Medicaid Expansion at Title X Clinics: Client Volume, Payer Mix, and Contraceptive Method Type.

BACKGROUND: Title X supports access to family planning and preventive care services. Given its focus on low-income clients, Title X clinics may have been particularly affected by the Affordable Care Act's Medicaid expansion. OBJECTIVES: To examine the impact of the Affordable Care Act's Medicaid expansion on Title X client volumes, health insurance coverage, and contraceptive method mix. RESEARCH DESIGN: A difference-in-differences design compared changes in the outcomes of interest before and after expansion, for expansion versus nonexpansion states. SUBJECTS: Administrative data from Family Planning Annual Reports that describe Title X clients who sought services. MEASURES: Female client volume was measured using a participation ratio defined as the number of female clients per 100 women aged 15-44 with incomes <250% of the federal poverty line. We also examined the share of clients by insurance type and contraceptive method type. RESULTS: We did not find evidence that expansion was related to changes in client volume. We did find a significant 9.9 percentage point increase in the share of clients with Medicaid and a significant 10.0 percentage point decrease in the share of clients without coverage. We found suggestive evidence that expansion was associated with increased use of long-acting reversible contraceptives, but those results were somewhat sensitive to model specification. CONCLUSIONS: Expansion was associated with meaningful increases in Medicaid coverage at Title X clinics and declines in uninsurance. Our results have important implications for the financial stability of Title X clinics in light of historical declines in Title X grant revenues.

Nationwide Actions Against Heart Failure Pandemic in Japan　- What Should We Do From Academia?

Heart failure pandemic is rapidly approaching in Japan, requiring nationwide actions. In particular, the Japanese Circulation Society and related societies launched the Stroke and Cardiovascular Disease Control Act, which was passed by the National Diet, as the first ever legislative policy measure against stroke and cardiovascular disease. In association with this, actions against heart failure pandemic from the scientific field are also important. Because heart failure pandemic is a critical problem not only in Japan but also in many developed countries, we believe the nationwide approach, as summarized here, will greatly contribute to the development of cardiovascular medicine, particularly the management and treatment of heart failure worldwide.

Cost-Free Preventive Care Under the ACA Faces Legal Challenge.

This Viewpoint examines the recent decision by a federal district court that undercuts the Affordable Care Act's mandate for cost-free coverage of preventive services, including contraception, some vaccinations, many screenings, and preexposure prophylaxis for HIV, among others.

Worldwide Exposures to Cardiovascular Risk Factors and Associated Health Effects: Current Knowledge and Data Gaps.

Information on exposure to, and health effects of, cardiovascular disease (CVD) risk factors is needed to develop effective strategies to prevent CVD events and deaths. Here, we provide an overview of the data and evidence on worldwide exposures to CVD risk factors and the associated health effects. Global comparative risk assessment studies have estimated that hundreds of thousands or millions of CVD deaths are attributable to established CVD risk factors (high blood pressure and serum cholesterol, smoking, and high blood glucose), high body mass index, harmful alcohol use, some dietary and environmental exposures, and physical inactivity. The established risk factors plus body mass index are collectively responsible for ≈9.7 million annual CVD deaths, with high blood pressure accounting for more CVD deaths than any other risk factor. Age-standardized CVD death rates attributable to established risk factors plus high body mass index are lowest in high-income countries, followed by Latin America and the Caribbean; they are highest in the region of central and eastern Europe and central Asia. However, estimates of the health effects of CVD risk factors are highly uncertain because there are insufficient population-based data on exposure to most CVD risk factors and because the magnitudes of their effects on CVDs in observational studies are likely to be biased. We identify directions for research and surveillance to better estimate the effects of CVD risk factors and policy options for reducing CVD burden by modifying preventable risk factors.

How the Affordable Care Act Has Improved Americans' Ability to Buy Health Insurance on Their Own: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.

Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers' experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people's ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.

Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency.

Jean Adams and colleagues argue that population interventions that require individuals to use a low level of agency to benefit are likely to be most effective and most equitable.

Knowledge of and Attitudes Toward Evidence-Based Guidelines for and Against Clinical Preventive Services: Results from a National Survey.

POLICY POINTS: Both the underuse and overuse of clinical preventive services relative to evidence-based guidelines are a public health concern. Informed consumers are an important foundation of many components of the Affordable Care Act, including coverage mandates for proven clinical preventive services recommended by the US Preventive Services Task Force. Across sociodemographic groups, however, knowledge of and positive attitudes toward evidence-based guidelines for preventive care are extremely low. Given the demonstrated low levels of consumers' knowledge of and trust in guidelines, coupled with their strong preference for involvement in preventive care decisions, better education and decision-making support for evidence-based preventive services are greatly needed. CONTEXT: Both the underuse and overuse of clinical preventive services are a serious public health problem. The goal of our study was to produce population-based national data that could assist in the design of communication strategies to increase knowledge of and positive attitudes toward evidence-based guidelines for clinical preventive services (including the US Preventive Services Task Force, USPSTF) and to reduce uncertainty among patients when guidelines change or are controversial. METHODS: In late 2013 we implemented an Internet-based survey of a nationally representative sample of 2,529 adults via KnowledgePanel, a probability-based survey panel of approximately 60,000 adults, statistically representative of the US noninstitutionalized population. African Americans, Hispanics, and those with less than a high school education were oversampled. We then conducted descriptive statistics and multivariable logistic regression analysis to identify the prevalence of and sociodemographic characteristics associated with key knowledge and attitudinal variables. FINDINGS: While 36.4% of adults reported knowing that the Affordable Care Act requires insurance companies to cover proven preventive services without cost sharing, only 7.7% had heard of the USPSTF. Approximately 1 in 3 (32.6%) reported trusting that a government task force would make fair guidelines for preventive services, and 38.2% believed that the government uses guidelines to ration health care. Most of the respondents endorsed the notion that research/scientific evidence and expert medical opinion are important for the creation of guidelines and that clinicians should follow guidelines based on evidence. But when presented with patient vignettes in which a physician made a guideline-based recommendation against a cancer-screening test, less than 10% believed that this recommendation alone, without further dialogue and/or the patient's own research, was sufficient to make such a decision. CONCLUSIONS: Given these demonstrated low levels of knowledge and mistrust regarding guidelines, coupled with a strong preference for shared decision making, better consumer education and decision supports for evidence-based guidelines for clinical preventive services are greatly needed.

Impact Evaluation of a Policy Intervention for HIV Prevention in Washington, DC.

Syringe exchange programs (SEPs) lower HIV risk. From 1998 to 2007, Congress prohibited Washington, DC, from using municipal revenue for SEPs. We examined the impact of policy change on IDU-associated HIV cases. We used surveillance data for new IDU-associated HIV cases between September 1996 and December 2011 to build an ARIMA model and forecasted the expected number of IDU-associated cases in the 24 months following policy change. Interrupted time series analyses (ITSA) were used to assess epidemic impact of policy change. There were 176 IDU-associated HIV cases in the 2 years post-policy change; our model predicted 296 IDU-associated HIV cases had the policy remained in place, yielding a difference of 120 averted HIV cases. ITSA identified significant immediate (B = -6.0355, p = .0005) and slope changes (B = -.1241, p = .0427) attributed to policy change. Policy change is an effective structural intervention for HIV prevention when it facilitates the implementation of services needed by vulnerable populations.

Women's Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk.

Issue: Since enactment of the Affordable Care Act (ACA), many more women have health insurance than before the law, in part because it prohibits insurer practices that discriminate against women. However, gaps in women's health coverage persist. Insurers often exclude health services that women are likely to need, leaving women vulnerable to higher costs and denied claims that threaten their economic security and physical health. Goal: To uncover the types and incidence of insurer exclusions that may disproportionately affect women's coverage. Method: The authors examined qualified health plans from 109 insurers across 16 states for 2014, 2015, or both years. Key findings and conclusions: Six types of services are frequently excluded from insurance coverage: treatment of conditions resulting from noncovered services, maintenance therapy, genetic testing, fetal reduction surgery, treatment of self-inflicted conditions, and preventive services not covered by law. Policy change recommendations include prohibiting variations within states' "essential health benefits" benchmark plans and requiring transparency and simplified language in plan documents.

Dignum et justum est: Obamacare and Travail of the Little Sisters.

This essay traces the Affordable Care Act from initiation through the bureaucratic unfolding of required preventive health services for women and presents the ethically reasoned objections to provision of certain services and compliance with regulations for implementation by the Little Sisters of the Poor, an international order of consecrated nuns dedicated to care of the elderly poor. The author's intent is to understand and intelligently convey the fundamental issues raised by their challenge.

Effect of the USPSTF Grade D Recommendation against Screening for Prostate Cancer on Incident Prostate Cancer Diagnoses in the United States.

PURPOSE: In October 2011 the USPSTF (U.S. Preventive Services Task Force) issued a draft guideline discouraging prostate specific antigen based screening for prostate cancer (grade D recommendation). We evaluated the effect of the USPSTF guideline on the number and distribution of new prostate cancer diagnoses in the United States. MATERIALS AND METHODS: We identified incident cancers diagnosed between January 2010 and December 2012 in NCDB (National Cancer Database). We performed an interrupted time series to evaluate the trend of new prostate cancers diagnosed each month before and after the draft guideline with colon cancer as a comparator. RESULTS: Incident monthly prostate cancer diagnoses decreased by -1,363 cases (12.2%, p<0.01) in the month after the USPSTF draft guideline and continued to decrease by 164 cases per month relative to baseline (-1.8%, p<0.01). In contrast monthly colon cancer diagnoses remained stable. Diagnoses of low, intermediate and high risk prostate cancers decreased significantly but new diagnoses of nonlocalized disease did not change. Subgroups of age, comorbidity, race, income and insurance showed comparable decreases in incident prostate cancer following the draft guideline. CONCLUSIONS: There was a 28% decrease in incident diagnoses of prostate cancer in the year after the USPSTF draft recommendation against prostate specific antigen screening. This study helps quantify the potential benefits (reduced harms of over diagnosis and overtreatment of low risk disease and disease found in elderly men) and potential harms (missed opportunities to diagnose important cancers in men who may benefit from treatment) of this guideline.

Coverage of Certain Preventive Services Under the Affordable Care Act. Final rules.

This document contains final regulations regarding coverage of certain preventive services under section 2713 of the Public Health Service Act (PHS Act), added by the Patient Protection and Affordable Care Act, as amended, and incorporated into the Employee Retirement Income Security Act of 1974 and the Internal Revenue Code. Section 2713 of the PHS Act requires coverage without cost sharing of certain preventive health services by non-grandfathered group health plans and health insurance coverage. These regulations finalize provisions from three rulemaking actions: Interim final regulations issued in July 2010 related to coverage of preventive services, interim final regulations issued in August 2014 related to the process an eligible organization uses to provide notice of its religious objection to the coverage of contraceptive services, and proposed regulations issued in August 2014 related to the definition of "eligible organization,'' which would expand the set of entities that may avail themselves of an accommodation with respect to the coverage of contraceptive services.

Achieving compliance with the International Health Regulations by overseas territories of the United Kingdom of Great Britain and Northern Ireland.

The 2005 International Health Regulations (IHR) came into force for all Member States of the World Health Organization (WHO) in June 2007 and the deadline for achieving compliance was June 2012. The purpose of the IHR is to prevent, protect against, control - and provide a public health response to - international spread of disease. The territory of the United Kingdom of Great Britain and Northern Ireland and that of several other Member States, such as China, Denmark, France, the Netherlands and the United States of America, include overseas territories, which cover a total population of approximately 15 million people. Member States have a responsibility to ensure that all parts of their territory comply with the IHR. Since WHO has not provided specific guidance on compliance in the special circumstances of the overseas territories of Member States, compliance by these territories is an issue for self-assessment by Member States themselves. To date, no reports have been published on the assessment of IHR compliance in countries with overseas territories. We describe a gap analysis done in the United Kingdom to assess IHR compliance of its overseas territories. The findings and conclusions are broadly applicable to other countries with overseas territories which may have yet to assess their compliance with the IHR. Such assessments are needed to ensure compliance across all parts of a Member States' territory and to increase global health security.

Le Règlement sanitaire international de 2005 (RSI) est entré en vigueur pour tous les États membres de l'Organisation mondiale de la Santé en juin 2007, et la date limite pour sa mise en conformité était juin 2012. L'objectif du RSI est de prévenir, de protéger, de contrôler ­ et d'apporter une réponse de santé publique ­ à la propagation internationale des maladies. Le territoire du Royaume-Uni de Grande-Bretagne et d'Irlande du Nord et celui d'autres États membres, comme la Chine, le Danemark, la France, les Pays-Bas et les États-Unis d'Amérique, se composent de territoires d'outre-mer, lesquels couvrent une population totale d'environ 15 millions d'habitants. Les États membres ont la responsabilité de veiller à ce que toutes les parties de leur territoire se conforment au RSI. Étant donné que l'OMS ne fournit pas d'orientation spécifique concernant la conformité dans les circonstances spéciales des territoires d'outre-mer des États membres, leur conformité est une question d'auto-évaluation par les États membres eux-mêmes. À ce jour, aucun rapport n'a été publié sur l'évaluation de la conformité au RSI dans les pays possédant des territoires d'outre-mer. Nous décrivons une analyse des lacunes effectuée au Royaume-Uni pour évaluer la conformité au RSI de ses territoires d'outre-mer. Les résultats et les conclusions sont largement applicables aux autres pays possédant des territoires d'outre-mer, qui peuvent cependant évaluer leur propre conformité au RSI. Ces évaluations sont nécessaires pour veiller à la conformité dans toutes les parties du territoire d'un État membre et pour augmenter la sécurité sanitaire mondiale.

El Reglamento Sanitario Internacional 2005 (RSI) entró en vigor para todos los Estados miembros de la Organización Mundial de la Salud (OMS) en junio de 2007 con junio de 2012 como fecha límite para lograr el cumplimiento. El objetivo del RSI es prevenir, proteger, controlar y proporcionar una respuesta de salud pública a la propagación internacional de enfermedades. El territorio del Reino Unido de Gran Bretaña e Irlanda del Norte y otros Estados miembros como China, Dinamarca, Francia, los Países Bajos y los Estados Unidos de América cuentan con territorios de ultramar que abarcan una población total de aproximadamente 15 millones de personas. Los Estados miembros tienen la responsabilidad de garantizar que todos sus territorios cumplan con el RSI. Puesto que la OMS no ha proporcionado orientación específica sobre el cumplimiento para las circunstancias especiales de los territorios de ultramar de los Estados miembros, el cumplimiento por parte de estos territorios es un problema que los propios Estados miembros tienen que evaluar. Hasta la fecha no se han publicado informes sobre la evaluación del cumplimiento del RSI en los países con territorios de ultramar. Describimos un análisis de las deficiencias realizado en el Reino Unido con objeto de evaluar el cumplimiento del RSI de sus territorios de ultramar. Los resultados y conclusiones son ampliamente aplicables a otros países con territorios de ultramar que quizá aún tengan que evaluar su cumplimiento con el RSI. Dichas evaluaciones son necesarias para asegurar el cumplimiento en todos los territorios de los Estados miembros y para aumentar la seguridad sanitaria mundial.

Chlamydia screening for sexually active young women under the Affordable Care Act: new opportunities and lingering barriers.

The Affordable Care Act of 2010 (ACA) contains a provision requiring private insurers issuing or renewing plans on or after September 23, 2010, to provide, without cost sharing, preventive services recommended by US Preventive Services Task Force (grades A and B), among other recommending bodies. As a grade A recommendation, chlamydia screening for sexually active young women 24 years and younger and older women at risk for chlamydia falls under this requirement. This article examines the potential effect on chlamydia screening among this population across private and public health plans and identifies lingering barriers not addressed by this legislation. Examination of the impact on women with private insurance touches upon the distinction between coverage under grandfathered plans, where the requirement does not apply, and nongrandfathered plans, where the requirement does apply. Acquisition of private health insurance through health insurance Marketplaces is also discussed. For public health plans, coverage of preventive services without cost sharing differs for individuals enrolled in standard Medicaid, covered under the Medicaid expansion included in the ACA, or those enrolled under the Children's Health Insurance Program or who fall under Early, Periodic, Screening, Diagnosis and Treatment criteria. The discussion of lingering barriers not addressed by the ACA includes the uninsured, physician reimbursement, cost sharing, confidentiality, low rates of appropriate sexual history taking by providers, and disclosures of sensitive information. In addition, the role of safety net programs that provide health care to individuals regardless of ability to pay is examined in light of the expectation that they also remain a payer of last resort.