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Kavanagh NM, Campbell AL, McIntyre A. Medicare Eligibility and Reported Support for Proposals to Expand Medicare. JAMA 2024; 331:882-884. [PMID: 38345789 PMCID: PMC10862260 DOI: 10.1001/jama.2024.0379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024]
Abstract
This study estimates the association between Medicare eligibility and support for recent proposals to expand program participation and benefits.
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Affiliation(s)
- Nolan M. Kavanagh
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts
| | - Andrea L. Campbell
- Department of Political Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
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2
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McIntyre A, Aboulafia G, Sommers BD. Preliminary Data on "Unwinding" Continuous Medicaid Coverage. N Engl J Med 2023; 389:2215-2217. [PMID: 37991840 DOI: 10.1056/nejmp2311336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Affiliation(s)
- Adrianna McIntyre
- From the Harvard T.H. Chan School of Public Health, Boston (A.M., B.D.S.), and Harvard University, Cambridge (G.A.) - both in Massachusetts
| | - Gabriella Aboulafia
- From the Harvard T.H. Chan School of Public Health, Boston (A.M., B.D.S.), and Harvard University, Cambridge (G.A.) - both in Massachusetts
| | - Benjamin D Sommers
- From the Harvard T.H. Chan School of Public Health, Boston (A.M., B.D.S.), and Harvard University, Cambridge (G.A.) - both in Massachusetts
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3
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Steenland MW, Fabi RE, Bellerose M, Desir A, White MS, Wherry LR. State Public Insurance Coverage Policies and Postpartum Care Among Immigrants. JAMA 2023; 330:238-246. [PMID: 37462705 PMCID: PMC10354679 DOI: 10.1001/jama.2023.10249] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/25/2023] [Indexed: 07/21/2023]
Abstract
Importance Professional medical organizations recommend that adults receive routine postpartum care. Yet, some states restrict public insurance coverage for undocumented immigrants and recently documented immigrants (those who received legal documentation status within the past 5 years). Objective To examine the association between public insurance coverage and postpartum care among low-income immigrants and the difference in receipt of postpartum care among immigrants relative to nonimmigrants. Design, Setting, and Participants A pooled, cross-sectional analysis was conducted using data from the Pregnancy Risk Assessment Monitoring System for 19 states and New York City including low-income adults with a live birth between 2012 and 2019. Exposure Giving birth in a state that offered public insurance coverage for postpartum care to recently documented or undocumented immigrants. Main Outcomes and Measures Self-reported receipt of postpartum care by the category of coverage offered (full coverage: states that offered publicly funded postpartum care regardless of immigration status; moderate coverage: states that offered publicly funded postpartum care to lawfully residing immigrants without a 5-year waiting period, but did not offer postpartum care to undocumented immigrants; no coverage: states that did not offer publicly funded postpartum care to lawfully present immigrants before 5 years of legal residence or to undocumented immigrants). Results The study included 72 981 low-income adults (20 971 immigrants [29%] and 52 010 nonimmigrants [71%]). Of the 19 included states and New York City, 6 offered full coverage, 9 offered moderate coverage, and 4 offered no coverage; 1 state (Oregon) switched from offering moderate coverage to offering full coverage. Compared with the states that offered full coverage, receipt of postpartum care among immigrants was 7.0-percentage-points lower (95% CI, -10.6 to -3.4 percentage points) in the states that offered moderate coverage and 11.3-percentage-points lower (95% CI, -13.9 to -8.8 percentage points) in the states that offered no coverage. The differences in the receipt of postpartum care among immigrants relative to nonimmigrants were also associated with the coverage categories. Compared with the states that offered full coverage, there was a 3.3-percentage-point larger difference (95% CI, -5.3 to -1.4 percentage points) in the states that offered moderate coverage and a 7.7-percentage-point larger difference (95% CI, -10.3 to -5.0 percentage points) in the states that offered no coverage. Conclusions and Relevance Compared with states without insurance restrictions, immigrants living in states with public insurance restrictions were less likely to receive postpartum care. Restricting public insurance coverage may be an important policy-driven barrier to receipt of recommended pregnancy care and improved maternal health among immigrants.
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Affiliation(s)
- Maria W. Steenland
- Population Studies and Training Center, Brown University, Providence, Rhode Island
| | - Rachel E. Fabi
- Center for Bioethics and Humanities, State University of New York Upstate Medical University, Syracuse
| | - Meghan Bellerose
- School of Public Health, Brown University, Providence, Rhode Island
| | - Arielle Desir
- School of Public Health, Brown University, Providence, Rhode Island
| | - Maggie S. White
- School of Public Health, Brown University, Providence, Rhode Island
| | - Laura R. Wherry
- Robert F. Wagner Graduate School of Public Service, New York University, New York, New York
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4
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Schoenbrunner A, Beckmeyer A, Kunnath N, Ibrahim A, Pawlik TM, Venkataramani A, Kuzon WM, Diaz A. Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery. JAMA 2023; 329:819-826. [PMID: 36917051 PMCID: PMC10015311 DOI: 10.1001/jama.2023.0878] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/03/2023] [Indexed: 03/15/2023]
Abstract
Importance Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. Objective To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Design, Setting, and Participants Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. Exposures California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Main Outcomes and Measures Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. Results A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Conclusions and Relevance Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.
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Affiliation(s)
- Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus
| | | | - Nicholas Kunnath
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor
| | | | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Opportunity for Health Labs, University of Pennsylvania, Philadelphia
| | | | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, The Ohio State University, Columbus
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5
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Harris E. Medicaid Expansion Tied to Reduction in Postpartum Hospitalizations. JAMA 2023; 329:458. [PMID: 36696140 DOI: 10.1001/jama.2023.0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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6
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Mello MM, O'Connell AJ. The Fresh Assault on Insurance Coverage Mandates. N Engl J Med 2023; 388:1-3. [PMID: 36449734 DOI: 10.1056/nejmp2213835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Michelle M Mello
- From Stanford Law School (M.M.M., A.J.O.), the Department of Health Policy, Stanford University School of Medicine (M.M.M.), and the Freeman Spogli Institute for International Studies (M.M.M.), Stanford University - all in Stanford, CA
| | - Anne Joseph O'Connell
- From Stanford Law School (M.M.M., A.J.O.), the Department of Health Policy, Stanford University School of Medicine (M.M.M.), and the Freeman Spogli Institute for International Studies (M.M.M.), Stanford University - all in Stanford, CA
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Hsu J, Fung V, Newhouse JP. Expiration of Pandemic-Related Marketplace Insurance Policies: Implications for Affordability and Coverage. JAMA 2022; 327:2187-2188. [PMID: 35594053 DOI: 10.1001/jama.2022.8318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John Hsu
- Mongan Institute, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Vicki Fung
- Mongan Institute, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Joseph P Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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8
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Affiliation(s)
- Utsha G Khatri
- From the Department of Emergency Medicine and the Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York (U.G.K.); and the Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, and the Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute - both in Minneapolis (T.N.A.W.)
| | - Tyler N A Winkelman
- From the Department of Emergency Medicine and the Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York (U.G.K.); and the Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, and the Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute - both in Minneapolis (T.N.A.W.)
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9
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Affiliation(s)
- Rachel E Sachs
- From Washington University School of Law, St. Louis (R.E.S.); and Harvard Medical School, Boston (M.A.K.)
| | - Michael Anne Kyle
- From Washington University School of Law, St. Louis (R.E.S.); and Harvard Medical School, Boston (M.A.K.)
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10
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Metzger GA, Asti L, Quinn JP, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level. J Am Coll Surg 2021; 233:776-793.e16. [PMID: 34656739 PMCID: PMC8627499 DOI: 10.1016/j.jamcollsurg.2021.08.694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/21/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points). CONCLUSIONS The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.
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Affiliation(s)
- Gregory A Metzger
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - John P Quinn
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Medical Student Research Program, College of Medicine, The Ohio State University, Columbus, OH
| | - Deena J Chisolm
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Henry Xiang
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
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Rodriguez MI, Skye M, Lindner S, Caughey AB, Lopez-DeFede A, Darney BG, McConnell KJ. Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care. JAMA Netw Open 2021; 4:e2138983. [PMID: 34910148 PMCID: PMC8674744 DOI: 10.1001/jamanetworkopen.2021.38983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid. OBJECTIVE To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception. DESIGN, SETTING, AND PARTICIPANTS This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021. EXPOSURES Medicaid coverage of postpartum care. MAIN OUTCOMES AND MEASURES Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery. RESULTS The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.
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Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Megan Skye
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Ana Lopez-DeFede
- Institute for Families in Society, University of South Carolina, Columbia
| | - Blair G. Darney
- Divisionof Complex Family Planning, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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Affiliation(s)
- Rachel E Sachs
- From Washington University School of Law, St. Louis (R.E.S.); and University of Michigan Law School, Ann Arbor (N.B.)
| | - Nicholas Bagley
- From Washington University School of Law, St. Louis (R.E.S.); and University of Michigan Law School, Ann Arbor (N.B.)
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13
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Affiliation(s)
- Eli Y Adashi
- Medical Science, Medicine and Biological Sciences, Brown University, Providence, Rhode Island
| | - Daniel P O'Mahony
- Library Planning and Assessment, Brown University Library, Providence, Rhode Island
| | - I Glenn Cohen
- Harvard Law School, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard University, Cambridge, Massachusetts
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14
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Affiliation(s)
- Barak Richman
- From the Duke University School of Law, Durham (B.R.), and the Wake Forest University Schools of Law and Medicine, Winston-Salem (M.H.) - both in North Carolina; and the Clinical Excellence Research Center, School of Medicine (B.R., K.S.), and the Graduate School of Business (K.S.), Stanford University, Stanford, CA
| | - Mark Hall
- From the Duke University School of Law, Durham (B.R.), and the Wake Forest University Schools of Law and Medicine, Winston-Salem (M.H.) - both in North Carolina; and the Clinical Excellence Research Center, School of Medicine (B.R., K.S.), and the Graduate School of Business (K.S.), Stanford University, Stanford, CA
| | - Kevin Schulman
- From the Duke University School of Law, Durham (B.R.), and the Wake Forest University Schools of Law and Medicine, Winston-Salem (M.H.) - both in North Carolina; and the Clinical Excellence Research Center, School of Medicine (B.R., K.S.), and the Graduate School of Business (K.S.), Stanford University, Stanford, CA
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La Forgia A, Bond AM, Braun RT, Kjaer K, Zhang M, Casalino LP. Association of Surprise-Billing Legislation with Prices Paid to In-Network and Out-of-Network Anesthesiologists in California, Florida, and New York: An Economic Analysis. JAMA Intern Med 2021; 181:1324-1331. [PMID: 34398193 PMCID: PMC8369382 DOI: 10.1001/jamainternmed.2021.4564] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/26/2021] [Indexed: 11/14/2022]
Abstract
Importance Several states have passed surprise-billing legislation to protect patients from unanticipated out-of-network medical bills, yet little is known about how state laws influence out-of-network prices and whether spillovers exist to in-network prices. Objective To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation. Design, Setting, and Participants This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states. Exposures Temporal and state-level variation in exposure to surprise-billing legislation. Main Outcomes and Measures The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists. Results This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, -$12.71 (95% CI, -$25.70 to -$0.27; P = .05) and Florida, -$35.67 (95% CI, -$46.27 to -$25.07; P < .001). In New York, a decline in the overall out-of-network price was not statistically significant (-$7.91; 95% CI, -$17.48 to -$1.68; P = .10); however, by the fourth quarter of 2017, the decline was -$41.28 (95% CI, -$70.24 to -$12.33; P = .01). In-network prices decreased in California by -$10.68 (95% CI, -$12.70 to -$8.66; P < .001); in Florida, -$3.18 (95% CI, -$5.17 to -$1.19; P = .002); and in New York, -$8.05 (95% CI, -$11.46 to -$4.64; P < .001). Conclusions and Relevance This retrospective study found that prices paid to in-network and out-of-network anesthesiologists in hospital outpatient departments and ambulatory surgery centers decreased after the introduction of surprise-billing legislation, providing early insights into how prices may change under the federal No Surprises Act and in states that have recently passed their own legislation.
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Affiliation(s)
- Ambar La Forgia
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Amelia M. Bond
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Klaus Kjaer
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Manyao Zhang
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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McMorrow S. Stabilizing and Strengthening the Affordable Care Act: Opportunities for a New Administration. J Health Polit Policy Law 2021; 46:549-562. [PMID: 33503256 DOI: 10.1215/03616878-8970753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
For the past decade, the Affordable Care Act (ACA) has successfully reduced uninsurance and improved access to and affordability of health care services for millions of Americans. But the law was weakened when the Trump administration shortened the open enrollment period in the federal Marketplace, reduced outreach and enrollment funding, and revised the public charge rule, among other actions. The Biden administration will have the chance to reverse some of these changes and further strengthen the law to improve health care access and affordability. In this article, the author explores options for expanding access to affordable coverage and care for those who do not qualify for Medicaid or marketplace financial assistance and further discusses opportunities for increasing enrollment among those who are already eligible. The author also examines opportunities for expanding access to specific services, including reproductive health care, among those with insurance. Any attempts to modify or build on the ACA will likely be complicated by the ongoing coronavirus pandemic as well as slim Democratic majorities in the House and Senate, but regulatory solutions will likely be easier to achieve than those that require changes to federal law or state policy.
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Abstract
In January 2021, the incoming Biden administration inherited urgent priorities for curbing health care spending and expanding health care coverage to millions of Americans while also addressing the COVID-19 pandemic and resulting economic downturn. Among these competing priorities is the issue of access to and affordability of prescription drugs. Here, the authors outline Biden's plan for directly lowering prescription drug spending for payers and patients and for expanding access to prescription medications through improved health insurance coverage. These policies could provide important financial protections for Americans against high prescription drug prices. Despite widespread public support for addressing prescription drug prices, many of Biden's plans rely on congressional action, which will be complicated by the narrow majority held by Democrats in the House and an evenly divided Senate. However, there may be other opportunities for reducing prescription drug spending and improving health insurance enrollment among the uninsured. While directly lowering drug prices would provide the most widespread savings for payers and patients alike, any successful effort for increasing the number of Americans enrolled in health insurance or rendering it more affordable will still likely effectively lower patients' out-of-pocket costs and improve access to prescription drugs.
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Jaramillo JD, Arnow K, Trickey AW, Dickerson K, Wagner TH, Harris AHS, Tran LD, Bereknyei S, Morris AM, Spain DA, Knowlton LM. Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage. J Trauma Acute Care Surg 2021; 91:249-259. [PMID: 33783416 DOI: 10.1097/ta.0000000000003195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE Economic, level IV.
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Affiliation(s)
- Joshua D Jaramillo
- From the Division of General Surgery, Department of Surgery (J.D.J., K.D.), Stanford University School of Medicine; Department of Surgery, (K.A., A.W.T., T.H.W., A.H.S.H., L.D.T., S.B., A.M.M., L.M.K.), Stanford-Surgery Policy Improvement Research and Education Center, Stanford University School of Medicine; and Department of Surgery (D.A.S., L.M.K.), Section of Trauma, Surgical Critical Care and Acute Care Surgery (L.M.K.), Stanford University, Stanford, California
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Affiliation(s)
- Sara Rosenbaum
- From the Milken Institute School of Public Health, George Washington University, Washington, DC
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Daw JR, Eckert E, Allen HL, Underhill K. Extending Postpartum Medicaid: State and Federal Policy Options during and after COVID-19. J Health Polit Policy Law 2021; 46:505-526. [PMID: 33647969 DOI: 10.1215/03616878-8893585] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The United States is facing a maternal health crisis with rising rates of maternal mortality and morbidity and stark disparities in maternal outcomes by race and socioeconomic status. Among the efforts to address this issue, one policy proposal is gaining particular traction: extending the period of Medicaid eligibility for pregnant women beyond 60 days after childbirth. The authors examine the legislative and regulatory pathways most readily available for extending postpartum Medicaid, including their relative political, economic, and public health trade-offs. They also review the state and federal policy activity to date and discuss the impact of the COVID-19 pandemic on the prospects for policy change.
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Affiliation(s)
| | - Emily Eckert
- American College of Obstetricians and Gynecologists
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21
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Affiliation(s)
- Samuel U Takvorian
- From the Division of Hematology and Oncology (S.U.T.) and the Department of Internal Medicine (S.U.T., C.E.G.), Perelman School of Medicine, and the Leonard Davis Institute of Health Economics (S.U.T., C.E.G.), University of Pennsylvania, Philadelphia; and the Division of Health Policy and Economics, Department of Population Health Sciences, Weill Medical College, Cornell University, New York (W.L.S.)
| | - Carmen E Guerra
- From the Division of Hematology and Oncology (S.U.T.) and the Department of Internal Medicine (S.U.T., C.E.G.), Perelman School of Medicine, and the Leonard Davis Institute of Health Economics (S.U.T., C.E.G.), University of Pennsylvania, Philadelphia; and the Division of Health Policy and Economics, Department of Population Health Sciences, Weill Medical College, Cornell University, New York (W.L.S.)
| | - William L Schpero
- From the Division of Hematology and Oncology (S.U.T.) and the Department of Internal Medicine (S.U.T., C.E.G.), Perelman School of Medicine, and the Leonard Davis Institute of Health Economics (S.U.T., C.E.G.), University of Pennsylvania, Philadelphia; and the Division of Health Policy and Economics, Department of Population Health Sciences, Weill Medical College, Cornell University, New York (W.L.S.)
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22
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Spargo A, Yost C, Squires P, Raju A, Schroader B, Brown JD. The effects of oral anticancer parity laws on out-of-pocket spending and adherence among commercially insured patients with chronic myeloid leukemia. J Manag Care Spec Pharm 2021; 27:554-564. [PMID: 33908275 PMCID: PMC10391131 DOI: 10.18553/jmcp.2021.27.5.554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Over the past 12 years, 43 states and Washington DC have implemented oral anticancer medication parity laws in response to the burden of pharmacy cost sharing. Parity laws are designed to provide equal coverage and cost sharing between orally and parenterally administered anticancer medications for patients in commercial, fully insured health plans (FIHPs). However, there is considerable state-level variation in the requirements to achieve compliance with parity laws, and the clinical and economic effectiveness of parity is not fully known. OBJECTIVES: To (a) understand the impact of parity laws on out-of-pocket (OOP) spending and adherence to tyrosine kinase inhibitors (TKI) among commercially insured patients with chronic myeloid leukemia (CML) and (b) compare these effects across states with and without per prescription or per 30-day OOP spending limits as part of their parity laws. METHODS: Patients aged 18-64 years with CML, at least 1 pharmacy claim for a TKI, and residence in a state that implemented oral anticancer parity legislation between January 1, 2007, and January 1, 2017, were identified from the IBM MarketScan Commercial Claims and Encounters database. A propensity score-weighted difference-in-difference approach was used to measure the impact of parity on OOP spending and adherence in the 6 months after the first pharmacy claim for a TKI (index date) for patients enrolled in FIHPs (subject to parity) and self-funded health plans (SFHPs; exempt from parity). OOP spending was standardized to a 30-day equivalent amount and adjusted to 2017 US dollars. Adherence was assessed using the proportion of days covered (PDC), and patients were categorized as adherent with PDC ≥ 0.80. RESULTS: Of 1,887 patients initiating a TKI before or after their state's parity law, 678 (35.9%) were enrolled in FIHPs (480 before vs 198 after parity), and 1,209 (64.1%) were enrolled in SFHPs (688 before vs 521 after parity). Implementation of parity laws was not associated with any changes in mean OOP spending; however, it was associated with a reduced likelihood of paying $0 per 30 days across all states (adjusted difference-in-difference [aDD] OR = 0.662; 95% CI = 0.535-0.820) and states without OOP spending limits (aDD OR = 0.654; 95% CI = 0.508-0.848), but not in states with limits. Nonsignificant but directionally opposite changes at each end of the OOP spending distribution were observed for states with and without OOP spending limits, with increased spending observed at the 75th, 90th, and 95th percentiles in states without limits. Mean PDC and adherence showed a nonsignificant increase among FIHP and SFHP patients across all states, states with limits, and states without limits. CONCLUSIONS: Oral anticancer parity laws are not associated with reduced OOP spending or improved adherence in a commercially insured sample of patients with CML. These findings were consistent for states that included OOP spending limits as a component of their parity laws. DISCLOSURES: This study did not receive any external funding. Spargo, Yost, Raju, and Schroader are or were employees of Xcenda, which receives contracts from various industry partners unrelated to this work. There are no other conflicts of interest to disclose.
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Affiliation(s)
- Andrew Spargo
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, and Xcenda, Palm Harbor, FL
| | - Christopher Yost
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, and Xcenda, Palm Harbor, FL
| | - Patrick Squires
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation & Safety, University of Florida College of Pharmacy, Gainesville, FL
| | | | | | - Joshua D Brown
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation & Safety, University of Florida College of Pharmacy, Gainesville, FL
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Affiliation(s)
- Karan R Chhabra
- From the Department of Surgery, Brigham and Women's Hospital, Boston (K.R.C.), the College of Law, Georgia State University, Atlanta (E.F.B.), and the Center for Evaluating Health Reform and the School of Public Health, University of Michigan, Ann Arbor (A.M.R.)
| | - Erin Fuse Brown
- From the Department of Surgery, Brigham and Women's Hospital, Boston (K.R.C.), the College of Law, Georgia State University, Atlanta (E.F.B.), and the Center for Evaluating Health Reform and the School of Public Health, University of Michigan, Ann Arbor (A.M.R.)
| | - Andrew M Ryan
- From the Department of Surgery, Brigham and Women's Hospital, Boston (K.R.C.), the College of Law, Georgia State University, Atlanta (E.F.B.), and the Center for Evaluating Health Reform and the School of Public Health, University of Michigan, Ann Arbor (A.M.R.)
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24
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Affiliation(s)
- John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Editor, JAMA Health Forum
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25
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Abstract
OBJECTIVE To provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use. DATA SOURCE/STUDY SETTING The Treatment Episodes Data Set (TEDS), 1996 to 2017. STUDY DESIGN A quasi-experimental difference-in-differences design using observational data. DATA COLLECTION The TEDS provides administrative data on admissions to specialty SUD treatment. PRINCIPAL FINDINGS Expansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6-18 years old are not statistically associated with SUD treatment. CONCLUSIONS Private insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.
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Affiliation(s)
- Sarah Hamersma
- Department of Public Administration and International AffairsSyracuse UniversitySyracuseNew YorkUSA
- Center for Policy ResearchSyracuseNew YorkUSA
| | - Johanna Catherine Maclean
- Department of EconomicsTemple UniversityPhiladelphiaPennsylvaniaUSA
- National Bureau of Economic ResearchCambridgeMassachusettsUSA
- Institute for the Study of LaborBonnGermany
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Affiliation(s)
- Vinay K Rathi
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Section of General Medicine (J.S.R.), Yale School of Medicine (J.L.J.), New Haven, CT; and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (S.S.D.)
| | - James L Johnston
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Section of General Medicine (J.S.R.), Yale School of Medicine (J.L.J.), New Haven, CT; and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (S.S.D.)
| | - Joseph S Ross
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Section of General Medicine (J.S.R.), Yale School of Medicine (J.L.J.), New Haven, CT; and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (S.S.D.)
| | - Sanket S Dhruva
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Section of General Medicine (J.S.R.), Yale School of Medicine (J.L.J.), New Haven, CT; and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (S.S.D.)
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27
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Kates J, Dawson L, Horn TH, Killelea A, McCann NC, Crowley JS, Walensky RP. Insurance coverage and financing landscape for HIV treatment and prevention in the USA. Lancet 2021; 397:1127-1138. [PMID: 33617778 DOI: 10.1016/s0140-6736(21)00397-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 08/21/2020] [Accepted: 09/25/2020] [Indexed: 11/17/2022]
Abstract
In 2010, the US health insurance system underwent one of its most substantial transformations with the passage of the Affordable Care Act, which increased coverage for millions of people in the USA, including those with and at risk of HIV. Even so, the system of HIV care and prevention services in the USA is a complex patchwork of payers, providers, and financing mechanisms. People with HIV are primarily covered by Medicaid, Medicare, private insurance, or a combination of these; many get care through other programmes, particularly the Ryan White HIV/AIDS Program, which serves as the nation's safety net for people with HIV who remain uninsured or underinsured but offers modest to no support for prevention services. While uninsurance has drastically declined over the past decade, the USA trails other high-income countries in key HIV-specific metrics, including rates of viral suppression. In this paper in the Series, we provide an overview of the coverage and financing landscape for HIV treatment and prevention in the USA, discuss how the Affordable Care Act has changed the domestic health-care system, examine the major programmes that provide coverage and services, and identify remaining challenges.
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Affiliation(s)
| | | | - Tim H Horn
- National Alliance of State and Territorial AIDS Directors (NASTAD), Washington, DC, USA
| | - Amy Killelea
- National Alliance of State and Territorial AIDS Directors (NASTAD), Washington, DC, USA
| | - Nicole C McCann
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey S Crowley
- O'Neill Institute for National and Global Health Law, Georgetown University, Washington, DC, USA
| | - Rochelle P Walensky
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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Malik AT, Alexander J, Khan SN, Scharschmidt TJ. Has the Affordable Care Act Been Associated with Increased Insurance Coverage and Early-stage Diagnoses of Bone and Soft-tissue Sarcomas in Adults? Clin Orthop Relat Res 2021; 479:493-502. [PMID: 32805094 PMCID: PMC7899708 DOI: 10.1097/corr.0000000000001438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of bone and soft-tissue sarcomas can be costly, and therefore, it is not surprising that insurance status of patients is a prognostic factor in determining overall survival. Furthermore, uninsured individuals with suspected bone and/or soft-tissue masses routinely encounter difficulty in obtaining access to basic healthcare (such as office visits, radiology scans), and therefore are more likely to be diagnosed with later stages at presentation. The Patient Protection and Affordable Care Act (ACA) mandate of 2010 aimed to increase access to care for uninsured individuals by launching initiatives, such as expanding Medicaid eligibility, subsidizing private insurance, and developing statewide mandates requiring individuals to have a prescribed minimum level of health insurance. Although prior reports have demonstrated that the ACA increased both coverage and the proportion of early-stage diagnoses among patients with common cancers (including breast, colon, prostate, and lung), it is unknown whether similar improvements have occurred for patients with bone and soft-tissue sarcomas. Understanding changes in insurance coverages and stage at diagnosis of patients with bone and soft-tissue sarcomas would be paramount in establishing policies that will ensure orthopaedic cancer care is made equitable and accessible to all. QUESTIONS/PURPOSES (1) Has the introduction of the ACA been associated with changes in insurance coverage for adult patients with newly diagnosed bone and soft-tissue sarcomas? (2) Did the introduction of health reforms under the ACA lead to an increased proportion of sarcoma diagnoses occurring at earlier disease stages? METHODS The 2007 to 2015 Surveillance, Epidemiology and End Results database was queried using International Classification of Diseases for Oncology codes for primary malignant bone tumors of the upper and lower extremity (C40.0 to C40.3), unspecified or other overlapping bone, articular cartilage, and joint and/or ribs, sternum, or clavicle (C40.8 to C40.9, C41.3, and C41.8 to C41.9), vertebral column (C41.2), pelvis (C41.4, C41.8, and C41.9), and soft-tissue sarcomas of the upper or lower extremity and/or pelvis (C49.1, C49.2, and C49.5). A total of 15,287 patients with newly diagnosed cancers were included, of which 3647 (24%) were malignant bone tumors and 11,640 (76%) were soft-tissue sarcomas. The study sample was divided into three cohorts according to specified time periods: pre-ACA from 2007 to 2010 (6537 patients), pre-Medicaid expansion from 2011 to 2013 (5076 patients), and post-Medicaid expansion from 2014 to 2015 (3674 patients). The Pearson chi square tests were used to assess for changes in the proportion of Medicaid and uninsured patients across the specified time periods: pre-ACA, pre-expansion and post-expansion. A differences-in-differences analysis was also performed to assess changes in insurance coverage for Medicaid and uninsured patients among states that chose to expand Medicaid coverage in 2014 under the ACA's provision versus those who opted out of Medicaid expansion. Since the database switched to using the American Joint Commission on Cancer (AJCC) 7th edition staging system in 2010, linear regression using data only from 2010 to 2015 was performed that assessed changes in cancer stage at diagnosis from 2010 to 2015 alone. After stratifying by cancer type (bone or soft-tissue sarcoma), Pearson chi square tests were used to assess for changes in the proportion of patients who were diagnosed with early, late, and unknown stage at presentation before Medicaid expansion (2011-2013) and after Medicaid expansion (2014-2015) among states that chose to expand versus those who did not. RESULTS After stratifying by time cohorts: pre-ACA (2007 to 2010), pre-expansion (2011 to 2013) and post-expansion (2014 to 2015), we observed that the most dramatic changes occurred after Medicaid eligibility was expanded (2014 onwards), with Medicaid proportions increasing from 12% (pre-expansion, 2011 to 2013) to 14% (post-expansion, 2014 to 2015) (p < 0.001) and uninsured proportions decreasing from 5% (pre-expansion, 2011 to 2013) to 3% (post-expansion, 2014 to 2015) (p < 0.001). A differences-in-differences analysis that assessed the effect of Medicaid expansion showed that expanded states had an increase in the proportion of Medicaid patients compared with non-expanded states, (3.6% [95% confidence interval 0.4 to 6.8]; p = 0.03) from 2014 onwards. For the entire study sample, the proportion of early-stage diagnoses (I/II) increased from 56% (939 of 1667) in 2010 to 62% (1137 of 1840) in 2015 (p = 0.003). Similarly, the proportion of unknown stage diagnoses decreased from 11% (188 of 1667) in 2010 to 7% (128 of 1840) in 2015 (p = 0.002). There was no change in proportion of late-stage diagnoses (III/IV) from 32% (540 of 1667) in 2010 to 31% (575 of 1840) in 2015 (p = 0.13). CONCLUSION Access to cancer care for patients with primary bone or soft-tissue sarcomas improved after the ACA was introduced, as evidenced by a decrease in the proportion of uninsured patients and corresponding increase in Medicaid coverage. Improvements in coverage were most significant among states that adopted the Medicaid expansion of 2014. Furthermore, we observed an increasing proportion of early-stage diagnoses after the ACA was implemented. The findings support the preservation of the ACA to ensure cancer care is equitable and accessible to all vulnerable patient populations. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Azeem Tariq Malik
- A. T. Malik, J. Alexander, S. N. Khan, T. J. Scharschmidt, The James Cancer Hospital and Solove Research Institute, the Ohio State University Wexner Medical Center, Columbus, OH, USA
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29
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Affiliation(s)
- Stacie B Dusetzina
- Vanderbilt University School of Medicine, Department of Health Policy, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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30
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Affiliation(s)
- Melissa W Wachterman
- VA Boston Healthcare System, Boston, Massachusetts
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Benjamin D Sommers
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
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Affiliation(s)
| | | | - Lawrence O Gostin
- O'Neill Institute for National and Global Health Law, Georgetown University, Washington, DC
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32
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Affiliation(s)
- Andrew Bindman
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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33
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Affiliation(s)
- Daphna Stroumsa
- From the Department of Obstetrics and Gynecology (D.S.), the Institute for Healthcare Policy and Innovation (D.S.), and the Institute for Research on Women and Gender (A.R.K.), University of Michigan, Ann Arbor
| | - Anna R Kirkland
- From the Department of Obstetrics and Gynecology (D.S.), the Institute for Healthcare Policy and Innovation (D.S.), and the Institute for Research on Women and Gender (A.R.K.), University of Michigan, Ann Arbor
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Angier H, Huguet N, Ezekiel-Herrera D, Marino M, Schmidt T, Green BB, DeVoe JE. New hypertension and diabetes diagnoses following the Affordable Care Act Medicaid expansion. Fam Med Community Health 2020; 8:e000607. [PMID: 33334850 PMCID: PMC7747613 DOI: 10.1136/fmch-2020-000607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess the Affordable Care Act (ACA) Medicaid expansion's impact on new hypertension and diabetes diagnoses in community health centres (CHCs). DESIGN Rates of new hypertension and diabetes diagnoses were computed using generalised estimating equation Poisson models and we tested the difference-in-difference (DID) pre-ACA versus post-ACA in states that expanded Medicaid compared with those that did not. SETTING We used electronic health record data (pre-ACA: 1 January 2012-31 December 2013-post-ACA: 1 January 2014-31 December 2016) from the Accelerating Data Value Across a National Community Health Center Network clinical data network. We included clinics with ≥50 patients contributing to person-time-at risk in each study year. PARTICIPANTS Patients aged 19-64 with ≥1 ambulatory visit in the study period were included. We then excluded patients who were pregnant during the study period (N=127 530). For the hypertension outcome, we excluded individuals with a diagnosis of hypertension prior to the start of the study period, those who had a hypertension diagnosis on their first visit to a clinic or their first visit after 3 years without a visit, and those who had a diagnosis more than 3 years after their last visit (pre-ACA non-expansion N=130 973; expansion N=193 198; post-ACA non-expansion N=186 341; expansion N=251 015). For the diabetes analysis, we excluded patients with a diabetes diagnosis prior to study start, on their first visit or first visit after inactive patient status, and diagnosis while not an active patient (pre-ACA non-expansion N=145 435; expansion N=198 558; post-ACA non-expansion N=215 039; expansion N=264 644). RESULTS In non-expansion states, adjusted hypertension diagnosis rates saw a relative decrease of 6%, while in expansion states, the adjusted rates saw a relative increase of 7% (DID 1.14, 95% CI 1.11 to 1.18). For diabetes diagnosis, adjusted rates in non-expansion states experienced a significant relative increase of 28% and in expansion states the relative increase was 25%; yet these differences were not significant pre-ACA to post-ACA comparing expansion and non-expansion states (DID 0.98, 95% CI 0.91 to 1.05). CONCLUSION There was a differential impact of Medicaid expansion for hypertension and diabetes diagnoses. Moderate increases were found in diabetes diagnosis rates among all patients served by CHCs post-ACA (both in expansion and non-expansion states). These increases suggest that ACA-related opportunities to gain health insurance (such as marketplaces and the Medicaid expansion) may have facilitated access to diagnostic tests for this population. The study found a small change in hypertension diagnosis rates from pre-ACA to post-ACA (a decrease in non-expansion and an increase in expansion states). Despite the significant difference between expansion and non-expansion states, the small change from pre-ACA to post-ACA suggests that the diagnosis of hypertension is likely documented for patients, regardless of health insurance availability. Future studies are needed to understand the impact of the ACA on hypertension and diabetes treatment and control.
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Affiliation(s)
- Heather Angier
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nathalie Huguet
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Miguel Marino
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon, USA
| | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Jennifer E DeVoe
- Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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35
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Affiliation(s)
- R Alta Charo
- From the University of Wisconsin Law School, Madison
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36
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Perone AK. Protecting Health Care for Transgender Older Adults Amidst a Backlash of U.S. Federal Policies. J Gerontol Soc Work 2020; 63:743-752. [PMID: 32921277 DOI: 10.1080/01634372.2020.1808139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 06/11/2023]
Abstract
While transgender older adults and advocacy organizations have won important victories in health care for transgender older adults, significant barriers remain. New federal leadership in the United States has brought a bevy of backlash in federal policies that present challenges in accessing health care for transgender older adults. This article focuses on three key areas: insurance coverage for medically necessary care, discrimination, and religious-based exemptions to providing services. Social workers can play a pivotal role in supporting transgender older adults by staying informed of key policy issues and taking proactive steps to protecting the health care of this community.
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Affiliation(s)
- Angela K Perone
- School of Social Work, University of Michigan , Ann Arbor, Michigan, USA
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37
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Pauly MV. Health Policy after a Trump Election Victory. N Engl J Med 2020; 383:1503-1505. [PMID: 33053281 DOI: 10.1056/nejmp2029380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mark V Pauly
- From the Wharton School, University of Pennsylvania, Philadelphia
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Affiliation(s)
- Katherine Baicker
- From the University of Chicago, Chicago (K.B.); and the National Bureau of Economic Research (K.B., A.C.) and Harvard University (A.C.) - both in Cambridge, MA
| | - Amitabh Chandra
- From the University of Chicago, Chicago (K.B.); and the National Bureau of Economic Research (K.B., A.C.) and Harvard University (A.C.) - both in Cambridge, MA
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39
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Affiliation(s)
- Matthew Fiedler
- From the USC-Brookings Schaeffer Initiative for Health Policy, Brookings Institution, Washington, DC
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40
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Affiliation(s)
- Sandro Galea
- Boston University School of Public Health, Boston, MA 02119, USA.
| | - Catherine K Ettman
- Boston University School of Public Health, Boston, MA 02119, USA; Brown University School of Public Health, Providence, RI, USA
| | - Salma M Abdalla
- Boston University School of Public Health, Boston, MA 02119, USA
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Leopold C, Haffajee RL, Lu CY, Wagner AK. The Complex Cancer Care Coverage Environment - What is the Role of Legislation? A Case Study from Massachusetts. J Law Med Ethics 2020; 48:538-551. [PMID: 33021165 DOI: 10.1177/1073110520958879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Over the past decades, anti-cancer treatments have evolved rapidly from cytotoxic chemotherapies to targeted therapies including oral targeted medications and injectable immuno-oncology and cell therapies. New anti-cancer medications come to markets at increasingly high prices, and health insurance coverage is crucial for patient access to these therapies. State laws are intended to facilitate insurance coverage of anti-cancer therapies.Using Massachusetts as a case study, we identified five current cancer coverage state laws and interviewed experts on their perceptions of the relevance of the laws and how well they meet the current needs of cancer care given rapid changes in therapies. Interviewees emphasized that cancer therapies, as compared to many other therapeutic areas, are unique because insurance legislation targets their coverage. They identified the oral chemotherapy parity law as contributing to increasing treatment costs in commercial insurance. For commercial insurers, coverage mandates combined with the realities of new cancer medications - including high prices and often limited evidence of efficacy at approval - compound a difficult situation. Respondents recommended policy approaches to address this challenging coverage environment, including the implementation of closed formularies, the use of cost-effectiveness studies to guide coverage decisions, and the application of value-based pricing concepts. Given the evolution of cancer therapeutics, it may be time to evaluate the benefits and challenges of cancer coverage mandates.
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Affiliation(s)
- Christine Leopold
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
| | - Rebecca L Haffajee
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
| | - Christine Y Lu
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
| | - Anita K Wagner
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
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GOLDENBERG TAMAR, L. REISNER SARI, W. HARPER GARY, E. GAMAREL KRISTI, STEPHENSON ROB. State-Level Transgender-Specific Policies, Race/Ethnicity, and Use of Medical Gender Affirmation Services among Transgender and Other Gender-Diverse People in the United States. Milbank Q 2020; 98:802-846. [PMID: 32808696 PMCID: PMC7482380 DOI: 10.1111/1468-0009.12467] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Policy Points Protective transgender-specific policies (including those related to experiences of discrimination, health insurance coverage, and changing legal documents) are associated with increased access to medical gender affirmation services (hormone treatment, therapy/counseling) for transgender and other gender-diverse people. Restrictive transgender-specific policies are associated with less access to these services. The relationship between race/ethnicity and use of medical gender affirmation services varies across states and is context specific, indicating that race/ethnicity also plays a role in access to these types of care across states. Advocacy is needed to prevent or overturn restrictive policies and promote protective policies for transgender and other gender-diverse people, especially for people of color. CONTEXT In the 2010s, the number of federal, state, and local transgender-specific policies increased. Some of these policies advanced protections for transgender and other gender-diverse (TGGD) people, and others were restrictive. Little is known about the relationships between these policies and use of medical gender affirmation services (eg, hormone treatment, therapy/counseling), or about how these associations may vary among different racial and ethnic groups. METHODS Multilevel modeling was used to examine the associations between state-level transgender-specific policies and the use of medical gender affirmation services among TGGD people in the United States. Data are from the 2015 U.S. Trans Survey of nearly 28,000 TGGD people. The medical gender affirmation services examined in this study were hormone treatment and therapy/counseling. The state policies we analyzed addressed discrimination, health insurance coverage, and changing legal documents; these policies were measured individually and as a composite index. Race/ethnicity was included in the multilevel regression models as a random slope to determine whether the relationship between race/ethnicity and the use of medical gender affirmation services varied by state. FINDINGS Individual policies and the policy index were associated with both outcomes (use of therapy/counseling and hormone treatment services), indicating that protective policies were associated with increased care. Broad religious exemption laws and Medicaid policies that excluded transgender-specific care were both associated with less use of therapy/counseling, whereas transgender-care-inclusive Medicaid policies were associated with more use of therapy/counseling. Nondiscrimination protections that include gender identity were associated with increased use of hormone treatment services. The relationship between race/ethnicity and medical gender affirmation services varied across states. CONCLUSIONS State-level transgender-specific policies influence medical gender affirmation service use and seem to affect use by non-Hispanic white TGGD people and TGGD people of color differently. Advocacy is needed to repeal restrictive policies and promote protective policies in order to reduce health inequities among TGGD people, especially people of color.
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Affiliation(s)
- TAMAR GOLDENBERG
- Carolina Population CenterUniversity of North Carolina at Chapel Hill
| | - SARI L. REISNER
- Harvard Medical School/Boston Children's Hospital
- Harvard T.H. Chan School of Public Health
- Fenway Health
| | | | - KRISTI E. GAMAREL
- University of Michigan School of Public Health
- Center for Sexuality and Health DisparitiesUniversity of Michigan
| | - ROB STEPHENSON
- Center for Sexuality and Health DisparitiesUniversity of Michigan
- University of Michigan School of Nursing
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Abstract
This commentary describes limitations of mental health parity requirements in ensuring access to insurance coverage for mental health treatment and surveys regulatory options employed by states in Medicaid managed care programs as supplements to parity that can further reduce the risk of inappropriate denials of coverage.
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Affiliation(s)
- Matthew B Lawrence
- Matthew B. Lawrence, J.D., is Associate Professor at Emory Law and affiliated faculty and an academic fellow alumnus of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School
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44
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Affiliation(s)
- Andrew D Carlo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Brian S Barnett
- Neurological Institute, Center for Behavioral Health, Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
| | - Richard G Frank
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Glied S, Khalid A, Tavenner MB. The Secretary Shall . . . : Implementing the Affordable Care Act's Private Insurance Expansions. J Health Polit Policy Law 2020; 45:517-532. [PMID: 32186329 DOI: 10.1215/03616878-8255457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The federal bureaucracy played a critical role in implementing most aspects of the Affordable Care Act's private insurance coverage expansion. Through brief case studies, the authors review three dimensions of this role: the development of the Center for Consumer Information and Insurance Oversight, rulemaking in the formulation of the essential health benefits package, and the implementation of the federal website. They relate these to themes in the public administration literature. Politics-both through state decisions and through continuing congressional action (and inaction)-pervaded the implementation process. The challenges of staffing and situating the new bureaucracy effectively changed vertical boundaries within the Department of Health and Human Services, with long-lasting consequences. Finally, the complex design of the policy itself made passage of the legislation easier but implementation much more difficult. Ultimately, however, implementation was remarkably successful, achieving improvements in coverage consistent with the Congressional Budget Office's projections.
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Moss HA, Wu J, Kaplan SJ, Zafar SY. The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review. J Natl Cancer Inst 2020; 112:779-791. [PMID: 32277814 PMCID: PMC7825479 DOI: 10.1093/jnci/djaa043] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum. METHODS A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria. RESULTS A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities. CONCLUSIONS Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.
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Affiliation(s)
| | - Jenny Wu
- Duke University School of Medicine, Durham NC, USA
| | | | - S Yousuf Zafar
- Duke Cancer Institute, Duke-Margolis Center for Health Policy, Durham, NC, USA
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47
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Oberlander J. Introduction: The ACA at 10. J Health Polit Policy Law 2020; 45:461-464. [PMID: 32186348 DOI: 10.1215/03616878-8255409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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48
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Rajbhandari-Thapa J, Zhang D, MacLeod KE, Thapa K. Impact of Medicaid Expansion on Insurance Coverage Rates Among Adult Populations with Low Income and by Obesity Status. Obesity (Silver Spring) 2020; 28:1219-1223. [PMID: 32304356 PMCID: PMC8627371 DOI: 10.1002/oby.22793] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study examines insurance coverage rates among working-age adults with low income and with or without obesity before and after Medicaid expansion under the Affordable Care Act. METHODS Individual-level data on noninstitutionalized and nonpregnant adult participants aged 18 to 64 years with household income below $15,000 from the Centers for Disease Control and Prevention 2006-2017 Behavioral Risk Factor Surveillance System were used. A difference-in-differences design with logistic regression was used to examine the likelihood of insurance coverage before and after Medicaid expansion. RESULTS Working-age adults (analytic sample N = 316,151) who were white, female, less educated, unemployed, and living in a Medicaid-expansion state were more likely to have insurance coverage. The insurance coverage rate in Medicaid-expanded states in years after expansion increased for both subgroups with and without obesity. However, the increase was slightly lower for the subpopulation with obesity (5.59%, 95% CI: 2.35%-8.83%) compared with the subpopulation without obesity (7.35%, 95% CI: 5.35%-9.34%). CONCLUSIONS Increased attention should be paid to reduce insurance coverage barriers for working-age adults with low income and obesity to address potential health disparities caused by lack of access to care. This is important, as access to care provides opportunities to increase prevention and treatment-oriented services to address obesity and associated health care costs.
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Affiliation(s)
- Janani Rajbhandari-Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Donglan Zhang
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Kara E. MacLeod
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
| | - Kiran Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia, USA
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Abstract
OBJECTIVE Diabetes is a chronic health condition contributing to a substantial burden of disease. According to the Robert Wood Johnson Foundation, 10.9 million people were newly insured by Medicaid between 2013 and 2016. Considering this coverage expansion, the Affordable Care Act (ACA) could significantly affect people with diabetes in their management of the disease. This study evaluates the impact of the Medicaid expansion under the ACA on diabetes management. RESEARCH DESIGN AND METHODS This study includes 22,335 individuals with diagnosed diabetes from the 2011 to 2016 Behavioral Risk Factor Surveillance System. It uses a difference-in-differences approach to evaluate the impact of the Medicaid expansion on self-reported access to health care, self-reported diabetes management, and self-reported health status. Additionally, it performs a triple-differences analysis to compare the impact between Medicaid expansion and nonexpansion states considering diabetes rates of the states. RESULTS Significant improvements in Medicaid expansion states as compared with non-Medicaid expansion states were evident in self-reported access to health care (0.09 score; P = 0.023), diabetes management (1.91 score; P = 0.001), and health status (0.10 score; P = 0.026). Among states with large populations with diabetes, states that expanded Medicaid reported substantial improvements in these areas in comparison with those that did not expand. CONCLUSIONS The Medicaid expansion has significant positive effects on self-reported diabetes management. While states with large diabetes populations that expanded Medicaid have experienced substantial improvements in self-reported diabetes management, non-Medicaid expansion states with high diabetes rates may be facing health inequalities. The findings provide policy implications for the diabetes care community and policy makers.
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Affiliation(s)
- Jusung Lee
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX
| | - Timothy Callaghan
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX
| | - Marcia Ory
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX
| | - Hongwei Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX
| | - Jane N Bolin
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX
- College of Nursing, Texas A&M University, College Station, TX
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50
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Affiliation(s)
- Benjamin D Sommers
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Heidi L Allen
- School of Social Work, Columbia University, New York, New York
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