Kentucky’s Medicaid Expansion Showing Early Promise On Coverage And Access To Care

Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region

BACKGROUND

Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown.

OBJECTIVE

This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area.

DESIGN

This study was a retrospective, descriptive, and ecological study.

SETTINGS

This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database.

PATIENTS

All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay.

RESULTS

Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001).

LIMITATIONS

This study is subject to the limitations inherent in being retrospective and using a partially de-identified database.

CONCLUSION

This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays.

IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY

ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).

Medicaid Expansion and Change in Federally Qualified Health Center Accessibility From 2008 to 2016

BACKGROUND

The Affordable Care Act expanded health coverage for low-income residents through Medicaid expansion and increased funding for Health Center Program New Access Points from 2009 to 2015, improving federally qualified health center (FQHC) accessibility. The extent to which these provisions progressed synergistically as intended when states could opt out of Medicaid expansion is unknown.

OBJECTIVE

To compare change in FQHC accessibility among census tracts in Medicaid expansion and nonexpansion states.

RESEARCH DESIGN

Tract-level FQHC accessibility scores for 2008 and 2016 were estimated applying the 2-step floating catchment area method to American Community Survey and Health Resources and Services Administration data. Multivariable linear regression compared changes in FQHC accessibility between tracts in Medicaid expansion and nonexpansion states, adjusting for sociodemographic and health system factors and accounting for state-level clustering.

SUBJECTS

In total, 7058 census tracts across 10 states.

RESULTS

FQHC accessibility increased comparably among tracts in Medicaid expansion and nonexpansion states (coef: 0.3; 95% CI: -0.3, 0.8; P -value: 0.36). FQHC accessibility increased more in tracts with higher poverty and uninsured rates, and those with lower proportions of non-English speakers and Black or African American residents.

CONCLUSION

Similar gains in FQHC accessibility across Medicaid expansion and nonexpansion states indicate improvements progressed independently from Medicaid expansion, rather than synergistically as expected. Accessibility increases appeared consistent with HRSA's goal to improve access for individuals experiencing economic barriers to health care but not for those experiencing cultural or language barriers to health care.

The Effect of Louisiana Medicaid Expansion on Affordability of Health Care

OBJECTIVES

Louisiana extended Medicaid coverage on July 1, 2016, to previously ineligible populations. We aimed to estimate the effect of Louisiana's Medicaid expansion on self-reported affordability of health care.

METHODS

We used 2011-2019 data from the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS measured affordability of health care by asking respondents 2 questions: (1) whether they could not see a doctor due to cost in the previous 12 months and (2) whether they could not get a prescribed medication due to cost in the previous 12 months. We estimated difference-in-differences and difference-in-difference-in-differences analytical models using multivariable linear regression that compared trends in Louisiana with trends in states that did not expand Medicaid during the study period.

RESULTS

Compared with adults aged <65 with annual household income >138% of the federal poverty level (FPL) in nonexpansion states, Medicaid expansion in Louisiana decreased the percentage of adults aged <65 with annual household income ≤138% FPL who reported being unable to see a doctor due to cost by 5.1 percentage points (95% CI, -6.5 to -3.6; P < .001) and unable to afford prescribed medication by 7.9 percentage points (95% CI, -9.2 to -6.6; P < .001). We found similar estimates when we limited the comparison group to Southern nonexpansion states.

CONCLUSIONS

Louisiana's Medicaid expansion lowered cost barriers to health care. Further research may find improvements in health care affordability in states that have not yet expanded Medicaid.

Racial disparities in health care utilization, the affordable care act and racial concordance preference

The Affordable Care Act was implemented with the aim of increasing coverage and affordable access with hopes of improving health outcomes and reducing costs. Yet, disparities persist. Coverage and affordable access alone cannot explain the health care gap between racial/ethnic minorities and white patients. Instead, the focus has turned to other factors affecting utilization rates such as the patient-provider relationship. Data from nationally represented U.S. households in 2009-2017 were used to study the association between patient-provider social distance as measured by "racial/ethnic concordance" and health care utilization rates for periods covering pre- and post-ACA. Despite the reduction in financial barriers to health access with the implementation of the ACA, the correlation between racial/ethnic concordance and utilization remains positive and significant. The results suggest that while the ACA may have improved coverage and affordability, other dimensions of access, particularly acceptability, as measured by patient-provider clinical interaction experience, remains a factor in the decision to utilize care.

Effects of medicaid expansion on poverty disparities in health insurance coverage

BACKGROUND

More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level.

METHOD

American Community Survey (2012-2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) < 138 %, (2) 138-400 % and (3) > 400 % federal poverty level (FPL).

RESULTS

Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for < 138 %, 138-400 %, and > 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and < 138 % FPL group had the highest uninsured rate. Compared with ≥ 138 % FPL groups, there was a 2.54 % reduction in uninsured risk after Medicaid expansion among < 138 % FPL group in Medicaid expansion states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18 % decrease was estimated.

CONCLUSION

Poverty disparity in uninsured rates improved with Medicaid expansion. However, < 138 % FPL population are still at a higher risk for being uninsured.

Medicaid expansion and accessibility to healthcare: The Illinois experience

OBJECTIVE

The study examined the impact that the Medicaid expansion in Illinois had upon insurance rates, access to medical care, dental care, pharmaceuticals, and mental-health counseling between rural and urban counties.

DESIGN AND SAMPLE

A serial cross-sectional design was used to assess the health perceptions of adults living in Illinois.

MEASURES

Survey data were collected in 2012 (n = 6,149) before the Medicaid expansion in Illinois and in 2015 (n = 3,532) after the expansion from rural (n = 4) and urban counties (n = 4).

INTERVENTION

Medicaid expansion reduced the uninsured rate in both rural (16.39%-4.87%) and urban counties (17.05%-5.2%) and improved self-reported health. It also increased access to all types of healthcare, with the biggest increase in dental coverage.

RESULTS

Path analysis indicated that the Medicaid expansion β = -1.03 (p < .01) and poor versus not poor β = -1.50 (p < .01) were a significant predictor to no healthcare access. Rural verses urban location was not significant (β = 0.04); however, race/ethnicity was significantly different (p < .01).

CONCLUSION

Findings suggest that although the expansion has increased access to care overall, those who are the most vulnerable are still not benefiting equally from the expansion. Therefore, strategies to assist high-risk adults in enrolling and using their Medicaid coverage need to developed and implemented.

Three Statistical Approaches for Assessment of Intervention Effects: A Primer for Practitioners

INTRODUCTION

Statistical methods to assess the impact of an intervention are increasingly used in clinical research settings. However, a comprehensive review of the methods geared toward practitioners is not yet available.

METHODS AND MATERIALS

We provide a comprehensive review of three methods to assess the impact of an intervention: difference-in-differences (DID), segmented regression of interrupted time series (ITS), and interventional autoregressive integrated moving average (ARIMA). We also compare the methods, and provide illustration of their use through three important healthcare-related applications.

RESULTS

In the first example, the DID estimate of the difference in health insurance coverage rates between expanded states and unexpanded states in the post-Medicaid expansion period compared to the pre-expansion period was 5.93 (95% CI, 3.99 to 7.89) percentage points. In the second example, a comparative segmented regression of ITS analysis showed that the mean imaging order appropriateness score in the emergency department at a tertiary care hospital exceeded that of the inpatient setting with a level change difference of 0.63 (95% CI, 0.53 to 0.73) and a trend change difference of 0.02 (95% CI, 0.01 to 0.03) after the introduction of a clinical decision support tool. In the third example, the results from an interventional ARIMA analysis show that numbers of creatinine clearance tests decreased significantly within months of the start of eGFR reporting, with a magnitude of drop equal to -0.93 (95% CI, -1.22 to -0.64) tests per 100,000 adults and a rate of drop equal to 0.97 (95% CI, 0.95 to 0.99) tests per 100,000 per adults per month.

DISCUSSION

When choosing the appropriate method to model the intervention effect, it is necessary to consider the structure of the data, the study design, availability of an appropriate comparison group, sample size requirements, whether other interventions occur during the study window, and patterns in the data.

The impact of the Affordable Care Act on health care access and self-assessed health in the Trump Era (2017-2018)

OBJECTIVE

To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self-assessed health during the first 2 years of the Trump administration (2017 and 2018).

DATA SOURCE

The 2011-2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self-assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year.

DESIGN

We estimate difference-in-difference-in-differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre-2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self-assessed health. We also examine differences by income and race/ethnicity.

PRINCIPAL FINDINGS

Despite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018.

CONCLUSIONS

While gains in access and self-assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time.

Mapping the healthcare chaplaincy workforce: a baseline description

Changing U.S. demographics and the growing emphasis on diversity in the healthcare workforce requires professional healthcare chaplains to examine the characteristics of its own workforce. Previous research suggested that chaplains were mainly Caucasian/White and Mainline Protestant. To explore further, this paper presents a baseline sketch of the workforce and identifies important differences among board-certified chaplains (BCCs), certified educators, certified educator candidates (CECs), and clinical pastoral education (CPE) students. Although missing data quickly became the central story of the analysis and thus requires caution in comparison, the preliminary results suggest BCCs and Certified Educators are older and Whiter/more Caucasian than CECs and CPE students. At least one-third of chaplains and Certified Educators identify as Mainline Protestant, but students and CECs reported greater variation in religious affiliation. Chaplains may be similar to users of healthcare and hospitalized persons in terms of gender and race/ethnicity. Recommendations include suggestions for improving the data infrastructure of professional chaplaincy organizations.

Changes in hospital service demand, cost, and patient illness severity following health reform

OBJECTIVE

To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states.

DATA SOURCES

Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey.

STUDY DESIGN

Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups.

FINDINGS

In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group).

CONCLUSIONS

Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.

Impact of health reform on health insurance status among persons who use opioids in eastern Kentucky: A prospective cohort analysis

BACKGROUND

Health insurance improves health and reduces mortality. Expanding insurance is a central feature of the Affordable Care Act (ACA). Persons who use drugs (PWUDs) have historically been at high risk of being uninsured. It is unknown if Appalachian PWUDs, who live in an extremely economically distressed region, are more likely to be insured since implementation of the ACA.

METHODS

Data from a cohort of 503 PWUDs from eastern Appalachian Kentucky, who were interviewed at seven time-points between 2008 and 2017, were analysed using mixed effects regression models.

RESULTS

At baseline, only 33.8% of participants were insured, which increased to 87.3% of the cohort at the last follow-up interview. The final multivariate model, which included baseline characteristics and interactions by time, indicated there were significant baseline differences in insurance status by gender, age, education, income, and history of injection. Differences in the predictive margin probabilities of being insured across these groups had dissipated by the final follow-up interview.

CONCLUSIONS

After Kentucky's implementation of the ACA, this cohort of Appalachian PWUDs made substantial gains in obtaining insurance that far exceeded the increases reported in national studies.

Ohio's Medicaid Expansion and Unmet Health Needs Among Low-Income Women of Reproductive Age

Objective To examine changes in the prevalence and odds of unmet healthcare needs and healthcare utilization among low-income women of reproductive age (WRA) after Ohio's 2014, ACA-associated Medicaid expansion, which extended coverage to non-senior adults with a family income ≤ 138% of the federal poverty level. Methods We analyzed publically available data from the 2012 and 2015 Ohio Medicaid Assessment Survey (OMAS), a cross-sectional telephone survey of Ohio's non-institutionalized adult population. The study included 489 low-income women in 2012 and 1273 in 2015 aged 19-44 years who were newly eligible for Medicaid after expansion in January 2014. Four unmet healthcare need and three healthcare utilization measures were examined. We fit survey-weighted logistic regression models adjusted for race/ethnicity, working status, and educational attainment to determine whether the odds of each measure differed between 2012 and 2015. Results In 2015, low-income WRA had a significantly lower odds of reporting an unmet dental care need (OR_adj = 0.72, 95% CI 0.54, 0.95), unmet vision care need (OR_adj = 0.68, 95% CI 0.50, 0.93), unmet mental health need (OR_adj = 0.57, 95% CI 0.39, 0.83), and unmet prescription need (OR_adj = 0.39, 95% CI 0.45, 0.80) compared to 2012. There were no significant differences in the odds of seeing a doctor or dentist in the past year or of having a usual source of care for low-income WRA in 2012 and 2015. Conclusions for Practice After Ohio's 2014 Medicaid expansion the odds of low-income WRA having unmet healthcare needs was reduced. Future research should examine outcomes after a longer period of follow-up and include additional measures, such as self-rated health status.

Effects of the Affordable Care Act on Health Care Access and Self-Assessed Health After 3 Years

Using data from the Behavioral Risk Factor Surveillance System, we examine the causal impact of the Affordable Care Act on health-related outcomes after 3 years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from 2 sources: (1) local area prereform uninsured rates from 2013 and (2) state participation in the Medicaid expansion. Including the third postreform year leads to 2 important insights. First, gains in health insurance coverage and access to care from the policy continued to increase in the third year. Second, an improvement in the probability of reporting excellent health emerged in the third year, with the effect being largely driven by the non-Medicaid expansions components of the policy.

Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky

BACKGROUND

Kentucky ranks first in the US in cancer incidence and mortality. Compounded by high poverty levels and a high rate of medically uninsured, cancer rates are even worse in Appalachian Kentucky. Being one of the first states to adopt the Affordable Care Act (ACA) Medicaid expansion, insurance coverage markedly increased for Kentucky residents. The purpose of our study was to determine the impact of Medicaid expansion on colorectal cancer (CRC) screening, diagnosis, and survival in Kentucky.

STUDY DESIGN

The Kentucky Cabinet for Health and Family Services and the Kentucky Cancer Registry were queried for individuals (≥20 years old) undergoing CRC screening (per US Preventative Services Task Force) or diagnosed with primary invasive CRC from January 1, 2011 to December 31, 2016. Colorectal cancer screening rates, incidence, and survival were compared before (2011 to 2013) and after (2014 to 2016) ACA implementation.

RESULTS

Colorectal cancer screening was performed in 930,176 individuals, and 11,441 new CRCs were diagnosed from 2011 to 2016. Screening for CRC increased substantially for Medicaid patients after ACA implementation (+230%, p < 0.001), with a higher increase in screening among the Appalachian (+44%) compared with the non-Appalachian (+22%, p < 0.01) population. The incidence of CRC increased after ACA implementation in individuals with Medicaid coverage (+6.7%, p < 0.001). Additionally, the proportion of early stage CRC (stage I/II) increased by 9.3% for Appalachians (p = 0.09), while there was little change for non-Appalachians (-1.5%, p = 0.60). Colorectal cancer survival was improved after ACA implementation (hazard ratio 0.73, p < 0.01), particularly in the Appalachian population with Medicaid coverage.

CONCLUSIONS

Implementation of Medicaid expansion led to a significant increase in CRC screening, CRC diagnoses, and overall survival in CRC patients with Medicaid, with an even more profound impact in the Appalachian population.

Physicians as Mediators of Health Policy: Acceptance of Medicaid in the Context of Buprenorphine Treatment

Increasing numbers of individuals with opioid use disorder (OUD) are insured by Medicaid. Little is known about whether providers of buprenorphine, an evidence-based OUD pharmacotherapy, accept this type of payment. Data are scant regarding whether Medicaid acceptance varies by physician and state-level characteristics. To address these gaps, national survey data from 1174 buprenorphine-prescribing physicians (BPPs) and state characteristics were examined in a multi-level model of Medicaid acceptance. Only 52.0% of BPPs accepted Medicaid for buprenorphine-related office visits. Specialists in addiction and psychiatry were significantly less likely to accept Medicaid than other specialties, as were BPPs delivering buprenorphine in individual medical practice. Perceived adequacy of Medicaid reimbursement was positively associated with accepting Medicaid. Medicaid acceptance was not associated with states' implementation of the Medicaid expansion. Individuals who are covered by Medicaid may face barriers to accessing buprenorphine treatment, which has high public health significance given the ongoing opioid epidemic.

Did Health Care Reform Help Kentucky Address Disparities in Coverage and Access to Care among the Poor?

OBJECTIVE

To evaluate the impact of Kentucky's full rollout of the Affordable Care Act on disparities in access to care due to poverty.

DATA SOURCE

Restricted version of the Behavioral Risk Factor Surveillance System (BRFSS) for Kentucky and years 2011-2015.

STUDY DESIGN

We use a difference-in-differences framework to compare trends before and after implementation of the Affordable Care Act (ACA) in health insurance coverage, several access measures, and health care utilization for residents in higher versus lower poverty ZIP codes.

PRINCIPAL FINDINGS

Much of the reduction in Kentucky's uninsured rate appears driven by large uptakes in coverage from areas with higher concentrations of poverty. Residents in high-poverty communities experienced larger reductions, 8 percentage points (pp) in uninsured status and 7.5 pp in reporting unmet needs due to costs, than residents of lower poverty areas. These effects helped remove pre-ACA disparities in uninsured rates across these areas.

CONCLUSION

Because we observe positive effects on coverage and reductions in financial barriers to care among those from poorer communities, our findings suggest that expanding Medicaid helps address the health care needs of the impoverished.

Improved Health and Insurance Status Among Cigarette Smokers After Medicaid Expansion, 2011-2016

OBJECTIVES

The high concentration of smokers among subgroups targeted by the Affordable Care Act and the historically worse health and lower access to health care among smokers warrants an evaluation of how Medicaid expansion affects smokers. We evaluated the impact of Medicaid expansion on smoking behavior, access to health care, and health of low-income adults, and we compared outcomes of all low-income people with outcomes of low-income current smokers by states' Medicaid expansion status.

METHODS

We obtained data from the Behavioral Risk Factor Surveillance System (2011-2016) for low-income adults aged 18-64. We estimated multivariable linear ordinary least squares probability models using a quasi-experimental difference-in-difference approach to compare smoking behavior, access to health care, and health between people in expansion states and nonexpansion states and, specifically, on low-income adults and the subgroup of low-income current smokers.

RESULTS

Compared with low-income smokers in nonexpansion states, low-income smokers in expansion states were 7.6 percentage points (95% confidence interval [CI], 5.7-9.6; P < .001) more likely to have health insurance, 3.2 percentage points (95% CI, 1.3-5.2; P = .001) more likely to report good or better health, and 2.0 percentage points (95% CI, -3.9 to -0.1; P = .044) less likely to have cost-related barriers to care. Health and insurance gains among current smokers in expansion states were larger relative to health gains (1.6 percentage points; 95% CI, 0.5-2.7; P = .003) and insurance gains (4.6 percentage points; 95% CI, 3.5-5.8; P < .001) of all low-income adults in these states.

CONCLUSIONS

Greater improvements among low-income smokers in Medicaid expansion states compared with nonexpansion states could influence future smoking behaviors and warrant longer-term monitoring. Additionally, health and insurance gains among low-income smokers in expansion states suggest the potential for Medicaid expansion to improve health among smokers compared with nonsmokers.

The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender

OBJECTIVE

Examine the ACA Medicaid expansion effects on Medicaid take-up and private coverage through 2015 and coverage disparities by age, race/ethnicity, and gender.

DATA SOURCES

2011-2015 American Community Survey for 3,137,989 low-educated adults aged 19-64 years.

STUDY DESIGN

Difference-in-differences regressions accounting for national coverage trends and state fixed effects.

PRINCIPAL FINDINGS

Expansion effects doubled in 2015 among low-educated adults, with a nearly 8 percentage-point increase in Medicaid take-up and 6 percentage-point decline in uninsured rate. Significant coverage gains were observed across virtually all examined groups by age, gender, and race/ethnicity. Take-up and insurance declines were strongest among younger adults and were generally close by gender and race/ethnicity. Despite the increased take-up however, coverage disparities remained sizeable, especially for young adults and Hispanics who had declining but still high uninsured rates in 2015. There was some evidence of private coverage crowd-out in certain subgroups, particularly among young adults aged 19-26 years and women, including in both individually purchased and employer-sponsored coverage.

CONCLUSIONS

The ACA Medicaid expansions have continued to increase coverage in 2015 across the entire population of low-educated adults and have reduced age disparities in coverage. However, there is still a need for interventions that target eligible young and Hispanic adults.

Influencers and preference predictors of HPV vaccine uptake among US male and female young adult college students

Objective

The purpose of the study was to assess the knowledge, attitudes and beliefs of male and female college students in Kentucky about HPV associated diseases and vaccines, and to determine which parameters predicted self-reported uptake of HPV vaccination.

Materials and methods

A self-selected cross-sectional sample of college students completed an evidence-based online survey.

Results

Of approximately 1200 potential respondents, 585 completed the survey. The average age was 20.6 (SD 3.15) and 78% were female; 84% of the population had had one or more sexual partners. Concern for HPV vaccine safety and potential need for boosters did not significantly deter vaccine uptake. Likewise, knowledge about HPV associated cancers was not predictive of vaccine uptake. On the other hand, parental influence for vaccination was a strong predictor for vaccine uptake (aOR = 5.32, 2.71–13.03), and free vaccine nearly doubled the likelihood of being vaccinated (aOR 1.90, 1.05–3.41). In addition, the strong preference for the respondent's partner to be HPV vaccinated predicted vaccine uptake (aOR = 4.04, 95% CI: 2.31–7.05), but the lack of preference for partner vaccination predicted an unvaccinated self (aOR = 0.50, 0.27–0.93).

Conclusions

HPV vaccination has been successful in young adult college students in Kentucky. Young adults prefer their partners to be HPV vaccinated regardless of whether they themselves are vaccinated. Parental influence and free vaccine were positive predictors for vaccine uptake in this population.

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Young adults have a very strong preference for their partner to be HPV vaccinated.

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Doctors do not influence young college adults’ decisions to be HPV vaccinated.

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Parents are a significant influencer for young adult HPV vaccine uptake.

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Young adults realize need for cervical cancer screening regardless of vaccine.

After Medicaid Expansion In Kentucky, Use Of Hospital Emergency Departments For Dental Conditions Increased

Access to oral health care is a critical need for the adult Medicaid population. Following the 2014 expansion of Medicaid eligibility in Kentucky, millions of adults became eligible to receive dental benefits. We examined the impact of the expansion on adult Medicaid enrollees' use of hospital emergency departments (EDs) for conditions related to dental or oral health in the period 2010-14. Based on our analysis of data for Kentucky from the State Emergency Department Databases, we found that the rate of discharges for these conditions from the ED increased significantly, from 1,833 per 100,000 population in 2013 to 5,635 in 2014. Adults covered by Medicaid who used the ED for treatment of oral health conditions in 2014 had high levels of chronic comorbidities and were more likely to be male and nonwhite than those in earlier years. To avoid costly and inappropriate use of the ED, states considering adding an adult Medicaid dental benefit should consider also making changes to assist beneficiaries in obtaining access to the dental health care delivery system.

Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access

OBJECTIVE

To assess racial/ethnic differential impacts of the ACA's Medicaid expansion on low-income, nonelderly adults' access to primary care.

DATA SOURCES

Behavioral Risk Factor Surveillance System, State Physicians Workforce Data Book, and Bureau of Labor Statistics, in 2013 and 2015.

STUDY DESIGN

Quasi-experimental design with difference-in-differences analyses. Outcomes included health insurance coverage, having personal doctor(s), being unable to see doctors because of cost, and receiving a flu shot. We tested racial/ethnic differential impacts using the "Seemingly unrelated estimation" method. Multiple imputations and survey weights were used.

DATA COLLECTION/EXTRACTION METHODS

Low-income, nonelderly adults were identified based on age, household income, and family size.

PRINCIPAL FINDINGS

Among the low-income, nonelderly adults, Medicaid expansion was associated with statistically significant gains in health insurance coverage, having personal doctors, and affordability. Hispanics got the fewest benefits, which significantly widened racial/ethnic disparities for the Hispanic group. Racial/ethnic disparity in having personal doctors narrowed for non-Hispanic black and non-Hispanic others, although not statistically significant.

CONCLUSION

Medicaid expansion improved access to primary care, but it had differential effects among racial/ethnic groups resulting in mixed effects on disparities. Further research is necessary to develop tailored policy tools for racial/ethnic groups.

Geographic Variation in Medicaid Acceptance Across Michigan Primary Care Practices in the Era of the Affordable Care Act

Coverage and access have improved under the Affordable Care Act, yet it is unclear whether recent gains have reached those regions within states that were most in need of improved access to care. We examined geographic variation in Medicaid acceptance among Michigan primary care practices before and after Medicaid expansion in the state, using data from a simulated patient study of primary care practices. We used logistic regression analysis with time indicators to assess regional changes in Medicaid acceptance over time. Geographic regions with lower baseline (<50%) Medicaid acceptance had significant increases in Medicaid acceptance at 4 and 8 months post-expansion, while regions with higher baseline (≥50%) Medicaid acceptance did not experience significant changes in Medicaid acceptance. As state Medicaid expansions continue to be implemented across the country, policy makers should consider the local dynamics of incentives for provider participation in Medicaid.

Association of Expanded Medicaid Coverage With Hospital Length of Stay After Injury

Importance

The expansion of Medicaid eligibility under the Affordable Care Act is a state-level decision that affects how patients with traumatic injury (trauma patients) interact with locoregional health care systems. Washington, DC; Maryland; and Virginia represent 3 unique payer systems with liberal, moderate, and no Medicaid expansion, respectively, under the Affordable Care Act. Characterizing the association of Medicaid expansion with hospitalization after injury is vital in the disposition planning for these patients.

Objective

To determine the association between expanded Medicaid eligibility under the Affordable Care Act and duration of hospitalization after injury.

Design, Setting, and Participants

This retrospective cohort study included patients admitted from Virginia, Maryland, and Washington, DC, to a single level I trauma center. Data were collected from January 1, 2013, through March 6, 2016, in Virginia and Washington, DC, and from May 1, 2013, through March 6, 2016, in Maryland. All patients with Medicare or Medicaid coverage and all uninsured patients were included. Patients with private insurance, patients with severe head or pelvic injuries, and those who died during hospitalization were excluded.

Main Outcomes and Measures

Hospital length of stay (LOS) and whether its association with patient insurance status varied by state of residence.

Results

A total of 2314 patients (1541 men [66.6%] and 773 women [33.4%]; mean [SD] age, 52.9 [22.8] years) were enrolled in the study. The uninsured rate in the Washington, DC, cohort (190 of 1699 [11.2%]) was significantly lower compared with rates in the Virginia (141 of 296 [47.6%]) or the Maryland (106 of 319 [33.2%]) cohort (P < .001). On multivariate regression controlling for injury severity and demographic variables, the difference in LOS for Medicaid vs non-Medicaid recipients varied significantly by state. For Medicaid recipients, mean LOS in Washington, DC, was significantly shorter (2.57 days; 95% CI, 2.36-2.79 days) than in Maryland (3.51 days; 95% CI, 2.81-4.38 days; P = .02) or Virginia (3.9 days; 95% CI, 2.79-5.45 days; P = .05).

Conclusions and Relevance

Expanded Medicaid eligibility is associated with shorter hospital LOS in mildly injured Medicaid recipients.

Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes

BACKGROUND

Thirty-one states approved Medicaid expansion after implementation of the Affordable Care Act. The objective of this study was to evaluate the effect of Medicaid expansion on cardiac surgery volume and outcomes comparing one state that expanded to one that did not.

METHODS

Data from the Virginia (nonexpansion state) Cardiac Services Quality Initiative and the Michigan (expanded Medicaid, April 2014) Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were analyzed to identify uninsured and Medicaid patients undergoing coronary bypass graft or valve operations, or both. Demographics, operative details, predicted risk scores, and morbidity and mortality rates, stratified by state and compared across era (preexpansion: 18 months before vs postexpansion: 18 months after), were analyzed.

RESULTS

In Virginia, there were no differences in volume between eras, whereas in Michigan, there was a significant increase in Medicaid volume (54.4% [558 of 1,026] vs 84.1% [954 of 1,135], p < 0.001) and a corresponding decrease in uninsured volume. In Virginia Medicaid patients, there were no differences in predicted risk of morbidity or mortality or postoperative major morbidities. In Michigan Medicaid patients, a significant decrease in predicted risk of morbidity or mortality (11.9% [8.1% to 20.0%] vs 11.1% [7.7% to 17.9%], p = 0.02) and morbidities (18.3% [102 of 558] vs 13.2% [126 of 954], p = 0.008) was identified. Postexpansion was associated with a decreased risk-adjusted rate of major morbidity (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.91; p = 0.01) in Michigan Medicaid patients.

CONCLUSIONS

Medicaid expansion was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates. In addition to improving health care financing, Medicaid expansion may positively affect patient care and outcomes.

The Affordable Care Act Reduced Socioeconomic Disparities In Health Care Access

The United States has the largest socioeconomic disparities in health care access of any wealthy country. We assessed changes in these disparities in the United States under the Affordable Care Act (ACA). We used survey data for the period 2011-15 from the Behavioral Risk Factor Surveillance System to assess trends in insurance coverage, having a personal doctor, and avoiding medical care due to cost. All analyses were stratified by household income, education level, employment status, and home ownership status. Health care access for people in lower socioeconomic strata improved in both states that did expand eligibility for Medicaid under the ACA and states that did not. However, gains were larger in expansion states. The absolute gap in insurance coverage between people in households with annual incomes below $25,000 and those in households with incomes above $75,000 fell from 31 percent to 17 percent (a relative reduction of 46 percent) in expansion states and from 36 percent to 28 percent in nonexpansion states (a 23 percent reduction). This serves as evidence that socioeconomic disparities in health care access narrowed significantly under the ACA.

Perceived Impacts of the Affordable Care Act: Perspectives of Buprenorphine Prescribers

The Affordable Care Act (ACA) has been heralded as a major policy change that is expected to transform the delivery of substance use disorder (SUD) treatment. Few studies have reported on the perceived impacts of ACA from the perspectives of SUD treatment providers, such as physicians who prescribe buprenorphine to patients with opioid use disorder. The present study describes buprenorphine prescribers' perceptions regarding impacts of the ACA on the delivery of buprenorphine and examines whether state-level approaches to implementing ACA are associated with its perceived impacts. Data are drawn from a national sample of current buprenorphine prescribers (n = 1,174) who were surveyed by mail. On average, buprenorphine prescribers reported ambivalence regarding the impacts of the ACA, as indicated by a mean of 2.75 (SD = 0.69) on a scale that ranged from 1 ("strongly disagree") to 5 ("strongly agree"). A multi-level mixed-effects regression model indicated that physicians practicing in states that were supportive of ACA, as indicated by adopting both the Medicaid expansion and implementing a state-based health insurance exchange, had more positive perceptions of the ACA than physicians in states that had declined both of these policies. This study suggests that state approaches to ACA may be associated with varied impacts.

Health and Access to Care during the First 2 Years of the ACA Medicaid Expansions

BACKGROUND

By September 2015, a total of 29 states and Washington, D.C., were participating in Medicaid expansions under the Affordable Care Act. We examined whether Medicaid expansions were associated with changes in insurance coverage, health care use, and health among low-income adults.

METHODS

We compared changes in outcomes during the 2 years after implementation of the Medicaid expansion (2014 and 2015) relative to the 4 years before expansion (2010 through 2013) in states with and without expansions, using data from the National Health Interview Survey. The sample consisted of 60,766 U.S. citizens who were 19 to 64 years of age and had incomes below 138% of the federal poverty level. Outcomes included insurance coverage, access to and use of medical care in the past 12 months, and health status as reported by the respondents.

RESULTS

A total of 29 states and Washington, D.C., expanded Medicaid by September 1, 2015. In year 2 after implementation, uninsurance rates were reduced in expansion states relative to nonexpansion states (difference-in-differences estimate, -8.2 percentage points; P<0.001) and rates of Medicaid coverage were increased (difference-in-differences estimate, 15.6 percentage points; P<0.001). Expansions were not associated with significant changes in the likelihood of a doctor visit or overnight hospital stay or health status as reported by the respondent. However, as compared with nonexpansion states, expansion states had a decrease in reports of inability to afford needed follow-up care (difference-in-differences estimate, -3.4 percentage points; P=0.002) and in reports of worry about paying medical bills (difference-in-differences estimate, -7.9 percentage points; P=0.002) and an increase in reports of medical care being delayed because of wait times for appointments (difference-in-differences estimate, 2.6 percentage points; P=0.02).

CONCLUSIONS

Medicaid expansion was associated with increased insurance coverage and access to care during the second year of implementation, but it was also associated with longer wait times for appointments, which suggests that challenges in access to care persist.

Medicaid Expansion Under the Affordable Care Act and Insurance Coverage in Rural and Urban Areas

PURPOSE

To analyze the differential rural-urban impacts of the Affordable Care Act Medicaid expansion on low-income childless adults' health insurance coverage.

METHODS

Using data from the American Community Survey years 2011-2015, we conducted a difference-in-differences regression analysis to test for changes in the probability of low-income childless adults having insurance in states that expanded Medicaid versus states that did not expand, in rural versus urban areas. Analyses employed survey weights, adjusted for covariates, and included a set of falsification tests as well as sensitivity analyses.

FINDINGS

Medicaid expansion under the Affordable Care Act increased the probability of Medicaid coverage for targeted populations in rural and urban areas, with a significantly greater increase in rural areas (P < .05), but some of these gains were offset by reductions in individual purchased insurance among rural populations (P < .01). Falsification tests showed that the insurance increases were specific to low-income childless adults, as expected, and were largely insignificant for other populations.

CONCLUSIONS

The Medicaid expansion increased the probability of having "any insurance" for the pooled urban and rural low-income populations, and it specifically increased Medicaid coverage more in rural versus urban populations. There was some evidence that the expansion was accompanied by some shifting from individual purchased insurance to Medicaid in rural areas, and there is a need for future work to understand the implications of this shift on expenditures, access to care and utilization.

Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States

The Affordable Care Act (ACA) aimed to achieve nearly universal health insurance coverage in the United States through a combination of insurance market reforms, mandates, subsidies, health insurance exchanges, and Medicaid expansions, most of which took effect in 2014. This paper estimates the causal effects of the ACA on health insurance coverage in 2014 using data from the American Community Survey. We utilize difference-in-difference-in-differences models that exploit cross-sectional variation in the intensity of treatment arising from state participation in the Medicaid expansion and local area pre-ACA uninsured rates. This strategy allows us to identify the effects of the ACA in both Medicaid expansion and non-expansion states. Our preferred specification suggests that, at the average pre-treatment uninsured rate, the full ACA increased the proportion of residents with insurance by 5.9 percentage points compared to 2.8 percentage points in states that did not expand Medicaid. Private insurance expansions from the ACA were due to increases in both employer-provided and non-group coverage. The coverage gains from the full ACA were largest for those without a college degree, non-whites, young adults, unmarried individuals, and those without children in the home. We find no evidence that the Medicaid expansion crowded out private coverage.

The Affordable Care Act's Impacts on Access to Insurance and Health Care for Low-Income Populations

The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. Understanding the law's impact on coverage, access, utilization, and health outcomes, especially among low-income populations, is critical to informing ongoing debates about its effectiveness and implementation. Early findings indicate that there have been significant reductions in the rate of uninsurance among the poor and among those who live in Medicaid expansion states. In addition, the law has been associated with increased health care access, affordability, and use of preventive and outpatient services among low-income populations, though impacts on inpatient utilization and health outcomes have been less conclusive. Although these early findings are generally consistent with past coverage expansions, continued monitoring of these domains is essential to understand the long-term impact of the law for underserved populations.

Medicaid's Role in Health Reform and Closing the Coverage Gap

Medicaid coverage matters for millions of low-income Americans, and especially for those with ongoing and serious health challenges. A source of comprehensive and affordable coverage, Medicaid has long been a cornerstone of federal and state efforts to improve access and health outcomes for very poor and medically vulnerable populations. The Affordable Care Act (ACA) leveraged Medicaid's role in serving the poor to broaden the program's reach to millions of low-income uninsured adults, and positioned the program as a fundamental component of the newly established continuum of public and private coverage. Looking ahead, if more states embrace the Medicaid expansion, there is the potential to build on this progress to significantly reduce the number of uninsured Americans.