Assuring TRICARE Coverage of Preventive Health Services for Women Beneficiaries of the Military Health System.

WHY DEFENSE HEALTH HORIZONS PERFORMED THIS STUDY: The primary role of the Military Health System is to assure readiness by protecting the health of the force by providing expert care to wounded, ill, and injured service members. In addition to this mission, the Military Health System (both directly through its own personnel and indirectly, through TRICARE) provides health services to millions of military family members, retirees, and their dependents. Women's preventive health services are an important part of comprehensive health care to reduce rates of disease and premature death and were included in the 2010 Patient Protection and Affordable Care Act's (ACA) expanded coverage of women's preventive health services, based on the best available evidence and guidelines. These guidelines were updated by the Health Resources and Services Administrations and the American College of Obstetrics and Gynecology in 2016. However, TRICARE is not subject to the ACA, and therefore, TRICARE's provisions or the access of TRICARE's female beneficiaries to women's preventive health services was not directly changed by the ACA. This report compares women's reproductive health care coverage under TRICARE with coverage available to women enrolled in civilian health insurance plans subject to the 2010 ACA. WHAT DEFENSE HEALTH HORIZONS RECOMMENDS: Three recommendations are proposed to ensure that women who are TRICARE beneficiaries have access to and receive preventive reproductive health services that are consistent with Health Resources and Services Administration recommendations as implemented in the ACA. Each recommendation has strengths and weaknesses that are described in detail in the body of this paper. WHAT DEFENSE HEALTH HORIZONS FOUND: In covering contraceptive drugs and devices, TRICARE appears to reflect the scope of coverage found in ACA-compliant plans but, by not incorporating the term "all FDA-approved methods" of contraception, TRICARE leaves open the possibility that a narrower definition could be adopted at a future date. There are important differences in how TRICARE and ACA-compliant plans address reproductive counseling and health screening, including TRICARE's more restrictive counseling benefit and some limits to preventive screening. By not aligning with policies related to the provision of clinical preventive services established under the ACA, TRICARE allows health care providers in purchased care to diverge from evidence-based guidelines. Although the ACA respects medical judgment when providing women's preventive services, standards restrict the extent to which health care systems and providers can depart from evidence-based screening and prevention guidelines essential to optimizing quality, cost, and patient outcomes.

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design.

Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states' expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states.

How the Trump Administration's Pandemic Health Care Response Failed Racial Health Equity: Case Studies of Structural Racism and a Call for Equity Mindfulness in Federal Health Policy Making.

CONTEXT: The racial health equity implications of the Trump administration's response to the COVID-19 pandemic. METHODS: We focus on four key health care policy decisions made by the administration in response to the public health emergency: rejecting a special Marketplace enrollment period, failing to use its full powers to enhance state Medicaid emergency options, refusing to suspend the public charge rule, and failing to target provider relief funds to providers serving the uninsured. FINDINGS: In each case, the administration's policy choices intensified, rather than mitigated, racial health inequality. Its choices had a disproportionate adverse impact on minority populations and patients who are more likely to depend on public programs, be poor, experience pandemic-related job loss, lack insurance, rely on health care safety net providers, and be exposed to public charge sanctions. CONCLUSIONS: Ending structural racism in health care and promoting racial health care equity demands an equity-mindful approach to the pursuit of policies that enhance-rather than undermine-health care accessibility and effectiveness and resources for the poorest communities and the providers that serve them.

Venous Thromboembolism in Pediatric Inflammatory Bowel Disease: A Case-Control Study.

OBJECTIVES: Inflammatory bowel disease (IBD) is associated with increased risk of venous thromboembolism (VTE). Despite this recognized risk, there are limited data and no anticoagulation guidelines for hospitalized pediatric IBD patients. The objectives of this study were to characterize pediatric IBD patients with VTE and determine risk factors. METHODS: This was a nested case-control study comparing hospitalized children with IBD diagnosed with VTE to those without VTE over a decade at a large referral center. Standard descriptive statistics were used to describe the VTE group. Multivariable conditional logistic regression was used to assess risk factors. RESULTS: Twenty-three cases were identified. Central venous catheter (CVC) presence (odds ratio [OR] 77.9; 95% confidence interval [CI]: 6.9--880.6; P < 0.001) and steroid use (OR 12.7; 95% CI: 1.3--126.4; P = 0.012) were independent risk factors. Median age at VTE was 17 years (interquartile range [IQR] 13.5--18.2), and in 48%, VTE was the indication for admission. Median duration of anticoagulation was 3.8 months (IQR 2.3--7.6), and there were no major bleeding events for patients on anticoagulation. There were no patients with known sequelae from VTE, though 22% had severe VTE that required interventions. CONCLUSIONS: Pediatric patients with IBD are at risk for VTE, although the absolute risk remains relatively low. The safety and efficacy of pharmacologic thromboprophylaxis needs to be further evaluated in this population with attention to risk factors, such as steroid use and presence of CVC.

The Future of the Indispensable Insurer: The Biden Administration and Medicaid.

Medicaid presents both legislative and regulatory challenges and opportunities. As it moves a legislative agenda forward, the Biden administration also will confront a series of immediate regulatory matters, some of which have been made urgent because of pending judicial action. Chief among these pressing matters are ending Medicaid work requirements and block grant experiments, rescinding the public charge rule, ensuring optimal use of Medicaid's enrollment and renewal simplification tools, rescinding the Title X family planning rule (which has enormous implications for Medicaid beneficiaries), and, when the time comes, preparing states to wind down the "Families First" Medicaid maintenance of effort protection while avoiding erroneous beneficiary disenrollment. The administration could consider encouraging remaining nonexpansion states to pursue §1115 Medicaid expansion experiments; additionally, the administration could pursue Medicaid pandemic recovery demonstrations to support health system recovery during the long period that lies ahead. Thus, while certain advances must await legislation, the administration can move Medicaid forward through executive action.

Ensuring Equitable Access To COVID-19 Vaccines In The US: Current System Challenges And Opportunities.

There has been a worldwide effort to accelerate the development of safe and effective vaccines for severe acute respiratory syndrome coronavirus-2. When vaccines become licensed and available broadly to the public, the final hurdle is equitable distribution and access for all who are recommended for vaccination. Frameworks and existing systems for allocation, distribution, vaccination, and monitoring for safety and effectiveness are assets of the current immunization delivery system that should be leveraged to ensure the equitable distribution and broad uptake of licensed vaccines. The system should be strengthened to address gaps in access to immunization services and to modernize the public health infrastructure. We offer five recommendations as guideposts to ensure that policies and practices at the federal, state, local, and tribal levels support equity, transparency, accountability, availability, and access to coronavirus disease 2019 vaccines.

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.

The Potential and Realized Impact of the Affordable Care Act on Health Equity.

The Affordable Care Act (ACA) was designed with multiple goals in mind, including a reduction in social disparities in health care and health status. This was to be accomplished through some novel provisions and a significant infusion of resources into long-standing public programs with an existing track record related to health equity. In this article, we discuss seven ACA provisions with regard to their intended and realized impact on social inequalities in health, focusing primarily on socioeconomic and racial/ethnic disparities. Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. In addition, the ACA has had a significant impact on the volume/range of services offered and the financial security of community health centers, and through section 1557, the ACA broadened the civil rights landscape in which the health care system operates. Less clear is how the ACA has contributed to improved health outcomes and health equity. Extant evidence suggests that the part of the ACA that has had the greatest impact on social disparities in health outcomes-including preterm births and mortality-is the Medicaid expansion.

Closing The Medicaid Coverage Gap: Options For Reform.

Eight years after the US Supreme Court's landmark decision in National Federation of Independent Business v. Sebelius, more than two million of the nation's poorest working-age adults continue to feel its effects. These are the people who, because of the decision, remain without a pathway to affordable health insurance coverage because they live in a state that has not expanded Medicaid under the Affordable Care Act (ACA). Closing the coverage gap created by NFIB v. Sebelius represents the ACA's most pressing piece of unfinished business. Several options, which vary in cost and political complexity, exist for closing the gap in ways that respect the ACA's pluralistic approach to insurance coverage while adhering to constitutional principles. These considerations must be balanced against the urgency of the problem and the fact that, constitutionally speaking, Medicaid alone can no longer guarantee a national remedy to the fundamental issue of health insurance inequality for the poorest Americans.

Metastasis Initiation Precedes Detection of Primary Cancer-Analysis of Metastasis Growth in vivo in a Colorectal Cancer Test Case.

Most cases of deaths from colorectal cancer (CRC) result from metastases, which are often still undetectable at disease detection time. Even so, in many cases, shedding is assumed to have taken place before that time. The dynamics of metastasis formation and growth are not well-established. This work aims to explore CRC lung metastasis growth rate and dynamics. We analyzed a test case of a metastatic CRC patient with four lung metastases, with data of four serial computed tomography (CT) scans measuring metastasis sizes while untreated. We fitted three mathematical growth models-exponential, logistic, and Gompertzian-to the CT measurements. For each metastasis, a best-fitted model was determined, tumor doubling time (TDT) was assessed, and metastasis inception time was extrapolated. Three of the metastases showed exponential growth, while the fourth showed logistic restraint of the growth. TDT was around 93 days. Predicted metastasis inception time was at least 4-5 years before the primary tumor diagnosis date, though they did not reach detectable sizes until at least 1 year after primary tumor resection. Our results support the exponential growth approximation for most of the metastases, at least for the clinically observed time period. Our analysis shows that metastases can be initiated before the primary tumor is detectable and implies that surgeries accelerate metastasis growth.