The Role of Health Literacy in Family Planning Use among Senegalese Women.

Health communication has contributed to an increase in family planning use through education and mass media as a means to increase health literacy. In this research, we investigate health literacy as an auxiliary component of health communication. We test the validity of the Health Literacy Skills Framework by examining the correlation of health literacy indicators to family planning use among Senegalese women in the 2014 Demographic Health Survey. We found that increased family planning use was most strongly associated with hearing family planning messages through television and radio. Other health literacy indicators, including access to printed family planning messaging, textual literacy, and knowledge of ovulatory cycles did not strengthen family planning use, even when performing a subgroup analysis of women who could read. The implications are that the Health Literacy Skills framework can measure health literacy's ability (assessed through proxy indicators of health literacy) to predict modern family planning use among Senegalese women and that audio and visual health literacy measures are most strongly associated with increased family planning use.

Monitoring health reform efforts: which state-level data to use?

This study compares estimates of health insurance coverage from the American Community Survey (ACS) to those in twelve state-specific surveys. Uninsurance estimates for the nonelderly are consistently higher in the ACS than in state surveys, as are direct purchase insurance estimates. Estimates for employer-sponsored insurance are similar, but public coverage rates are lower in the ACS. The ACS meets some but not all of the states' data needs; its large sample size and inclusion of all U.S. counties in the sample allow for comparison of insurance coverage within and across states. State-specific surveys provide the flexibility to add policy-relevant questions, including questions needed to examine how health insurance translates into access, use, and affordability of health services.

Effects of the Children's Health Insurance Reauthorization Act on immigrant children's healthcare access.

OBJECTIVE: To estimate the effects of Children's Health Insurance Reauthorization Act (CHIPRA), a policy that provided states the option to extend Medicaid/CHIP eligibility to immigrant children who have not been legal residents for five years or more, on insurance coverage, access, utilization, and health outcomes among immigrant children. DATA SOURCES: Restricted use 2000-2016 National Health Interview Survey (NHIS). STUDY DESIGN: We used a difference-in-differences design that compared changes in CHIPRA expansion states to changes in non-expansion states. DATA COLLECTION: Our sample included immigrant children who were born outside the US, aged 0-18 with family income below 300% of the Federal Poverty Level (FPL). Subgroup analyses were conducted across states that did and did not have a similar state-funded option prior to CHIPRA (state-funded vs. not state-funded), by the length of time in the US (5 years vs. 5-14 years), and global region of birth (Latin American vs. Asian countries). PRINCIPLE FINDINGS: We found that CHIPRA was associated with a significant 6.35 percentage point decrease in uninsured rates (95% CI: -11.25, -1.45) and an 8.1 percentage point increase in public insurance enrollment for immigrant children (95% CI: 1.26, 14.98). However, the effects of CHIPRA became small and statistically not significant 3 years after adoption. Effects on public insurance coverage were significant in states without state-funded programs prior to CHIPRA (15.50 percentage points; 95% CI:8.05, 22.95) and for children born in Asian countries (12.80 percentage points; 95% CI: 1.04, 24.56). We found no significant changes in health care access and utilization, and health outcomes, overall and across subgroups due to CHIPRA. CONCLUSIONS: CHIPRA's eligibility expansion was associated with increases in public insurance coverage for low-income children, especially in states where CHIPRA represented a new source of coverage versus a substitute for state-funded coverage. However, we found evidence of crowd-out in certain subgroups and no effect of CHIPRA on access to care and health. Our results suggest that public coverage may be an important tool for promoting the well-being of immigrant children but other investments are still needed.

The Association of Health Reform and Infant Health: Evidence from Massachusetts.

OBJECTIVE: To estimate whether the incidence of low birthweight and rates of infant mortality were associated with Massachusetts health reform in the overall population and for subgroups that are at higher risk for poor health outcomes. DATA SOURCES: Individual-level data on birthweight were obtained from the National Center for Health Statistics detailed natality files, and aggregated county-level mortality rates were generated from linked birth-death files. We used restricted versions of each file that had intact state and substate geographic identifiers. RESEARCH DESIGN: We employed a quasi-experimental difference-in-differences design. PRINCIPAL RESULTS: We found small and statistically nonsignificant associations between the reform and the incidence of low birthweight and infant mortality rates. Results were consistent across a number of subgroups and were robust to alternative comparison groups and alternative modeling assumptions. CONCLUSIONS: We found no evidence that the Massachusetts reform was associated with improvements in individual low birthweights or county-level infant mortality rates, despite increasing health insurance coverage rates for adult women of child-bearing age. Because our mortality analysis was ecological, we are not able to draw conclusions about how an individual-level health insurance intervention for uninsured pregnant women would affect the mortality outcomes of their infants.

Medical Financial Burden Declined For Consumers In The Nongroup Market.

The share of consumers in the nongroup health insurance market who spent more than 10 percent of family income on medical expenses declined by 6.7 percentage points after Affordable Care Act implementation (2013-15), and after adjustments for other factors. Average family medical expenses declined by $811 for nongroup consumers.

The long-term impacts of Medicaid exposure in early childhood: Evidence from the program's origin.

This paper examines the long-term impact of exposure to Medicaid in early childhood on adult health and economic status. The staggered timing of Medicaid's adoption across the states created meaningful variation in cumulative exposure to Medicaid for birth cohorts that are now in adulthood. Analyses of the Panel Study of Income Dynamics suggest exposure to Medicaid in early childhood (age 0-5) is associated with statistically significant and meaningful improvements in adult health (age 25-54), and this effect is only seen in subgroups targeted by the program. Results for economic outcomes are imprecise and we are unable to come to definitive conclusions. Using separate data we find evidence of two mechanisms that could plausibly link Medicaid's introduction to long-term outcomes: contemporaneous increases in health services utilization for children and reductions in family medical debt.

Residential High-Speed Internet Among Those Likely to Benefit From an Online Health Insurance Marketplace.

Using data from the 2013 American Community Survey, we found that 24.3 million people (about 1 in 4) who were either eligible for Medicaid/Children's Health Insurance Program (CHIP) or appeared likely to shop for Qualified Health Plan (QHP) lacked residential high-speed Internet. Specifically, 28.6% or 18.9 million people eligible for Medicaid/CHIP and 17.1% or 5.5 million people who appeared likely to shop for a QHP did not have high-speed Internet in the home. For both the Medicaid/CHIP eligible and those likely to shop for a QHP, the proportion of people living in households without Internet varied substantially by race, geography, and other socio-demographic characteristics.

Measurement Error in Public Health Insurance Reporting in the American Community Survey: Evidence from Record Linkage.

OBJECTIVE: Examine measurement error to public health insurance in the American Community Survey (ACS). DATA SOURCES/STUDY SETTING: The ACS and the Medicaid Statistical Information System (MSIS). STUDY DESIGN: We tabulated the two data sources separately and then merged the data and examined health insurance reports among ACS cases known to be enrolled in Medicaid or expansion Children's Health Insurance Program (CHIP) benefits. DATA COLLECTION/EXTRACTION METHODS: The two data sources were merged using protected identification keys. ACS respondents were considered enrolled if they had full benefit Medicaid or expansion CHIP coverage on the date of interview. PRINCIPAL FINDINGS: On an aggregated basis, the ACS overcounts the MSIS. After merging the data, we estimate a false-negative rate in the 2009 ACS of 21.6 percent. The false-negative rate varies across states, demographic groups, and year. Of known Medicaid and expansion CHIP enrollees, 12.5 percent were coded to some other coverage and 9.1 percent were coded as uninsured. CONCLUSIONS: The false-negative rate in the ACS is on par with other federal surveys. However, unlike other surveys, the ACS overcounts the MSIS on an aggregated basis. Future work is needed to disentangle the causes of the ACS overcount.

Medicaid 'welcome-mat' effect of Affordable Care Act implementation could be substantial.

The Affordable Care Act will have important impacts on state Medicaid programs, likely increasing participation among populations that are currently eligible but not enrolled. The size of this "welcome-mat" effect is of concern for two reasons. First, the eligible but uninsured constitute a substantial share of the uninsured population in some states. Second, the newly eligible population will affect states' Medicaid caseloads and budgets. Using the Massachusetts 2006 health reforms as a case study and controlling for other factors, we found that among low-income parents who were previously eligible for Medicaid in Massachusetts, Medicaid enrollment increased by 16.3 percentage points, and Medicaid participation by those without private coverage increased by 19.4 percentage points, in comparison to a group of control states. In many states the potential size of the welcome-mat effect could be even larger than what we observed in Massachusetts. Our analysis has potentially important implications for other states attempting to predict the impact of this effect on their budgets.

Wireless substitution: state-level estimates from the National Health Interview Survey, 2010-2011.

OBJECTIVES: This report updates subnational estimates of the percentage of adults and children living in households without a landline telephone but with at least one wireless telephone (i.e., wireless-only households). State-level estimates for 2011 are presented, as well as estimates for selected U.S. counties and groups of counties, for other household telephone service use categories (e.g., those that had only landlines and those that had landlines yet received all or almost all calls on wireless telephones), and for two earlier 12-month periods (January-December 2010 and July 2010-June 2011). METHODS: Small-area statistical modeling techniques were used to estimate the prevalence of adults and children living in households with various household telephone service types for 93 disjoint geographic areas that make up the United States. This modeling was based on 2007-2011 data from the National Health Interview Survey, 2006-2010 data from the American Community Survey, and auxiliary information on the number of listed telephone lines per capita in 2007-2011. RESULTS: The prevalence of wireless-only adults and children varied substantially across states. State-level estimates for 2011 ranged from 15.3% (Rhode Island) to 44.6% (Idaho) of adults and from 15.2% (Rhode Island) to 58.6% (Mississippi) of children.

Wireless substitution: state-level estimates from the National Health Interview Survey, January 2007-June 2010.

OBJECTIVES: This report presents state-level estimates of the percentage of adults and children living in households that did not have a landline telephone but did have at least one wireless telephone. National estimates for the 12-month time period from July 2009 through June 2010 indicate that 23.9% of adults and 27.5% of children were living in these wireless-only households. Estimates are also presented for selected U.S. counties and groups of counties, for other household telephone service use categories (e.g., those that had only landlines and those that had landlines yet received all or almost all calls on wireless telephones), and for 12-month time periods since January-December 2007. METHODS: Small-area statistical modeling techniques were used to estimate the prevalence of adults and children living in households with various household telephone service types for 93 disjoint geographic areas that make up the entire United States. This modeling was based on January 2007-June 2010 data from the National Health Interview Survey, 2006-2009 data from the American Community Survey, and auxiliary information on the number of listed telephone lines per capita in 2007-2010. RESULTS: The prevalence of wireless-only adults and children varied substantially across states. State-level estimates for July 2009-June 2010 ranged from 12.8% (Rhode Island and New Jersey) to 35.2% (Arkansas) of adults and from 12.6% (Connecticut and New Jersey) to 46.2% (Arkansas) of children. For adults, the magnitude of the increase from 2007 to 2010 was lowest in New Jersey (7.2 percentage points) and highest in Arkansas (14.5 percentage points).