Using Modernized Medicaid Data to Advance Evidence-Based Improvements in Maternal Health.

Medicaid is the primary payor for nearly half of all births in the United States and plays a disproportionate role in covering maternity care for low-income people, rural people, and minoritized racial groups. Newly available, modernized Medicaid claims data-the Transformed Medicaid Statistical Information System Analytic Files (TAF)-offer a significant opportunity to conduct novel research that can drive the development of evidence-based programs and policies for Medicaid beneficiaries before, during, and after pregnancy. Yet, the public health research community has so far underused the TAF for maternal health research. We provide an overview of the TAF and how they compare to other major data sets available to study maternal health. We highlight some major limitations of the TAF and offer strategies to maximize the potential of these novel data to accelerate timely, rigorous research to improve maternal health and health equity. (Am J Public Health. 2023;113(7):805-810. https://doi.org/10.2105/AJPH.2023.307287).

Framing incremental expansions to public health insurance systems: the case of Canadian pharmacare.

Canada is the only country in the world to offer universal comprehensive public health insurance that excludes outpatient prescription medicines. Few scholars have attempted to explain this policy puzzle. We study media coverage of prescription drug financing from 1990 to 2010 to elucidate how the policy problem and potential solutions have been framed in media discourse and identify the actors that have dominated media texts. We confirm previous analyses that have revealed the significant role played by policy elites in media coverage of health reform debates. We also find that proposed expansions to public coverage are presented as a financial liability that could "crowd out" the existing (and popular) public insurance program. Within the context of a predominantly public funded system, framing of incremental expansion reorients away from values and toward discourse related to costs--both of the current system and of potential reforms. This may reflect a strategic narrative used by actors to maintain "silos of values" for coverage for prescription medicines versus those for other services. This has significant implications for the motivation for reform among the electorate and politicians alike, and for the extent to which policy developments, if they occurred, would legitimately reflect societal values for health financing.

Late Postpartum Coverage Loss Before COVID-19: Implications For Medicaid Unwinding.

Using unique Pregnancy Risk Assessment Monitoring System follow-up data from before the COVID-19 pandemic, we found that only 68 percent of prenatal Medicaid enrollees maintained continuous Medicaid coverage through nine or ten months postpartum. Of the prenatal Medicaid enrollees who lost coverage in the early postpartum period, two-thirds remained uninsured nine to ten months postpartum. State postpartum Medicaid extensions could prevent a return to prepandemic rates of postpartum coverage loss.

Medicaid expansion and risk of eclampsia.

BACKGROUND: Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. OBJECTIVE: This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. STUDY DESIGN: This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. RESULTS: Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). CONCLUSION: Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

Medicaid Expansion Improved Perinatal Insurance Continuity For Low-Income Women.

Insurance churn, or moving between different insurance plans or between insurance and uninsurance, is common during the perinatal period. We used survey data from the 2012-17 Pregnancy Risk Assessment Monitoring System to estimate the impact of Affordable Care Act-related state Medicaid expansions on continuity of insurance coverage for low-income women across three time points: preconception, delivery, and postpartum. We found that Medicaid expansion resulted in a 10.1-percentage-point decrease in churning between insurance and uninsurance, representing a 28 percent decrease from the prepolicy baseline in expansion states. This decrease was driven by a 5.8-percentage-point increase in the proportion of women who were continuously insured and a 4.2-percentage-point increase in churning between Medicaid and private insurance. Medicaid expansion improved insurance continuity in the perinatal period for low-income women, which may improve the quality of perinatal health care, but it also increased churning between public and private health insurance.

Use of product listing agreements by Canadian provincial drug benefit plans.

BACKGROUND: Product listing agreements (PLAs) between drug manufacturers and drug plans are increasingly common worldwide. Use of PLAs by Canadian provinces has not previously been documented. METHODS: We collected data from all provinces on funding and PLA use for 25 drugs that were reviewed by the Common Drug Review (CDR) in 2010 or 2011 and funded by at least one province as of May 2012. We measured correlations between coverage and PLA use, and CDR recommendations and PLA use. RESULTS: The number of drugs from our sample funded by provinces ranged from three in Prince Edward Island to 21 in Ontario. PLA use ranged from zero in Quebec, Prince Edward Island, and Newfoundland and Labrador to 20 in Ontario. The correlation between drugs funded and PLAs used by each province was statistically significant (r=0.57, p=0.04); excluding Ontario, however, the correlation was not significant (r=0.10, p=0.40). There was a stronger correlation between the number of provinces funding a drug and the number using PLAs among the subset of drugs with negative CDR recommendations (r=0.87, p<0.01) versus those with positive recommendations (r=0.52, p=0.03). Of the 12 drugs sampled with a negative CDR recommendation, 10 were funded with a PLA in at least one province. INTERPRETATION: There is wide interprovincial variation in PLA use and evidence that PLAs may be used to fund drugs that are not otherwise cost-effective. If global pricing strategies are making PLAs necessary, Canadian governments should collaborate to improve the equity, transparency and effectiveness of PLAs across provinces.

Stitching the gaps in the Canadian public drug coverage patchwork?: a review of provincial pharmacare policy changes from 2000 to 2010.

OBJECTIVES: To describe recent changes and identify emergent trends in public drug benefit policies in Canada from 2000 to 2010. METHODS: For each province, we tracked pharmacare design (namely eligibility, premiums, and patient cost-sharing) over time for three beneficiary groups: social assistance recipients, seniors, and the general non-senior population. We assess which plan designs are emerging as a national standard, where the gaps in public coverage remain, and implications for progress towards national pharmacare. RESULTS: Expansion of public drug coverage has been limited. For social assistance recipients, first-dollar coverage is the standard. Seniors coverage remains varied, though means testing of eligibility or cost-sharing is common. Seniors benefits were significantly expanded in only one province. As of 2010, six provinces have embraced age irrelevant catastrophic income-based coverage, in some, resulting in the elimination of seniors drug benefits. CONCLUSIONS: Universal income-based catastrophic coverage appears to be emerging as an implicit national standard for provincial pharmacare. However, due to the variation and high level of patient cost-sharing required under these programs, convergence on this model does not equate to substantial progress towards expanding coverage or reducing interprovincial disparities. Leverage of federal spending power to promote standards for public drug coverage is necessary to uniformly protect Canadians against high drug costs.