Association of Medicaid expansion with birth outcomes: evidence from a natural experiment in Texas.

BACKGROUND: Empirical evidence on the effects of Medicaid expansion is mixed and highly state-dependent. The objective of this study is to examine the association of Medicaid expansion with preterm birth and low birth weight, which are linked to a higher risk of infant mortality and chronic health conditions throughout life, providing evidence from a non-expansion state, overall and by race/ethnicity. METHODS: We used the newborn patient records obtained from Texas Public Use Data Files from 2010 to 2019 for hospitals in Texarkana, which is located on the border of Texas and Arkansas, with all of the hospitals serving pregnancy and childbirth patients on the Texas side of the border. We employed difference-in-differences models to estimate the effect of Medicaid expansion on birth outcomes (preterm birth and low birth weight) overall and by race/ethnicity. Newborns from Arkansas (expanded Medicaid in 2014) constituted the treatment group, while those from Texas (did not adopt the expansion) were the control group. We utilized a difference-in-differences event study framework to examine the gradual impact of the Medicaid expansion on birth outcomes. RESULTS: Medicaid expansion was associated with a 1.38-percentage-point decrease (95% confidence interval (CI), 0.09-2.67) in preterm birth overall. Event study results suggest that preterm births decreased gradually over time. Medicaid expansion was associated with a 2.04-percentage-point decrease (95% CI, 0.24-3.85) in preterm birth and a 1.75-percentage-point decrease (95% CI, 0.42-3.08) in low birth weight for White infants. However, Medicaid expansion was not associated with significant changes in birth outcomes for other race/ethnicity groups.  CONCLUSIONS: Our findings suggest that Medicaid expansion in Texas can potentially improve birth outcomes. However, bridging racial disparities in birth outcomes might require further efforts such as promoting preconception and prenatal care, especially among the Black population.

The Association Between Medicaid Expansion and Diabetic Ketoacidosis Hospitalizations.

Background and objective Diabetic ketoacidosis (DKA) is a potentially fatal complication of uncontrolled diabetes and remains a significant source of morbidity and mortality even though it is considered preventable. Diabetes is a chronic illness that requires constant monitoring and regular check-ups. Delaying or foregoing necessary diabetes care due to a lack of health insurance can result in severe complications. The Affordable Care Act (ACA) Medicaid expansion is intended to increase access to healthcare and improve health outcomes. This study aimed to examine the relationship between the ACA Medicaid expansion and hospitalizations with DKA. Methods This retrospective cross-sectional study used discharge records from 2010 to 2017 for hospitals in Texarkana, located on the border of Texas and Arkansas. The study employed a difference-in-differences method. Patients from Arkansas, which expanded Medicaid in 2014, constituted the treatment group, while those from Texas, which did not adopt the expansion, were the control group. A triple difference methodology was used to compare the impact of the expansion on patients with different socioeconomic backgrounds. The main outcome measure was DKA per 1000 discharges. Results A total of 89,184 inpatient discharges from Texarkana hospitals were analyzed; 43,286 patients were from Arkansas (48.54%) and 45,898 (51.46%) were from Texas. Even though DKA cases increased from pre-expansion (2010-2013) to post-expansion (2014-2017) period among patients from Arkansas (by a mean of 4.33) and Texas (by a mean of 8.28), the increase was milder among Arkansas patients with an adjusted decrease of 4.17 per 1000 discharges (95% CI: -5.04 to -3.31; p<0.001), implying a 42% lower risk of hospitalizations with DKA compared to the baseline averages. The triple difference analysis suggested that the decrease in incidences was more pronounced for patients from low-income areas with an adjusted decrease of 13.47 per 1000 discharges (95% CI: -22.45 to -4.49; p=0.003). Conclusions Based on our findings, Medicaid expansion decreases hospitalizations with DKA, presumably due to better monitoring and care of diabetes made possible by increasing access to healthcare among individuals with low incomes.

How Would Medicaid Expansion Affect Texas Hospitals? Evidence From a Retrospective Quasi-Experimental Study.

This study aims to estimate the impact of a potential Medicaid expansion on Texas hospitals. The Affordable Care Act (ACA) Medicaid expansion increased access to health care and improved health outcomes. Still, several states, including Texas, have not adopted the expansion. This is a retrospective quasi-experimental study. We obtained inpatient data containing discharges from Texas hospitals between 2010 and 2017 from the Texas Department of State Health Services. Texas hospitals receive a significant number of patients from the adjacent states. We use a difference-in-differences methodology, where the patients from the neighboring states that expanded Medicaid in 2014 are the treatment group, and those that reside in Texas are the control group. The outcome variables are the payer mix and the cost of treatment, proxied by Diagnoses Related Group (DRG) weights assigned by the Centers for Medicare and Medicaid Services (CMS). The Medicaid expansion is associated with 4.15% lower costs of treatment among the patients from the expansion states (P < .01). Also, the uninsured rate decreased by 4.7 percentage points (from 11.3%, P < .01), while the share of Medicaid patients increased by 10.9 percentage points (from 30.7%, P < .01). There are no significant changes in the share of privately insured or Medicare patients. Texas hospitals can benefit significantly from Medicaid expansion due to reductions in average treatment costs and the share of the uninsured.

The effects of health insurance on the choice of medical procedures: Evidence from heart attacks and childbirths.

This paper investigates the effect of health insurance on the use of alternative procedures to treat a given medical condition. In particular, we estimate the effect of health insurance on the use of bypass surgery after a heart attack and on the use of a C-section after a normal pregnancy. These procedures are the most expensive, compared to the alternatives. Theoretically, the demand for some procedures like bypass surgery is likely to be inelastic. In this situation, health insurance should have no effect on the use of the procedure. For other procedures such as C-section, demand may be more elastic, especially after a normal pregnancy without complications. We use a nationally representative dataset of inpatient hospital admissions from the United States and control for individual and hospital characteristics. The results from our empirical analysis support our predictions. For patients admitted to a hospital because of a heart attack, being uninsured has no effect on the probability of bypass surgery. However, for patients admitted for childbirth, the uninsured have a substantially lower probability of a C-section delivery.

The Effect of Shelter-in-Place Orders on Social Distancing and the Spread of the COVID-19 Pandemic: A Study of Texas.

Objectives: We study how the state-wide shelter-in-place order affected social distancing and the number of cases and deaths in Texas. Methods: We use daily data at the county level. The COVID-19 cases and fatalities data are from the New York Times. Social distancing measures are from SafeGraph. Both data are retrieved from the Unfolded Studio website. The county-level COVID-related policy responses are from the National Association of Counties. We use an event-study design and regression analysis to estimate the effect of the state-wide shelter-in-place order on social distancing and the number of cases and deaths. Results: We find that the growth rate of cases and deaths is significantly lower during the policy period when the percentage of the population that stays at home is highest. The crucial question is whether the policy has a causal impact on the sheltering percentages. The fact that some counties in Texas adopted local restrictive policies well before the state-wide policy helps us address this question. We do not find evidence that this top-down restrictive policy increased the percentage of the population that exercised social distancing. Discussion: Shelter-in-place policies are more effective at the local level and should go along with efforts to inform and update the public about the potential consequences of the disease and its current state in their localities.

The health conditions and the health care consumption of the uninsured.

This paper investigates the difference in the health conditions and the health care consumption of uninsured individuals as compared to individuals with private insurance, using a nationally representative data set of inpatient hospital admissions from the US. In line with the previous literature, our results indicate that uninsured individuals are, on average, in worse health conditions. However, if we compare individuals within the same diagnosis category, the uninsured are actually healthier, with a lower number of chronic conditions and a lower risk of mortality. This indicates that the uninsured are admitted to the hospital only for more serious conditions. In addition, our results show that uninsured individuals consume less health care. In particular, conditional on being admitted to a hospital and controlling for health conditions, the uninsured have lower total charges, fewer procedures, and a higher mortality rate.