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Objective: To ascertain the impact of Affordable Care Act (ACA) state Medicaid expansion on human papillomavirus (HPV) vaccination among both adolescent and young adult US women. Data Sources: We used state-level data on ACA Medicaid expansion and individuallevel data on US women aged 15-25 years living at or below 138% of the Federal Poverty Level (FPL) from the 2011-2017 waves of the National Survey of Family Growth (N = 2408). Study Design: We conducted a quasi-experimental study examining the association between ACA state Medicaid expansion and HPV vaccination initiation among eligible adolescent and young adult US women. Methods: We used linear probability modeling within a difference-in-differences approach, adjusting for individual- and state-level covariates. Principal Findings: Adjusting for individual- and state-level covariates, we found a negative association between Medicaid expansion and HPV vaccination among US women aged 15-25 years living in low-income households in the first year post-expansion (coefficient: -15.9 percentage points; 95% confidence interval [CI]: -30.1, -1.6 points). In contrast, we observed a positive association in the third year post-expansion (coefficient: 20.5 percentage points; 95% confidence interval [CI]: -1.8, 42.9 points). Conclusions: Medicaid expansion may have increased HPV vaccination among adolescent and young adult US women over time. Additional research is needed to identify the mechanisms and differential effects of Medicaid expansion on HPV vaccination among diverse subgroups of US women. KEYWORDS adolescents, human papillomavirus vaccination, Medicaid expansion, women, young adults What is known about the topic * Uptake of the human papillomavirus (HPV) vaccine has been slow and remains below Healthy People 2030 targets. * Affordable Care Act (ACA) state Medicaid expansion increased HPV vaccination among US adolescents aged 13-17 years. * Limited information exists on the impact of ACA Medicaid expansion on US young adults. What this study adds * ACA Medicaid expansion was associated with HPV vaccination among US women aged 15-25 years in the first three years post-expansion. * There was a positive association between ACA Medicaid expansion and HPV vaccination among adolescent and young adult US women in the third year post-expansion. * ACA Medicaid expansion may have increased HPV vaccine uptake among both adolescent and young adult US women over time., 1 | INTRODUCTION Human papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) in the United States. (1) Data suggest that, in 2013-2016, the prevalence of any HPV Infection [...]

The Affordable Care Act Marketplaces may improve access to dental insurance, but little is known about the availability of such coverage. We used data from state and federal Marketplace sources to describe the availability of adult dental plans, including Stand-alone Dental Plans and those embedded in medical plans. We also examined the characteristics of counties with limited dental insurer participation and those that experienced a net loss of Stand-alone Dental Plan insurers between 2016 and 2023. We found that in 2023, at least one Stand-alone Dental Plan was offered in every state, and thirty-six states offered embedded dental plans. Most counties (63.6 percent) had access to more than five insurers offering adult dental plans, whereas approximately 4 percent had only one insurer offering adult dental plans. Counties in state-based Marketplaces, rural areas, and dentist shortage areas were more likely to be counties with limited dental insurer participation. The net loss of Stand-alone Dental Plans between 2016 and 2023 was more common in state-based Marketplaces and disadvantaged counties. Our findings can inform future policies to improve the dental insurance Marketplace and access to affordable dental care.

Objective: To examine the effect of the 2010 Affordable Care Act (ACA) extended dependent coverage and no cost-sharing provisions on human papillomavirus (HPV) vaccination in relation to sexual orientation identity among U.S. women. Data Sources: 2006-2010 and 2011-2015 National Survey of Family Growth. Study Design: We used an interrupted time series design and multivariable Poisson regression to assess differences in HPV vaccination initiation before (2007-2010) and after (2011-2015) the 2010 ACA provisions among heterosexual, bisexual, and lesbian U.S. women aged 15-25 years (N = 7033), adjusting for temporal trends and demographic factors. Data Collection: Computer-assisted personal interview and audio computer-assisted self-interview questionnaires. Principal Findings: The adjusted prevalence of HPV vaccination initiation was significantly higher among lesbian and bisexual women after compared to before the 2010 ACA--at 19.1 (95% confidence interval [CI]: 5.4, 32.9) and 15.7 (95% CI: 4.4, 27.1) percentage points in 2015 compared to 2007-2010, respectively. We observed no association between the 2010 ACA provisions and HPV vaccination initiation among heterosexual women after adjusting for temporal trends and demographic factors. Conclusions: The 2010 ACA provisions may have improved HPV vaccination initiation among lesbian and bisexual women. Policies and programs that increase access to health insurance and provide HPV vaccines at no cost to patients may facilitate HPV vaccine uptake in these marginalized populations. KEYWORDS Affordable Care Act, health inequities, human papillomavirus vaccination, sexual orientation, women, 1 | INTRODUCTION Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States. (1) Each year, approximately 7 million U.S. women are newly infected with [...]

Objective: To estimate and describe factors driving variation in spending for breast cancer patients within geographic region.Data Source: Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2009-2013.Study Design: The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient-level and physician-level variance in spending. Services associated with high spending physicians were estimated using linear regression.Data Extraction Method: A total of 20 818 women with a breast cancer diagnosis in 2010-2011.Principal Findings: We observed substantial between-patient and between-provider variation in spending following diagnosis and at the end-of-life. Immediately following diagnosis, 48% of between-patient and 31% of between-physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end-of-life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days.Conclusions: Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient-doctor discussions.KEYWORDSbreast cancer, spending, variation, 1 | INTRODUCTIONApproximately one in eight women develop breast cancer during their lifetime, making it the most common cancer in women. (1) Total spending for breast cancer treatment is correspondingly [...]

Objective. To determine whether Medicare's Nonpayment Program was associated with decline in venous thromboembolism (VTE) following hip and knee replacements; and whether the decline was greater among hospitals at risk of larger financial losses from the Program.Data Sources. State Inpatient Database for New York (NY) from 2005 to 2013.Study Design. The primary outcome was an occurrence of VTE. Medicare Utilization Ratio (MUR), which is the proportion of inpatient days in a hospital that is financed by Medicare, represented a hospital's financial sensitivity. We used hierarchical logistic regressions with difference-in-differences estimation to study the Program effects.Principal Findings. A total of 98,729 hip replacement and 111,361 knee replacement stays were identified. For hip replacement, the Program was associated with significant reduction (Range: 44% to 53%) in VTE incidence among hospitals in MUR quartiles 2 to 4. For knee replacement, the Program was associated with significant reduction (47%) in VTE incidence only among quartile 2 hospitals.Conclusion. Implementation of the Program was associated with a reduction in VTE, especially for hip replacements, in higher MUR hospitals. Payment reforms such as Medicare's Nonpayment Program that withhold payments for complications are effective and should be continued.Key Words. Nonpayment program, hip and knee replacements, venous thromboembolism, Hip and knee replacements are the most frequently performed inpatient surgeries for older Medicare beneficiaries and the single largest surgical expenditure for Medicare. In 2014, more than 450,000 Medicare beneficiaries [...]

Objective. To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care. Data Sources. 2009-2011 national Medicare and commercial insurance administrative data. Design. We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. Methods. We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these. Principal Findings. Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. Conclusions. Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type. Key Words. Low-value care, overuse, waste, regional variation, Health care spending varies broadly across regions of the United States, but it results in few differences in outcomes (survival, function), patient satisfaction, physician satisfaction, or access to care (Fisher [...]

Objective. To examine the impact of pay for performance in Medicaid on the quality and utilization of care. Data Sources. Medicaid claims and encounter data in three intervention states (Pennsylvania, Minnesota, and Alabama) and three comparison states. Study Design. Difference-in-difference analysis with propensity score-matched comparison group. Primary outcomes of interest were Healthcare Effectiveness Data and Information Set (HEDIS)-like process measures of quality, utilization by service category, and ambulatory care-sensitive admissions and emergency department visits. Principal Findings. In Pennsylvania, there was a statistically significant reduction of 88 ambulatory visits per 1,000 enrollee months compared with Florida. In Minnesota, there was a significant decrease of 7.2 hospital admissions per thousand enrollee months compared with Wisconsin. In Alabama, where incentives were not paid out until the end of a 2-year waiver period, there was a decline of 1.6 hospital admissions per thousand member months, and an increase of 59 ambulatory visits per 1,000 enrollees compared with Georgia. No significant quality improvements in intervention relative to control states. Conclusions. Our findings are mixed, with no measurable quality improvements across the three states, but reductions in hospital admissions in two programs. As states move to value-based payment for patient-centered medical homes and Accountable Care Organizations, lessons learned from these pioneering states should inform program design. Key Words. Pay for performance, Medicaid, value-based purchasing in provider relationships, shared savings, Pay-for-performance (P4P) programs for health care providers are now widely implemented in the hope of improving the quality of care and, increasingly, to control costs. The Affordable Care Act of [...]