Opioid and Substance Use Disorder and Receipt of Treatment Among Parents Living With Children in the United States, 2015-2017.

PURPOSE: Little is known about the prevalence of opioid use disorder (OUD) among parents who are living with children and their receipt of treatment, which could reduce the harmful effects of OUD on families. METHODS: We used 2015-2017 cross-sectional national survey data to estimate prevalence and treatment of opioid use disorder and other substance use disorders (SUD) among parents living with children. RESULTS: An estimated 623,000 parents with opioid use disorder are living with children, and less than one-third of these parents received treatment for illicit drug or alcohol use at a specialty facility or doctor's office. Treatment rates were even lower among the more than 4,000,000 parents estimated to have other SUDs. CONCLUSION: Many parents in both groups have concurrent mental health issues, including suicidal thoughts and behavior. Primary care practices can play a critical role in screening and facilitating treatment initiation.

Appointment availability after increases in Medicaid payments for primary care.

BACKGROUND: Providing increases in Medicaid reimbursements for primary care, a key provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers. The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states before policymakers had much empirical evidence about its effects. METHODS: We measured the availability of and waiting times for appointments in 10 states during two periods: from November 2012 through March 2013 and from May 2014 through July 2014. Trained field staff posed as either Medicaid enrollees or privately insured enrollees seeking new-patient primary care appointments. We estimated state-level changes over time in a stable cohort of primary care practices that participated in Medicaid to assess whether willingness to provide appointments for new Medicaid enrollees was related to the size of increases in Medicaid reimbursements in each state. RESULTS: The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups. CONCLUSIONS: Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.).

Price Transparency in Primary Care: Can Patients Learn About Costs When Scheduling an Appointment?

BACKGROUND: Cost-sharing in health insurance plans creates incentives for patients to shop for lower prices, but it is unknown what price information patients can obtain when scheduling office visits. OBJECTIVE: To determine whether new patients can obtain price information for a primary care visit and identify variation across insurance types, offices, and geographic areas. DESIGN: Simulated patient methodology in which trained interviewers posed as non-elderly adults seeking new patient primary care appointments. Caller insurance type (employer-sponsored insurance [ESI], Marketplace, or uninsured) and plan were experimentally manipulated. Callers who were offered a visit asked for price information. Unadjusted means and regression-adjusted differences by insurance, office types, and geography were calculated. PARTICIPANTS: Calls to a representative sample of primary care offices in ten states in 2014: Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas (N = 7865). MAIN MEASURES: Callers recorded whether they were able to obtain a price. If not, they recorded whether they were referred to other sources for price information. KEY RESULTS: Overall, 61.8% of callers with ESI were able to obtain a price, versus 89.2% of uninsured and 47.3% of Marketplace callers (P < 0.001 for differences). Price information was also more readily available in small offices and in counties with high uninsured rates. Among callers not receiving a price, 72.1% of callers with ESI were referred to other sources (billing office or insurance company), versus 25.8% of uninsured and 50.9% of Marketplace callers (P < 0.001). A small fraction of insured callers were told their visit would be free. If not free, mean visit prices ranged from $157 for uninsured to $165 for ESI (P < 0.05). Prices were significantly lower at federally qualified health centers (FQHCs), smaller offices, and in counties with high uninsured and low-income rates. CONCLUSIONS: Price information is often unavailable for privately insured patients seeking primary care visits at the time a visit is scheduled.

Access to Primary Care Appointments Following 2014 Insurance Expansions.

PURPOSE: The Patient Protection and Affordable Care Act (ACA) expanded coverage to roughly 12 million individuals by mid-2014 and 20 million by 2016, raising concern about the capacity of the primary care system to absorb these individuals. We set out to determine how justified the concern was. METHODS: We used an audit design in which simulated patients called primary care practices seeking new-patient appointments in 10 diverse states (Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas) from November 2012 through March 2013 and from May 2014 through July 2014, before and after the major ACA insurance expansions. Callers were randomly assigned to scripts specifying either private or Medicaid insurance and called only offices identified as "in network" for each plan. RESULTS: We completed 5,385 private insurance and 4,352 Medicaid calls in 2012-2013 and 2,424 private insurance and 2,474 Medicaid calls in 2014. Overall appointment rates for private insurance remained stable from 2012 (84.7%) to 2014 (85.8%) with Massachusetts and Pennsylvania experiencing significant increases. Overall, Medicaid appointment rates increased 9.7 percentage points (57.9% to 67.6%) with substantial variation by state. Across all callers, median wait times for those obtaining an appointment were 7 days in 2012 and 5 days in 2014, but the difference was not statistically significant. CONCLUSIONS: Contrary to widespread concern, we find no evidence that the millions of individuals newly insured through the ACA decreased new-patient appointment availability across 10 states as shown by stable wait times and appointment rates for private insurance as of mid-2014.

Primary Care Appointment Availability and the ACA Insurance Expansions.

In the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, both Medicaid patients and the privately insured experienced a one-day increase in median wait times. Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new Medicaid enrollees. In this Issue Brief, we summarize our study's findings, expand on possible explanations, and extend the analysis by examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these results suggest coverage provisions in the ACA have not overwhelmed primary care capacity.

Primary Care Appointment Availability for Medicaid Patients: Comparing Traditional and Premium Assistance Plans.

BACKGROUND: Arkansas and Iowa received waivers from the federal government in 2014 to use federal Medicaid expansion funding to enroll beneficiaries in commercial insurance plans on the Marketplaces. One key hypothesis of these "private option" or "premium assistance" programs was that Medicaid beneficiaries would experience increased access to care. In this study, we compare new patient primary care appointment availability and wait-times for beneficiaries of traditional Medicaid and premium assistance Medicaid. METHODS: Trained field staff posing as patients, randomized to traditional Medicaid or Marketplace plans, called primary care practices seeking new patient appointments in Arkansas and Iowa in May to July 2014. All calls were made to offices that previously indicated being in-network for the plan. Offices were drawn randomly, within insurance type, based on the county proportion of the population with each insurance type. We calculated appointment rates and wait-times for new patients for traditional Medicaid and Marketplace plans. RESULTS: In Arkansas, Marketplace appointment rates were 27.2 percentage points higher than traditional Medicaid appointment rates (83.2% compared with 55.5%, P<0.001), while in Iowa, Marketplace appointment rates were 12.0 percentage points higher (86.3% compared with 74.3%, P<0.001). Conditional on receiving an appointment, median wait-times were roughly 1 week in each state without significant differences by insurance type. CONCLUSIONS: The experiences of Arkansas and Iowa suggest that enrolling Medicaid beneficiaries into Marketplace plans may lead to higher primary care appointment availability for new patients at participating providers. Further research is needed on whether premium assistance programs affect quality and continuity of care, and at what cost.

Access points for the underserved: primary care appointment availability at federally qualified health centers in 10 States.

BACKGROUND: Federally Qualified Health Centers (FQHCs) are a vital source of primary care for underserved populations, such as Medicaid enrollees and the uninsured. Their role in delivering care may increase through new funding allocations in the Affordable Care Act and expanded Medicaid programs across many states. OBJECTIVE: Examine differences in appointment availability and wait-times for new patient visits between FQHCs and other providers. RESEARCH DESIGN: We use experimental data from a simulated patient study to compare new patient appointment rates across FQHC and non-FQHC practices for 3 insurance types (private, Medicaid, and self-pay). Trained auditors, posing as patients requesting the first available new patient appointment, were randomized to call primary care providers in 10 states in late 2012 and early 2013. Multivariate regression models adjust for caller-level, clinic-level, and area-level variables. STUDY SETTING: The sample comprises 10,904 calls, including 544 calls to FQHCs. RESULTS: FQHCs grant new patient appointments at high rates, irrespective of patient insurance status. Adjusting for caller, clinic, and area variables, the Medicaid appointment rate at FQHCs is 22 percentage points higher than other primary care practices. Although the appointment rate difference between FQHCs and non-FQHCs is somewhat smaller for the self-pay group, FQHCs are much more likely to provide a lower-cost visit to these patients. Conditional on receiving an appointment, wait-times at FQHCs are comparable with other providers. CONCLUSION: FQHCs' greater willingness to accept new underserved patients before 2014 underscores their potential key roles as health reform proceeds.

Determinants of receipt of recommended preventive services: implications for the Affordable Care Act.

OBJECTIVES: We examined preventive care use by nonelderly adults (aged 18-64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns. METHODS: We used data from the 2005-2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income. RESULTS: There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers. CONCLUSIONS: Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.

Black-White Disparities in Asthma Hospitalizations and ED Visits Among Medicaid-Enrolled Children.

BACKGROUND AND OBJECTIVES: Asthma is a common, potentially serious childhood chronic condition that disproportionately afflicts Black children. Hospitalizations and emergency department (ED) visits for asthma can often be prevented. Nearly half of children with asthma are covered by Medicaid, which should facilitate access to care to manage and treat symptoms. We provide new evidence on racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children. METHODS: We used comprehensive Medicaid claims data from the Transformed Medicaid Statistical Information System. Our study population included 279 985 Medicaid-enrolled children with diagnosed asthma. We identified asthma hospitalizations and ED visits occurring in 2019. We estimated differences in the odds of asthma hospitalizations and ED visits for non-Hispanic Black versus non-Hispanic white children, adjusting for sex, age, Medicaid eligibility group, Medicaid plan type, state, and rurality. RESULTS: In 2019, among Black children with asthma, 1.2% had an asthma hospitalization and 8.0% had an asthma ED visit compared with 0.5% and 3.4% of white children with a hospitalization and ED visit, respectively. After adjusting for other characteristics, the rates for Black children were more than twice the rates for white children (hospitalization adjusted odds ratio 2.45, 95% confidence interval 2.23-2.69; ED adjusted odds ratio 2.42; 95% confidence interval 2.33-2.51). CONCLUSIONS: There are stark racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children with asthma. To diminish these disparities, it will be important to implement solutions that address poor quality care, discriminatory treatment in health care settings, and the structural factors that disproportionately expose Black children to asthma triggers and access barriers.

Health status, risk factors, and medical conditions among persons enrolled in Medicaid vs uninsured low-income adults potentially eligible for Medicaid under the Affordable Care Act.

IMPORTANCE: Under the Affordable Care Act (ACA), states can extend Medicaid eligibility to nearly all adults with income no more than 138% of the federal poverty level. Uncertainty exists regarding the scope of medical services required for new enrollees. OBJECTIVE: To document the health care needs and health risks of uninsured adults who could gain Medicaid coverage under the ACA. These data will help physicians, other clinicians, and state Medicaid programs prepare for the possible expansions. DESIGN, SETTING, AND PATIENTS: Data from the National Health and Nutrition Examination Survey 2007-2010 were used to analyze health conditions among a nationally representative sample of 1042 uninsured adults aged 19 through 64 years with income no more than 138% of the federal poverty level, compared with 471 low-income adults currently enrolled in Medicaid. MAIN OUTCOMES AND MEASURES: Prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests, measures of self-reported health status including medical conditions, and risk factors such as measured obesity status. RESULTS: Compared with those already enrolled in Medicaid, uninsured adults were less likely to be obese and sedentary and less likely to report a physical, mental, or emotional limitation. They also were less likely to have several chronic conditions. For example, 30.1% (95% CI, 26.8%-33.4%) of uninsured adults had hypertension, hypercholesterolemia, or diabetes compared with 38.6% (95% CI, 32.0%-45.3%) of those enrolled in Medicaid (P = .02). However, if they had these conditions, uninsured adults were less likely to be aware of them and less likely to have them controlled. For example, 80.1% (95% CI, 75.2%-85.1%) of the uninsured adults with at least 1 of these 3 conditions had at least 1 uncontrolled condition, compared with 63.4% (95% CI, 53.7%-73.1%) of adults enrolled in Medicaid. CONCLUSION AND RELEVANCE: Compared with adults currently enrolled in Medicaid, uninsured low-income adults potentially eligible to enroll in Medicaid under the ACA had a lower prevalence of many chronic conditions. A substantial proportion of currently uninsured adults with chronic conditions did not have good disease control; projections based on sample weighting suggest this may represent 3.5 million persons (95% CI, 2.9 million-4.2 million). These adults may need initial intensive medical care following Medicaid enrollment.

Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children.

OBJECTIVE: To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously. DATA SOURCES: We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation. STUDY DESIGN: We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state. DATA EXTRACTION METHODS: We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions. PRINCIPAL FINDINGS: Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations. CONCLUSIONS: Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

Variation in Medicaid eligibility and participation among adults: implications for the Affordable Care Act.

Steep declines in the uninsured population under the Affordable Care Act (ACA) will depend on high enrollment among newly Medicaid-eligible adults. We use the 2009 American Community Survey to model pre-ACA eligibility for comprehensive Medicaid coverage among nonelderly adults. We identify 4.5 million eligible but uninsured adults. We find a Medicaid participation rate of 67% for adults; the rate is 17 percentage points lower than the national Medicaid participation rate for children, and it varies substantially across socioeconomic and demographic subgroups and across states. Achieving substantial increases in coverage under the ACA will require sharp increases in Medicaid participation among adults in some states.

How did the Affordable Care Act Medicaid Expansion Affect Coverage and Access to Care for Low-Income Parents Who Were Eligible for Medicaid Before the Law Was Passed?

We use the National Health Interview Survey from 2010 to 2017 and a difference-in-differences approach to assess the impact of the Affordable Care Cct (ACA) Medicaid expansion on coverage and access to care for a subset of low-income parents who were already eligible for Medicaid when the ACA was passed. Any gains in coverage would typically be expected to improve access to and affordability of care, but there were concerns that by increasing the total population with coverage and thereby straining provider capacity, that the ACA would reduce access to care for individuals who were already eligible for Medicaid prior to the passage of the law. We found that the expansion reduced uninsurance among previously eligible parents by 12.6 percentage points, or a 40 percent decline from their 2012-2013 uninsurance rate. Moreover, these effects grew stronger over time with a 55 percent decline in uninsurance 2 to 3 years following expansion. Though we identified very few statistically significant impacts of the expansion on affordability of care, descriptive estimates show substantial declines in unmet needs due to cost and problems paying family medical bills. Descriptively, we find no significant increases in provider access problems for previously eligible parents, and very limited evidence that the Medicaid expansion was associated with more constrained provider capacity. Though sample size constraints were likely a factor in our ability to identify impacts on access and affordability measures, our overall findings suggest that the ACA Medicaid expansion positively affected our sample of low-income parents who met pre-ACA Medicaid eligibility criteria.

Children's Health Insurance Coverage: Progress, Problems, And Priorities For 2021 And Beyond.

Expansion of Medicaid and establishment of the Children's Health Insurance Program (CHIP) represent a significant success story in the national effort to guarantee health insurance for children. That success is reflected in the high rates of coverage and health care access achieved for children, including those in low-income families. But significant coverage gaps remain-gaps that have been increasing since 2016 and are likely to accelerate with the coronavirus disease 2019 (COVID-19) pandemic and the associated recession. Using National Health Interview Survey data, we found that the proportion of uninsured children was 5.5 percent in 2018. Children continue to face coverage interruptions, and Latino, adolescent, and noncitizen children continue to face elevated risks of being uninsured. Although we note the benefits of a universal, federally financed, single-payer approach to coverage, we also offer two possible reform pathways that can take place within the current multipayer system, aimed at ensuring coverage, access, continuity, and comprehensiveness to move the nation closer to the goal of providing the health care that children need to reach their full potential and to reduce racial and economic inequalities.

ACA Medicaid Expansion and Insurance Coverage Among New Mothers Living in Poverty.

BACKGROUND: Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act's (ACA's) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty. METHODS: We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010-2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers. RESULTS: A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers. CONCLUSIONS: ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.

Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey.

OBJECTIVE: Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN: We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS: Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS: We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.

Changes in primary care access at community health centers between 2012/2013 and 2016.

OBJECTIVE: To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act. DATA SOURCE: Ten state primary care audit conducted in 2012/2013 and 2016. STUDY DESIGN: CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type. PRINCIPAL FINDINGS: In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance. CONCLUSION: Appointment availability at CHCs improved after ACA implementation, without increased wait times.

Most Primary Care Physicians Provide Appointments, But Affordability Remains A Barrier For The Uninsured.

The US uninsurance rate has nearly been cut in half under the Affordable Care Act, and access to care has improved for the newly insured, but less is known about how the remaining uninsured have fared. In 2012-13 and again in 2016 we conducted an experiment in which trained auditors called primary care offices, including federally qualified health centers, in ten states. The auditors portrayed uninsured patients seeking appointments and information on the cost of care and payment arrangements. In both time periods, about 80 percent of uninsured callers received appointments, provided they could pay the full cash amount. However, fewer than one in seven callers in both time periods received appointments for which they could make a payment arrangement to bring less than the full amount to the visit. Visit prices in both time periods averaged about $160. Trends were largely similar across states, despite their varying changes in the uninsurance rate. Federally qualified health centers provided the highest rates of primary care appointment availability and discounts for uninsured low-income patients.