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Hall SV, Zivin K, Piatt GA, Weaver A, Tilea A, Zhang X, Moyer CA. The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012-2018. BMC Health Serv Res 2024; 24:149. [PMID: 38291449 PMCID: PMC10826065 DOI: 10.1186/s12913-023-10539-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/30/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees. METHODS We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum. RESULTS ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis. CONCLUSION The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.
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Affiliation(s)
- Stephanie V Hall
- Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.
- Department of Learning Health Sciences, University of Michigan, 1111 E Catherine St, Ann Arbor, MI, 48109, USA.
| | - Kara Zivin
- Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Gretchen A Piatt
- Department of Learning Health Sciences, University of Michigan, 1111 E Catherine St, Ann Arbor, MI, 48109, USA
| | - Addie Weaver
- School of Social Work, University of Michigan, 1080 S University Ave, Ann Arbor, MI, 48109, USA
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Xiaosong Zhang
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Cheryl A Moyer
- Department of Learning Health Sciences, University of Michigan, 1111 E Catherine St, Ann Arbor, MI, 48109, USA
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
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Leguizamon JS. Health insurance and fertility among low-income, childless, single women: evidence from the ACA Medicaid expansions. HEALTH ECONOMICS, POLICY, AND LAW 2024; 19:21-45. [PMID: 37989597 DOI: 10.1017/s1744133123000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Expansions of Medicaid family planning services have been associated with decreases in pregnancy rates. Access to a broader range of medical, non-family planning services may influence pregnancy rates as well if the increased exposure to medical services spills over to other kinds of behaviour. Using a difference-in-difference approach, I examine the impact of the Affordable Care Act (ACA) Medicaid expansions on the propensity of low-income, single women to become single mothers. Previous expansions of Medicaid family planning services allow us to also investigate the influence of access to other medical services (i.e. non-family planning). I find that although access to contraceptives is associated with a reduction in the propensity of becoming a single mother among adult, low-income women, medical services beyond access to contraceptives can provide additional impacts.
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Larrabee Sonderlund A, Williams NJ, Charifson M, Ortiz R, Sealy-Jefferson S, De Leon E, Schoenthaler A. Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes. SSM Popul Health 2023; 24:101529. [PMID: 37841218 PMCID: PMC10570581 DOI: 10.1016/j.ssmph.2023.101529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023] Open
Abstract
Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.
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Affiliation(s)
- Anders Larrabee Sonderlund
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Natasha J. Williams
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
| | - Mia Charifson
- Department of Population Health, NYU Grossman School of Medicine, USA
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA
| | - Robin Ortiz
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Department of Pediatrics, NYU Grossman School of Medicine, USA
| | | | - Elaine De Leon
- Department of Population Health, NYU Grossman School of Medicine, USA
| | - Antoinette Schoenthaler
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
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Chatterji P, Glenn H, Markowitz S, Montez JK. Affordable Care Act Medicaid expansions and maternal morbidity. HEALTH ECONOMICS 2023; 32:2334-2352. [PMID: 37417880 PMCID: PMC10691745 DOI: 10.1002/hec.4724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre-conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference-in-difference models in conjunction with event studies. Data come from individual-level birth certificates and state-level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre-pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery.
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Gutierrez JA, Hirth JM, Zoorob R, Levine RS. Racial, ethnic and gender trends in lung cancer mortality rates in the United States-Mexico border and non-border areas. Prev Med 2023; 175:107686. [PMID: 37648086 DOI: 10.1016/j.ypmed.2023.107686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/21/2023] [Accepted: 08/26/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Geographic patterns of lung cancer mortality rate differ in the region bordering Mexico in contrast to the US. This study compares lung cancer mortality between border and non-border counties by race/ethnicity and gender. METHODS This study utilized population-level death certificate data from US Centers for Disease Control and Prevention Public Internet Wide-Ranging Online Data for Epidemiologic Research dataset between 1999 and 2020. Established algorithms were implemented to examine lung cancer deaths among US residents. We analyzed the age-adjusted data by year, race/ethnicity, gender, and geographic region. Joinpoint regression was used to determine mortality trends across time. RESULTS Lung cancer mortality rates were lower in border counties compared to non-border counties across time (p < 0.05). Hispanic lung cancer mortality rates were not different in border counties compared to non-border counties during the same period (p > 0.05). Lung cancer mortality among non-Hispanic White living in border counties was lower than non-Hispanic White residing in non-border counties (p < 0.01), and non-Hispanic Black living in border counties had lower lung cancer mortality than non-Hispanic Black in non-border counties in all but three years (p < 0.05). Both female and male mortality rates were lower in border counties compared to non-border counties (p < 0.05). CONCLUSION Differences in lung cancer mortality between border counties and non-border counties reflect lower mortality in Hispanics overall and a decline for non-Hispanic White and non-Hispanic Black living in border counties experiencing lower lung cancer mortality rates than non-border counties. Further studies are needed to identify specific causes for lower mortality rates in border counties.
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Affiliation(s)
- Judith A Gutierrez
- Baylor College of Medicine, Family and Community Medicine Department, 3701 Kirby Drive, Suite 600, Houston, TX 77098, USA.
| | - Jacqueline M Hirth
- Baylor College of Medicine, Family and Community Medicine Department, 3701 Kirby Drive, Suite 600, Houston, TX 77098, USA
| | - Roger Zoorob
- Baylor College of Medicine, Family and Community Medicine Department, 3701 Kirby Drive, Suite 600, Houston, TX 77098, USA
| | - Robert S Levine
- Baylor College of Medicine, Family and Community Medicine Department, 3701 Kirby Drive, Suite 600, Houston, TX 77098, USA
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Edwards TL, Greene CA, Piekos JA, Hellwege JN, Hampton G, Jasper EA, Velez Edwards DR. Challenges and Opportunities for Data Science in Women's Health. Annu Rev Biomed Data Sci 2023; 6:23-45. [PMID: 37040736 PMCID: PMC10877578 DOI: 10.1146/annurev-biodatasci-020722-105958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
The intersection of women's health and data science is a field of research that has historically trailed other fields, but more recently it has gained momentum. This growth is being driven not only by new investigators who are moving into this area but also by the significant opportunities that have emerged in new methodologies, resources, and technologies in data science. Here, we describe some of the resources and methods being used by women's health researchers today to meet challenges in biomedical data science. We also describe the opportunities and limitations of applying these approaches to advance women's health outcomes and the future of the field, with emphasis on repurposing existing methodologies for women's health.
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Affiliation(s)
- Todd L Edwards
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Catherine A Greene
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacqueline A Piekos
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacklyn N Hellwege
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gabrielle Hampton
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Elizabeth A Jasper
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Digna R Velez Edwards
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Kramer MR, Labgold K, Zertuche AD, Runkle JD, Bryan M, Freymann GR, Austin D, Adams EK, Dunlop AL. Severe Maternal Morbidity in Georgia, 2009-2020. Med Care 2023; 61:258-267. [PMID: 36638324 PMCID: PMC10079300 DOI: 10.1097/mlr.0000000000001819] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The increasing focus of population surveillance and research on maternal-and not only fetal and infant-health outcomes is long overdue. The United States maternal mortality rate is higher than any other high-income country, and Georgia is among the highest rates in the country. Severe maternal morbidity (SMM) is conceived of as a "near miss" for maternal mortality, is 50 times more common than maternal death, and efforts to systematically monitor SMM rates in populations have increased in recent years. Much of the current population-based research on SMM has occurred in coastal states or large cities, despite substantial geographical variation with higher maternal and infant health burdens in the Southeast and rural regions. METHODS This population-based study uses hospital discharge records linked to vital statistics to describe the epidemiology of SMM in Georgia between 2009 and 2020. RESULTS Georgia had a higher SMM rate than the United States overall (189.2 vs. 144 per 10,000 deliveries in Georgia in 2014, the most recent year with US estimates). SMM was higher among racially minoritized pregnant persons and those at the extremes of age, of lower socioeconomic status, and with comorbid chronic conditions. SMM rates were 5 to 6 times greater for pregnant people delivering infants <1500 grams or <32 weeks' gestation as compared with those delivering normal weight or term infants. Since 2015, SMM has increased in Georgia. CONCLUSION SMM represents a collection of life-threatening emergencies that are unevenly distributed in the population and require increased attention. This descriptive analysis provides initial guidance for programmatic interventions intending to reduce the burden of SMM and, subsequently, maternal mortality in the US South.
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Affiliation(s)
| | | | | | - Jennifer D. Runkle
- North Carolina Institute for Climate Studies, North Carolina State University, Asheville, NC
| | - Michael Bryan
- Division of Epidemiology, Maternal and Child Health Epidemiology Unit, Georgia Department of Public Health
| | - Gordon R. Freymann
- Georgia Department of Public Health, Office of Health Indicators for Planning
| | - David Austin
- Georgia Department of Public Health, Office of Health Indicators for Planning
| | - E. Kathleen Adams
- Department of Health Policy and Management, Rollins School of Public Health
| | - Anne L. Dunlop
- Department of Gynecology and Obstetrics, Emory University, Atlanta, GA
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Constantin J, Wehby GL. Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity. Am J Prev Med 2023; 64:377-384. [PMID: 36481185 DOI: 10.1016/j.amepre.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The purpose of this study is to examine year-by-year effects of the 2014 Affordable Care Act Medicaid expansion on infant mortality by race and ethnicity over the first 6 years. METHODS Publicly available 2011-2019 Multiple Cause of Death data were extracted in October and analyzed by November 2021. A difference-in-differences event-study design compared infant mortality changes in states that expanded in 2014 to nonexpansion states. RESULTS In the main model, the 2014 Medicaid expansions were associated with a statistically significant decline in Black infants' mortality in 2018 and 2019 by 1.19 (95% CI= -2.27, -0.12) and 1.35 (95% CI= -2.45, -0.26) deaths per 1,000 live births, respectively. There was also a decline in mortality for Hispanic infants in 2015-2019, including by 0.8 (95% CI= -1.25, -0.36) and 1.28 (95% CI= -1.88, -0.68) deaths per 1,000 live births in 2015 and 2019, respectively. Overall, infant mortality declined by 0.37 (95% CI= -0.70, -0.05) deaths per 1,000 live births in 2019. CONCLUSIONS The study adds evidence on the association of the Affordable Care Act Medicaid expansions with a decline in mortality of Black and Hispanic infants. The findings shed light on the importance of examining year-by-year effects over multiple years.
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Affiliation(s)
- Joanne Constantin
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa.
| | - George L Wehby
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa
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Masoumirad M, Harvey SM, Bui LN, Yoon J. Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion. J Womens Health (Larchmt) 2023; 32:300-310. [PMID: 36716274 DOI: 10.1089/jwh.2022.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objectives: We compared the use of sexual and reproductive health (SRH) services for Medicaid-enrolled women of reproductive age (WRA) living in Oregon by urban/rural status and examined the effect of the Affordable Care Act (ACA) Medicaid expansion on the use of SRH services for these women. Methods: We linked Oregon Medicaid enrollment files and claims for the years 2008-2016 to identify 392,111 WRA. Outcome measures included receipt of five key SRH services. The main independent variables were urban/rural status (urban, large rural cities, and small rural towns) and an indicator for the post-Medicaid expansion time period (2014-2016). We performed (conditional) fixed-effects logistic regression and multiple-group interrupted time-series analyses. Results: Women living in small rural towns were less likely than women living in urban areas to receive well-woman visits (odds ratio [OR] = 0.87; 95% confidence interval [95% CI] [0.80-0.94]), sexually transmitted infection (STI) screening (OR = 0.81; 95% CI [0.72-0.90]), and pap tests (OR = 0.91; 95% CI [0.84-0.99]). Women living in large rural cities were less likely than women living in urban areas to receive STI screening (OR = 0.91; 95% CI [0.84-0.98]). Following the implementation of ACA Medicaid expansion, the average number of all five SRH services increased for all women. With the exception of contraceptive services, the average number of SRH services examined increased more for urban women than for women living in small rural towns. Conclusions: Although Medicaid expansion contributed to increased use of SRH services for all WRA, the policy was unsuccessful in reducing disparities in access to SRH services for WRA living in rural areas compared with urban areas.
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Affiliation(s)
- Mandana Masoumirad
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - S Marie Harvey
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Linh N Bui
- School of Natural Sciences, Mathematics, and Engineering, California State University, Bakersfield, Bakersfield, California, USA
| | - Jangho Yoon
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA.,School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023. [DOI: 10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
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Swan LET. Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023; 40:5. [DOI: https:/doi.org/10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 06/22/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
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12
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The Differential Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among US Women by Medicaid Expansion and Race and Ethnicity. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 29:E137-E146. [PMID: 36729927 DOI: 10.1097/phh.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The 2014 Medicaid expansion improved racial and ethnic equity in insurance coverage and access to maternal care among women of reproductive age. This study examines differential effects of the COVID-19 pandemic on prenatal care utilization by Medicaid expansion and by race and ethnicity. METHODS Using the pooled 2019-2020 National Natality file (N = 7 361 190), logistic regression was used to estimate the effect of COVID-19 on prenatal care utilization among US women aged 10 to 54 years after controlling for maternal age, race, ethnicity, marital status, parity, nativity/immigrant status, education, payment type, and smoking during pregnancy. Outcome measures were having no care and delayed prenatal care (third trimester or no care). Stratified models by race/ethnicity and Medicaid expansion status yielded the differential effects of COVID-19 on prenatal care utilization. RESULTS During the COVID-19 pandemic, the adjusted odds of having no prenatal care decreased by 4% (adjusted odds ratio [AOR] = 0.96; 95% confidence interval [CI], 0.94-0.97) in expansion states but increased by 13% (AOR = 1.13; 95% CI, 1.11-1.15) in nonexpansion states. While most racial/ethnic groups in expansion states experienced a decrease in having no prenatal care, the adjusted odds of having no prenatal care increased by 15% for non-Hispanic Whites, 9% for non-Hispanic Blacks, 33% for American Indians/Alaska Natives, 25% for Asian/Pacific Islanders, and 13% for Hispanics in nonexpansion states. Women in expansion states experienced no change in delayed prenatal care during the pandemic, but women in nonexpansion states experienced an increase in delayed care. CONCLUSIONS Prenatal care utilization decreased during the pandemic among women in nonexpansion states, particularly for American Indians/Alaska Natives and Asian/Pacific Islanders, compared with expansion states.
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Swan LET, McDonald SE, Price SK. Pathways to reproductive autonomy: Using path analysis to predict family planning outcomes in the United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e6487-e6499. [PMID: 36317755 PMCID: PMC10092462 DOI: 10.1111/hsc.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/19/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
In the United States, about half of pregnancies are unintended, and most women of reproductive age are at risk of unintended pregnancy. Research has explored predictors of contraceptive use and unintended pregnancy, but there is a lack of research regarding access to preferred contraceptive method(s) and the complex pathways from sociodemographic factors to these family planning outcomes. This study applied Levesque et al.'s (2013) healthcare access framework to investigate pathways from sociodemographic factors and indicators of access to family planning outcomes using secondary data. Data were collected at four time points via an online survey between November 2012 and June 2014. Participants were US women of reproductive age who were seeking to avoid pregnancy (N = 1036; Mage = 27.91, SD = 5.39; 6.9% Black, 13.6% Hispanic, 70.2% white, 9.4% other race/ethnicity). We conducted mediational path analysis, and results indicated that contraceptive knowledge (β = 0.116, p = 0.004), insurance coverage (β = 0.423, p < 0.001), and relational provider engagement (β = 0.265, p = 0.011) were significant predictors of access to preferred contraceptive method. Access to preferred contraceptive method directly predicted use of more effective contraception (β = 0.260, p < 0.001) and indirectly predicted decreased likelihood of experiencing unintended pregnancy via contraceptive method(s) effectiveness (β = -0.014, 95% confidence interval: -0.041, -0.005). This study identifies pathways to and through access to preferred contraceptive methods that may be important in determining family planning outcomes such as contraceptive use and unintended pregnancy. This information can be used to improve access to contraception, ultimately increasing reproductive autonomy by helping family planning outcomes align with patients' needs and priorities.
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Affiliation(s)
- Laura E. T. Swan
- Department of Population Health SciencesUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Shelby E. McDonald
- Virginia Commonwealth UniversityClark‐Hill Institute for Positive Youth DevelopmentRichmondVirginiaUSA
| | - Sarah K. Price
- Virginia Commonwealth UniversitySchool of Social WorkRichmondVirginiaUSA
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Swan LET, McDonald SE, Price SK. Pathways to reproductive autonomy: Using path analysis to predict family planning outcomes in the United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30. [DOI: http:/doi.org/10.1111/hsc.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/16/2022] [Indexed: 06/22/2023]
Affiliation(s)
- Laura E. T. Swan
- Department of Population Health Sciences University of Wisconsin‐Madison Madison Wisconsin USA
| | - Shelby E. McDonald
- Virginia Commonwealth University Clark‐Hill Institute for Positive Youth Development Richmond Virginia USA
| | - Sarah K. Price
- Virginia Commonwealth University School of Social Work Richmond Virginia USA
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Gartner DR, Kaestner R, Margerison CE. Impacts of the Affordable Care Act's Medicaid Expansion on Live Births. Epidemiology 2022; 33:406-414. [PMID: 35067567 PMCID: PMC9040191 DOI: 10.1097/ede.0000000000001462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We hypothesize that the Affordable Care Act's (ACA) Medicaid expansion, which extended health insurance coverage to preconception, between-conception, and postconception periods for women meeting income eligibility guidelines, impacted the number of live births in the United States by increasing access to contraception and financial well-being. These impacts may differ by maternal socioeconomic and demographic characteristics. METHODS Using data from birth certificates aggregated to the state-year level and a difference-in-differences design, we estimated the association between Medicaid expansion and count of live births. We also examined whether associations differed by socioeconomic and demographic characteristics. RESULTS Overall, Medicaid expansion was not meaningfully associated with the count of births (difference-in-differences ß = 0.002; 95% confidence interval [CI] = -0.010, 0.015). However, among certain groups, Medicaid expansion was associated with meaningful changes in the count of live births, though all confidence intervals included the null value. The estimate of the relation between Medicaid expansion and the count of live births was -0.025 (95% CI = -0.052, 0.001) for those ages 18-24 years; -0.078 (95% CI = -0.231, 0.075) for those who were married, and -0.035 (95% CI = -0.104, 0.034) for those who were unmarried. CONCLUSIONS Despite its potential to impact live births, our results indicate that the ACA's Medicaid expansion was not, in general, associated with live births of US residents of reproductive age. However, for younger, married, and unmarried women, the magnitude of estimates supports the hypothesis of a potentially meaningful effect of Medicaid expansions on live births.
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Affiliation(s)
- Danielle R. Gartner
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Robert Kaestner
- Harris School of Public Policy, University of Chicago, Chicago, Illinois
| | - Claire E. Margerison
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
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16
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Impact of Medicaid Expansion on Interpregnancy Interval. Womens Health Issues 2022; 32:226-234. [PMID: 35016841 DOI: 10.1016/j.whi.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 11/28/2021] [Accepted: 12/10/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Medicaid expansion under the Affordable Care Act (ACA) improved access to reproductive health care for low-income women and birthing people who were previously ineligible for Medicaid. We aimed to evaluate if the expansion affected the risk of having a short interpregnancy interval (IPI), a preventable risk factor for adverse pregnancy outcomes. METHODS We evaluated parous singleton births to mothers aged 19 or older from U.S. birth certificate data 2009-2018. We estimated the effect of residing in a state that expanded Medicaid access (expansion status determined at 60 days after the prior live birth) on the risk of having a short IPI (<12 months) using difference-in-differences (DID) methods in linear probability models. We stratified the analyses by maternal characteristics and county-level reproductive health care access. RESULTS Overall risk of short IPI was 14.9% in expansion states and 16.3% in non-expansion states. The expansion was not associated with a significant change in risk of having a short IPI (adjusted mean percentage point change 1.24 [-1.64, 4.12]). Stratified results also did not provide support for an association. CONCLUSIONS ACA Medicaid expansion did not have an impact on risk of short IPI. Preventing short IPI may require more comprehensive policy interventions in addition to health care access.
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Coverage Effects of the ACA's Medicaid Expansion on Adult Reproductive-Aged Women, Postpartum Mothers, and Mothers with Older Children. Matern Child Health J 2022; 26:1104-1114. [PMID: 35249171 PMCID: PMC8898501 DOI: 10.1007/s10995-022-03384-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2022] [Indexed: 11/10/2022]
Abstract
Objectives We estimate the effect of the Affordable Care Act’s (ACA) Medicaid expansions on Medicaid coverage of reproductive-aged women at varying childbearing stages. Methods Using data from the American Community Survey (ACS) (n = 1,977,098) and a difference-in-differences approach, we compare Medicaid coverage among low-income adult women without children, postpartum mothers, and mothers of children older than one year in expansion states to non-expansion states, before and after the expansions. Results The ACA’s Medicaid expansion increased Medicaid coverage among adult women with incomes between 101 and 200% of the federal poverty line (FPL) without children by 10.7 percentage points (54 percent, p < 0.01). Coverage of mothers with children older than one year increased by 9.5 percentage points (34 percent, p < 0.01). Coverage of mothers with infants rose by 7.9 percentage points (21 percent, p < 0.01). Conclusions for Practice Within the population of adult reproductive-aged women, we find a “fanning out” of effects from the ACA’s Medicaid expansions. Childless women experience the largest gains in coverage while mothers of infants experience the smallest gains; mothers of children greater than one year old fall in the middle. These results are consistent with ACA gains being the smallest among the groups least targeted by the ACA, but also show substantial gains (one fifth) even among postpartum mothers.
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Rapp KS, Volpe VV, Hale TL, Quartararo DF. State-Level Sexism and Gender Disparities in Health Care Access and Quality in the United States. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2022; 63:2-18. [PMID: 34794351 DOI: 10.1177/00221465211058153] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In this investigation, we examined the associations between state-level structural sexism-a multidimensional index of gender inequities across economic, political, and cultural domains of the gender system-and health care access and quality among women and men in the United States. We linked administrative data gauging state-level gender gaps in pay, employment, poverty, political representation, and policy protections to individual-level data on health care availability, affordability, and quality from the national Consumer Survey of Health Care Access (2014-2019; N = 24,250). Results show that higher state-level sexism is associated with greater inability to access needed health care and more barriers to affording care for women but not for men. Furthermore, contrary to our hypothesis, women residing in states with higher state-level sexism report better quality of care than women in states with lower levels of sexism. These findings implicate state-level sexism in perpetuating gender disparities in health care.
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Xiao MZX, Whitney D, Guo N, Sun EC, Wong CA, Bentley J, Butwick AJ. Association of Medicaid Expansion With Neuraxial Labor Analgesia Use in the United States: A Retrospective Cross-Sectional Analysis. Anesth Analg 2022; 134:505-514. [PMID: 35180167 DOI: 10.1213/ane.0000000000005878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The Affordable Care Act has been associated with increased Medicaid coverage for childbirth among low-income US women. We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia. METHODS We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017. Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate. Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion. Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level. RESULTS The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states. In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76.3%. Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1.7% in expansion states (95% CI, 1.6-1.8) and 0.9% (95% CI, 0.9-1.0) in nonexpansion states. The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0.47% points (95% CI, -0.63 to 1.57; P = .39). CONCLUSIONS Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period. Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.
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Affiliation(s)
- Maggie Z X Xiao
- From the Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dylan Whitney
- From the Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nan Guo
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Eric C Sun
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Jason Bentley
- Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
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20
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Eliason EL, Daw JR, Allen HL. Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age. J Womens Health (Larchmt) 2022; 31:949-956. [PMID: 35180356 DOI: 10.1089/jwh.2021.0451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.
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Affiliation(s)
- Erica L Eliason
- Columbia University School of Social Work, New York, New York, USA
| | - Jamie R Daw
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Heidi L Allen
- Columbia University School of Social Work, New York, New York, USA
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21
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Lin CCC, Lee H, Snyder JE. Rural-Urban Differences in the Utilization of Hospital-Based Care for Women of Reproductive Age. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:20-30. [PMID: 35136873 PMCID: PMC8812499 DOI: 10.1089/whr.2021.0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/13/2022]
Abstract
Background: To investigate rural-urban differences in hospital-based care utilization among women of reproductive age (18-44 years). Methods: Rural-urban differences were estimated for hospital outpatient visits, emergency department (ED) visits, hospitalizations, and associated expenditures both overall and by insurance status, by analyzing a nationally representative sample of women of reproductive age from the Medical Expenditure Panel Survey (2006-2015). Results: The study sample consisted of 48,114 women of reproductive age. Unadjusted results showed that rural women reported higher likelihood of hospital outpatient visits (rural vs. urban: 17.10% vs. 13.34%) although, among those using such care, fewer average visits (rural vs. urban: 2.00 vs. 2.56 visits). Rural women reported higher likelihood of ED visits (rural vs. urban: 18.13% vs. 15.11%) and more hospital stays (rural vs. urban: 0.13 vs. 0.11 stays). Adjusted results showed rural women had higher likelihood of outpatient care use (+2.5 percentage points; 95% confidence interval [CI] = 0.002-0.049) but fewer visits (-0.314 visits, 95% CI = -0.566 to -0.062). For the privately insured, rural women had greater likelihood of outpatient care (+3.1 percentage points, 95% CI = 0.001-0.060) and fewer ED visits (-0.031 visits, 95% CI = -0.061 to -0.003); for the publicly insured, rural women had more hospital stays (+0.045 stays, 95% CI = 0.009-0.083); for the uninsured, rural women had fewer outpatient visits among those using such care (-1.118 visits, 95% CI = -1.865 to -0.372) and shorter hospital stays overall (-0.093 nights, 95% CI = -0.181 to -0.005). Rural-urban expenditure differences were not significant between any insurance grouping. Conclusions: Rural-urban differences in hospital-based care utilization were observed, although somewhat heterogeneous by insurance status. Strengthening outpatient and preventive service access, particularly for publicly insured and uninsured rural women of reproductive age, is important for shifting care to lower cost settings and improving population health.
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Affiliation(s)
- Ching-Ching Claire Lin
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan. Formally Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, Maryland, USA
| | - Hyunjung Lee
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee, USA.,Office of Health Equity (OHE), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, Maryland, USA
| | - John E Snyder
- Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, Maryland, USA
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22
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Bellerose M, Collin L, Daw JR. The ACA Medicaid Expansion And Perinatal Insurance, Health Care Use, And Health Outcomes: A Systematic Review. Health Aff (Millwood) 2022; 41:60-68. [PMID: 34982621 DOI: 10.1377/hlthaff.2021.01150] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility for low-income adults regardless of their pregnancy or parental status. Variation in states' adoption of this expansion created a natural experiment to study the effects of expanding public insurance on insurance coverage, health care use, and health outcomes during preconception, pregnancy, and postpartum. We conducted a systematic review of relevant literature on this topic, analyzing twenty-four studies published between January 2014 and April 2021. We found that the ACA Medicaid expansion increased preconception and postpartum Medicaid coverage with corresponding declines in uninsurance, private insurance coverage, and insurance churn. There was limited evidence that Medicaid expansion increased perinatal health care use or improved infant birth outcomes overall, although some studies reported reduced racial and ethnic disparities in rates of prenatal and postpartum visit attendance, maternal mortality, low birthweight, and preterm births. Stronger data collection on preconception and postpartum outcomes with sufficient sample sizes to stratify by race and ethnicity is needed to assess the full impact of the ACA and emerging Medicaid policy changes, such as the postpartum Medicaid extension.
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Affiliation(s)
- Meghan Bellerose
- Meghan Bellerose , Columbia University Mailman School of Public Health, New York, New York
| | - Lauren Collin
- Lauren Collin, Columbia University Mailman School of Public Health
| | - Jamie R Daw
- Jamie R. Daw, Columbia University Mailman School of Public Health
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23
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Gopalan M, Lombardi CM, Bullinger LR. Effects of parental public health insurance eligibility on parent and child health outcomes. ECONOMICS AND HUMAN BIOLOGY 2022; 44:101098. [PMID: 34929550 PMCID: PMC9301861 DOI: 10.1016/j.ehb.2021.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/29/2021] [Accepted: 12/08/2021] [Indexed: 06/14/2023]
Abstract
Many states expanded their Medicaid programs to low-income adults under the Affordable Care Act (ACA). These expansions increased Medicaid coverage among low-income parents and their children. Whether these improvements in coverage and healthcare use lead to better health outcomes for parents and their children remains unanswered. We used longitudinal data on a large, nationally representative cohort of elementary-aged children from low-income households from 2010 to 2016. Using a difference-in-differences approach in state Medicaid policy decisions, we estimated the effect of the ACA Medicaid expansions on parent and child health. We found that parents' self-reported health status improved significantly post-expansion in states that expanded Medicaid through the ACA by 4 percentage points (p < 0.05), a 4.7% improvement. We found no significant changes in children's use of routine doctor visits or parents' assessment of their children's health status. We observed modest decreases in children's body mass index (BMI) of about 2% (p < 0.05), especially for girls.
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Barbee LA. New Evidence for Antimicrobial-Resistant Gonorrhea Control Programs: Lessons Learned from the SURRG Project. Sex Transm Dis 2021; 48:S93-S96. [PMID: 34618779 DOI: 10.1097/olq.0000000000001523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Lindley A Barbee
- From the Division of Infectious Diseases, Department of Medicine, University of Washington; and Public Health-Seattle & King County HIV/STD Program, Seattle, WA
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25
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Choi S, Stein MD, Raifman J, Rosenbloom D, Clark JA. Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy. Drug Alcohol Depend 2021; 229:109162. [PMID: 34768053 PMCID: PMC8671210 DOI: 10.1016/j.drugalcdep.2021.109162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy. METHODS Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not. FINDINGS Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively. CONCLUSIONS State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.
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Affiliation(s)
- Sugy Choi
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA.
| | - Michael D. Stein
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - Julia Raifman
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - David Rosenbloom
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - Jack A Clark
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
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26
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Austin AE, Sokol RL, Rowland C. Medicaid expansion and postpartum depressive symptoms: Evidence from the 2009-2018 Pregnancy Risk Assessment Monitoring System survey. Ann Epidemiol 2021; 68:9-15. [DOI: 10.1016/j.annepidem.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/11/2021] [Accepted: 12/22/2021] [Indexed: 11/01/2022]
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Hale N, Manalew WS, Leinaar E, Smith M, Sen B, Sharma P, Khoury A. Contraceptive Use and Pregnancy Outcomes Among Women Enrolled in South Carolina Medicaid Programs. Matern Child Health J 2021; 25:1960-1971. [PMID: 34637063 DOI: 10.1007/s10995-021-03260-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS FOR PRACTICE 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.
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Affiliation(s)
- Nathan Hale
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA.
| | - Wondimu S Manalew
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
| | - Edward Leinaar
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
| | - Michael Smith
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
| | - Bisakha Sen
- Department of Health Care Organization and Policy, The University of Alabama at Birmingham School of Public Health, 1665 University Blvd, RPHB 330F, Birmingham, AL, 35294, USA
| | - Pradeep Sharma
- Department of Health Care Organization and Policy, The University of Alabama at Birmingham School of Public Health, 1665 University Blvd, RPHB 320C, Birmingham, AL, 35294, USA
| | - Amal Khoury
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
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Margerison CE, Hettinger K, Kaestner R, Goldman-Mellor S, Gartner D. Medicaid Expansion Associated With Some Improvements In Perinatal Mental Health. Health Aff (Millwood) 2021; 40:1605-1611. [PMID: 34606358 DOI: 10.1377/hlthaff.2021.00776] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Poor perinatal mental health is a common pregnancy-related morbidity with potentially serious impacts that extend beyond the individual to their family. A possible contributing factor to poor perinatal mental health is discontinuity in health insurance coverage, which is particularly important among low-income people. We examined impacts of Medicaid expansion on prepregnancy depression screening and self-reported depression and postpartum depressive symptoms and well-being among low-income people giving birth. Medicaid expansion was associated with a 16 percent decline in self-reported prepregnancy depression but was not associated with postpartum depressive symptoms or well-being. Associations between Medicaid expansion and prepregnancy mental health measures increased with time since expansion. Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.
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Affiliation(s)
- Claire E Margerison
- Claire E. Margerison is an associate professor in the Department of Epidemiology and Biostatistics, Michigan State University, in East Lansing, Michigan
| | - Katlyn Hettinger
- Katlyn Hettinger is a graduate research assistant in the Department of Epidemiology and Biostatistics and a doctoral student in the Department of Economics, Michigan State University
| | - Robert Kaestner
- Robert Kaestner is a research professor in the Harris School of Public Policy, University of Chicago, in Chicago, Illinois
| | - Sidra Goldman-Mellor
- Sidra Goldman-Mellor is an associate professor of public health at the University of California Merced, in Merced, California
| | - Danielle Gartner
- Danielle Gartner is a research associate in the Department of Epidemiology and Biostatistics, Michigan State University
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Patel KS, Bakk J, Pensak M, DeFranco E. Influence of Medicaid expansion on short interpregnancy interval rates in the United States. Am J Obstet Gynecol MFM 2021; 3:100484. [PMID: 34517145 DOI: 10.1016/j.ajogmf.2021.100484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Short interpregnancy intervals have been associated with poor maternal and infant outcomes. Contraception access could affect the short interpregnancy interval rates. OBJECTIVE To assess the influence of Medicaid on short interpregnancy intervals. We tested the hypothesis that Medicaid expansion and subsequent access to birth control would be associated with decreased short interpregnancy intervals. STUDY DESIGN Using the United States birth certificate data, we performed a population-based retrospective cohort study including multiparous women who had live births in 2012 and 2016, which is before and after Medicaid expansion had been implemented in 2014. Multivariate logistic regression estimated the influence of Medicaid expansion on short interpregnancy intervals (<12 months). The rate differences of short interpregnancy intervals in 2012 and 2016 were compared between Medicaid expansion vs non-Medicaid expansion states. RESULTS There were a total of 7,916,908 live births in 2012 and 2016 in the United States, of which 3,362,904 (42.5%) were in multiparous women with data on interpregnancy intervals (n=1,961,683 [58.3%]) in Medicaid expansion states and in non-Medicaid expansion states (n=1,401,221 [41.7%]). The rate of short interpregnancy intervals in the United States was slightly lower in 2016 (17.3%) than in 2012 (17.4%), P=.0006; rate difference 0.13% (95% confidence interval, 0.05-0.20). Short interpregnancy intervals occurred more frequently in non-Medicaid expansion states than in Medicaid expansion states in both 2012 (18.1% vs 16.6%, respectively; P<.001) and 2016 (18.1% vs 16.4%, respectively; P<.001). The rate of short interpregnancy intervals decreased by 0.11% (95% confidence interval, 0.01-0.22) in Medicaid expansion states and increased by 0.04% (95% confidence interval, 0.09-0.17) in non-Medicaid expansion states. In 2016, living in a Medicaid expansion state was associated with a modestly decreased risk of short interpregnancy intervals (adjusted relative risk, 0.97; 95% confidence interval, 0.97-0.98), even after adjustment for coexisting risks. CONCLUSION The risk of short interpregnancy intervals decreased in the Medicaid expansion states even after adjusting for risk factors. Moreover, the short interpregnancy interval rates increased in nonexpansion states but decreased in Medicaid expansion states. If non-Medicaid expansion states had experienced the same rate of decrease in short interpregnancy intervals as Medicaid expansion states, 1122 fewer women would have had a short interpregnancy interval in 2016. Considering the known association between short interpregnancy intervals and adverse maternal and infant outcomes, these findings indicate that Medicaid expansion could improve perinatal outcomes.
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Affiliation(s)
- Kriya S Patel
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Juliana Bakk
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Meredith Pensak
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Emily DeFranco
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.
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Ercia A. The impact of the Affordable Care Act on patient coverage and access to care: perspectives from FQHC administrators in Arizona, California and Texas. BMC Health Serv Res 2021; 21:920. [PMID: 34488758 PMCID: PMC8420058 DOI: 10.1186/s12913-021-06961-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 08/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) enabled millions of people to gain coverage that was expected to improve access to healthcare services. However, it is unclear the extent of the policy's impact on Federally Qualified Health Centers (FQHC) and the patients they served. This study sought to understand FQHC administrators' views on the ACA's impact on their patient population and organization. It specifically explores FQHC administrators' perspective on 1) patients' experience with gaining coverage 2) their ability to meet patients' healthcare needs. METHODS Twenty-two semi-structured interviews were conducted with administrators from FQHCs in urban counties in 2 Medicaid-expanded states (Arizona and California) and 1 non-expanded state (Texas). An inductive thematic analysis approach was used to analyze the interview data. RESULTS All FQHC administrators reported uninsured patients were more likely to gain coverage from Medicaid than from private health insurance. Insured patients generally experienced an improvement in accessing healthcare services but depended on their plan's covered services, FQHCs' capacity to meet demand, and specialist providers' willingness to accept their coverage type. CONCLUSION Gaining coverage helped improved newly insured patients' access to care, but limitations remained. Additional policies are required to better address the gaps in the depth of covered services in Medicaid and the most affordable PHI plans and capacity of providers to meet demand to ensure beneficiaries can fully access the health care services they need.
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Affiliation(s)
- Angelo Ercia
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PT, UK.
- Cievert, an Evergreen Life Company, Evergreen Business Centre, Clowes St, Manchester, M3 5NA, UK.
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Geiger CK, Sommers BD, Hawkins SS, Cohen JL. Medicaid expansions, preconception insurance, and unintended pregnancy among new parents. Health Serv Res 2021; 56:691-701. [PMID: 33905119 PMCID: PMC8313946 DOI: 10.1111/1475-6773.13662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first-time parents. DATA SOURCE This study used individual-level data from the national Pregnancy Risk Assessment Monitoring System (2006-2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy. STUDY DESIGN Outcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female-identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year. DATA COLLECTION/EXTRACTION METHODS The sample included all individuals aged 20-44 with a first live birth in 2009-2017. PRINCIPAL FINDINGS Among all first-time parents, a 10-percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high-school degree or less. CONCLUSIONS Increasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first-time parents.
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Affiliation(s)
- Caroline K Geiger
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
- Genentech, Inc., San Francisco, California, USA
| | - Benjamin D Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Harvard Medical School/Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Summer S Hawkins
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, USA
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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Margerison CE, Kaestner R, Chen J, MacCallum-Bridges C. Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes. Am J Epidemiol 2021; 190:1488-1498. [PMID: 33423053 DOI: 10.1093/aje/kwaa289] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/30/2020] [Indexed: 01/04/2023] Open
Abstract
Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed.
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Margerison CE, Kaestner R, Chen J, MacCallum-Bridges C. Margerison et al. Respond to "Medicaid Policy and Reproductive Autonomy". Am J Epidemiol 2021; 190:1502-1503. [PMID: 33423058 PMCID: PMC8327192 DOI: 10.1093/aje/kwaa291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Claire E Margerison
- Correspondence to Dr. Claire E. Margerison, Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, 909 Wilson Road, Room 601B, East Lansing, MI 48824 (e-mail: )
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Johnston EM, McMorrow S, Alvarez Caraveo C, Dubay L. Post-ACA, More Than One-Third Of Women With Prenatal Medicaid Remained Uninsured Before Or After Pregnancy. Health Aff (Millwood) 2021; 40:571-578. [PMID: 33819081 DOI: 10.1377/hlthaff.2020.01678] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid has a long history of serving pregnant women, but many women are not eligible for Medicaid before pregnancy or after sixty days postpartum. We used data for new mothers with Medicaid-covered prenatal care in 2015-18 from forty-three states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) to describe patterns of perinatal uninsurance and health outcomes of women experiencing uninsurance. We found that 26.8 percent of new mothers with Medicaid-covered prenatal care were uninsured before pregnancy, 21.9 percent became uninsured two to six months postpartum, and 34.5 percent were uninsured in either period, with higher perinatal uninsurance rates in nonexpansion states and for Hispanic women who completed the PRAMS survey in Spanish. Together, our findings indicate that despite recent coverage gains, further policy change is needed to help women maintain health insurance coverage before and after pregnancy and to allow them to address ongoing health issues including obesity and depression.
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Affiliation(s)
- Emily M Johnston
- Emily M. Johnston is a senior research associate in the Health Policy Center, Urban Institute, in Washington, D.C
| | - Stacey McMorrow
- Stacey McMorrow is a principal research associate in the Health Policy Center, Urban Institute
| | - Clara Alvarez Caraveo
- Clara Alvarez Caraveo is a research assistant in the Health Policy Center, Urban Institute
| | - Lisa Dubay
- Lisa Dubay is a senior fellow in the Health Policy Center, Urban Institute
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35
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Menon A, Patel PK, Karmakar M, Tipirneni R. The Impact of the Affordable Care Act Medicaid Expansion on Racial/Ethnic and Sex Disparities in HIV Testing: National Findings from the Behavioral Risk Factor Surveillance System. J Gen Intern Med 2021; 36:1605-1612. [PMID: 33501535 PMCID: PMC8175492 DOI: 10.1007/s11606-021-06590-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Over half of Americans have not been tested for HIV in their lifetime, and over a third of all HIV diagnoses are made less than a year before progression to AIDS. The Affordable Care Act (ACA) Medicaid expansion of 2014 had potential to improve HIV and other health screenings. We assessed the differential impacts of Medicaid expansion on racial/ethnic and racial/ethnic-sex disparities in HIV testing. METHODS Using Behavioral Risk Factor Surveillance System data from all 50 states and D.C., we sampled low-income (≤ 138% of the federal poverty level) adults ages 19-64 who were non-pregnant and non-disabled. Using a difference-in-differences (DD) and triple difference-in-differences (DDD) study design, we assessed differential impacts by race/ethnicity (White, Black, Hispanic, and other) and race/ethnicity-sex between 2011 and 2013 and 2014-2018. Outcomes were (1) ever having received an HIV test and (2) having received an HIV test in the last year. RESULTS Overall, Medicaid expansion was associated with a significant increase in HIV testing (p = 0.003). White females and Black males appeared most likely to benefit from this increase (DD 4.5 and 4.8 percentage points; p = 0.001 and 0.130 respectively). However, despite having baseline higher rates of HIV diagnosis, Black and Hispanic females did not have increased rates of ever having HIV testing following Medicaid expansion (DD - 1.9 and 0.9 percentage points; p = 0.391 and 0.703, respectively), including when compared to a White male reference subgroup and across other race/ethnicity-sex subgroups. CONCLUSIONS Medicaid expansion was associated with an increased overall probability of HIV testing among low-income, nonelderly adults, but certain groups including Black females were not more likely to benefit from this increase, despite being disproportionately affected by HIV at baseline. Targeted and culturally informed interventions to increase Medicaid enrollment and access to primary care may be needed to expand HIV testing in vulnerable groups.
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Affiliation(s)
- Anitha Menon
- University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Payal K Patel
- University of Michigan Medical School, Ann Arbor, MI, USA
- Division of Infectious Diseases, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Monita Karmakar
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Renuka Tipirneni
- University of Michigan Medical School, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Lee LK, Chien A, Stewart A, Truschel L, Hoffmann J, Portillo E, Pace LE, Clapp M, Galbraith AA. Women's Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature. Health Aff (Millwood) 2021; 39:387-394. [PMID: 32119612 DOI: 10.1377/hlthaff.2019.01361] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Lois K Lee
- Lois K. Lee ( lois. lee@childrens. harvard. edu ) is a faculty physician in the Division of Emergency Medicine, Boston Children's Hospital, and an associate professor of pediatrics and emergency medicine at Harvard Medical School, both in Boston, Massachusetts
| | - Alyna Chien
- Alyna Chien is a faculty physician in the Division of General Pediatrics, Boston Children's Hospital, and an assistant professor of pediatrics at Harvard Medical School
| | - Amanda Stewart
- Amanda Stewart is a faculty physician in the Division of Emergency Medicine, Boston Children's Hospital, and an instructor of pediatrics at Harvard Medical School
| | - Larissa Truschel
- Larissa Truschel is a fellow in the Division of Emergency Medicine, Boston Children's Hospital, and an instructor of pediatrics at Harvard Medical School
| | - Jennifer Hoffmann
- Jennifer Hoffmann is a faculty physician in the Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, and an assistant professor of pediatrics at the Northwestern University Feinberg School of Medicine, both in Chicago, Illinois
| | - Elyse Portillo
- Elyse Portillo is a fellow physician in the Division of Emergency Medicine, Boston Children's Hospital, and an instructor of pediatrics at Harvard Medical School
| | - Lydia E Pace
- Lydia E. Pace is an associate physician in the Division of Women's Health, Brigham and Women's Hospital, and an assistant professor in medicine at Harvard Medical School
| | - Mark Clapp
- Mark Clapp is a faculty physician in the Department of Obstetrics and Gynecology, Massachusetts General Hospital, and an instructor in obstetrics, gynecology and reproductive medicine at Harvard Medical School
| | - Alison A Galbraith
- Alison A. Galbraith is an associate professor of population medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School, both in Boston
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Daw JR, Winkelman TNA, Dalton VK, Kozhimannil KB, Admon LK. Medicaid Expansion Improved Perinatal Insurance Continuity For Low-Income Women. Health Aff (Millwood) 2021; 39:1531-1539. [PMID: 32897793 DOI: 10.1377/hlthaff.2019.01835] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Insurance churn, or moving between different insurance plans or between insurance and uninsurance, is common during the perinatal period. We used survey data from the 2012-17 Pregnancy Risk Assessment Monitoring System to estimate the impact of Affordable Care Act-related state Medicaid expansions on continuity of insurance coverage for low-income women across three time points: preconception, delivery, and postpartum. We found that Medicaid expansion resulted in a 10.1-percentage-point decrease in churning between insurance and uninsurance, representing a 28 percent decrease from the prepolicy baseline in expansion states. This decrease was driven by a 5.8-percentage-point increase in the proportion of women who were continuously insured and a 4.2-percentage-point increase in churning between Medicaid and private insurance. Medicaid expansion improved insurance continuity in the perinatal period for low-income women, which may improve the quality of perinatal health care, but it also increased churning between public and private health insurance.
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Affiliation(s)
- Jamie R Daw
- Jamie R. Daw is an assistant professor in the Department of Health Policy and Management at the Columbia Mailman School of Public Health, in New York, New York
| | - Tyler N A Winkelman
- Tyler N. A. Winkelman is a clinician-investigator at Hennepin Healthcare and codirector of the Health, Homelessness, and Criminal Justice Lab at Hennepin Healthcare Research Institute, in Minneapolis, Minnesota
| | - Vanessa K Dalton
- Vanessa K. Dalton is a professor in the Department of Obstetrics and Gynecology, University of Michigan, in Ann Arbor, Michigan
| | - Katy B Kozhimannil
- Katy B. Kozhimannil is a professor in the Division of Health Policy and Management, University of Minnesota School of Public Health, in Minneapolis, Minnesota
| | - Lindsay K Admon
- Lindsay K. Admon is an assistant professor in the Department of Obstetrics and Gynecology, University of Michigan
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Gibbs SE, Harvey SM. Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon. J Womens Health (Larchmt) 2021; 31:55-62. [PMID: 33970712 DOI: 10.1089/jwh.2020.8941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.
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Affiliation(s)
- Susannah E Gibbs
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - S Marie Harvey
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
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39
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Lyu W, Wehby GL. Heterogeneous Effects of Affordable Care Act Medicaid Expansions Among Women with Dependent Children by State-Level Pre-Expansion Eligibility. J Womens Health (Larchmt) 2021; 30:1278-1287. [PMID: 33555950 DOI: 10.1089/jwh.2020.8776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Objectives: This study explores the heterogeneity in effects of the 2014 Affordable Care Act (ACA) Medicaid expansions on insurance coverage, health care access, and health status of low-income women with dependent children by pre-expansion state-level income eligibility. Materials and Methods: We employ a quasiexperimental difference-in-differences design comparing outcome changes in Medicaid expansion states to nonexpansion states. We estimate effects separately for three groups of expansion states based on pre-expansion (2013) parent income eligibility: low pre-expansion eligibility (<90% of federal poverty level [FPL]), high eligibility (90% to <138% FPL), and full eligibility (≥138% FPL). Study samples include women with dependent children below 138% FPL from the 2011 to 2018 American Community Survey for the insurance outcomes, and from the 2011 to 2018 Behavioral Risk Surveillance System for the access and health outcomes. Results: There is stark heterogeneity in changes of health insurance and health care access by pre-expansion income eligibility levels. In comparison to Medicaid non-expansion states, there are large increases in insured rate (9 percentage-points) and Medicaid coverage (16 percentage-points) in expansion states with low pre-expansion eligibility. Insurance changes are much smaller in states with high or full pre-expansion eligibility. Changes in access largely mirror those in coverage. There are no significant changes in health status regardless of pre-expansion eligibility. Conclusions: The ACA Medicaid expansions increased coverage and access for low-income women with dependent children primarily in states with low pre-expansion parent eligibility, and therefore, reduced differences in these outcomes between expansion states.
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Affiliation(s)
- Wei Lyu
- Division of Health Systems Management and Policy, University of Memphis, Memphis, Tennessee, USA.,Department of Health Management and Policy, University of Iowa, Iowa City, Iowa, USA
| | - George L Wehby
- Department of Health Management and Policy, University of Iowa, Iowa City, Iowa, USA.,Department of Economics, and University of Iowa, Iowa City, Iowa, USA.,Department of Preventive and Community Dentistry, University of Iowa, Iowa City, Iowa, USA.,Public Policy Center, University of Iowa, Iowa City, Iowa, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
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40
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Villavicencio J, Moniz MH. Legal Challenges to the Affordable Care Act During a Pandemic: What Is at Stake for Women in the US? JAMA HEALTH FORUM 2021; 2:e201584. [DOI: 10.1001/jamahealthforum.2020.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jen Villavicencio
- American College of Obstetricians and Gynecologists Darney/Landy Fellow, Ann Arbor, Michigan
| | - Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
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Myerson R, Crawford S, Wherry LR. Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, And Postpartum Contraception. Health Aff (Millwood) 2020; 39:1883-1890. [PMID: 33136489 PMCID: PMC7688246 DOI: 10.1377/hlthaff.2020.00106] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The period before pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. We evaluated whether increased access to health insurance under the Affordable Care Act Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and nonexpansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures.
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Affiliation(s)
- Rebecca Myerson
- Rebecca Myerson is an assistant professor in the Department of Population Health Sciences at the University of Wisconsin-Madison, in Madison, Wisconsin
| | - Samuel Crawford
- Samuel Crawford is a PhD student in the Department of Pharmaceutical and Health Economics at the University of Southern California School of Pharmacy, in Los Angeles, California
| | - Laura R Wherry
- Laura R. Wherry is an assistant professor of economics and public service in the Wagner Graduate School of Public Service at New York University, in New York, New York
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42
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Gibbs SE, Harvey SM, Larson A, Yoon J, Luck J. Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program. J Womens Health (Larchmt) 2020; 30:750-757. [PMID: 33085917 DOI: 10.1089/jwh.2020.8351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.
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Affiliation(s)
- Susannah E Gibbs
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - S Marie Harvey
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | | | - Jangho Yoon
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Jeff Luck
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
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The Effects of the Affordable Care Act on Health Access Among Adults Aged 18-64 Years With Chronic Health Conditions in the United States, 2011-2017. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 28:E85-E91. [PMID: 32956288 DOI: 10.1097/phh.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT The 2010 Patient Protection and Affordable Care Act (ACA) eliminated the restrictions on preexisting conditions for health care coverage. Little is known about the effects of the ACA on health care access among individuals with chronic health conditions. OBJECTIVE To determine how the implementations of the ACA affected health care access for adults with chronic health conditions. DESIGN, SETTING, AND PARTICIPANTS Data from respondents aged 18 to 64 years to the 2011-2017 nationally representative Behavioral Risk Factor Surveillance System (BFRSS) who reported preexisting chronic health conditions (n = 1 133 609). Multivariable logistic regression models were used to examine the changes in health care access from 2011-2013 (before the ACA) to 2015-2017 (after the ACA), overall and by sociodemographic groups. MAIN OUTCOMES MEASURES Self-reported access to health care coverage, skipped doctor visits because of cost issues, and having a routine checkup in the past 12 months. RESULTS The percentage of adults with chronic health conditions having no health care coverage declined from 19.7% before the ACA to 11.9% after the ACA (adjusted odds ratio [AOR] = 0.5], P < .001), the percentage of skipped doctor visits because of cost declined from 24.6% to 20.0% (AOR = 0.8, P < .001), and the percentage with an annual routine checkup increased from 69.6% to 72.5% (AOR = 1.1, P < .001). The improvements in health care access were pronounced across sociodemographic groups after the ACA, especially among some disadvantaged groups (ie, young adults, non-Hispanic Blacks and Hispanics, and those with low income and low education). However, substantial disparities in health care access persisted, especially among individuals with low socioeconomic status. CONCLUSIONS This study identifies substantial improvements in health care access among adults with chronic health conditions after ACA implementation, especially among disadvantaged populations.
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Dunlop AL, Joski P, Strahan AE, Sierra E, Adams EK. Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act. Womens Health Issues 2020; 30:426-435. [PMID: 32958368 DOI: 10.1016/j.whi.2020.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ensuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods. METHODS We used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services. RESULTS Women who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use. CONCLUSIONS Ohio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.
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Affiliation(s)
- Anne L Dunlop
- Emory University Nell Hodgson Woodruff School of Nursing, Emory University School of Medicine, Atlanta, Georgia
| | - Peter Joski
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Andrea E Strahan
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | - E Kathleen Adams
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia.
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Palmer M. Preconception subsidized insurance: Prenatal care and birth outcomes by race/ethnicity. HEALTH ECONOMICS 2020; 29:1013-1030. [PMID: 32529714 DOI: 10.1002/hec.4116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/30/2020] [Accepted: 05/01/2020] [Indexed: 06/11/2023]
Abstract
Low-income pregnant women have been Medicaid eligible since the 1980s, but the Affordable Care Act (ACA)'s expansion of Medicaid to women preconception has the potential to improve pregnancy and birth outcomes by removing delays in Medicaid enrollment. More substantially, the ACA expanded subsidized nongroup maternity coverage. Pre-ACA, nongroup health insurance had generally excluded maternity coverage and was prohibitively expensive for low-income individuals, but the ACA's creation of the Marketplace made maternity coverage mandatory and provides income-based subsidies. I use a simulated eligibility approach to measure how these two aspects of the ACA impacted pregnancy and birth outcomes for first-time mothers, paying special attention to racial-ethnic differences. I find expanding Medicaid to women prior to pregnancy significantly improves the share of women with a prenatal care visit in the first trimester for non-Hispanic Whites and Blacks. Expansions in non-Medicaid subsidized insurance, such as Marketplace insurance, significantly reduce the share of births paid by Medicaid and increased breastfeeding across all racial and ethnic groups. Neither type of subsidized insurance had significant, robust impacts on birth outcomes.
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Affiliation(s)
- Makayla Palmer
- Department of Economics, University of Nevada, Las Vegas, Las Vegas, NV, USA
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Hsu J, Qin X, Mirabelli MC, Dana Flanders W. Medicaid expansion, health insurance coverage, and cost barriers to care among low-income adults with asthma: the Adult Asthma Call-Back Survey. J Asthma 2020; 58:1478-1487. [PMID: 32730723 DOI: 10.1080/02770903.2020.1804577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine Medicaid expansion (ME) effects on health insurance coverage (HIC) and cost barriers to medical care among people with asthma. METHOD We analyzed 2012-2013 and 2015-2016 data from low-income adults with current asthma aged 18-64 years in the Behavioral Risk Factor Surveillance System Asthma Call-Back Survey (state-level telephone survey). We calculated weighted percentages and 95% confidence intervals from ME and non-ME jurisdictions (according to 2014 ME status). Outcomes were HIC and cost barriers to buying asthma medication (MED), seeing a health care provider for asthma (HCP), or any asthma care (AAC). Using SUDAAN, we performed survey-weighted difference-in-differences analyses, adjusting for demographics. Subgroup analyses were stratified by demographics. RESULTS Our study population included 6445 participants from 25 states plus Puerto Rico. In 2015-2016 compared to 2012-2013, HIC was more common in ME jurisdictions (P < 0.001) but unchanged in non-ME jurisdictions. Adjusted difference-in-differences analyses showed ME was associated with a statistically significant 13.36 percentage-point increase in HIC (standard error = 0.053). Cost barriers to MED, HCP, and AAC did not change significantly for either group in descriptive and difference-in-differences analyses. In subgroup analyses, we noted variation in outcomes by demographics and 2014 ME status. CONCLUSIONS We found ME significantly affected HIC among low-income adults with asthma, but not cost barriers to asthma-related health care. Strategies to reduce cost barriers to asthma care could further improve health care access among low-income adults with asthma in ME jurisdictions.
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Affiliation(s)
- Joy Hsu
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Xiaoting Qin
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maria C Mirabelli
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - W Dana Flanders
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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McMorrow S, Blumberg LJ, Holahan J. Ten Years Later: Reflections on Critics' Worst-Case Scenarios for the Affordable Care Act. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2020; 45:465-483. [PMID: 32186341 DOI: 10.1215/03616878-8255421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The primary goals of the Affordable Care Act (ACA) were to increase the availability and affordability of health insurance coverage and thereby improve access to needed health care services. Numerous studies have overwhelmingly confirmed that the law has reduced uninsurance and improved affordability of coverage and care for millions of Americans. Not everyone believed that the ACA would lead to positive outcomes, however. Critics raised numerous concerns in the years leading up to the law's passage and full implementation, including about its consequences for national health spending, labor supply, employer health insurance markets, provider capacity, and overall population health. This article considers five frequently heard worst-case scenarios related to the ACA and provides research evidence that these fears did not come to pass.
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Meltzer R, Markus AR. An Analysis of Payment Mix Patterns of Preterm Births in a Post-Affordable Care Act Insurance Market: Implications for the Medicaid Program. Womens Health Issues 2020; 30:248-259. [PMID: 32505430 DOI: 10.1016/j.whi.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 02/10/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The United States has a relatively high preterm birth rate compared with other developed nations. Before the enactment of the Affordable Care Act in 2010, many women at risk of a preterm birth were not able to access affordable health insurance or a wide array of preventive and maternity care services needed before, during, and after pregnancy. The various health insurance market reforms and coverage expansions contained in the Affordable Care Act sought in part to address these problems. This analysis aims to describe changes in the patterns of payer mix of preterm births in the context of a post-Affordable Care Act insurance market, explore possible factors for the observed changes, and discuss some of the implications for the Medicaid program. METHODS We applied a repeated cross-sectional study design to explore payment mix patterns of all births and preterm births between 2011 and 2016, using publicly available National Vital Statistics Birth Data. We included an equal number of years with payment source available in the dataset before and after January 1, 2014, when the coverage expansions became effective. RESULTS We found a small relative change in payment mix during the study period. Private health insurance (PHI) paid for a higher percentage of all births and this rate increased steadily between 2011 and 2016. Preterm births paid by PHI increased by 1.4 percentage points between 2011 and 2016 and self-pay/uninsured preterm births decreased by 0.3 percentage points over the same time period. Medicaid had the highest, and a relatively stable, preterm birth coverage percentage (48.9% in 2011, 49.2% in 2014, and 48.9% in 2016). Medicaid was also more likely to pay for preterm births than PHI, but this likelihood decreased by more than one-half after 2014 (8.2% in 2013 vs. 3.8% in 2014). CONCLUSIONS After the 2010 reforms, Medicaid remained a constant source of coverage for the most vulnerable women in society when faced with the high cost of a preterm birth. Nationwide, of the 64 million women ages 15 to 44, 4% gained PHI (directly purchased or employer sponsored) and another 4% Medicaid, with a concomitant 8% decrease in uninsured women of reproductive age between 2013 and 2017. More research is needed to conclude with certainty that the reforms worked as intended, but the important role of Medicaid as a financial safety net is undeniable.
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Affiliation(s)
| | - Anne Rossier Markus
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC.
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Johnston EM, McMorrow S, Thomas TW, Kenney GM. ACA Medicaid Expansion and Insurance Coverage Among New Mothers Living in Poverty. Pediatrics 2020; 145:peds.2019-3178. [PMID: 32295817 DOI: 10.1542/peds.2019-3178] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act's (ACA's) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty. METHODS We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010-2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers. RESULTS A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers. CONCLUSIONS ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.
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Margerison CE, MacCallum CL, Chen J, Zamani-Hank Y, Kaestner R. Impacts of Medicaid Expansion on Health Among Women of Reproductive Age. Am J Prev Med 2020; 58:1-11. [PMID: 31761513 PMCID: PMC6925642 DOI: 10.1016/j.amepre.2019.08.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Preconception and interconception health care are critical means of identifying, managing, and treating risk factors originating before pregnancy that can harm fetal development and maternal health. However, many women in the U.S. lack health insurance, limiting their ability to access such care. State-level variation in Medicaid eligibility, particularly before and after the 2014 Medicaid expansions, offers a unique opportunity to test the hypothesis that increasing healthcare coverage for low-income women can improve preconception and interconception healthcare access and utilization, chronic disease management, overall health, and health behaviors. METHODS In 2018-2019, data on 58,365 low-income women aged 18-44 years from the 2011-2016 Behavioral Risk Factor Surveillance System were analyzed, and a difference-in-difference analysis was used to examine the impact of Medicaid expansions on preconception health. RESULTS Expanded Medicaid eligibility was associated with increased healthcare coverage and utilization, better self-rated health, and decreases in avoidance of care because of cost, heavy drinking, and binge drinking. Medicaid eligibility did not impact diagnoses of chronic conditions, smoking cessation, or BMI. Medicaid eligibility was associated with greater gains in health insurance, utilization, and health among married (vs unmarried) women. Conversely, women with any (vs no) dependent children experienced smaller gains in insurance following the Medicaid expansion, but greater take-up of insurance when eligibility increased and larger behavioral responses to gaining insurance. CONCLUSIONS Expanded Medicaid coverage may improve access to and utilization of health care among women of reproductive age, which could ultimately improve preconception health.
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Affiliation(s)
- Claire E Margerison
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan.
| | - Colleen L MacCallum
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Jiajia Chen
- Department of Economics, University of Illinois at Chicago, Chicago, Illinois
| | - Yasamean Zamani-Hank
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Robert Kaestner
- Harris School of Public Policy, University of Chicago, Chicago, Illinois
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