancy (HDP) are on the rise in the United States, especially in the South, which has a heavy chronic disease burden and large number of Medicaid nonexpansion states. Sizeable disparities in HDP outcomes exist by race/ethnicity, geography, and health insurance coverage. Our objective is to explore HDP in the Alabama Medicaid maternity population, and the association of maternal sociodemographic, clinical, and care utilization characteristics with HDP diagnosis. Materials and Methods: Data were from Alabama Medicaid delivery claims in 2017. Bivariate analyses were used to examine maternal characteristics by HDP diagnosis. Hierarchical generalized linear models, with observations nested at the county level, were used to assess multivariable relationships between maternal characteristics and HDP diagnosis. Results: Among women with HDP diagnosis, a higher proportion were older, Black, had other comorbidities, and had more perinatal hospitalizations or emergency visits compared with those without HDP diagnosis. There were increased odds of an HDP diagnosis for older women and those with comorbidities. Black women (adjusted odds ratio [aOR] = 1.24, 95% confidence interval [CI]: 1.16-1.33), women insured only during pregnancy by Sixth Omnibus Reconciliation Act Medicaid (aOR = 1.08, 95% CI: 1.02-1.15), and women entering prenatal care (PNC) in the second trimester (aOR = 1.10, 95% CI: 1.03-1.18) had elevated odds of HDP diagnosis compared with their counterparts. Conclusions: Beyond traditional demographic and clinical risk factors, not having preconception insurance coverage or first trimester PNC entry were associated with higher odds of HDP diagnosis. Improving the provision and timing of maternity coverage among Medicaid recipients, particularly in nonexpansion states, may help identify and treat women at risk of HDP and associated adverse perinatal outcomes.

Association of Medicaid vs Marketplace Eligibility on Maternal Coverage and Access With Prenatal and Postpartum Care

Importance

Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown.

Objective

To compare maternal coverage and care by Medicaid vs marketplace eligibility.

Design, Setting, and Participants

A retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey.

Exposures

Eligibility for Medicaid or marketplace coverage under the Affordable Care Act.

Main Outcomes and Measures

Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use.

Results

The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified.

Conclusions and Relevance

In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue

OBJECTIVE

To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends.

METHODS

This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed.

RESULTS

During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period.

CONCLUSION

Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.

Women's Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature

Women of working age (ages 19-64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women's experiencing uninsurance, underinsurance, and increased financial burdens related to obtaining health care. This literature review summarizes evidence on the law's effects on women's health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes. Despite major progress after the Affordable Care Act's implementation, barriers to coverage, access, and affordability remain, and serious threats to women's health still exist. Highlighting the law's effects on women's health is critical for informing future policies directed toward the continuing improvement of women's health care and health.

Private coverage mandates, business cycles, and provider treatment intensity

The Affordable Care Act (ACA) is the source of multiple large-scale health insurance expansions affecting various segments of the US population. Although much has been done to quantify the first-order effects of these policies, less empirical investigation has been devoted to the effects on the supply-side of health care. We focus on a well-known ACA initiative (the young adult dependent coverage mandate) to offer novel evidence on two fronts: the policy's heterogeneous effect across different labor markets and the potential for the policy-induced shift in payer mix to influence provider treatment decisions. First, we show that the federal mandate's direct effect on young adult private insurance take-up is strongly mitigated by the Great Recession. Second, we demonstrate that providers do not treat young adults more aggressively when more of them hold private coverage. Policymakers should keep these broader considerations and more diffuse risk protection implications in mind when contemplating changes to the law.

Barriers to Prenatal Care Among Food-Insufficient Women: Findings from the Pregnancy Risk Assessment Monitoring System

Background: This study examines the relationship among food insufficiency, adequacy of prenatal care, and barriers to prenatal care. Materials and Methods: Using data from the Pregnancy Risk Assessment Monitoring System (PRAMS), 2009-2016, negative binomial and logistic regression models were used to assess the association among food insufficiency during pregnancy, late onset of prenatal care, the number of prental care visits, as well as barriers to prenatal care. Results: Findings indicate that food insufficiency is associated with not initiating prenatal care during the first trimester and having fewer overall visits. In addition, food insufficiency is associated with more overall barriers to prenatal care, and this association operates through several specific barriers, including not having enough money, lacking transportation to get to the clinic or doctor's office, not being able to get time off work, not having a Medicaid card, having too many other things going on, and having no one to take care of children. Conclusion: Considering the adverse consequences of both food insufficiency and a lack of sufficient prenatal care for maternal and child health, study findings suggest a need to develop targeted interventions that expand access and remove barriers to prenatal care among food-insufficient women.

Timing of Prenatal Care Initiation in the Health Resources and Services Administration Health Center Program in 2017

BACKGROUND

Early prenatal care is vital for improving maternal health outcomes and health behaviors, but medically vulnerable and underserved populations are less likely to begin prenatal care in the first trimester. In 2017, the Health Center Program provided safety-net care to more than 27 million persons, including 573 026 prenatal patients, at approximately 12 000 sites across the United States and U.S. jurisdictions. As part of a mandatory reporting requirement, health centers tracked whether patients initiated prenatal care in their first trimester of pregnancy.

OBJECTIVE

To identify health center characteristics associated with the initiation of prenatal care in the first trimester, as well as actionable steps policymakers, providers, and health centers can take to promote early initiation of prenatal care.

DESIGN

Secondary analysis of cross-sectional data from the 2017 Uniform Data System.

SETTING

The United States and 8 U.S. jurisdictions.

PARTICIPANTS

Health center grantees with prenatal patients (n = 1281).

MEASUREMENTS

Multinomial logistic regression (adjusted for state or jurisdiction clustering) was used to identify health center characteristics associated with achievement of the Healthy People 2020 baseline (77.1%) and target (84.8%) for women receiving prenatal care in the first trimester (Maternal, Infant, and Child Health Objective 10.1).

RESULTS

Overall, 57.4% of health centers met the Healthy People 2020 baseline (mean, 78%; median, 81%), and 37.9% met the Healthy People 2020 target. Several characteristics were positively associated with meeting the baseline (larger proportion of prenatal patients aged 20 to 24 years) and target (more total patients, prenatal care by referral only, a larger proportion of prenatal patients aged 25 to 44 or ≥45 years, and a larger proportion of White or privately insured patients). Other characteristics were negatively associated with the baseline (location outside New England, location in a rural area, and a large proportion of prenatal patients aged <15 years) and target (more prenatal patients, location outside New England, provision of prenatal care to women living with HIV, and more uninsured patients or patients eligible for both Medicare and Medicaid).

LIMITATION

The data set is at the health center grantee level and does not contain information on timing or quality of follow-up prenatal care.

CONCLUSION

Most health centers met the Healthy People 2020 baseline, but opportunities for improvement remain and the Healthy People 2020 target is still a challenge for many health centers. Policymakers, providers, and health centers can learn from high-achieving centers to promote early initiation of prenatal care among medically vulnerable and underserved populations.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

The Association between Travel Time and Prenatal Care Attendance

OBJECTIVE

This study aimed to evaluate the association between a patient's travel time to clinic and her prenatal care attendance.

STUDY DESIGN

We conducted a retrospective cohort study of women (≥18 years) who received prenatal care and delivered at North Carolina Women's Hospital between July 1, 2014, and June 30, 2016 (n = 2,808 women, 24,021 appointments). We queried demographic data from the electronic medical record and calculated travel time with ArcGIS. Multinomial logistic regression models estimated the association between travel time and attendance, adjusted for sociodemographic covariates.

RESULTS

For every 10 minutes of additional travel time, women were 1.05 (95% confidence interval [CI]: 1.02-1.08, p < 0.001) times as likely to arrive late and 1.03 (95% CI: 1.01-1.04, p < 0.001) times as likely to cancel appointments than arrive on time. Travel time did not significantly affect a patient's likelihood of not showing for appointments. Non-Hispanic black patients were 71% more likely to arrive late and 51% more likely to not show for appointments than non-Hispanic white patients (p < 0.05). Publicly insured women were 28% more likely to arrive late to appointments and 82% more likely to not show for appointments than privately insured women (p < 0.05).

CONCLUSION

Changes to transportation availability alone may only modestly affect outcomes compared with strategically improving access for sociodemographically marginalized women.

Medications for opioid use disorder among pregnant women referred by criminal justice agencies before and after Medicaid expansion: A retrospective study of admissions to treatment centers in the United States

BACKGROUND

Criminal justice involvement is common among pregnant women with opioid use disorder (OUD). Medications for OUD improve pregnancy-related outcomes, but trends in treatment data among justice-involved pregnant women are limited. We sought to examine trends in medications for OUD among pregnant women referred to treatment by criminal justice agencies and other sources before and after the Affordable Care Act's Medicaid expansion.

METHODS AND FINDINGS

We conducted a serial, cross-sectional analysis using 1992-2017 data from pregnant women admitted to treatment facilities for OUD using a national survey of substance use treatment facilities in the United States (N = 131,838). We used multiple logistic regression and difference-in-differences methods to assess trends in medications for OUD by referral source. Women in the sample were predominantly aged 18-29 (63.3%), white non-Hispanic, high school graduates, and not employed. Over the study period, 26.3% (95% CI 25.7-27.0) of pregnant women referred by criminal justice agencies received medications for OUD, which was significantly less than those with individual referrals (adjusted rate ratio [ARR] 0.45, 95% CI 0.43-0.46; P < 0.001) or those referred from other sources (ARR 0.51, 95% CI 0.50-0.53; P < 0.001). Among pregnant women referred by criminal justice agencies, receipt of medications for OUD increased significantly more in states that expanded Medicaid (n = 32) compared with nonexpansion states (n = 18) (adjusted difference-in-differences: 12.0 percentage points, 95% CI 1.0-23.0; P = 0.03). Limitations of this study include encounters that are at treatment centers only and that do not encompass buprenorphine prescribed in ambulatory care settings, prisons, or jails.

CONCLUSIONS

Pregnant women with OUD referred by criminal justice agencies received evidence-based treatment at lower rates than women referred through other sources. Improving access to medications for OUD for pregnant women referred by criminal justice agencies could provide public health benefits to mothers, infants, and communities. Medicaid expansion is a potential mechanism for expanding access to evidence-based treatment for pregnant women in the US.

The Proximity of Spatial Clusters of Low Birth Weight and Risk Factors: Defining a Neighborhood for Focused Interventions

BACKGROUND

Low birth weight (LBW) is associated with significant mortality and morbidity and remains a significant preventable problem. Risk factors include socioeconomic, demographics, and characteristics of the environment. Spatial analysis can uncover unusual frequencies of health problems in neighborhoods, eventually leading to insights for targeted interventions.

OBJECTIVES

This study's goals were to 1. Evaluate the geographic distribution of spatial clusters of LBW births and maternal risk factors. 2. Determine the spatial relationship between risk factors and LBW.

METHODS

This study obtained data on LBW newborns and risk factors from 19,013 births over 5 years (2012-2016) for Escambia County Census Tracts, extracted from FloridaCharts.com. Software was used to detect significant spatial clusters; these clusters were then plotted on a map. Poisson regression determined the statistical relationship between Census Tract risk factors and LBW. A separate analysis of the LBW cluster controlling for risk factors was also performed.

RESULTS

All risk factor clusters resided in similar locations as the LBW cluster. The multiple Poisson regression model containing all risk factors fully explained the LBW cluster. On bivariate Poisson regression all risk factors in the Census Tract were significantly related to LBW whereas in multivariable Poisson regression, the proportion of births to African American women in the Census Tract remained significant after adjusting for other risk factors (p < 0.001).

CONCLUSIONS FOR PRACTICE

Clusters of LBW and risk factors were located in the same region of the county, with the proportion of births to African American women in the Census Tract remaining significant on multiple Poisson Regression. Targeted interventions should be directed at the geographic level.

Medicaid expansion and infant mortality, revisited: A difference-in-differences analysis

OBJECTIVE

To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.

DATA SOURCES

State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.

STUDY DESIGN

The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.

PRINCIPAL FINDINGS

Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).

CONCLUSIONS

Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.

Market Share of US Catholic Hospitals and Associated Geographic Network Access to Reproductive Health Services

IMPORTANCE

Access to reproductive health services is a public health goal. It is unknown how geographic and health plan network availability of Catholic and non-Catholic hospitals may be associated with access to reproductive health services in the United States.

OBJECTIVE

To characterize the market share of Catholic hospitals in the United States, both overall and within Marketplace health insurance plans' hospital networks.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of US counties used data on hospitals' Catholic affiliation and discharges, hospital networks in Marketplace health insurance plans, and US Census population data to construct a national, county-level data set. The Catholic hospital market share overall in each county and in Marketplace plans' hospital networks in each county were calculated. The study examined whether the Catholic hospital market share was different within Marketplace networks compared with the counties they served. Data analysis was conducted in May and June 2018.

MAIN OUTCOMES AND MEASURES

The overall Catholic hospital market share was calculated on the basis of the share of discharges in Catholic hospitals in a county compared with all hospital discharges. Overall market share was categorized as minimal (≤2%), low (>2% to ≤20%), high (>20% to ≤70%), or dominant (>70%). The Catholic hospital market share in Marketplace networks was calculated as the share of Catholic hospital discharges in each Marketplace network.

RESULTS

The sample included 4450 hospitals in 3101 counties. Overall, 26.1% of US counties had minimal Catholic hospital market share, 38.6% had low Catholic hospital market share, and 35.3% had high or dominant Catholic hospital market share; 38.7% of US reproductive-aged women resided in counties with high or dominant Catholic hospital market share. Among counties with Catholic hospital market share greater than 2%, the distribution of the median Marketplace network's Catholic hospital market share (median [interquartile range], 4.6% [0%-24.3%]) was lower than overall Catholic hospital market share (median [interquartile range], 18.5% [8.1%-36.5%]). The median Marketplace hospital network had a lower Catholic hospital market share than the county overall in 68.0% of US counties with Catholic hospital market share greater than 2%.

CONCLUSIONS AND RELEVANCE

In this national study, 35.3% of counties had high or dominant Catholic hospital market share serving an estimated 38.7% of US women of reproductive age. Marketplace health insurance plans' hospital networks included a lower share of Catholic hospitals than the counties they serve.

The effects of the dependent coverage provision on young women's utilization of sexual and reproductive health services

The Affordable Care Act dependent coverage provision expanded insurance for young adults by allowing maintained coverage through a parent's plan until the age of 26. This study examines whether this provision was associated with changes in sexual and reproductive health service utilization among young adult women, and if effects differed by race/ethnicity. The National Survey of Family Growth data were used to examine utilization among women before (2006-2009) and after (2011-2013) enactment of the provision. A difference-in-differences model was used to evaluate the effects on four measures of sexual and reproductive health services and one measure of health insurance coverage, treating women 19-25 years old as the exposure group and women 27-34 years old as the control group. This study finds that the dependent coverage provision was associated with a significant decrease in the probability of lacking health insurance, but finds no effects on sexual and reproductive health service utilization overall. In stratified models, increases in receipt of birth control prescriptions and methods as well as birth control check-ups or tests were present only for Hispanic women. There were no significant effects on birth control counseling or information or STD service utilization for any groups. Lacking health insurance coverage decreased only among non-Hispanic White women and Hispanic women, but was not significant for non-Hispanic Black women. These results suggest that women's utilization of sexual and reproductive health services overall may not increase with parental insurance gains, but Hispanic women do increase utilization of some birth control services with this improved coverage.

Pyloric Stenosis: National Trends in the Incidence Rate and Resource Use in the United States From 2012 to 2016

OBJECTIVES

Infantile hypertrophic pyloric stenosis (IHPS) is the most common reason for abdominal surgery in infants; however, national-level data on incidence rate and resource use are lacking. We aimed to examine the national trends in hospitalizations for IHPS and resource use in its management in the United States from 2012 to 2016.

METHODS

We performed a retrospective serial cross-sectional study using data from the National Inpatient Sample, the largest health care database in the United States. We included infants aged ≤1 year assigned an International Classification of Diseases, Ninth Revision, or International Classification of Diseases, 10th Revision, code for IHPS who underwent pyloromyotomy or pyloroplasty. We examined the temporal trends in the incidence rate (cases per 1000 live births) according to sex, insurance status, geographic region, and race. We examined resource use using length of stay (LOS) and hospital costs. Linear regression was used for trend analysis.

RESULTS

Between 2012 and 2016, there were 32 450 cases of IHPS and 20 808 149 live births (incidence rate of 1.56 per 1000). Characteristics of the study population were 82.7% male, 53% white, and 63.3% on Medicaid, and a majority were born in large (64%), urban teaching hospitals (90%). The incidence of IHPS varied with race, sex, socioeconomic status, and geographic region. In multivariable regression analysis, the incidence rate of IHPS decreased from 1.76 to 1.57 per 1000 (adjusted odds ratio 0.93; 95% confidence interval 0.92-0.93). The median cost of care was $6078.30, whereas the median LOS was 2 days, and these remained stable during the period.

CONCLUSIONS

The incidence rate of IHPS decreased significantly between 2012 and 2016, whereas LOS and hospital costs remained stable. The reasons for the decline in the IHPS incidence rate may be multifactorial.

Effects of ACA Expansion of Dependent Coverage on Hospital-Based Care of Young Adults With Early Psychosis

OBJECTIVE

Since 2010, the Affordable Care Act has required private health plans to extend dependent coverage to adults up to age 26. Because psychosis often begins in young adulthood, expanded private insurance benefits may affect early psychosis treatment. The authors examined changes in insurance coverage and hospital-based service use among young adults with psychosis before and after this change.

METHODS

The study included a national sample (2006-2013) of discharges and emergency department visits. Using a difference-in-differences study design, the authors compared changes in insurance coverage (measured as payer source), per capita admissions, and 30-day readmissions for psychosis before and after ACA dependent coverage expansion among targeted individuals (ages 20-25) and a comparison group (ages 27-29).

RESULTS

After dependent coverage expansion, hospitalization for psychosis among young adults was 5.8 percentage points more likely to be reimbursed by private insurance among the targeted age group (ages 20-25), compared with the slightly older age group (ages 27-29). Dependent coverage expansion was not associated with changes in overall insurance coverage, per capita admissions, or 30-day readmission for psychosis.

CONCLUSIONS

Although dependent coverage expansion was unrelated to changes in use of hospital-based treatments for psychosis among young adults, care was more likely to be covered by private insurance, and coverage of these hospitalizations by public insurance decreased. This shift from public to private insurance may reduce public spending on young-adult treatments for early-episode psychosis but may leave young adults without coverage for rehabilitation services.

Comparison of Insurance Status and Diagnosis Stage Among Patients With Newly Diagnosed Cancer Before vs After Implementation of the Patient Protection and Affordable Care Act

Importance

Having health insurance is a strong determinant of cancer outcomes in the United States, and Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) may have reduced the prevalence of uninsured patients. Prior research has only assessed the aggregate effects of expansions, and little is known about changes in uninsured patients by state and key sociodemographic groups, including sex, race/ethnicity, census tract-level poverty, and rurality.

Objective

To examine changes in the percentage of uninsured patients and stage at diagnosis among nonelderly patients with cancer by state and key sociodemographic groups after implementation of the ACA.

Design, Setting, and Participants

This study used difference-in-differences analysis to determine the percentage of uninsured patients and early-stage cancer diagnoses among patients aged 18 to 64 years from the population-based cancer registries of 40 states before (January 1, 2010, to December 31, 2013) and after (January 1, 2014, to December 31, 2014) the ACA Medicaid expansion. Data analysis was performed from November 2017 to April 2018.

Main Outcomes and Measures

Changes in the percentage of uninsured patients and early-stage diagnoses.

Results

A total of 2 471 154 patients (mean age, 52.7 years; age range, 18-64 years; 51.4% female; 70.9% non-Hispanic white) were included from Medicaid expansion (n = 1 234 156) and nonexpansion (n = 1 236 998) states. In 2014, the percentage of uninsured patients decreased in almost all states. However, decreases were greater in expansion than nonexpansion states and were greatest in expansion states with high baseline uninsured rates. For example, the percentage of uninsured patients decreased from 8.3% before implementation of the ACA to 2.1% (-6.2 difference) after implementation of the ACA in the expansion state of Kentucky compared with 9.1% to 7.5% (-1.5 difference) in the nonexpansion state of Tennessee. In expansion states, the decreases in the percentage of uninsured patients were higher among minorities and patients in high-poverty or rural areas, diminishing or eliminating disparities. In contrast, sociodemographic disparities in the percentage of uninsured patients remained high in nonexpansion states. Stage at diagnosis shifted slightly to earlier stage for most cancer types in Medicaid expansion states.

Conclusions and Relevance

This study found state variation in reductions in the percentage of uninsured patients among nonelderly patients with cancer after implementation of the ACA, with larger decreases in expansion than nonexpansion states. Disparities in the percentage of uninsured patients by race/ethnicity, census tract-level poverty, and rurality were diminished or eliminated in Medicaid expansion states but remained high in nonexpansion states, highlighting the promising role of Medicaid expansion in reducing disparities among sociodemographic subpopulations. Future studies should monitor changes in cancer presentation, treatment, and outcomes after implementation of the ACA.

Insurance Differences in Preventive Care Use and Adverse Birth Outcomes Among Pregnant Women in a Medicaid Nonexpansion State: A Retrospective Cohort Study

Background: Lack of quality preventive care has been associated with poorer outcomes for pregnant women with low incomes. Health policy changes implemented with the Affordable Care Act (ACA) were designed to improve access to care. However, insurance coverage remains lower among women in Medicaid nonexpansion states. We compared health care use and adverse birth outcomes by insurance status among women giving birth in a large health system in a Medicaid nonexpansion state. Materials and Methods: We conducted a population-based retrospective cohort study using data for 9,613 women with deliveries during 2014-2015 at six hospitals associated with a large vertically integrated health care system in North Carolina. Adjusted logistic regression and zero-inflated negative binomial models examined associations between insurance status at delivery (commercial, Medicaid, or uninsured) and health care utilization (well-woman visits, late prenatal care, adequacy of prenatal care, postpartum follow-up, and emergency department [ED] visits) and outcomes (preterm birth, low birth weight, preeclampsia, and gestational diabetes). Results: Having Medicaid at delivery was associated with lower rates of well-woman visits (rate ratio [RR] 0.25, 95% CI 0.23-0.28), higher rates of ED visits (RR 2.93, 95% CI 2.64-3.25), and higher odds of late prenatal care (odds ratio [OR] 1.18, 95% CI 1.03-1.34) compared to having commercial insurance, with similar results for uninsured women. Differences in adverse pregnancy outcomes were not statistically significant after adjusting for patient characteristics. Conclusions: Findings suggest that large gaps exist in use of preventive care between Medicaid/uninsured and commercially insured women. Policymakers should consider ways to improve potential and realized access to care.

[Job] Locked and [Un]loaded: The effect of the Affordable Care Act dependency mandate on reenlistment in the U.S. Army

One concern with employer-based health insurance is job lock or the inability for employees to leave their current employment for better opportunities for fear of losing benefits. We use the implementation of the Affordable Care Act's dependency mandate as a natural experiment. Data from the United States Army overcome some limitations in previous studies including the ability to examine workers with fixed contract expiration dates, uniform pay, and health coverage. We find that the ACA decreased reenlistment rates by 3.13 percent for enlisted soldiers aged 23-25. We also find that younger veterans who leave the Army are more likely to attend college. These findings show that the ACA reduced job lock and increased college-going.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Area-level deprivation and preterm birth: results from a national, commercially-insured population

BACKGROUND

Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors.

METHODS

We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects.

RESULTS

In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association.

CONCLUSIONS

Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.

The Affordable Care Act and Access to Care for Reproductive-Aged and Pregnant Women in the United States, 2010-2016

OBJECTIVES

To estimate the association between the Affordable Care Act (ACA), health insurance coverage, and access to care among reproductive-aged and pregnant women.

METHODS

We performed an observational study comparing current insurance type, cost-related barriers to medical care, and no usual source of care among reproductive-aged (n = 128 352) and pregnant (n = 2179) female respondents to the National Health Interview Survey in the United States, before (2010-2013) and after (2015-2016) the ACA coverage expansions.

RESULTS

Among reproductive-aged women, the ACA was associated with a 7.4 percentage-point decrease in the probability of uninsurance (95% confidence interval [CI] = -8.6, -6.2), a 3.6 percentage-point increase in Medicaid (95% CI = 2.5, 4.7), and a 3.1 percentage-point increase in nongroup private coverage (95% CI = 2.1, 4.1). The ACA was also associated with a 1.5 percentage-point decline in cost-related barriers to medical care (95% CI = -2.6, -0.5) and a 2.4 percentage-point reduction in lacking a usual source of care (95% CI = -4.5, -0.3). We did not find significant changes in insurance or cost-related barriers to care for pregnant women.

CONCLUSIONS

The ACA was associated with expanded insurance coverage and improvements in access to care for women of reproductive age, particularly for those with lower incomes.

Affordable Care Act-dependent Insurance Coverage and Access to Care Among Young Adult Women With a Recent Live Birth

BACKGROUND

The Affordable Care Act (ACA)-dependent coverage Provision (the Provision), implemented in 2010, extended family insurance coverage to adult children until age 26.

OBJECTIVES

To examine the impact of the ACA Provision on insurance coverage and care among women with a recent live birth.

RESEARCH DESIGN, SUBJECTS, AND OUTCOME MEASURES

We conducted a difference-in-difference analysis to assess the effect of the Provision using data from the Pregnancy Risk Assessment Monitoring System among 22,599 women aged 19-25 (treatment group) and 22,361 women aged 27-31 years (control group). Outcomes include insurance coverage in the month before and during pregnancy, and at delivery, and receipt of timely prenatal care, a postpartum check-up, and postpartum contraceptive use.

RESULTS

Compared with the control group, the Provision was associated with a 4.7-percentage point decrease in being uninsured and a 5.9-percentage point increase in private insurance coverage in the month before pregnancy, and a 5.4-percentage point increase in private insurance coverage and a 5.9-percentage point decrease in Medicaid coverage during pregnancy, with similar changes in insurance coverage at delivery. Findings demonstrated a 3.6-percentage point increase in receipt of timely prenatal care, and no change in receipt of a postpartum check-up or postpartum contraceptive use.

CONCLUSIONS

Among women with a recent live birth, the Provision was associated with a decreased likelihood of being uninsured and increased private insurance coverage in the month before pregnancy, a shift from Medicaid to private insurance coverage during pregnancy and at delivery, and an increased likelihood of receiving timely prenatal care.

Young Single Mothers Benefit from the Affordable Care Act

But a study shows uneven results in birth outcomes.