Adequacy of Prenatal Care Utilization in a Pathways Community HUB Model Program: Results of a Propensity Score Matching Analysis.

INTRODUCTION: The THRIVE (Toward Health Resiliency and Infant Vitality & Equity) program aims to reduce racial disparities in birth outcomes by addressing individual risks and social determinants of health using the Pathways Community HUB model. This study examines (1) racial disparities among THRIVE participants and propensity score matched (PSM) comparisons in adequacy of prenatal care, and whether THRIVE participation (2) attenuates such disparities, and (3) improves odds of having adequate prenatal care. METHODS: Birth certificate and Care Coordination Systems client data were merged for analysis. PSM was employed for 1:1 matching per birth year (2017-2020) and race for participating and non-participating first-time births in Stark County, Ohio. Additional matching variables were age, marital status, education attainment, birth quarter, census tract poverty rate, and Women Infant & Children (WIC) enrollment. Logistic regression assessed racial differences in adequate prenatal care utilization (APNCU) and examined differences between the intervention and comparison groups on APNCU. RESULTS: THRIVE participants averaged more prenatal care visits and had a higher percentage of adequate care utilization than the comparison group. THRIVE program participation, educational attainment, and WIC enrollment were associated with higher odds of adequate prenatal care utilization (OR 4.74; 95% CI 2.62, 8.57). Race was not significant for APNCU. DISCUSSION: Although accessing and maintaining prenatal care is only one aspect of improving birth outcomes, the findings contribute to the understanding of the effects of the program of interest and other similar programs on factors which may promote desired birth outcomes in high-risk populations.

Healthcare for the Homeless (HCH) Projects and Medicaid Expansion.

Medicaid expansion was ruled optional in 2012 by the Supreme Court, which allowed some states to adopt it while others did not. This study examines the differences in the percent uninsured, healthcare utilization by service type, and clinical quality of care measures at HCH (Healthcare for the Homeless) projects between expansion and non-expansion states. An exploratory state-level retrospective analysis of annual Uniform Data System data limited to HCHs from 2012 to 2019 from 50 states plus Washington DC is presented. Using descriptive statistics and linear mixed models, we found that the percentage of uninsured HCH patients decreased across all states, but the decrease was greater in states that expanded Medicaid compared to states that did not (- 8.23, p < .0.0001). This implies HCH projects can rely less on grants and more on insurance reimbursement. When examining specific service categories, medical services in expansion states increased at a statistically significant rate post expansion as compared to non-expansion states (2.52, p = 0.0085). The percentage of substance use visits were lower in expansion states compared to non-expansion states (- 0.79, p = 0.0267). Finally, there were three preventive clinical quality of care measures at HCH projects that showed significant improvement in expansion states post expansion: colorectal cancer screening, blood pressure control, and diabetes control. Maintaining Medicaid expansion is advantageous given its association with reductions in uninsured, increased medical services utilization, and improvement in some clinical quality of care measures for homeless populations receiving services at HCH projects in expansion states.

Public Program Enrollment Following US State Medicaid Expansion and Outreach.

OBJECTIVES: To examine the joint impact of states' Medicaid expansion and participation in Medicaid enrollment outreach at the take-up of other means-tested public programs (Women, Infants, and Children [WIC], Supplemental Nutrition Assistance Program [SNAP]). METHODS: Data were used from the American Community Survey, WIC, and SNAP. We used difference-in-differences analyses to compare the combined impact of Medicaid expansion and enrollment outreach on program enrollment. RESULTS: Enrollment in means-tested programs decreased after 2014, regardless of Medicaid expansion and outreach status. However, gaps in enrollment among states that both expanded Medicaid and conducted outreach, compared with states that did neither, increased after expansion of SNAP and WIC enrollment (10.15% and 4.57%, respectively) and favored those states that did both. CONCLUSIONS: States that both expanded Medicaid and conducted Medicaid enrollment outreach experienced smaller decreases in SNAP and WIC enrollment in comparison with other states. Moreover, enrollment in SNAP has shown to reduce health care expenditures. Greater collaboration among public programs, such as streamlining eligibility data and concerted outreach efforts, is one of the achievements of the Affordable Care Act that should be continued.

Medicaid Coverage for Routine Foot Care.

BACKGROUND: Despite national and international guidelines supporting podiatric services as a means of prevention for lower-extremity complications, especially in at-risk individuals, current coverage for these services under the US Medicaid program is not universal. The vast differences between state Medicaid programs regarding reimbursable foot care services is confusing and potentially serves as a barrier for the most vulnerable populations to receive preventative services. This article provides a brief discussion of "routine" podiatric services from a clinical perspective and provides a review of state Medicaid programs including optional services (eg, podiatric coverage). METHODS: Using data from a national survey of state Medicaid programs, we present and discuss common Medicaid coverage schemes for routine foot care provided by podiatric physicians. RESULTS: Analysis demonstrated that states vary dramatically in basic descriptions of preventive foot care, levels of coverage, eligibility, and methods of documenting coverage details. CONCLUSIONS: The authors recommend bringing Medicaid in line with other federal health programs and including podiatric physicians in the definition of "physician" for coverage purposes. States should move away from describing preventative services as "routine" and choose language that more accurately reflects the true nature and purpose of the care.

Medicaid Coverage for Podiatric Care: A National Survey.

OBJECTIVES: Medicaid provides health insurance for low-income people meeting specific eligibility requirements. It is funded and administered by both the federal and state governments; this decentralization leads to vastly different programs across the country. The objective of this legal surveillance project was to describe state-by-state differences in podiatric care coverage for nonelderly adults across Medicaid programs. METHODS: We used policy surveillance, a form of advanced legal mapping. It is the systematic collection and analysis of written policies across jurisdictions. Policy surveillance captures the important features of law through a rigorous scientific process to turn these policies into structured, quantitative legal data that are suitable for further evaluation or modeling. Data for the 51 jurisdictions were current as of September 1, 2020. RESULTS: The vast majority of jurisdictions (82%) covered podiatric services for all classes of Medicaid beneficiaries, but the rules, restrictions, and limitations around coverage differed. Twenty-five jurisdictions had no limits on the number of podiatric visits during a specified period; 26 jurisdictions indicated a cap. Ten jurisdictions had no explicit limitations on coverage of routine foot care, whereas 33 jurisdictions covered routine foot care only when medically necessary or with a triggering condition. Eight jurisdictions did not cover routine foot care at all, and 28 jurisdictions required prior authorizations. CONCLUSIONS: Podiatric care coverage, which is often preventive, varies greatly by state. This variability in coverage, which has not been previously tracked at the level of detail provided in our study, has implications for cost and health outcomes. The value of podiatric care is especially apparent in Medicaid populations. The compilation of these data can serve as a valuable resource for clinicians, researchers, and policy makers.

The Effects of the COVID-19 Economic Downturn on Medicaid Coverage for Podiatry Services.

As of 2016, Medicaid accounted for nearly 20% of state general fund budgets. Optional Medicaid services such as podiatry are often subject to cost-cutting measures in periods of economic downturn, as was the case in the wake of the 2007 financial crisis. Although the cuts were intended as a cost-saving measure, research indicates that they had the opposite effect. The restriction and limitation of these services during the Great Recession resulted in both poorer health outcomes for beneficiaries, and poorer financial outcomes for state Medicaid programs. With states citing record levels of unemployment as of April of 2020 and projecting significant declines in annual revenue in 2021, the economic conditions resulting from the coronavirus disease of 2019 pandemic are likely to rival those of the Great Recession. Given the historical precedent for restricting or eliminating optional Medicaid services as a cost-saving measure, it is likely that podiatric services will once again come under scrutiny. Previous efforts by state-level podiatric societies have proven successful in lobbying for the reinstatement of coverage under Medicaid by conveying evidence of the negative outcomes associated with elimination to stakeholders. The specialty must once again engage policymakers by drawing on evidence gleaned and lessons learned from past cuts of optional Medicaid services to avert counterproductive coverage restrictions intended to mitigate the financial impact of the coronavirus disease of 2019 pandemic.

Medicaid Expansion and Emergency Medical Service Transports.

The primary objective of this investigation was to determine if there was a change in emergency medical service (EMS) utilization following implementation of Medicaid expansion under the Affordable Care Act. The National Emergency Medical Service Information System (NEMSIS) data from 2010-2016 were evaluated in an interrupted time series analysis. Data were stratified by pediatric and adult EMS activations. No significant changes in level or trend were observed in adult EMS activations. A significant level change was observed in the pediatric EMS activations; however, the trend change reduced the impact of the level change over the study period. These results suggest that Medicaid expansion was not associated with a significant change in adult EMS use. Further investigation into pediatric EMS activations following Medicaid expansion is indicated, as these results suggest there may have been a temporary effect.

Pregnant or recently pregnant opioid users: contraception decisions, perceptions and preferences.

BACKGROUND: Multiple factors are linked to extremely high unintended pregnancy rates among women who use opioids, including various barriers to contraception adherence. These include patient level barriers such as lack of knowledge and education about highly effective contraception, and potential provider barriers. Using a mixed-methods framework to examine the contraception-related perceptions and preferences of opioid using women is a necessary next step to understanding this phenomenon. METHODS: A mixed-method study was conducted which included both self-report questionnaires along with a semi-structured qualitative interview of opioid-using pregnant or recently pregnant women in two drug treatment facilities in Ohio. RESULTS: Forty-two women completed the study. The majority of recent (75%) and total pregnancies were unintended. Male condoms were reported as the highest form of lifetime contraception used within the present sample (69%). Participants reported low lifetime use of long acting reversible contraception (LARC) (ranging from 5 to 12%). Participants preferred hormonal injections first (40%), followed by IUDs (17%). Reasons for preferences of injections and LARC were similar: not needing to remember, side effects, and long-term effectiveness. CONCLUSIONS: Most of the study population participants stated they would utilize contraception, particularly Tier 1 LARC methods, if freely available; however, high rates of unintended pregnancy were observed in this sample. This indicates the need for contraception education, and addressing the procedural, logistical and economic barriers that may be preventing the use of LARC among this population.

The affordable care act and family planning services: the effect of optional medicaid expansion on safety net programs.

BACKGROUND: Title X of the Public Health Service Act provides funding for a range of reproductive health services, with a priority given to low-income persons. Now that many of these services are provided to larger numbers of people with low-income since the passage of the Affordable Care Act and Medicaid expansion, questions remain on the continued need for the Title X program. The current project highlights the importance of these safety net programs. METHODS: To help inform this policy issue, research was conducted to examine the revenue and service changes for Title X per state and compare those findings to the states' Medicaid expansion and demographics. The dataset include publicly available data from 2013 and 2014 Family Planning Annual Reports (FPAR). Paired samples differences of means t-tests were then used to compare the means of family planning participation rates for 2013 and 2014 across the different categories for Medicaid expansion states and non-expansion states. RESULTS: The ACA has had an impact on Title X services, but the link is not as direct as previously thought. The findings indicate that all states' Title X funded clinics lost revenue; however, expansion states fared better than non-expansion states. DISCUSSION: While the general statements from the FPAR National surveys certainly are supported in that Title X providers have decreased in number and scope of services, which has led to the decrease in total clients, these variations are not evenly applied across the states. The ACA has very likely had an impact on Title X services, but the link is not as obvious as previously thought. CONCLUSION: Title X funded clinics have helped increase access to health insurance at a greater rate in expansion states than non-expansion states. There was much concern from advocates that with the projected increased revenue from Medicaid and private insurance, that Title X programs could be deemed unnecessary. However, this revenue increase has yet to actually pan out. Title X still helps fill a much needed service gap for a vulnerable population.