Search

OBJECTIVE: To investigate Covid-19 vaccination as a potential secondary public health benefit of case management for Medicaid beneficiaries with health and social needs. DATA SOURCES AND STUDY SETTING: The CommunityConnect case management program for Medicaid beneficiaries is run by Contra Costa Health, a county safety net health system in California. Program enrollment data were merged with comprehensive county vaccination records. STUDY DESIGN: Individuals with elevated risk of hospital and emergency department use were randomized each month to a case management intervention or usual care. Interdisciplinary case managers offered coaching, community referrals, healthcare connections, and other support based on enrollee interest and need. Using survival analysis with intent-to-treat assignment, we assessed rates of first-dose Covid-19 vaccination from December 2020 to September 2021. In exploratory sub-analyses we also examined effect heterogeneity by gender, race/ethnicity, age, and primary language. DATA COLLECTION AND EXTRACTION METHODS: Data were extracted from county and program records as of September 2021, totaling 12,866 interventions and 25,761 control enrollments. PRINCIPAL FINDINGS: Approximately 58% of enrollees were female and 41% were under age 35. Enrollees were 23% White, 12% Asian/Pacific Islander, 20% Black/African American, and 36% Hispanic/Latino, and 10% other/unknown. Approximately 35% of the intervention group engaged with their case manager. Approximately 56% of all intervention and control enrollees were vaccinated after 9 months of analysis time. Intervention enrollees had a higher vaccination rate compared to control enrollees (adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 1.02-1.10). In sub-analyses, the intervention was associated with stronger likelihood of vaccination among males and individuals under age 35. CONCLUSIONS: Case management infrastructure modestly improved Covid-19 vaccine uptake in a population of Medicaid beneficiaries that over-represents social groups with barriers to early Covid-19 vaccination. Amidst mixed evidence on vaccination-specific incentives, leveraging trusted case managers and existing case management programs may be a valuable prevention strategy.

BACKGROUND: Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery. METHODS: The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity. RESULTS: Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or other race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers. CONCLUSIONS: The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

ImportanceHousing deposits and tenancy supports have become new Medicaid benefits in multiple states; however, evidence on impacts from these specific housing interventions is limited.ObjectiveTo evaluate the association of rental housing deposits and health care use among Medicaid beneficiaries receiving social needs case management as part of a Whole-Person Care (Medicaid 1115 waiver) pilot program in California.Design, setting, and participantsThis cohort study compared changes in health care use among a group of adults who received a housing deposit between October 2018 and December 2021 along with case management vs a matched comparison group who received case management only in Contra Costa County, California, a large county in the San Francisco Bay Area. All participants were enrolled in health and social needs case management based on elevated risk of acute care use. Data analysis took place from March 2023 to June 2024.ExposureRental housing deposit funds that covered 1-time moving transition costs. Funds averaged $1750 per recipient.Main outcomes and measuresChanges in hospitalizations, emergency department visits, primary care visits, specialty care visits, behavioral health visits, psychiatric emergency services, or detention intakes during the 6 months before vs 6 months after deposit receipt. Changes 12 months before and after deposit receipt were examined as a sensitivity analysis.ResultsOf 1690 case management participants, 845 received a housing deposit (362 [42.8%]

Musculoskeletal urgent care centers (MUCCs) are an increasingly common alternative to emergency departments for patients with orthopedic injuries. As there is a lack of longitudinal data regarding MUCCs impact on the emergency health care system, our study seeks to understand recent trends in MUCC growth and their acceptance of Medicaid insurance. Over the last 6 years, at 2-year intervals (2019, 2021, and 2023), we performed a search to identify all MUCCs in the United States. We determined the affiliation and Medicaid acceptance status of all MUCCs, including those that closed/opened between 2019, 2021, and 2023, to analyze trends in MUCC availability and Medicaid acceptance. In 2019, there were 558 MUCCs, which increased to 596 MUCCs in 2021 and then decreased to 555 MUCCs in 2023, representing a growth and then decline of approximately 7%. Overall, since June 2019, 90 MUCCs have opened and 95 MUCCs have closed. Medicaid acceptance increased nationally between 2019 and 2023, from 58% to 71%. Medicaid acceptance increased for both nonaffiliated and privately affiliated MUCCs. Medicaid acceptance has increased nationally from 2019 to 2023, while MUCC availability has gone through a period of growth and then reversion to 2019 levels. As MUCCs have demonstrated limited Medicaid acceptance previously, it is promising that Medicaid acceptance has improved and MUCCs are providing patients with an additional avenue to access orthopedic care.

ImportanceSignificant insurance status disparities have been demonstrated in head and neck cancer (HNC) outcomes. The effects of insurance status on HNC outcomes may be explained by differential access to high-quality care.ObjectiveTo evaluate the association of insurance status with the quality of the treating hospital and receipt of guideline-compliant care among patients with HNC.Design, setting, and participantsThis retrospective cohort study of data from the California Cancer Registry dataset linked with discharge records and hospital characteristics from the California Department of Health Care Access and Information included adult patients with HNC diagnosed between January 1, 2010, and December 31, 2019. Data were analyzed from May 10, 2023, to March 25, 2024.ExposuresInsurance status: commercial, Medicare, Medicaid, uninsured, other, or unknown.Main outcomes and measuresQuality of the treating hospital (tertiles), receipt of National Comprehensive Cancer Network guideline-compliant care, and overall survival.ResultsA total of 23 933 patients (mean [SD] age, 64.8 [12.3] years; 75.3% male) met the inclusion criteria. Treatment in top-tertile hospitals (hazard ratio, 0.87; 95% CI, 0.79-0.95) was associated with improved overall survival compared with treatment in bottom-tertile hospitals. Medicare (odds ratio [OR], 0.78; 95% CI, 0.73-0.84), Medicaid (OR, 0.60; 95% CI, 0.54-0.66), and uninsured (OR, 0.38; 95% CI, 0.29-0.49) status were associated with lower likelihood of treatment in high-quality hospitals compared with commercial insurance. Among patients with advanced disease, Medicaid (OR, 0.72; 95% CI, 0.62-0.83) and uninsured (OR, 0.64; 95% CI, 0.44-0.93) patients were less likely to receive dual-modality therapy. Among patients with surgically resected advanced disease, Medicaid coverage (OR, 0.73; 95% CI, 0.58-0.93) was associated with lower likelihood of receiving adjuvant radiotherapy.Conclusions and relevanceThis study found significant insurance disparities in quality of care among patients with HNC. These findings highlight the need for continued health insurance reform in the US to improve the quality of insurance coverage, in addition to expanding access to health insurance.

In 2008, Oregon expanded its Medicaid program using a lottery, creating a rare opportunity to study the effects of Medicaid coverage using a randomized controlled design (Oregon Health Insurance Experiment). Analysis showed that Medicaid coverage lowered the risk of depression. However, this effect may vary between individuals, and the identification of individuals likely to benefit the most has the potential to improve the effectiveness and efficiency of the Medicaid program. By applying the machine learning causal forest to data from this experiment, we found substantial heterogeneity in the effect of Medicaid coverage on depression; individuals with high predicted benefit were older and had more physical or mental health conditions at baseline. Expanding coverage to individuals with high predicted benefit generated greater reduction in depression prevalence than expanding to all eligible individuals (21.5 vs 8.8 percentage-point reduction; adjusted difference = +12.7 [95% CI, +4.6 to +20.8]; P = 0.003), at substantially lower cost per case prevented ($16 627 vs $36 048; adjusted difference = -$18 598 [95% CI, -156 953 to -3120]; P = 0.04). Medicaid coverage reduces depression substantially more in a subset of the population than others, in ways that are predictable in advance. Targeting coverage on those most likely to benefit could improve the effectiveness and efficiency of insurance expansion. This article is part of a Special Collection on Mental Health.

BackgroundThe Affordable Care Act expanded Medicaid coverage for people with low income in the United States. Expanded insurance coverage could promote more timely access to cancer treatment, which could improve overall survival (OS), yet the long-term effects of Medicaid expansion (ME) remain unknown. We evaluated whether ME was associated with improved timely treatment initiation (TTI) and 3-year OS among patients with breast, cervical, colon, and lung cancers who were affected by the policy.MethodsMedicaid-insured or uninsured patients aged 40-64 with stage I-III breast, cervical, colon, or non-small cell lung cancer within the National Cancer Database (NCDB). A difference-in-differences (DID) approach was used to compare changes in TTI (within 60 days) and 3-year OS between patients in ME states versus nonexpansion (NE) states before (2010-2013) and after (2015-2018) ME. Adjusted DID estimates for TTI and 3-year OS were calculated using multivariable linear regression and Cox proportional hazards regression models, respectively.ResultsME was associated with a relative increase in TTI within 60 days for breast (DID = 4.6; p

INTRODUCTION: The U.S. safety net, which provides critical aid to households with low income, is composed of a patchwork of separate programs, and many people with low income benefit from accessing

The healthcare system in the United States ought to provide its citizens with unhindered access to high quality medical care as well as equitable treatment and coverage. Legislation to advance access to healthcare, such as the creation of the Medicare and Medicaid programs in 1965 and the Affordable Care Act in 2008, have been appropriate steps forward in achieving these goals, but obstacles to healthcare access still persist for many Americans. Healthcare access is hindered by foundational problems, such as a large uninsured population, inadequate infrastructure and facilities, and high costs for services. In rural communities, these problems assume different social and economic contexts and thus require their own separate evaluation. Rural Americans currently lack effective access to healthcare, despite existing policies aimed at improving access by making healthcare more affordable. In this article, I will explain different facts of the discussion revolving around rural healthcare access and analyze specific problems in the area. There are three policy directives that are essential to the expansion of rural healthcare access: public private partnerships, loan forgiveness for doctors serving at critical access hospitals, and expansion of the telehealth network. These avenues expand rural healthcare access, minimize government expenditure, and maximize public benefits.

BACKGROUND: While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (Californias Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

OBJECTIVE: There has been little evidence of the impact of preventive services during pregnancy covered under the Affordable Care Act (ACA) on birthing parent and infant outcomes. To address this gap, this study examines the association between Medicaid expansion under the ACA and birthing parent and infant outcomes of low-income pregnant people. METHODS: This study used individual-level data from the 2004-2017 annual waves of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is a surveillance project of the Centers for Disease Control and Prevention and health departments that annually includes a representative sample of 1,300 to 3,400 births per state, selected from birth certificates. Birthing parents outcomes of interest included timing of prenatal care, gestational diabetes, hypertensive disorders of pregnancy, cigarette smoking during pregnancy, and postpartum care. Infant outcomes included initiation and duration of breastfeeding, preterm birth, and birth weight. The association between ACA Medicaid expansion and the birthing parent and infant outcomes were examined using difference-in-differences estimation. RESULTS: There was no association between Medicaid expansion and the outcomes examined after correcting for multiple testing. This finding was robust to several sensitivity analyses. CONCLUSIONS FOR PRACTICE: Study findings suggest that expanded access to more complete insurance benefits with limited cost-sharing for pregnant people, a group that already had high rates of insurance coverage, did not impact the birthing parents and infant health outcomes examined.

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

Objective: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. Methods: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. Results: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (-.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (-.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (-.35%, P-value= .02). Conclusions: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.

INTRODUCTION/OBJECTIVES: More time spent with interpreters may support clinician-patient communication for patients with limited English proficiency (LEP), especially when interpreter support before and after clinical encounters is considered. We assessed whether more time spent with interpreters is associated with better patient-reported experiences of clinician-patient communication and interpreter support among patients with LEP. METHODS: Patients with LEP (n = 338) were surveyed about their experiences with both the clinician and interpreter. Duration of interpreter support during the encounter (in min) and auxiliary time spent before and after encounters supporting patients (in min) were documented by interpreters. Multivariable linear regression models were estimated to assess the association of the time duration of interpreter support and patient experiences of (1) clinician-patient communication, and (2) interpreter support, controlling for patient and encounter characteristics. RESULTS: The average encounter duration was 47.7 min (standard deviation, SD = 25.1), the average auxiliary time was 43.8 min (SD = 16.4), and the average total interpreter time was 91.1 min (SD = 28.6). LEP patients reported better experiences of interpreter support with a mean score of 97.4 out of 100 (SD = 6.99) compared to clinician-patient communication, with a mean score of 93.7 out of 100 (SD = 14.1). In adjusted analyses, total patient time spent with an interpreter was associated with better patient experiences of clinician-patient communication (β = 7.23, P

BackgroundThe rates of suicide and opioid use disorder (OUD) among pregnant and postpartum women continue to increase. This research characterized OUD and suicide attempts among Medicaid-enrolled perinatal women and examined prenatal OUD diagnosis as a marker for postpartum suicide attempts.MethodsData from Oregon birth certificates, Medicaid eligibility and claims files, and hospital discharge records were linked and analyzed. The sample included Oregon Medicaid women aged 15-44 who became pregnant and gave live births between January 2008 and January 2016 (N = 61,481). Key measures included indicators of suicide attempts (separately for any means and opioid poisoning) and OUD diagnosis, separately assessed during pregnancy and the one-year postpartum period. Probit regression was used to examine the overall relationship between prenatal OUD diagnosis and postpartum suicide attempts. A simultaneous equations model was employed to explore the link between prenatal OUD diagnosis and postpartum suicide attempts, mediated by postpartum OUD diagnosis.ResultsThirty-three prenatal suicide attempts by any means were identified. Postpartum suicide attempts were more frequent with 58 attempts, corresponding to a rate of 94.3 attempts per 100,000. Of these attempts, 79% (46 attempts) involved opioid poisoning. A total of 1,799 unique women (4.6% of the sample) were diagnosed with OUD either during pregnancy or one-year postpartum with 53% receiving the diagnosis postpartum. Postpartum suicide attempts by opioid poisoning increased from 55.5 per 100,000 in 2009 to 105.1 per 100,000 in 2016. The rate of prenatal OUD also almost doubled over the same period. Prenatal OUD diagnosis was associated with a 0.15%-point increase in the probability of suicide attempts by opioid poisoning within the first year postpartum. This increase reflects a three-fold increase compared to the rate for women without a prenatal OUD diagnosis. A prenatal OUD diagnosis was significantly associated with an elevated risk of postpartum suicide attempts by opioid poisoning via a postpartum OUD diagnosis.ConclusionsThe risk of suicide attempt by opioid poisoning is elevated for Medicaid-enrolled reproductive-age women during pregnancy and postpartum. Women diagnosed with prenatal OUD may face an increased risk of postpartum suicides attempts involving opioid poisoning.

Objective Study Setting and Design Data Sources and Analytic Sample Principal Findings Conclusions To assess multi‐level factors influencing the sustainability of 26 social care pilots integrating medical and social services for Medicaid enrollees across California in newly developed Medicaid benefits.This qualitative study assessed the sustainability of Whole Person Care (WPC) pilots implemented between 2016 and 2021. Pilots (n = 26) represented a majority of counties in California.Primary qualitative data were collected between June and August 2021 and included 58 hour‐long, semi‐structured individual and group interviews with administrators, middle managers, and frontline case management staff representing all WPC pilots. We used hybrid inductive–deductive thematic analysis to identify and analyze patterns, and outliers, in factors influencing sustainment. Deductive codes included established implementation science factors influencing the sustainability of new programs (e.g., innovation characteristics, capacity, processes and interactions, and context).Of 26 WPC pilots, 22 pilots sustained WPC by contracting with Medicaid managed care plans to provide services as part of newly developed Medicaid benefits. Three pilots chose not to sustain before the pilot period ended and one pilot decided not to sustain following completion of the full pilot. Factors influencing sustainability included: (1) program adaptability and flexibility; (2) funding structure and reimbursement requirements; (3) shared leadership with managed care plans; and (4) whether pilots chose to build out program infrastructure internally or contracted out core components to partner organizations. Many pilots, particularly those in rural areas, indicated that system and policy changes introduced as part of transitioning pilot services into Medicaid benefits reduced the sustainability of WPC for participating providers.Multi‐level factors including program adaptability, funding, leadership, and capacity to build out infrastructure influenced the sustainability of WPC pilots. These findings have significant implications for health equity as equitable distribution of services, resources, and benefits from these programs can be supported through sustained implementation over time. [ABSTRACT FROM AUTHOR]

Objective Data Sources and Study Setting Study Design/Data Collection Principal Findings Conclusions To identify collaboration strategies used to integrate health, behavioral health, and social services for Medicaid members in California's Medi‐Cal Whole Person Care Pilot program (WPC).WPC was a social care intervention implemented to identify and address eligible members' health, behavioral health, and social needs. Data included semi‐structured key informant interviews conducted in 2018–2019 (n = 221) and 2021 (n = 167); pilot‐level surveys; whole‐network surveys of 507 organizations in all 25 pilots participating in WPC; and documents submitted by pilots to the state. Pilots served a total of 247,887 unique members between 2017 and 2021, the majority of whom were non‐white (72%) and over half of whom experienced homelessness.Data were collected as part of the statewide evaluation of WPC. We analyzed qualitative data to examine strategies used by pilots to integrate care, network data to identify pilots that improved cross‐sector collaboration (i.e., strengthened density or multiplexity of cross‐sector ties) following WPC implementation, and comparative case analysis to identify strategies that differentiated pilots that improved collaboration from those that did not.Pilots used multiple strategies to facilitate the integration of care. Network analyses identified 10 pilots that significantly improved either density or multiplexity of cross‐sector ties, and one pilot with high cross‐sector collaboration prior to WPC. Compared to pilots that did not improve cross‐sector collaboration, these pilots meaningfully engaged partners in program design and implementation, used braided funds, and leveraged WPC to support broader systems change. These pilots also reported fewer challenges in developing and managing contractual relationships and ensuring meaningful use of data‐sharing infrastructure by frontline staff responsible for care coordination.Data sharing is necessary but not sufficient for systems alignment. Collaboration strategies focused on addressing financial barriers to integration and strengthening normative and interpersonal integration are also needed. [ABSTRACT FROM AUTHOR]

Objectives. To compare pregnancy-related mortality ratios (PRMRs) associated with COVID-19 by race/ethnicity, by region of residence, and in states with and without Medicaid expansion. Methods. We used 2020–2021 data from the US Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research in our analysis. We stratified PRMRs by race/ethnicity, census regions, and Medicaid expansion and nonexpansion states. Results. The 2020–2021 PRMR was 40.3 per 100 000 live births. American Indian/ Alaska Native pregnant people had the greatest PRMR, followed by non-Hispanic Blacks and non-Hispanic Native Hawaiians/other Pacific Islanders. PRMRs associated with COVID-19 in the southern region were at least 2 times higher than in other regions and were highest for all pregnant people in the various racial/ethnic groups. PRMRs associated with COVID-19 were lower in Medicaid expansion states than in nonexpansion states. Conclusions. The US COVID-19 epidemic exacerbated racial and ethnic disparities in pregnancy-related mortality. Public Health Implications. The alarming increase in disparities among racial and ethnic pregnant people during the COVID-19 pandemic underscores the need to address social determinants of health at the structural level. (Am J Public Health. 2024;114(S9): S723–S730. https://doi.org/10.2105/AJPH.2024.307814) [ABSTRACT FROM AUTHOR]

Objective: To systematically review Medicaid policies state‐by‐state for gender‐affirming surgery coverage. Data Sources and Study Setting: Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals. Study Design: A cross‐sectional study evaluating Medicaid coverage for numerous gender‐affirming surgeries. Data Collection/Extraction Methods: We previously reported on state health policies that protect gender‐affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender‐affirming surgery. We analyzed Medicaid coverage for gender‐affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described. Principal Findings: Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender‐affirming chest procedure and at least one gender‐affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate. Conclusions: In 2022, 52.9% of states had health policies that protected gender‐affirming care under Medicaid; however, coverage for various gender‐affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction. [ABSTRACT FROM AUTHOR]

Objective: To examine differential changes in receipt of surgery at National Cancer Institute (NCI)‐designated comprehensive cancer centers (NCI‐CCC) and Commission on Cancer (CoC) accredited hospitals for patients with cancer more likely to be newly eligible for coverage under Affordable Care Act (ACA) insurance expansions, relative to those less likely to have been impacted by the ACA. Data Sources and Study Setting: Pennsylvania Cancer Registry (PCR) for 2010–2019 linked with discharge records from the Pennsylvania Health Care Cost Containment Council (PHC4). Study Design: Outcomes include whether cancer surgery was performed at an NCI‐CCC or a CoC‐accredited hospital. We conducted a difference‐in‐differences analysis, estimating linear probability models for each outcome that control for residence in a county with above median county‐level pre‐ACA uninsurance and the interaction between county‐level baseline uninsurance and cancer treatment post‐ACA to capture differential changes in access between those more and less likely to become newly eligible for insurance coverage (based on area‐level proxy). All models control for age, sex, race and ethnicity, cancer site and stage, census‐tract level urban/rural residence, Area Deprivation Index, and year‐ and county‐fixed effects. Data Collection/Extraction Methods: We identified adults aged 26–64 in PCR with prostate, lung, or colorectal cancer who received cancer‐directed surgery and had a corresponding surgery discharge record in PHC4. Principal Findings: We observe a differential increase in receiving care at an NCI‐CCC of 6.2 percentage points (95% CI: 2.6–9.8; baseline mean = 9.8%) among patients in high baseline uninsurance areas (p = 0.001). Our estimate of the differential change in care at the larger set of CoC hospitals is positive (3.9 percentage points [95% CI: −0.5‐8.2; baseline mean = 73.7%]) but not statistically significant (p = 0.079). Conclusions: Our findings suggest that insurance expansions under the ACA were associated with increased access to NCI‐CCCs. [ABSTRACT FROM AUTHOR]

National Federation of Independent Businesses v. Sebelius reshaped unconstitutional coercion jurisprudence: creating a three-part test for unconstitutional coercion while leaving the limits of the test undefined. Courts and commentators, faced with the confusion of applying Sebelius, have struggled to determine when and if Sebelius should apply. Stepping into this quagmire, this Comment applies the Sebelius rationale to Estate Recovery Programs (ERPs), a mandatory feature of Medicaid. Every year, millions of Americans are impacted by ERPs. The main feature of ERPs is the seizure of a Medicaid patient’s estate following their death to repay the cost of providing medical care. When states effectuate recovery, decedents’ families are often left shocked, unaware the state could take their family home. Notably, ERPs exacerbate existing wealth disparities and are linked to reduced access to healthcare, as knowing patients avoid Medicaid to escape the ERP. ERPs are ideal for exploring the limits of Sebelius because, to induce adoption of the ERP requirement, Congress and the Department of Health and Human Services threatened to end existing state Medicaid grants. This threat is the same inducement contemplated in Sebelius and held to be unconstitutionally coercive. To resolve the confusion about Sebelius, this Comment first presents a brief history of Medicaid. Then, it traces the development of ERPs and the impact of the requirement. The next section analyzes ERPs under the Sebelius coercion standard. Using this analysis, this Comment posits that the Sebelius coercion standard could apply to various federal programs and argues states should cease their ERPs. [ABSTRACT FROM AUTHOR]

Background: Psoriasis is a chronic, inflammatory skin condition requiring long-term care. However, many psoriasis patients may not regularly receive care. Several factors affect access to care in the United States, including health insurance status. Additionally, it is unknown how health insurance status impacts the healthcare-seeking behavior of psoriasis patients. Healthcare-seeking behavior is broadly defined as an individual's actions to prevent or treat a perceived health problem, such as visiting a physician's office. Because early diagnosis and timely treatment improve patient outcomes, determining how insurance status impacts psoriasis patients' healthcare-seeking behavior and their ability to get care is important. This allows us to identify patients at risk for being untreated or undertreated. In this study, we aimed to assess the relationship between insurance status and (1) the degree to which psoriasis patients delay seeking or receiving care and (2) the degree to which psoriasis patients are unable to obtain care. Methods: This population-based study used 20 years of data from the Medical Expenditure Panel Survey from 2002 to 2021. We calculated descriptive statistics and performed adjusted multivariable logistic regression analyses. Results: We identified a weighted total of 4,506,850 psoriasis patients. Compared to those with private insurance, psoriasis patients with public-only insurance were 2.7 times more likely to delay seeking or receiving care (95% CI, 1.26–5.87). Compared to private insurance patients, uninsured psoriasis patients were 3.4 times more likely to be unable to obtain care (95% CI, 1.31–8.92). Compared to those with public-only insurance, uninsured psoriasis patients were 3.7 times more likely to be unable to obtain care (95% CI, 1.32–10.38). Conclusions: This study found that psoriasis patients with public-only insurance were significantly more likely to delay seeking or receiving care compared to those with private insurance. This study also found that uninsured psoriasis patients were significantly more likely to be unable to obtain care than psoriasis patients with private insurance and those with public-only insurance. Developing strategies to increase healthcare access is necessary to ensure equitable, timely, and appropriate care for all psoriasis patients, regardless of their insurance status. [ABSTRACT FROM AUTHOR]

Introduction: Since the implementation of the Patient Protection and Affordable Care Act (ACA) and Medicaid expansion, states that adopted the policy have seen reduced uninsured rates. However, it is unclear whether increased healthcare access, particularly for minority and socioeconomically disadvantaged groups, has translated into measurable improvements in health outcomes. Objective: Our study aims to evaluate the impact of the ACA and Medicaid expansion on breast cancer outcomes in Louisiana, which has implemented the policy, compared to Georgia, which has not, as of 2024. Methodology: We conducted a retrospective study using SEER registry data from January 2011 to December 2021, including women aged 18-64 diagnosed with breast cancer. The impact of the ACA and Medicaid expansion on cancer-specific survival (CSS), overall survival (OS), and stage at presentation was evaluated. The cohort was divided into pre-ACA (2011-2015) and post-ACA (2017-2021) periods, with a one-year washout (2016). A difference-in-difference (DID) approach compared outcomes between Louisiana and Georgia. Results: The study analyzed 62,381 women with breast cancer, with 32,220 cases in the pre-ACA period (51.7%) and 30,161 in the post-ACA period (48.3%). In Georgia, 43,279 women were included (52.3% pre-ACA vs. 47.7% post-ACA), while Louisiana had 19,102 women (50.1% pre-ACA vs. 49.9% post-ACA). Medicaid expansion in Louisiana was associated with a 0.26 percentage point reduction in overall deaths (95% CI: -10.9 to 10.4) and a 5.97 percentage point reduction in cancer-specific mortality (95% CI: -26.1 to 14.2). There was also no significant difference in disease stage at presentation compared to Georgia. Conclusion: This study found no significant differences in overall mortality, cancer-specific mortality, or disease stage at presentation among women with breast cancer in Louisiana, which implemented Medicaid expansion in 2016, compared to Georgia, which has not expanded Medicaid. [ABSTRACT FROM AUTHOR]

Objective Study Setting and Design Data Sources and Analytic Sample Principal Findings Conclusions To test quantitative process measures characterizing the work of social needs case managers as they assisted patients with diverse health‐related needs—spanning both medical and social domains.The study analyzed secondary data on 7076 patients working with 147 case managers from the CommunityConnect social needs case management program in Contra Costa County, California from 2018 to 2021. The service—designed to be holistic with a focus on social determinants as root causes of health issues—helped patients navigate social services, health care, and mental health care.We used cross‐sectional analyses to quantitatively characterize electronic health records (EHRs) derived measures of case management intensity (goal updates), duration (days goal was open), and outcomes for 19 different categories of health and social goals. Mixed‐effects regression models were used to examine how work process measures varied according to goal categories. Models nested goals within patients within case managers and adjusted for patient‐level covariates.The most common goals were dental care (53%), food (40%), and housing (39%). In adjusted analyses, housing goals had significantly more case manager updates than any other type of goal with a marginal mean of 14.0 updates (95% CI: 13.4–14.7), were worked on for significantly longer (marginal mean of 417 days, 95% CI: 360–474) than any goal except dental care, and were least likely to be resolved. Utilities, insurance, and medication coordination goals were most likely to be resolved.Case managers and patients repeatedly worked on goals over many months. Meeting housing needs and accessing dental care were issues that were not easily resolved and required extensive follow‐up. One‐time referral interventions may need follow‐up systems to meaningfully support social and health needs. [ABSTRACT FROM AUTHOR]

Objective Study Setting and Design Data Sources and Analytic Sample Principal Findings Conclusions To evaluate healthcare cost and utilization changes among Medicaid and dually eligible participants of a supportive housing program implemented by a managed care organization and community‐based organization.Healthcare claims were reviewed retrospectively for 80 program participants in one urban Pennsylvania county between 1/1/2018 and 9/28/2023 who had ≥6 months of claims data in both pre‐ and post‐housing periods. Eligibility included age >18 years, Medicaid/Special Needs Plan enrollment, and housing need. Due to limited housing units, potential participants were prioritized by medical need and history of unplanned care.Healthcare cost and utilization were compared during pre‐ (i.e., 12 months before housing initiation) and post‐periods (i.e., 12 months after housing initiation).Compared to the pre‐period, significantly lower medical (−40.4%, p = 0.004), emergency department (−62.7%, p = 0.02), and total (−33.3%, p = 0.02) costs of care were observed in the post‐period. Significantly lower primary care (−50.0%, p = 0.0003), specialist (−31.3%, p = 0.02), and emergency department (−50.0%, p = 0.03) utilization were also observed.Healthcare cost and utilization among medically complex individuals were lower with supportive housing. Future evaluations with randomized designs can address the potential causal impact of supportive housing as a healthcare intervention on specific outcomes. [ABSTRACT FROM AUTHOR]

Background/Objectives: Tobacco use remains a significant public health issue, particularly among individuals with low incomes, including Medicaid recipients who often face multiple barriers to quitting. This study aimed to identify barriers, from the perspective of Medicaid managed care organizations (MCOs), influencing Medicaid recipient participation in tobacco cessation programs. Methods: Focus group interviews were conducted with Florida Medicaid MCOs to elicit processes for case identification, outreach, referral, program participation, and incentives. Answers were synthesized into themes. Results: Medicaid recipients were primarily identified through nicotine dependency claim codes or Health Risk Assessments (HRAs). Individuals were referred to state and local community tobacco cessation programs through text messaging and outreach by MCO case managers. The MCOs identified the following as barriers: primary care physicians (PCPs) with limited knowledge about cessation programs and pharmacologic treatments for nicotine dependence, low availability of health coaches, long wait times for entry into cessation programs, weak coordination between MCOs and cessation programs, and insufficient incentives for individuals for program participation. Suggested strategies to overcome barriers were continuing medical education (CME) for PCPs about tobacco cessation programs and prescription therapies, increasing the training of health coaches, more investment in quitlines, increasing data sharing between MCOs and cessation programs, and increasing incentives for individuals. Conclusions: These findings highlight the importance of engaging MCOs in discussions about policy and program improvements, as their insights can drive meaningful changes in how tobacco cessation and other preventive health programs are structured and implemented. Targeted interventions are needed to enhance tobacco cessation program participation among Medicaid recipients. [ABSTRACT FROM AUTHOR]

Objective Data Sources Study Design Data Collection/Extraction Methods Principal Findings Conclusions To examine the relationship between insurers' commercial market power and negotiated prices in Medicaid Managed Care (MMC) plans for hospital care.MMC prices from hospital‐disclosed price transparency data as of July 2023 compiled by Turquoise Health, insurance enrollment information from the 2021 Clarivate InterStudy enrollment data.Log‐transformed linear regression with hospital and procedure fixed effects estimating the within‐hospital MMC price variation as a function of insurers' commercial market share quartile and MMC market share for 15 common outpatient hospital services.A total of 39,049 MMC price samples measured at hospital‐procedure‐MMC insurer level are merged with county‐insurer level market share data.Around 25% of price variation in MMC plans are driven by within‐hospital factors. Compared with MMC insurers from the lowest commercial market share quartile (<0.8%), those from the highest commercial market share quartile (>17%) are associated with negotiating 4.6% (95% confidence interval: [2.8%–6.4%], p < 0.001) lower MMC prices for outpatient hospital care, including 3.6% (p < 0.05) for medical/surgical procedures, 3.6% (p < 0.01) for radiology, and 6.7% (p < 0.001) for emergency department visits.MMC insurers with substantial commercial market share negotiate lower MMC prices for multiple outpatient hospital services. [ABSTRACT FROM AUTHOR]

The impact of uncertainty in information systems is difficult to assess, especially when drawing conclusions from human observation records. In this study, we investigate survival variation in a population experiencing infectious disease as a proxy to investigate uncertainty problems. Using Centers for Medicare and Medicaid Services claims, we discovered 1,543,041 HIV+ persons, 363,425 of whom were observed dying from all-cause mortality. Once aggregated by HIV status, year of birth and year of death, Age-Period-Cohort disambiguation and regression models were constructed to produce explanations of variance in survival. We used Age-Period-Cohort as an alternative method to work around under-observed features of uncertainty like infection transmission, receiver host dynamics or comorbidity noise impacting survival variation. We detected ages that have a consistent, disproportionate share of deaths independent of study year or year of birth. Variation in seasonality of mortality appeared stable in regression models; in turn, HIV cases in the United States do not have a survival gain when uncertainty is uncontrolled for. Given the information complexity issues under observed exposure and transmission, studies of infectious diseases should either include robust decedent cases, observe transmission physics or avoid drawing conclusions about survival from human observation records. [ABSTRACT FROM AUTHOR]

Objectives. To assess the relationship between doula utilization and health outcomes of females enrolled in Medicaid-affiliated plans in the United States. Methods. In this retrospective, observational cohort study, we used Medicaid claims data from a national health insurer to compare health outcomes between females who used and who did not use a doula (2014–2023). We conducted propensity score matching using a 1:1 case‒control match, without replacement, and fit logistic regressions to analyze the relative risks for maternal health outcomes. Results. The study population included 722 matched pairs with and without a doula. Results indicate females with doulas had a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth, and were 46% more likely to attend a postpartum checkup (all differences P <.05). Conclusions. Doula care is associated with improved health outcomes among Medicaid enrollees. Public Health Implications. Doulas have garnered increasing interest from policymakers as a strategy to address increasing trends in maternal morbidity and persistent health disparities. This study provides evidence from Medicaid enrollees across the United States that doula care can improve maternal health. (Am J Public Health. 2024;114(11):1275–1285. https://doi.org/10.2105/AJPH.2024.307805) [ABSTRACT FROM AUTHOR]

The authors call on researchers, public health professionals, medical providers, and policymakers to address the access of foster care youth to preexposure prophylaxis (PrEP) from a number of appropriate dimensions. Topics include independent yet interconnected dimensions of access suggested by R. Penchansky and J. W. Thomas, dimensions of preexposure prophylaxis access, and prioritizing HIV prevention strategies for foster youths.

A growing body of research documents positive long-term impacts of public health insurance that go far beyond improving recipients' health. In this study, we expand the analysis to assess whether expanding Medicaid coverage generates reductions in crime. We find that increased Medicaid eligibility during childhood generates significant reductions in crime in early adulthood. Cohorts who experienced expanded Medicaid eligibility during childhood had significantly fewer arrests for property crime, drug-related crime, and driving under the influence in early adulthood. The effects are concentrated among males, are larger for Blacks than whites, and larger for eligibility experienced later in childhood. [End Page 1741] [ABSTRACT FROM AUTHOR]

The present study investigates the geographic distribution patterns of the responsiveness of four safety net programs during the significant economic downturn triggered by the 2020 pandemic: Unemployment Insurance, the Supplemental Nutrition Assistance Program, Medicaid, and Temporary Assistance for Needy Families. An analysis of each state's enrollment changes in these safety net programs from the pre-pandemic to the pandemic period relative to labor-market performance, using a responsiveness index, revealed which programs were most responsive to the pandemic recession in specific states or regions. Consistent with national findings, the present study suggests that Unemployment Insurance responded the most to the economic downturn of 2020, followed by the Supplemental Nutrition Assistance Program, Medicaid, and Temporary Assistance for Needy Families. Findings also show that Arizona and New Mexico responded highly across all four programs relative to labor-market performance. We used exploratory spatial data analysis to determine whether the spatial patterns of the responsiveness index identified in the study are statistically significant globally and locally within a given neighborhood structure. Our findings suggest that spatial distribution patterns are not random for the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families at the global level. Moreover, statistically low-low clusters were found in different areas of these two programs: the Supplemental Nutrition Assistance Program in northern states and Temporary Assistance for Needy Families in southern states. Our analyses of the four safety nets' responsiveness to labor market performance are consistent with the underlying social sustainability principles, particularly livelihood security and social well-being. Our findings can help policymakers make data-driven and better-informed decisions to assist those facing financial hardship, paving the way for improved policies and new opportunities for prosperity. [ABSTRACT FROM AUTHOR]

Problem definition: This study identifies a resource misallocation problem in Medicare Advantage (MA), the United States' largest healthcare capitation program, which may result in discrepancies between patients' health status and the healthcare resources allocated to them. Methodology/results: Utilizing a large commercial insurance database with claims from more than 2 million MA enrollees, this research investigates the allocation of MA capitation payments. By exploiting an exogenous policy shock on MA capitation payments through a difference-in-difference design, we find empirical evidence of an illegal practice known as "cross-subsidization." This practice involves MA health plans strategically reallocating portions of the capitation payments intended for one group of patients to spend on another group of patients. Additionally, we show that this cross-subsidization practice is associated with the risk selection problem in MA, where low-risk patients are more likely to enroll in MA compared with high-risk patients. Managerial implications: This research unveils a previously undocumented healthcare resource misallocation problem, that is, strategic cross-subsidization. This practice is explicitly prohibited by law in the United States due to its heightened effect on the undesired risk selection within capitation programs, where health plans cherry-pick profitable enrollees through strategic benefit designs. Our study has direct practical implications as it underscores the need for greater transparency in MA claims data to enable the Centers for Medicare & Medicaid Services to more effectively administer the MA program. Supplemental Material: The online appendices are available at https://doi.org/10.1287/msom.2023.0637. [ABSTRACT FROM AUTHOR]

Background: Following carpal tunnel release (CTR), patients may be indicated for subsequent hand surgery (contralateral CTR and/or trigger finger release [TFR]). While surgeons typically take pride in patient loyalty, the rate of returning to the same hand surgeons has not been previously characterized. Methods: Patients undergoing CTR were isolated from 2010–2021 PearlDiver M151 dataset. Subsequent CTR or TFR were identified and characterized as being performed by the same or different surgeon, with patient factors associated with changing to a different surgeon determined by multivariable analyses. Results: In total, 1,121,922 CTR patients were identified. Of these, subsequent surgery was identified for 307,385 (27.4%: CTR 289,455 [94.2%] and TFR 17,930 [5.8%]). Of the patients with a subsequent surgery, 257,027 (83.6%) returned to the same surgeon and 50,358 (16.4%) changed surgeons. Multivariable analysis found factors associated with changing surgeon (in order of decreasing odds ration [OR]) to be: TFR as the second procedure (OR 2.98), time between surgeries greater than 2-years (OR 2.30), Elixhauser-Comorbidity Index (OR 1.14 per 2-point increase), and male sex (OR 1.06), with less likely hood of changing for those with Medicare (OR 0.95 relative to commercial insurance) (p<0.001 for each). Pertinent negatives included: age, Medicaid, and having a 90-day adverse event after the index procedure. Conclusions: Over fifteen percent of patients who required a subsequent CTR or TFR following CTR did not return to the same surgeon. Understanding what factors lead to outmigration of patients form a practice may help direct efforts for patient retention. [ABSTRACT FROM AUTHOR]

Objective Data Sources and Study Setting Study Design Data Collection/Extraction Methods Principal Findings Conclusions To characterize the landscape of policies that determine eligibility for family planning services through Medicaid programs and describe trends in eligibility and its determinants over time.Secondary data were collected for all states in the United States for the years 2008 through 2023. Data on economic and demographic characteristics came from the American Community Survey (ACS).Our descriptive study characterized state adoptions of Medicaid family planning section 1115 waivers and state plan amendments (SPA) and their eligibility criteria. We then estimated the proportion of women aged 19–44 years who were eligible for family planning services through Medicaid and identified the key determinants of changes in eligibility, by state and year.Information on state Medicaid policies was extracted from documentation on the Centers for Medicare & Medicaid Services website. When estimating the eligible population sizes, the denominator was women aged 19–44 years, the group most likely to be eligible for Medicaid family planning programs. Supplemental data on program enrollment or utilization were collected from states' websites and reports.Though eligibility limits for family planning through Medicaid generally increased over time, the proportion of women aged 19–44 years eligible for at least limited benefits decreased from 45.0% in 2012 to 39.4% in 2022, largely because of increases in household income. Trends varied considerably across states and by eligibility pathway. Among women with incomes below the poverty level, the proportion who were not eligible for Medicaid family planning services decreased from 6.3% in 2013 to 1.5% in 2022.Our data demonstrated substantial geographic and temporal variation in eligibility for family planning services through Medicaid. We identified key drivers of eligibility changes that may have important implications for health services analyses of means‐tested public programs. [ABSTRACT FROM AUTHOR]

Objective Data Sources/Study Setting Study Design Data Collection/Extraction Methods Principal Findings Conclusions To examine the association of Medicaid home‐ and community‐based services (HCBS) expenditures on the home care workforce.We use two national, secondary data sources from 2008 to 2019: state‐level Medicaid HCBS expenditures and the American Community Survey, in which we identify direct care workers in the home (i.e., home care workers), defined as nursing, psychiatric, and home health aides or personal care aides working in home health care services, individual and family services, and private households.Our key explanatory variable is HCBS expenditures per state per year. To estimate the association between changes in Medicaid HCBS expenditures and the workforce size, hourly wages and hours worked, we use negative binomial, linear, and generalized ordered logit regression, respectively. All models include demographic and socioeconomic characteristics, the number of potential HCBS beneficiaries (individuals with a disability and income under the federal maximum income eligibility limits), indicators for minimum wage and/or overtime protections for direct care workers, wage pass‐through policies, and state and year fixed effects.We exclude states with incomplete reporting of expenditures.States' HCBS expenditures increased between 2008 and 2019 after adjusting for inflation and the number of potential HCBS beneficiaries. Yet, home care workers' wages remained stagnant at $11–12/h. We find no association between changes in Medicaid HCBS expenditures and wages. For every additional $1 million in Medicaid HCBS expenditures, the expected number of workers increases by 1.2 and the probability of working overtime increased (0.0015% points; p < 0.05). Results are largely robust under multiple sensitivity analyses.We find no evidence of a statistically significant relationship between changes in state‐level changes in Medicaid HCBS expenditures and worker wages but do find a significant, but small, association with hours worked and workforce size. [ABSTRACT FROM AUTHOR]

Objective Data Sources and Setting Study Design Data Collection/Extraction Methods Principal Findings Conclusion The 2020 Family First Coronavirus Response Act (FFCRA) extended Medicaid coverage for enrollees without rechecking eligibility. Before that, women were eligible for Medicaid coverage up to 60 days postpartum. We examine the FFCRA's effect on Medicaid postpartum coverage, depression symptoms, and birth control use beyond 60 days after delivery.We use data from the 2016–2021 Pregnancy Risk Assessment Monitoring System (PRAMS). The primary sample includes 56,828 women who were income eligible up to 60 days postpartum or beyond in their state.We employ a difference‐in‐differences design comparing outcomes before and after the FFCRA between women who were not income eligible for Medicaid coverage beyond 60 days postpartum in their state and those who were income eligible. We estimate models without and with controlling for state‐specific trends in outcomes over time.N/A.There is an 8.1 percentage‐point increase in the likelihood of having Medicaid coverage without controlling for state‐specific trends, and 5.4 percentage‐points when controlling for state‐specific trends (both p < 0.05). There is a decline in likelihood of being uninsured by 3 percentage‐points (p < 0.05) without state‐specific trends and a smaller and non‐significant decline when including state‐specific trends. Estimated effects on depression symptoms and birth control use are small and statistically non‐significant.Following the FFCRA, there was an increase in Medicaid coverage beyond 60 days postpartum among women who would have been income ineligible for Medicaid after 60 days. However, there is a less pronounced effect on likelihood of being uninsured, which might be partly due to some switching from private to Medicaid coverage. There were no discernable effects on depression symptoms and birth control use. Examining additional health and health care utilization measures over a longer postpartum period is needed to further understand the FCCRA effects on these outcomes. [ABSTRACT FROM AUTHOR]

Safety net organizations in rural regions face structural barriers to providing services. Organizations that serve rural Latino communities may face additional barriers related to restrictive immigration policies and anti‐immigrant climates. This study examines the impacts of restrictive immigration policies on safety net organizations that provide critical services to Latinos in rural areas to elucidate the mechanisms by which immigration policies influence Latino health. We conducted a qualitative analysis of 20 in‐depth interviews with safety net organizations providing legal, nutritional, healthcare, labor, educational, and advocacy services to Latinos in rural California. Rural Latino‐serving safety net organizations face immigration‐related funding restrictions and anti‐immigrant climates. Under restrictive immigration policies, rural safety net organizations are forced to extend beyond their organizational missions to circumvent immigration‐related funding restrictions and address anti‐immigrant climates to deliver their services. Staff working in these organizations are at the frontlines of anti‐immigrant climates and experienced an emotional toll from their work. States should address anti‐immigrant climates and increase funding to support organizations who serve Latinos in rural regions. To ensure that rural safety net organizations meet their mission, immigration‐related eligibility requirements from safety net services should be removed. In addition, funders should allocate resources towards mental health services to address the impacts of anti‐immigrant climates on staff who serve in rural Latino communities. [ABSTRACT FROM AUTHOR]

Objective Data Sources and Study Setting Study Design Principal Findings Conclusions To examine whether Medicaid managed care plan (MCP) utilization management policies for buprenorphine–naloxone and injectable naltrexone are related to key state Medicaid program policy decisions.We abstracted data on state Medicaid regulatory and policy information from publicly available sources and publicly available insurance benefit documentation from all 241 Medicaid MCPs operating in 2021.In this cross‐sectional study, we used bivariate and multivariate analyses to examine whether Medicaid MCP prior authorization and quantity limits on receipt of buprenorphine and injectable naltrexone were associated with key state Medicaid choices to leverage federal funds to expand coverage and eligibility (Medicaid expansion, 1115 waivers) and to regulate Medicaid MCPs (uniform preferred drug lists, medical loss ratio remittance). Models were adjusted for MCP characteristics, including profit status, behavioral health contracting arrangement, National Committee for Quality Assurance accreditation, size, market share, and state opioid overdose death rates. Average marginal effects (AME) were reported.Utilization management was common among MCPs, and restrictions were more commonly applied to buprenorphine than injectable naltrexone, despite its higher cost. States that required MCPs to comply with utilization management policies stipulated in a uniform preferred drug list were more likely to require prior authorization for buprenorphine (AME: 0.29, 95% CI: 0.15–0.42) and injectable naltrexone (AME: 0.25, 95% CI: 0.12–0.38). MCPs in states that required plans to pay back earnings above a certain threshold were less likely to require prior authorization for buprenorphine (AME: −0.30, 95% CI: −0.43 to −0.18).Restrictions on medications for opioid use disorder are widespread among MCPs and vary by medication. State Medicaid regulatory and policy characteristics were strongly linked to MCPs' utilization management approaches. State Medicaid policy and contracting approaches may be levers to eliminate utilization management restrictions on medications for opioid use disorder. [ABSTRACT FROM AUTHOR]

Background: Multiple state and national health care organizations have invested in activities to screen for and address the health-related social needs (HRSNs) of their patients. However, patient perspectives concerning HRSN screening discussions and facilitated referrals to supports are largely unexplored. The main objectives of this study were to explore the ways in which Massachusetts Medicaid (MassHealth) members engage with their health care clinicians to discuss HRSNs, to identify common needs discussed, and to describe whether members feel these needs are being addressed by health care clinicians and staff. Methods: The study team performed a cross-sectional, qualitative research study that included in-depth, open-ended interviews with 44 adult MassHealth members. Interviews were conducted between June and October 2022. Interviews were recorded, transcribed, and systematically coded for analysis, and common themes were reported. The data collected for this study were part of a larger independent evaluation of MassHealth's 2017-2022 Section 1115 Demonstration that granted authority from CMS to implement health care delivery system reforms in Massachusetts. Results: In this qualitative study of Medicaid members, some reportedly felt comfortable freely discussing all of their clinical and social needs with their health care clinicians, while others noted feelings of apprehension. Several members recalled being asked about their HRSNs in various clinical or community settings, while others did not. The majority of members endorsed having an unmet HRSN, including housing, nutrition, financial, or transportation issues, and many barriers to addressing these HRSNs were discussed. Finally, many members cited a preference for discussing HRSNs with community-based care coordinators and social workers at the community partner organizations rather than with their health care clinicians. Community-based care coordinators were lauded as essential facilitators in making the connection to necessary resources to help address HRSNs. Conclusions: Study results highlight an opportunity to increase the effectiveness of HRSN screening and referral practices within the health care setting through relationship building between Medicaid members and diverse interdisciplinary care teams that include staff such as community health workers. Continued investment in cross-sector partnerships, screening workflows, and patient-clinician relationships may contribute to establishing an environment in which members can comfortably discuss HRSNs and connect with needed services to improve their health. [ABSTRACT FROM AUTHOR]

Access to nutritious foods, a social determinant of health, contributes to disparities in maternal and infant health outcomes such as mental health, breastfeeding intensity and cardiometabolic risk. This study explored perceived nutrition access and intake among pregnant or post‐partum women eligible for Medicaid. Qualitative, semistructured interviews were conducted with 18 women who were either currently pregnant (n = 4) or up to 12 months post‐partum (n = 14) in 2021–2022. Mothers spoke English (n = 11) or Spanish (n = 7) and lived in the Texas Panhandle. Interviews were audio‐recorded, transcribed, translated (Spanish to English) and verified. Two or more researchers coded each interview until consensus was reached using thematic analysis with ATLAS.ti software. The study revealed five drivers for nutrition access. (1) Social factors influenced nutrition; those with less support expressed limited ability to eat healthfully. (2) The Women, Infants and Children program was perceived as a helpful resource for some, while others faced challenges obtaining it. (3) Stress was bidirectionally related to unhealthy food choices, with food sometimes used as a coping mechanism. (4) Mothers prioritized their babies and others and had limited ability and time to prepare healthy meals. (5) Most participants felt they received inadequate nutrition guidance from their healthcare providers. Participants provided positive responses to a proposed nutritious home‐delivered meal intervention. Low‐income women may experience nutritional challenges specific to this life stage. Interventions that reduce stress and burden of household tasks (e.g. cooking) and improve education and access to nutritious foods may improve mothers' ability to consume nutritious foods. Key messages: Pregnant and post‐partum women desire to eat nutritious foods for their own health and that of their infants.More support is needed for women in the post‐partum period as prioritization of others and the stressful transition of caring for a newborn hinder women from maintaining healthy eating habits.Pregnant and post‐partum women want focused nutritional guidance from their healthcare providers.A home‐delivered, nutritious meal programme may be an acceptable intervention to help alleviate the nutritional barriers that are faced by pregnant and post‐partum women. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the congruence between patient assignment and established patients as well as their association with Healthcare Effectiveness Data and Information Set (HEDIS) quality performance. STUDY DESIGN: A retrospective cross-sectional analysis from January 2020 to February 2022. METHODS: The study setting is a fully integrated health care delivery system in Phoenix, Arizona. The study population includes Medicaid patients who received primary care services or were assigned to a primary care physician (PCP) at the study setting by 5 Medicaid managed care organizations (MCOs). We identified 4 possible relationships between the established patients (2 primary care visits) and the assigned patients (assigned by the MCO to the study setting): true-positive, false-positive, true-negative, and false-negative classifications. Precision and recall measures were used to assess congruence (or incongruence). Outcome measures were HEDIS quality metrics. RESULTS: A total of 100,030 Medicaid enrollees (adults and children) were established and/or assigned to the study setting from 5 separate payers. Only 15% were congruently established and assigned to the physician (true-positive). The overall precision was 21%, and the overall recall was 37%. The HEDIS quality performance was significantly higher (P< .05) for established patients for 5 of 6 metrics compared with patients who were not established. CONCLUSIONS: The vast majority of assigned patients were not treated by the assigned PCP, yet better patient outcomes were seen with an established patient. As the health system rapidly adopts value-based payments, more rigorous methodologies are essential to identify physician-patient relationships. [ABSTRACT FROM AUTHOR]

Background: The volume of online health information available makes it difficult to navigate and check its validity and reliability. A community-based MedlinePlus training program was developed to improve participants' ability to access credible online health information. Case Presentation: The program was a public-private partnership between a managed care organization and four local public libraries. A total of eight programs were held between October and November 2017. Each program had a 30- minute cooking demonstration followed by a 30-minute training on access to and navigation of the MedlinePlus website. Program participants were Medicaid beneficiaries, dually eligible for Medicare and Medicaid beneficiaries, and community members from a Pennsylvania county (n=39). A pre-and post-training questionnaire was administered to assess participants' knowledge and practice, and their ability to access health information on the MedlinePlus website. We conducted a retrospective analysis of the data collected during the MedlinePlus trainings. Results from the Wilcoxon Signed Rank test indicated no statistically significant change in participants' ability to access information (Z= -1.41, p=0.16) after attending the program. Conclusion: Although the median pre- to post-program responses improved from 'incorrect' to 'correct,' the number of programs held, and low attendance might be the reason for non-significant results. Participants reported that the program was informative, the website was comprehensive and user-friendly, and they were impressed by the healthy and inexpensive meal preparation from discount store-bought food. Holding MedlinePlus training programs in conjunction with a cooking program and collaborating with local public libraries might be a promising format that needs additional research. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of Medicaid Accountable Care Organizations (ACOs) on children's access to and utilization of health services. Study Setting and Design: This study employs difference‐in‐differences models comparing ACO and non‐ACO states from 2018 through 2021. Access measures are indicators for preventive and sick care sources, unmet healthcare needs, and having a personal doctor or nurse. Utilization measures are preventive and dental care, mental healthcare, specialist visits, emergency department visits, and hospital admissions. Data Sources and Analytic Sample: Secondary, de‐identified data come from the 2016–2021 National Survey of Children's Health. The sample includes children with public insurance and ranges between 21,452 and 37,177 depending on the outcome. Principal Findings: Medicaid ACO implementation was associated with an increase in children's likelihood of having a personal doctor or nurse by about 4 percentage‐points concentrated among states that implemented ACOs in 2018. Medicaid ACOs were also associated with an increase in specialist care use and decline in emergency visits by about 5 percentage‐points (the latter being concentrated among states that implemented ACOs in 2020). There were no discernable or robust associations with other pediatric outcomes. Conclusions: There is mixed evidence on the associations of Medicaid ACOs with pediatric access and utilization outcomes. Examining effects over longer periods post‐ACO implementation is important. [ABSTRACT FROM AUTHOR]

Objective: To estimate the association of Medicaid coverage of abortion care with cumulative lifetime abortion incidence among women insured by Medicaid. Data Sources and Study Setting: We use 2016–2019 (Pre‐Dobbs) data from the Survey of Women studies that represent women aged 18–44 living in six U.S. states. One state, Maryland, has a Medicaid program that has long covered the cost of abortion care. The other five states, Alabama, Delaware, Iowa, Ohio, and South Carolina, have Medicaid programs that do not cover the cost of abortion care. Our sample includes 8972 women residing in the study states. Study Design: Our outcome, cumulative lifetime abortion incidence, is identified using an indirect survey method, the double list experiment. We use a multivariate regression of cumulative lifetime abortion on variables including whether women were Medicaid‐insured and whether they were residing in Maryland versus in one of the other five states. Data Collection/Extraction Methods: This study used secondary survey data. Principal Findings: We estimate that Medicaid coverage of abortion care in Maryland is associated with a 37.0 percentage‐point (95% CI: 12.3–61.4) higher cumulative lifetime abortion incidence among Medicaid‐insured women relative to women not insured by Medicaid compared with those differences by insurance status in states whose Medicaid programs do not cover the cost of abortion care. Conclusions: We found that Medicaid coverage of abortion care is associated with a much higher lifetime incidence of abortion among individuals insured by Medicaid. We infer that Medicaid coverage of abortion care costs may have a very large impact on the accessibility of abortion care for low‐income women. [ABSTRACT FROM AUTHOR]

Objective: To understand Veterans Health Administration (VA) leaders' information and resource needs for managing post‐9/11 Veterans' VA enrollment and retention. Data Sources and Study Setting: Interviews conducted from March–May 2022 of VA Medical Center (VAMC) leaders (N = 27) across 15 sites, using stratified sampling based on VAMC characteristics: enrollment rates, number of recently separated Veterans in catchment area, and state Medicaid expansion status. Study Design: Interview questions were developed using Petersen et al.'s Factors Influencing Choice of Healthcare System framework as a guide. Interviews were transcribed verbatim, and two coders analyzed the interviews using Atlas.ti, a qualitative software program. Coders followed the qualitative coding philosophy developed by Crabtree and Miller, a process of developing codes for salient concepts as they are identified during the analysis process. Data Collection/Extraction Methods: Two coders analyzed 22% (N = 6) of the interviews and discussed and adjudicated any discrepancies. One coder independently coded the remainder of the interviews. Principal Findings: Several key themes were identified regarding facilitators and barriers for VA enrollment including reputation for high‐quality VA care, convenience of VA services, awareness of VA services and benefits, and VA mental health services. Nearly every VA leader actively used tools and data to understand enrollment and retention rates and sought to enroll and retain more Veterans. To improve the management of enrollment and retention, VA leaders would like data shared in an easily understandable format and the capability to share data between the VA and community healthcare systems. Conclusions: Enrollment and retention information is important for healthcare leaders to guide their health system decisions. Various tools are currently being used to try to understand the data. However, a multifunctional tool is needed to better aggregate the data to provide VA leadership with key information on Veterans' enrollment and retention. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in late‐ versus early‐stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania. Data Sources and Study Setting: We analyzed data from the Pennsylvania cancer registry (2010–2018) for adult Medicaid beneficiaries aged 21–64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital‐based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council). Study Design: We leveraged a natural experiment arising from county‐level variation in mandatory MMC in Pennsylvania. Using a stacked difference‐in‐differences design, we compared changes in the probability of late‐stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs. Data Collection/Extraction Methods: N/A. Principal Findings: Mandatory MMC was associated with a reduced probability of late‐stage cancer diagnosis (−3.9 percentage points; 95% CI: −7.2, −0.5; p = 0.02), particularly for screening‐amenable cancers (−5.5 percentage points; 95% CI: −10.4, −0.6; p = 0.03). We found no significant changes in late‐stage diagnosis among non‐screening amenable cancers. Conclusions: In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening‐amenable cancers. Considering that over half of the sample was diagnosed with late‐stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline‐concordant screening or diagnostic procedures. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of Medicaid expansion on state expenditures through the end of 2022. Data Sources: We used data from the National Association of State Budget Officers (NASBO)'s State Expenditure Report, Kaiser Family Foundation (KFF)'s Medicaid expansion tracker, US Bureau of Labor Statistics data (BLS), US Bureau of Economic Analysis data (BEA), and Pandemic Response Accountability Committee Oversight (PRAC). Study Design: We investigated spending per capita (by state population) across seven budget categories, including Medicaid spending, and four spending sources. We performed a difference‐in‐differences (DiD) analysis that compared within‐state changes in spending over time in expansion and nonexpansion states to estimate the effect of Medicaid expansion on state budgets. We adjusted for annual state unemployment rate, annual state per capita personal income, and state spending of Coronavirus Relief Funds (CRF) from 2020 to 2022 and included state and year fixed effects. Data Collection/Extraction Methods: We linked annual state‐level data on state‐reported fiscal year expenditures from NASBO with state‐level characteristics from BLS and BEA data and with CRF state spending from PRAC. Principal Findings: Medicaid expansion was associated with an average increase of 21% (95% confidence interval [CI]: 16%–25%) in per capita Medicaid spending after Medicaid expansion among states that expanded prior to 2020. After inclusion of an interaction term to separate between the coronavirus disease (COVID) era (2020–2022) and the prior period following expansion (2015–2019), we found that although Medicaid expansion led to an average increase of 33% (95% CI: 21%–45%) in federal funding of state expenditures in the post‐COVID years, it was not significantly associated with increased state spending. Conclusions: There was no evidence of crowding out of other state expenditure categories or a substantial impact on total state spending, even in the COVID‐19 era. Increased federal expenditures may have shielded states from substantial budgetary impacts. [ABSTRACT FROM AUTHOR]