Universal cash transfers and prescription utilization: Evidence from the Alaska permanent fund dividend.

We investigate the impact of a large cash transfer on prescription utilization. Our identification strategy leverages the Alaksa Permanent Fund Dividend (PFD), which is distributed annually in October and comprises 6% of the average household's annual income. We study the impact of the PFD on the use of prescription medications using a within-Alaska comparison group and difference-in-differences design. Using the IBM MarketScan Commercial Claims and Encounters Prescription Drug Database, we observe prescriptions for 50,866 commercially-insured individuals who filled prescriptions between 2013 and 2019. We find no changes in prescription use overall and are able to rule out changes larger than 0.5% in the week of the PFD and 1.4% the week after. Subgroup analyses find no changes by patient characteristics, degree of cost sharing, or prescription type. We also conduct a synthetic control analysis using a non-Alaska comparison group and find no effects of the PFD on prescriptions. These findings are useful for understanding liquidity sensitivity for prescription medication and the effects of cash distributions among individuals with employer-based health insurance.

Financial Outcomes Associated With the COVID-19 Pandemic in California Hospitals.

Importance: The COVID-19 pandemic challenged the financial solvency of hospitals, yet there is limited evidence examining hospital financial performance through the first 15 months of the pandemic. Objective: To assess the financial outcomes associated with the COVID-19 pandemic in California hospitals. Design, Setting, and Participants: This cross-sectional study tracked the financial performance of 348 hospitals in California using Hospital Quarterly Financial and Utilization Data from the State of California Office of Statewide Health Planning and Development. Hospital financial performance was examined from January 2019 to June 2021 for all hospitals in aggregate and by safety-net status. Exposures: Pre-COVID-19 financial outcomes vs COVID-19 period outcomes. Main Outcomes and Measures: Quarterly revenues, expenses, and profits. Results: In 348 California hospitals, hospital financial performance was highly variable during the COVID-19 pandemic. Losses were reduced by COVID-19 relief funding and strong equities market performance starting in the second quarter of 2020. Non-safety net hospitals maintained positive operating margins throughout the pandemic, while safety-net hospitals experienced large losses. Between the first quarter of 2020 and the second quarter of 2021, California safety-net hospitals' net operating losses were more than $3.2 billion. Conclusions and Relevance: In this cross-sectional study of California hospitals, hospital financial performance was tracked between the first quarter of 2019 and the second quarter of 2021. Although hospitals experienced reduced profits between January 2020 and June 2021, the interventions of government assistance programs were able to mitigate more detrimental fiscal consequences. When compared with non-safety net hospitals, safety-net hospitals were confronted with more concentrated financial losses.

Prenatal Substance Use Policies And Infant Maltreatment Reports.

We studied the effect of state punitive and supportive prenatal substance use policies on reports of infant maltreatment to child protection agencies. Punitive policies criminalize prenatal substance use or define it as child maltreatment, whereas supportive policies provide pregnant women with priority access to substance use disorder treatment programs. Using difference-in-differences methods, we found that total infant maltreatment reports increased by 19.0 percent after punitive policy adoption during the years of our study (2004-18). This growth was driven by a 38.4 percent increase in substantiated reports in which the mother was the alleged perpetrator. There were no changes in unsubstantiated reports after the adoption of punitive policies. We observed no changes in infant maltreatment reports after the adoption of supportive policies. Findings suggest that punitive policies lead to large increases in substantiated infant maltreatment reports, which in turn may lead to child welfare system involvement soon after childbirth in states with these policies. Policy makers should design interventions that emphasize support services and improve well-being for mothers and infants.

Prenatal substance use policies and newborn health.

We study the effect of punitive and priority treatment policies relating to illicit substance use during pregnancy on the rate of neonatal drug withdrawal syndrome, low birth weight, low gestational age, and prenatal care use. Punitive policies criminalize prenatal substance use, or define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights. Priority treatment policies are supportive and grant pregnant women priority access to substance use disorder treatment programs. Our empirical strategy relies on administrative data from 2008 to 2018 and a difference-in-differences framework that exploits the staggered implementation of these policies. We find that neonatal drug withdrawal syndrome increases by 10%-18% following the implementation of a punitive policy. This growth is accompanied by modest reductions in prenatal care, which may reflect deterrence from healthcare utilization. In contrast, priority treatment policies are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use. Taken together, our findings suggest that punitive approaches may be associated with unintended adverse pregnancy outcomes, and that supportive approaches may be more effective for improving perinatal health.

Marijuana liberalization policies and perinatal health.

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Medical marijuana laws are associated with increases in substance use treatment admissions by pregnant women.

BACKGROUND AND AIMS: Between 2002 and 2014, past-month marijuana use among pregnant women in the United States increased 62%, nearly twice the growth of the general population. This growth coincides with the proliferation of state medical marijuana laws (MMLs) authorizing physicians to recommend marijuana for approved conditions. We estimated the association between MMLs and substance use treatment utilization among pregnant and non-pregnant women of reproductive age. We also examined whether the association varied across MML provisions, age groups and treatment referral sources to clarify potential pathways. DESIGN: Nation-wide administrative data from the 2002-14 Treatment Episodes Data Set Admissions, and a difference-in-differences design that exploited the staggered implementation of MMLs to compare changes in outcomes before and after implementation between MML and non-MML states. SETTING: Twenty-one MML and 27 non-MML US states. PARTICIPANTS: Pregnant and non-pregnant women aged 12-49 admitted to publicly funded specialty substance use treatment facilities. MEASUREMENTS: The primary outcome variable was the number of treatment admissions per 100 000 women aged 12-49, aggregated at the state-year level (n = 606). Admissions for marijuana, alcohol, cocaine and opioids were considered. The primary independent variable was an indicator of MML implementation in a state. FINDINGS: Among pregnant women, the rate of marijuana treatment admissions increased by 4.69 [95% confidence interval (CI) = 1.32, 8.06] in MML states relative to non-MML states. This growth was accompanied by increases in treatment admissions involving alcohol (ß = 3.19; 95% CI = 0.97, 5.410 and cocaine (ß = 2.56; 95% CI = 0.34, 4.79), was specific to adults (ß = 5.50; 95% CI = 1.52, 9.47) and was largest in states granting legal protection for marijuana dispensaries (ß = 6.37; 95% CI = -0.97, 13.70). There was no statistically significant association between MMLs and treatment admissions by non-pregnant women. CONCLUSIONS: Medical marijuana law implementation in US states has been associated with greater substance use treatment utilization by pregnant adult women, especially in states with legally protected dispensaries.

Comparison group selection in the presence of rolling entry for health services research: Rolling entry matching.

OBJECTIVE: To demonstrate rolling entry matching (REM), a new statistical method, for comparison group selection in the context of staggered nonuniform participant entry in nonrandomized interventions. STUDY SETTING: Four Health Care Innovation Award (HCIA) interventions between 2012 and 2016. STUDY DESIGN: Center for Medicare and Medicaid Innovation HCIA participants entering these interventions over time were matched with nonparticipants who exhibited a similar pattern of health care use and expenditures during each participant's baseline period. DATA EXTRACTION METHODS: Medicare fee-for-service claims data were used to identify nonparticipating, fee-for-service beneficiaries as a potential comparison group and conduct REM. PRINCIPAL FINDINGS: Rolling entry matching achieved conventionally-accepted levels of balance on observed characteristics between participants and nonparticipants. The method overcame difficulties associated with a small number of intervention entrants. CONCLUSIONS: In nonrandomized interventions, valid inference regarding intervention effects relies on the suitability of the comparison group to act as the counterfactual case for the intervention group. When participants enter over time, comparison group selection is complicated. Rolling entry matching is a possible solution for comparison group selection in rolling entry interventions that is particularly useful with small sample sizes and merits further investigation in a variety of contexts.

Impact of Financial Incentives on Service Use, Spending, and Health in Medicaid.

INTRODUCTION: The Centers for Medicare and Medicaid Services provided grants to Medicaid programs through the Medicaid Incentives for Prevention of Chronic Diseases program to test whether financial incentives changed the use of healthcare services, Medicaid spending, and health outcomes. Six states implemented programs related to diabetes prevention, weight management, diabetes management, and hypertension management. The purpose of this study is to examine whether receipt of financial incentives increased use of services incentivized by the program; reduced expenditures, inpatient admissions, emergency department visits; and improved health outcomes. METHODS: State data on program participation and incentives (between 2011 and 2015) and 2 years of Medicaid claims data pre-Medicaid Incentives for Prevention of Chronic Diseases enrollment and >2 years of claims data after enrollment were analyzed using covariate-adjusted regression analyses. Negative binomial, logistic, and linear regressions were used, depending on the outcome variable of interest (services, inpatient admissions and emergency department visits, and total expenditures). Analyses were conducted in 2015 and 2016. RESULTS: Incentive recipients attended, on average, one to two more diabetes prevention classes than control participants, but incentives did not significantly improve uptake of other types of services, such as meetings with a health coach or doctor, gym visits, or attendance at Weight Watchers meetings. Modest improvements in health outcomes, such as weight loss, were observed, yet there were very few significant changes in inpatient admissions, emergency department visits, and Medicaid expenditures. CONCLUSIONS: Financial incentives are useful for engaging Medicaid enrollees in disease prevention programs, but program engagement may not necessarily lead to changing patterns of healthcare utilization and expenditures in the short run.

The role of health insurance on treatment for opioid use disorders: Evidence from the Affordable Care Act Medicaid expansion.

We estimate the effect of health insurance coverage on opioid use disorder treatment utilization and availability by exploiting cross-state variation in effective dates of Medicaid expansions under the Affordable Care Act. Using a difference-in-differences design, we find that aggregate opioid admissions to specialty treatment facilities increased 18% in expansion states, most of which involved outpatient medication-assisted treatment (MAT). Opioid admissions from Medicaid beneficiaries increased 113% without crowding out admissions from individuals with other health insurance. These effects appeared to be driven by market entry of select MAT providers and by greater acceptance of Medicaid payments among existing MAT providers. Moreover, effects were largest in expansion states with comprehensive MAT coverage. Our findings suggest that Medicaid expansions resulted in substantial utilization and availability gains to clinically efficacious and cost-effective pharmacological treatments, implying potential benefits of expanding Medicaid to non-expansion states and extending MAT coverage.

Medicaid Incentives for Preventing Chronic Disease: Effects of Financial Incentives for Smoking Cessation.

OBJECTIVE: To test the effectiveness of financial incentives for smoking cessation in the Medicaid population. DATA SOURCES: Secondary data from the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) program and Medicaid claims/encounter data from 2010 to 2015 for five states. STUDY DESIGN: Beneficiaries were randomized into receipt or no receipt of financial incentives. We ran multivariate regression models testing the impact of financial incentives on the use of counseling services, smoking behavior, and Medicaid expenditures and utilization. DATA EXTRACTION: Participating states provided Medicaid eligibility, claims and encounters, program enrollment, and incentivized service use data. PRINCIPAL FINDINGS: Participants who received incentives were more likely to call the Quitline and complete counseling sessions. Incentive receipt was positively associated with self-reported quit attempts, self-reported quits, or passing cotinine tests of smoking cessation in most programs, although results were only statistically significant in a subset. There was no systematic evidence that incentives affected health care use or spending. CONCLUSIONS: Financial incentives are a promising policy lever to motivate behavioral change in the Medicaid population, but more evidence is needed regarding optimal incentive size, effectiveness of process-versus outcome-based incentives, targeting of incentives, and long-run cost-effectiveness.

Public health insurance and disparate eligibility of spouses: The Medicare eligibility gap.

I exploit the age-based eligibility structure of Medicare and the age gap between spouses to examine the impact of Medicare eligibility of an older spouse on the insurance coverage of younger, Medicare-ineligible spouses. Using a regression discontinuity framework, I find that Medicare eligibility of an older spouse can crowd-out the health insurance coverage of a younger spouse. Medicare eligibility of older wives increases the likelihood that younger husbands are uninsured. Younger wives are less likely to be covered through an employer-based plan and more likely to have non-group coverage after an older husband turns 65.