Child Mental Health, Homelessness, and the Shelter System: Evidence from Medicaid in New York City.

We identified children who resided in the New York City shelter system during 2015-2020 by matching address histories in Medicaid insurance claims to publicly available homeless shelter addresses, permitting examination of health care use before, during, and after shelter stays. We found that 4.5% of NYC children aged 4-17 with consistent Medicaid coverage entered shelter over a three-to-five-year period. After shelter entry, children had increased probabilities of receiving mental health services, including therapy and diagnoses of neurodevelopmental disorders, but little change in physical health service use. Children placed in shelters co-located with mental health services were similar to children entering other shelters prior to entry but had particularly large and sustained increases in use of mental health services afterwards. Children without prior mental health claims placed in shelters co-located with mental health services were 38-48% more likely to receive mental health therapy and 14-16% more likely to receive neurodevelopmental diagnoses than similar children placed elsewhere. These children were also more likely to receive Supplemental Security Income and stayed in shelter longer. This example illustrates the potential of linking administrative data sets in order to study vulnerable populations.

Major Traffic Safety Reform and Road Traffic Injuries Among Low-Income New York Residents, 2009-2021.

Objectives. To evaluate the effects of a comprehensive traffic safety policy-New York City's (NYC's) 2014 Vision Zero-on the health of Medicaid enrollees. Methods. We conducted difference-in-differences analyses using individual-level New York Medicaid data to measure traffic injuries and expenditures from 2009 to 2021, comparing NYC to surrounding counties without traffic reforms (n = 65 585 568 person-years). Results. After Vision Zero, injury rates among NYC Medicaid enrollees diverged from those of surrounding counties, with a net impact of 77.5 fewer injuries per 100 000 person-years annually (95% confidence interval = -97.4, -57.6). We observed marked reductions in severe injuries (brain injury, hospitalizations) and savings of $90.8 million in Medicaid expenditures over the first 5 years. Effects were largest among Black residents. Impacts were reversed during the COVID-19 period. Conclusions. Vision Zero resulted in substantial protection for socioeconomically disadvantaged populations known to face heightened risk of injury, but the policy's effectiveness decreased during the pandemic period. Public Health Implications. Many cities have recently launched Vision Zero policies and others plan to do so. This research adds to the evidence on how and in what circumstances comprehensive traffic policies protect public health. (Am J Public Health. 2024;114(6):633-641. https://doi.org/10.2105/AJPH.2024.307617).

Racial and Ethnic Segregation in Primary Care and Association of Practice Composition With Quality of Care.

OBJECTIVE: To assess the extent of segregation between racial and ethnic minority and White patients across primary care physicians and the association of practice panel racial/ethnic composition with the quality of care delivered. RESEARCH DESIGN: We examined the degree of racial/ethnic dissimilarity (a measure of segregation) in visits and the allocation of patient visits by different groups across primary care physicians (PCPs). We assessed the regression-adjusted relationship between the racial/ethnic composition of PCP practices and measures of the quality of care delivered. We compared outcomes in the pre-Affordable Care Act (ACA) and post-ACA (2006-2010/2011-2016) periods. SUBJECTS: We analyzed data on all primary care visits to office-based practitioners in the 2006-2016 National Ambulatory Medical Care Survey. PCPs were defined as general/family practice or internal medicine physicians. We excluded cases with imputed race or ethnicity information. For the quality of care analyses, we limited the sample to adults. RESULTS: Racial and ethnic minority patients remain concentrated within a small group of PCPs: 35% of PCPs accounted for 80% of non-White patients' visits; 63% of non-White (or White) patients would need to switch physicians to make the distribution of visits across PCPs proportional between the groups. We observed little correlation between the PCPs panel's racial/ethnic composition and quality of care. These patterns did not change substantially over time. CONCLUSIONS: PCPs remain segregated, but the racial/ethnic composition of a practice panel is not associated with the quality of health care that individual patients receive in either the pre or post-ACA passage periods.

Lasting scars: The impact of depression in early adulthood on subsequent labor market outcomes.

A growing body of evidence indicates that poor health early in life can leave lasting scars on adult health and economic outcomes. While much of this literature focuses on childhood experiences, mechanisms generating these lasting effects-recurrence of illness and interruption of human capital accumulation-are not limited to childhood. In this study, we examine how an episode of depression experienced in early adulthood affects subsequent labor market outcomes. We find that, at age 50, people who had met diagnostic criteria for depression when surveyed at ages 27-35 earn 10% lower hourly wages (conditional on occupation), work 120-180 fewer hours annually, and earn 24% lower annual wage incomes. A portion of this income penalty (21%-39%) occurs because depression is often a chronic condition, recurring later in life. But a substantial share (25%-55%) occurs because depression in early adulthood disrupts human capital accumulation, by reducing work experience and by influencing selection into occupations with skill distributions that offer lower potential for wage growth. These lingering effects of early depression reinforce the importance of early and multifaceted intervention to address depression and its follow-on effects in the workplace.

Using machine-learning methods to predict in-hospital mortality through the Elixhauser index: A Medicare data analysis.

Accurate in-hospital mortality prediction can reflect the prognosis of patients, help guide allocation of clinical resources, and help clinicians make the right care decisions. There are limitations to using traditional logistic regression models when assessing the model performance of comorbidity measures to predict in-hospital mortality. Meanwhile, the use of novel machine-learning methods is growing rapidly. In 2021, the Agency for Healthcare Research and Quality published new guidelines for using the Present-on-Admission (POA) indicator from the International Classification of Diseases, Tenth Revision, for coding comorbidities to predict in-hospital mortality from the Elixhauser's comorbidity measurement method. We compared the model performance of logistic regression, elastic net model, and artificial neural network (ANN) to predict in-hospital mortality from Elixhauser's measures under the updated POA guidelines. In this retrospective analysis, 1,810,106 adult Medicare inpatient admissions from six US states admitted after September 23, 2017, and discharged before April 11, 2019 were extracted from the Centers for Medicare and Medicaid Services data warehouse. The POA indicator was used to distinguish pre-existing comorbidities from complications that occurred during hospitalization. All models performed well (C-statistics >0.77). Elastic net method generated a parsimonious model, in which there were five fewer comorbidities selected to predict in-hospital mortality with similar predictive power compared to the logistic regression model. ANN had the highest C-statistics compared to the other two models (0.800 vs. 0.791 and 0.791). Elastic net model and AAN can be applied successfully to predict in-hospital mortality.

Changes in the Public Charge Rule and Health of Mothers and Infants Enrolled in New York State's Medicaid Program, 2014‒2019.

Objectives. To examine the effect of the January 2017 leak of the federal government's intent to broaden the public charge rule (making participation in some public programs a barrier to citizenship) on immigrant mothers and newborns in New York State. Methods. We used New York State Medicaid data (2014-2019) to measure the effects of the rule leak (January 2017) on Medicaid enrollment, health care utilization, and severe maternal morbidity among women who joined Medicaid during their pregnancies and on the birth weight of their newborns. We repeated our analyses using simulated measures of citizenship status. Results. We observed an immediate statewide delay in prenatal Medicaid enrollment by immigrant mothers (odds ratio = 1.49). Using predicted citizenship, we observed significantly larger declines in birth weight (-56 grams) among infants of immigrant mothers. Conclusions. Leak of the public charge rule was associated with a significant delay in prenatal Medicaid enrollment among immigrant women and a significant decrease in birth weight among their newborns. Local public health officials should consider expanding health access and outreach programs to immigrant communities during times of pervasive antiimmigrant sentiment. (Am J Public Health. 2022; 112(12):1747-1756. https://doi.org/10.2105/AJPH.2022.307066).

Not a New Story: Place- and Race-Based Disparities in COVID-19 and Influenza Hospitalizations among Medicaid-Insured Adults in New York City.

While SARS-CoV-2 is a novel virus, contagious respiratory illnesses are not a new problem. Limited research has examined the extent to which place- and race-based disparities in severe illness are similar across waves of the COVID-19 pandemic and historic influenza seasons. In this study, we focused on these disparities within a low-income population, those enrolled in Medicaid in New York City. We used 2015-2020 New York State Medicaid claims to compare the characteristics of patients hospitalized with COVID-19 during three separate waves of 2020 (first wave: January 1-April 30, 2020; second wave: May 1-August 31, 2020; third wave: September 1-December 31, 2020) and with influenza during the 2016 (July 1, 2016-June 30, 2017) and 2017 influenza seasons (July 1, 2017-June 30, 2018). We found that patterns of hospitalization by race/ethnicity and ZIP code across the two influenza seasons and the first wave of COVID-19 were similar (increased risk among non-Hispanic Black (aOR = 1.17, 95% CI: 1.10-1.25) compared with non-Hispanic white Medicaid recipients). Black/white disparities in hospitalization dissipated in the second COVID wave and reversed in the third wave. The commonality of disparities across influenza seasons and the first wave of COVID-19 suggests there are community factors that increase hospitalization risk across novel respiratory illness incidents that emerge in the period before aggressive public health intervention. By contrast, convergence in hospitalization patterns in later pandemic waves may reflect, in part, the distinctive public health response to COVID-19.

Robotic Prostatectomy and Prostate Cancer-Related Medicaid Spending: Evidence from New York State.

BACKGROUND: Robotic prostatectomy is a costly new technology, but the costs may be offset by changes in treatment patterns. The net effect of this technology on Medicaid spending has not been assessed. OBJECTIVE: To identify the association of the local availability of robotic surgical technology with choice of initial treatment for prostate cancer and total prostate cancer-related treatment costs. DESIGN AND PARTICIPANTS: This cohort study used New York State Medicaid data to examine the experience of 9564 Medicaid beneficiaries 40-64 years old who received a prostate biopsy between 2008 and 2017 and were diagnosed with prostate cancer. The local availability of robotic surgical technology was measured as distance from zip code centroids of patient's residence to the nearest hospital with a robot and the annual number of robotic prostatectomies performed in the Hospital Referral Region. MAIN MEASURES: Multivariate linear models were used to relate regional access to robots to the choice of initial therapy and prostate cancer treatment costs during the year after diagnosis. KEY RESULTS: The mean age of the sample of 9564 men was 58 years; 30% of the sample were White, 26% were Black, and 22% were Hispanic. Doubling the distance to the nearest hospital with a robot was associated with a reduction in robotic surgery rates of 3.7 percentage points and an increase in the rate of use of radiation therapy of 5.2 percentage points. Increasing the annual number of robotic surgeries performed in a region by 10 was associated with a decrease in the probability of undergoing radiation therapy of 0.6 percentage point and a $434 reduction in total prostate cancer-related costs per Medicaid patient. CONCLUSIONS: A full accounting of the costs of a new technology will depend on when it is used and the payment rate for its use relative to payment rates for substitutes.

The Structure and Financing of Health Care Systems Affected How Providers Coped With COVID-19.

Policy Points We compared the structure of health care systems and the financial effects of the COVID-19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers. The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity-based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief. In a pandemic, activity-based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.

The Secretary Shall . . . : Implementing the Affordable Care Act's Private Insurance Expansions.

The federal bureaucracy played a critical role in implementing most aspects of the Affordable Care Act's private insurance coverage expansion. Through brief case studies, the authors review three dimensions of this role: the development of the Center for Consumer Information and Insurance Oversight, rulemaking in the formulation of the essential health benefits package, and the implementation of the federal website. They relate these to themes in the public administration literature. Politics-both through state decisions and through continuing congressional action (and inaction)-pervaded the implementation process. The challenges of staffing and situating the new bureaucracy effectively changed vertical boundaries within the Department of Health and Human Services, with long-lasting consequences. Finally, the complex design of the policy itself made passage of the legislation easier but implementation much more difficult. Ultimately, however, implementation was remarkably successful, achieving improvements in coverage consistent with the Congressional Budget Office's projections.

Options for Dialing Down From Single Payer.

There are formidable institutional obstacles to passing a single-payer health program in the United States. Advocates should consider incremental improvements that may better match legislative realities. There are three potential directions for incremental coverage policy.One possibility is to build on the successes of the Affordable Care Act; this might include rolling back regulatory changes, further incentivizing Medicaid expansion, enhancing coverage in the Affordable Care Act marketplaces, and imposing regulations on private employer-based insurance to ensure that all Americans have access to affordable coverage that provides adequate financial security. A second direction is to offer more publicly sponsored insurance options, which might involve offering a public option to those eligible for marketplace coverage, creating a Medicare or Medicaid buy-in program, lowering the eligibility age for Medicare, or developing a public plan that serves as a default for those who do not choose to buy alternative private coverage. A third direction is to build on federalism, offering states incentives to expand coverage.Federal and state legislators could also consider incremental cost-containment steps, such as rate setting.

Considering "Single Payer" Proposals in the U.S.: Lessons from Abroad.

Issue: When discussing universal health insurance coverage in the United States, policymakers often draw a contrast between the U.S. and high-income nations that have achieved universal coverage. Some will refer to these countries having "single payer" systems, often implying they are all alike. Yet such a label can be misleading, as considerable differences exist among universal health care systems. Goal: To compare universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance; and role of private insurance. Methods: Data from the Organisation for Economic Co-operation and Development, the Commonwealth Fund, and other sources are used to compare 12 high-income countries. Key Findings and Conclusion: Countries differ in the extent to which financial and regulatory control over the system rests with the national government or is devolved to regional or local government. They also differ in scope of benefits and degree of cost-sharing required at the point of service. Finally, while virtually all systems incorporate private insurance, its importance varies considerably from country to country. A more nuanced understanding of the variations in other countries' systems could provide U.S. policymakers with more options for moving forward.

Promoting Prevention Under the Affordable Care Act.

The Affordable Care Act (ACA) of 2010 placed a substantial emphasis on public health and prevention. Subsequent research on its effects reveals some notable successes and some missteps and offers important lessons for future legislators. The ACA's Prevention and Public Health Fund, intended to give public health budgetary flexibility, provided crucial funding for public health services during the Great Recession but proved highly vulnerable to subsequent budget cuts. Several programs that aimed to increase strategic thinking and planning around public health at the state level have proven to be more enduring, suggesting that the convening authority of the federal government can be a powerful tool for progress, especially when buttressed by some funding. Most important, by expanding insurance and mandating a minimum level of coverage, the ACA both increased access to clinical preventive services and freed up local public health budgets to engage in population health activities.

Implications of the 2017 Tax Cuts and Jobs Act for Public Health.

The recently passed Tax Cuts and Jobs Act will reduce total federal revenues by about 4% between 2018 and 2027. The law makes multiple changes to the taxation of individuals and corporations. It also repeals the Affordable Care Act's (ACA's) individual mandate penalties, which will erase some of the gains in insurance coverage achieved since implementation of the ACA's coverage expansions. The resulting increases in rates of uninsurance will likely lead to increased uncompensated care and deflect hospitals and health departments from addressing other prevention and public health needs. In addition, the law is expected to lead to substantial increases in the federal debt and, consequently, to calls for reductions in spending on entitlement programs, particularly Medicare, and on discretionary programs, including public health. Many other provisions of the law could also have second-order effects on public health.

How the Affordable Care Act Has Affected Health Coverage for Young Men with Higher Incomes.

Issue: The Affordable Care Act (ACA) regulates the price of health plans sold in the nongroup market. Premiums cannot be based on gender or health status, and price increases related to age are limited. These changes have lowered premiums for older, sicker people but raised them for younger, healthier ones--especially young men ineligible for premium subsidies. This has raised concerns that the latter have failed to gain coverage. Goal: Compare the impact of the ACA's rating rules on the number of insured young men, older adults, and others. Methods: We compared overall and nongroup coverage trends pre- and post-ACA among demographic groups, comparing residents of states where the rule changes had little effect on premiums to states where the rules had greater effect. Findings: People whose premiums fell because of the ACA's rating rules were slightly more likely to get nongroup coverage than those whose premiums rose. All groups, including higher-income young men, gained coverage because of the combined effects of ACA changes. Conclusion: Coverage rose after the ACA took effect among all demographic groups. Taken together, the ACA's individual mandate, marketing efforts, and effects on how people perceive the value of having insurance outweighed the impacts of changes in rating and benefit rules.

Who Entered and Exited the Individual Health Insurance Market Before and After the Affordable Care Act? Evidence from the Medical Expenditure Panel Survey.

Issue: The Affordable Care Act (ACA) made it easier for older adults and those with medical conditions to enroll in individual-market coverage by eliminating risk rating and limiting age rating. While the ACA also encourages young and healthy people to enroll through subsidies and the individual mandate, it's not clear whether these incentives have been sufficient to prevent the risk pool from becoming disproportionately old and sick. Goal: To assess whether patterns in individual-market participation changed following ACA implementation. Methods: Comparison of Medical Expenditure Panel Survey (MEPS) data for the periods 2003­09 and 2014­15. Findings and Conclusion: The analysis found few differences in individual-insurance market participation before and after the ACA. Adverse selection occurred during both: people switching into individual insurance coverage after being uninsured were higher utilizers prior to the switch than were those who remained uninsured. Those who disenrolled from individual plans tended to be lower utilizers of care before switching compared with those who kept their coverage. The main difference was that more people--especially young adults--switched from Medicaid to individual insurance, and vice versa, after the ACA. Adverse enrollment or disenrollment in the individual market did not increase following ACA implementation. The combination of easing rating rules and encouraging participation appears to have maintained market stability.