Loss of Medicaid Coverage During the Renewal Process.

Importance: Medicaid beneficiaries must periodically redemonstrate their eligibility in a process that is called renewal, redetermination, or recertification. The number and characteristics of people who lose Medicaid coverage due to renewal requirements are not known. Objective: To measure the proportion of people who lose Medicaid coverage at the renewal deadline, overall and by enrollee characteristics, and time until regaining Medicaid coverage among those losing coverage at the deadline. Design, Setting, and Participants: This cohort study tracked the duration of Medicaid enrollment among Wisconsin Medicaid enrollees with a 12-month renewal deadline. Data were collected for all nonelderly (aged <65 years) new enrollees from January 2016 through January 2018, except those enrolled due to disability or pregnancy. Individuals were followed through January 2020 to provide at least 24 months of data on each enrollment spell. Data were analyzed from August 2023 to February 2024. Main Outcomes and Measures: The primary outcome was coverage loss during the renewal process, defined as a loss in Medicaid coverage from month 12 to month 13 for people who were still enrolled at the start of month 12. Secondary outcomes included coverage loss prior to the renewal deadline and the duration of the gap in Medicaid coverage among those who lost coverage during the renewal process. Results: The study sample included 684 245 Medicaid enrollment spells across 586 044 people (51% female and 47% children 18 years or younger). Among enrollees, 20% lost Medicaid coverage at the renewal deadline. Of those who lost coverage, 37% regained Medicaid coverage within 6 months, and an additional 10% regained coverage within 12 months. Children younger than 12 years and people with more Medicaid-covered health care (top quartile of Medicaid-covered health care costs during the first 6 months of enrollment) were less likely than other groups to lose coverage during the renewal process (15% and 6% lost coverage at renewal, respectively) and more likely to regain Medicaid quickly. Personal characteristics such as gender and race and ethnicity remained associated with the risk of losing Medicaid at the renewal deadline after adjustment for baseline household income, enrollment group, and past use of Medicaid services. Conclusions and Relevance: In this cohort study, the risk of coverage loss during the Medicaid renewal process was associated with age, past use of care, and other personal characteristics. These findings shed light on how renewal requirements shape access to Medicaid.

Unwinding And The Medicaid Undercount: Millions Enrolled In Medicaid During The Pandemic Thought They Were Uninsured.

Policy responses to the March 31, 2023, expiration of the Medicaid continuous coverage provision need to consider the difference between self-reported Medicaid participation on government surveys and administrative records of Medicaid enrollment. The difference between the two is known as the "Medicaid undercount." The size of the undercount increased substantially after the continuous coverage provision took effect in March 2020. Using longitudinal data from the Current Population Survey, we examined this change. We found that assuming that all beneficiaries who ever reported enrolling in Medicaid during the COVID-19 pandemic public health emergency remained enrolled through 2022 (as required by the continuous coverage provision) eliminated the worsening of the undercount. We estimated that nearly half of the 5.9 million people who we projected were likely to become uninsured after the provision expired, or "unwound," already reported that they were uninsured in the 2022 Current Population Survey. This finding suggests that the impact of ending the continuous coverage provision on the estimated uninsurance rate, based on self-reported survey data, may have been smaller than anticipated. It also means that efforts to address Medicaid unwinding should include people who likely remain eligible for Medicaid but believe that they are already uninsured.

COVID-19 Hospitalization in Hawai'i and Patterns of Insurance Coverage, Race and Ethnicity, and Vaccination.

Importance: The people of Hawai'i have both high rates of health insurance and high levels of racial and ethnic diversity, but the degree to which insurance status and race and ethnicity contribute to health outcomes in COVID-19 remains unknown. Objective: To evaluate the associations of insurance coverage, race and ethnicity (using disaggregated race and ethnicity data), and vaccination with outcomes for COVID-19 hospitalization. Design, Setting, and Participants: This retrospective cohort study included hospitalized patients at a tertiary care medical center between March 2020 and March 2022. All patients hospitalized for acute COVID-19, identified based on diagnosis code or positive results on polymerase chain reaction-based assay for SARS-CoV-2, were included in analysis. Data were analyzed from May 2022 to May 2023. Exposure: COVID-19 requiring hospitalization. Main Outcome and Measures: Electronic medical record data were collected for all patients. Associations among race and ethnicity, insurance coverage, receipt of at least 1 COVID-19 vaccine, intensive care unit (ICU) transfer, in-hospital mortality, and COVID-19 variant wave (pre-Delta vs Delta and Omicron) were assessed using adjusted multivariable logistic regression. Results: A total of 1176 patients (median [IQR] age of 58 [41-71] years; 630 [54%] male) were hospitalized with COVID-19, with a median (IQR) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 (25-36) and Sequential Organ Failure Assessment score of 1 (0-2). The sample included 16 American Indian or Alaska Native patients, 439 Asian (not otherwise specified) patients, 15 Black patients, 66 Chinese patients, 246 Filipino patients, 76 Hispanic patients, 107 Japanese patients, 10 Korean patients, 299 Native Hawaiian patients, 523 Pacific Islander (not otherwise specified) patients, 156 Samoan patients, 5 Vietnamese patients, and 311 White patients (patients were able to identify as >1 race or ethnicity). When adjusting for age, BMI, sex, medical comorbidities, and socioeconomic neighborhood status, there were no differences in either ICU transfer (eg, Medicare vs commercial insurance: odds ratio [OR], 0.84; 95% CI, 0.43-1.64) or in-hospital mortality (eg, Medicare vs commercial insurance: OR, 0.85; 95% CI, 0.36-2.03) as a function of insurance type. Disaggregation of race and ethnicity revealed that Filipino patients were more likely to die in the hospital (OR, 1.79; 95% CI, 1.04-3.03; P = .03). When considering variant waves, mortality among Filipino patients was highest during the pre-Delta time period (OR, 2.72; 95% CI, 1.02-7.14; P = .04), when mortality among Japanese patients was lowest (OR, 0.19; 95% CI, 0.03-0.78; P = .04); mortality among Native Hawaiian patients was lowest during the Delta and Omicron period (OR, 0.35; 95% CI, 0.13-0.79; P = .02). Patients with Medicare, compared with those with commercial insurance, were more likely to have received at least 1 COVID-19 vaccine (OR, 1.85; 95% CI, 1.07-3.21; P = .03), but all patients, regardless of insurance type, who received at least 1 COVID-19 vaccine had reduced ICU admission (OR, 0.40; 95% CI, 0.21-0.70; P = .002) and in-hospital mortality (OR, 0.42; 95% CI, 0.21-0.79; P = .01). Conclusions and Relevance: In this cohort study of hospitalized patients with COVID-19, those with government-funded insurance coverage (Medicare or Medicaid) had similar outcomes compared with patients with commercial insurance, regardless of race or ethnicity. Disaggregation of race and ethnicity analysis revealed substantial outcome disparities and suggests opportunities for further study of the drivers underlying such disparities. Additionally, these findings illustrate that vaccination remains a critical tool to protect patients from COVID-19 mortality.

Disparities in insurance status negatively affect patients with infantile hypertrophic pyloric stenosis.

PURPOSE: Infantile hypertrophic pyloric stenosis (IHPS) is suspected to have worse outcomes when length of illness prior to presentation is prolonged. Our objective was to evaluate how social determinants of health influence medical care and outcomes for babies with IHPS. METHODS: A retrospective review was performed over 10 years. Census data were used as proxy for socioeconomic status via Geo-Identification codes and correlated with food access and social vulnerability variables. The cohort was subdivided to understand the impact of Medicaid Managed Care (MMC). RESULTS: The cohort (279 cases) was divided into two groups; early group from 2011 to 2015 and late from 2016 to 2021. Cases in the late group were older at the time of presentation (41.5 vs. 36.5 days; p = 0.022) and presented later in the disease course (12.8 vs. 8.9 days; p = 0.021). There was no difference in race (p = 0.282), gender (p = 0.874), or length of stay. CONCLUSIONS: Patients who presented with IHPS after implementation of phased MMC were older, had a longer symptomatic course, and shorter pylorus measurements. Patients with public insurance after the implementation of MMC were more likely to follow-up with an outpatient pediatrician within a month of hospitalization. These results suggest that MMC may have improved access to care for infants with IHPS.

Impact of Insurance Status and Region on Angiotensin Receptor-Neprilysin Inhibitor Prescription During Heart Failure Hospitalizations.

BACKGROUND: An angiotensin receptor-neprilysin inhibitor (ARNI) is the preferred renin-angiotensin system (RAS) inhibitor for heart failure with reduced ejection fraction (HFrEF). Among eligible patients, insurance status and prescriber concern regarding out-of-pocket costs may constrain early initiation of ARNI and other new therapies. OBJECTIVES: In this study, the authors sought to evaluate the association of insurance and other social determinants of health with ARNI initiation at discharge from HFrEF hospitalization. METHODS: The authors analyzed ARNI initiation from January 2017 to June 2020 among patients with HFrEF eligible to receive RAS inhibitor at discharge from hospitals in the Get With The Guidelines-Heart Failure registry. The primary outcome was the proportion of ARNI prescription at discharge among those prescribed RAS inhibitor who were not on ARNI on admission. A logistic regression model was used to determine the association of insurance status, U.S. region, and their interaction, as well as self-reported race, with ARNI initiation at discharge. RESULTS: From 42,766 admissions, 24,904 were excluded for absolute or relative contraindications to RAS inhibitors. RAS inhibitors were prescribed for 16,817 (94.2%) of remaining discharges, for which ARNI was prescribed in 1,640 (9.8%). Self-reported Black patients were less likely to be initiated on ARNI compared to self-reported White patients (OR: 0.64; 95% CI: 0.50-0.81). Compared to Medicare beneficiaries, patients with third-party insurance, Medicaid, or no insurance were less likely to be initiated on ARNI (OR: 0.47 [95% CI: 0.31-0.72], OR: 0.41 [95% CI: 0.25-0.67], and OR: 0.20 [95% CI: 0.08-0.47], respectively). ARNI therapy varied by hospital region, with lowest utilization in the Mountain region. An interaction was demonstrated between the impact of insurance disparities and hospital region. CONCLUSIONS: Among patients hospitalized between 2017 and 2020 for HFrEF who were prescribed RAS inhibitor therapy at discharge, insurance status, geographic region, and self-reported race were associated with ARNI initiation.

Persistent Inequities in Intravenous Thrombolysis for Acute Ischemic Stroke in the United States: Results From the Nationwide Inpatient Sample.

BACKGROUND: Despite its approval for acute ischemic stroke >25 years ago, intravenous thrombolysis (IVT) remains underused, with inequities by age, sex, race, ethnicity, and geography. Little is known about IVT rates by insurance status. METHODS AND RESULTS: We assessed temporal trends from 2002 to 2015 in IVT for acute ischemic stroke in the Nationwide Inpatient Sample using adjusted, survey-weighted logistic regression. We calculated odds ratios for IVT for each category in 2002 to 2008 (period 1) and 2009 to 2015 (period 2). IVT use for acute ischemic stroke increased from 1.0% in 2002 to 6.8% in 2015 (adjusted annual relative ratio, 1.15). Individuals aged ≥85 years had the most pronounced increase during 2002 to 2015 (adjusted annual relative ratio, 1.18) but were less likely to receive IVT compared with 18- to 44-year-olds in period 1 (adjusted odds ratio [aOR], 0.23) and period 2 (aOR, 0.36). Women were less likely than men to receive IVT, but the disparity narrowed over time (period 1: aOR, 0.81; period 2: aOR, 0.94). Inequities in IVT resolved for Hispanic individuals in period 2 (aOR, 0.96) but not for Black individuals (period 2: aOR, 0.81). The disparity in IVT for Medicare patients, compared with privately insured patients, lessened over time (period 1: aOR, 0.59; period 2: aOR, 0.75). Patients treated in rural hospitals remained less likely to receive IVT than in urban hospitals; a more dramatic increase in urbanity widened the inequity (period 2, urban nonteaching versus rural: aOR, 2.58, period 2, urban teaching versus rural: aOR, 3.90). CONCLUSIONS: IVT for acute ischemic stroke increased among adults. Despite some encouraging trends, the remaining disparities highlight the need for intensified efforts at addressing inequities.

Mortality and morbidity ramifications of proposed retractions in healthcare coverage for the United States.

In the absence of universal healthcare in the United States, federal programs of Medicaid and Medicare are vital to providing healthcare coverage for low-income households and elderly individuals, respectively. However, both programs are under threat, with either enacted or proposed retractions. Specifically, raising Medicare age eligibility and the addition of work requirements for Medicaid qualification have been proposed, while termination of continuous enrollment for Medicaid was recently effectuated. Here, we assess the potential impact on mortality and morbidity resulting from these policy changes. Our findings indicate that the policy change to Medicare would lead to over 17,000 additional deaths among individuals aged 65 to 67 and those to Medicaid would lead to more than 8,000 deaths among those under the age of 65. To illustrate the implications for morbidity, we further consider a case study among those people with diabetes who would be likely to lose their health insurance under the policy changes. We project that these insurance retractions would lead to the loss of coverage for over 700,000 individuals with diabetes, including more than 200,000 who rely on insulin.

Is private insurance enough to address barriers to accessing dental care? Findings from a Canadian population-based study.

BACKGROUND: In Canada, as in many other countries, private dental insurance addresses financial barriers to a great extent thereby facilitating access to dental care. That said, insurance does not guarantee affordability, as there are issues with the quality and level of coverage of insurance plans. As such, individuals facing barriers to dental care experience poorer oral health. Therefore, it is important to examine more keenly the socio-demographic attributes of people with private insurance to particularly identify those, who despite having insurance, face challenges in accessing dental care and experience poorer oral health. METHODS: This study is a secondary data analysis of the most recent available cycle (2017-18) of the Canadian Community Health Survey (CCHS), a national cross-sectional survey. Univariate analysis was conducted to determine the characteristics of Ontarians with private insurance (n = 17,678 representing 6919,814 Ontarians)-bivariate analysis to explore their financial barriers to dental care, and how they perceive their oral health. Additionally, logistic regressions were conducted to identify relationships between covariates and outcome variables. RESULTS: Analysis shows that the majority of those with private insurance do not experience cost barriers to dental care and perceive their oral health as good to excellent. However, specific populations, including those aged 20-39 years, and those earning less than $40,000, despite having private dental insurance, face significantly more cost barriers to access to care compared to their counterparts. Additionally, those with the lowest income (earning less than $20,000 annually) perceived their oral health as "fair to poor" more than those earning more. Adjusted estimates revealed that respondents aged 20-39 were six times more likely to report cost barriers to dental care and ten times more likely to visit the dentist only for emergencies than those aged 12-19. Additionally, those aged 40-59 were two times more likely to report poorer oral health status compared to those aged 12-19. CONCLUSION: Given the upcoming implementation of the Canadian Dental Care Plan, the results of this study can support in identifying vulnerable populations who currently are ineligible for the Plan but can be benefitted from the coverage.

The Rise and Risks of Medicare Advantage "Affinity Plans".

This Viewpoint discusses the proliferation of Medicare Advantage plans targeting specific groups of individuals and whether these plans will improve quality of care for beneficiaries.

Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults.

This study examines the association of partner Medicare Advantage plan status over 1 year with beneficiary and plan characteristics.

State Coverage and Reimbursement of Antiobesity Medications in Medicaid.

This study examines state Medicaid coverage policies for antiobesity medications and their trends in Medicaid reimbursement from 2011 to 2022.

Use of telemedicine to obtain contraception among young adults: Inequities by health insurance.

OBJECTIVES: The objective of this study was to describe the use of telemedicine for contraception in a sample of young adults and examine differences by health insurance coverage. STUDY DESIGN: We analyzed survey data collected from May 2020 to July 2022 from individuals at risk of pregnancy aged 18 to 29 recruited at 29 community colleges in California and Texas. We used multivariable mixed-effects logistic regression models with random effects for site and individual to compare the use of telemedicine to obtain contraception by insurance status, sociodemographic characteristics, and state. RESULTS: Our analytic sample included 6465 observations from 1630 individuals. Participants reported using a contraceptive method obtained through telemedicine in just 6% of observations. Uninsured participants were significantly less likely than those privately insured to use contraception obtained through telemedicine (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.31-0.97), as were participants who did not know their insurance status (aOR, 0.54; 95% CI, 0.29-0.99). Texas participants were less likely to use contraception obtained via telemedicine than those in California (aOR, 0.42; CI: 0.25-0.69). CONCLUSIONS: Few young people in this study obtained contraception through telemedicine, and insurance was crucial for access in both states. IMPLICATIONS: Although telemedicine holds promise for increasing contraceptive access, we found that few young adults were using it, particularly among the uninsured. Efforts are needed to improve young adults' access to telemedicine for contraception and address insurance disparities.

Prescription drug coverage and effective coverage of three chronic conditions of high prevalence in Chile: Hypertension, diabetes and dyslipidemia.

BACKGROUND: Access to medicines is a serious problem globally and in Chile. Despite the creation of coverage policies, part of the population with chronic conditions of high prevalence, still does not have access to the medicines it requires and disease control continues to be low. The objective of the study was to estimate the medication use and effective coverage for diabetes, dyslipidemia and hypertension in Chile, analyzing them according to sociodemographic variables and social determinants of health. METHODS: Cross-sectional analytical study with information from the 2016-2017 National Health Survey (sample = 6,233 people aged 15 years or older, expanded = 14,518,969). Descriptive analyses of medication use and effective coverage for hypertension, diabetes and dyslipidemia were carried out, and multivariate logistic regression models were developed to analyze possible associations with variables of interest. RESULTS: 60% of people with hypertension or diabetes use medications and only 27.7% in dyslipidemia. While 54.2% of those with diabetes have their glycemia controlled, in hypertension and dyslipidemia the effective coverage drops to 33.3% and 6.6%, respectively. There are no differences in use by health system, but there are differences in the control of hypertension and diabetes, favoring beneficiaries of the private subsystem. Effective coverage of dyslipidemia and hypertension also increases in those using medications. The drugs coincide with the established protocols, although beneficiaries of the private sector report greater use of innovative drugs. CONCLUSION: A significant proportion of Chileans with hypertension, diabetes or dyslipidemia still do not use the required medications and do not control their conditions.

Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures?

BACKGROUND: There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives. PURPOSE: To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures. METHODS: This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded. PREDICTOR: The primary predictor variable was primary payer (public, private, self-pay, and other/no charge). OUTCOME VARIABLE: The primary outcome variable was hospital admission (yes/no). COVARIATES: Covariates included patient-, medical/injury-, and hospital-related variables. ANALYSES: Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant. RESULTS: The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission. CONCLUSIONS: In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.

Trends in Health Care Coverage and Out-Of-Pocket Cost Barriers: A Gender Comparison.

Objective: The presence of disparities in access to health care and insurance coverage can have a tremendous impact on health care outcomes. Programs like the Affordable Care Act were implemented to improve health care access and to address the existing inequities. The objective of this study was to identify any disparities that exist between males and females regarding health care coverage and out-of-pocket cost to health care. Methods: This analysis was a cross-sectional study using the Behavioral Risk Factor Surveillance System survey data collected between 2013 and 2018. The primary predictor was sex assigned at birth (with the binary option of male vs. female). The primary outcome was adequate health coverage. Survey participants who indicated that they had health insurance with no out-of-pocket cost barriers to receiving medical care were considered to have adequate health coverage, while participants who did not meet these criteria were considered to have inadequate health coverage. Covariates measured were age, race/ethnicity, educational level, employment status, and annual household income. SAS survey procedures and weighting methods were used to measure the association between the sex and adequate health coverage, after controlling for covariates. Results: The data spanning 6 years included 2,249,749 adults, of whom 1,898,097 (84.4%) had adequate health coverage. Females made up 55.8% (N = 1,256,243) of the total sample. About 32.6% (N = 733,216) survey participants were aged ≥65 years. Most respondents, 77.6%, were White (Non-Hispanic). Across the 6-year period, females were more likely to have health insurance but with out-of-pocket costs that served as a barrier to their medical care (adjusted odds ratios with 95% CI from 2013 to 2018 were 1.36 [1.29-1.43], 1.38 [1.32-1.46], 1.31 [1.24-1.38], 1.33 [1.26-1.40], and 1.32 [1.25-1.40], respectively). Conclusions: Females were more likely than males to indicate an out-of-pocket cost barrier to medical care despite having health insurance.

Trends in Emergency Department Visits Among People Younger Than Age 65 by Insurance Status: United States, 2010-2021.

Purpose-This report describes trends in emergency department visits among people younger than age 65 from 2010 through 2021, by health insurance status and selected demographic and hospital characteristics. Methods-Estimates in this report are based on data collected in the 2010-2021 National Hospital Ambulatory Medical Care Survey. Data were weighted to produce annual national estimates. Patient and hospital characteristics are presented by primary expected source of payment. Results-Private insurance and Medicaid were the most common primary expected sources of payment at emergency department visits by people younger than age 65 from 2010 through 2013. Medicaid was the most common primary expected source of payment from 2014 through 2021. Among children younger than age 18 years, the most common primary expected source of payment was Medicaid across the entire period. The percentage of visits by children with no insurance decreased from 7.4% in 2010 to 3.0% in 2021. Among adults, the percentage of visits with Medicaid increased from 25.5% in 2010 to 38.9% in 2021, and the percentage of visits by those with no insurance decreased from 24.6% to 11.1% during this period. Among Black non-Hispanic and Hispanic people, Medicaid was the most frequent primary expected source of payment during the entire period. Among White non-Hispanic people, private insurance was the most frequent primary expected source of payment through 2015, while private insurance and Medicaid were the most frequent primary expected sources of payment from 2016 through 2021.

Social Determinants of Health and Hearing Loss in U.S. Adults.

OBJECTIVES: Social determinants of health (SDH) are nonmedical, societal factors that influence health. There is limited information on the current relationship between SDH and hearing loss (HL) in the United States. This study aims to compare the odds of HL among US adults by race/ethnicity, education level, income-to-poverty level ratio, health insurance coverage, and health care access. STUDY DESIGN: Cross-sectional study. METHODS: The 2015-2020 National Health and Nutrition Examination Survey data were analyzed to compare odds ratios (ORs) for HL, defined as pure tone average over 25 dB HL in at least one ear, by SDH categories using sample weights. Adjusted ORs were calculated using logistic regression models controlling for sex, age, race/ethnicity, education level, income-to-federal-poverty level, health care insurance coverage and access, and loud noise, pesticide, and cigarette exposure. RESULTS: A total of 6028 participants were included. Non-Hispanic Black participants had half the odds of HL as Non-Hispanic White participants (OR 0.52, p < 0.05). Lower education level correlated with higher odds of HL: those without a high school diploma had double the odds of HL compared with college graduates or above (OR 2.05, 1.91, p < 0.05). The income-to-federal-poverty level ratio of 1.3 to less than 2 had higher odds of HL than the 4+ group (OR 1.45, p < 0.05). Use of multiple health care locations was associated with nearly three times the odds of HL than the group using one location (OR 2.87, p < 0.05). CONCLUSION: SDH are associated with HL. Further investigation is needed into the mechanism of disparities for targeted prevention and treatment for hearing care equity. LEVEL OF EVIDENCE: IV Laryngoscope, 134:2848-2856, 2024.

Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment.

OBJECTIVE: To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion. STUDY SETTING: Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year. STUDY DESIGN: Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year. DATA EXTRACTION METHODS: We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status. PRINCIPAL FINDINGS: Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states). CONCLUSIONS: Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.