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2.
N C Med J ; 81(6): 370-376, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33139466

RESUMO

Prior to the passage of the Affordable Care Act, many individuals across the state and country faced numerous barriers to accessing affordable and quality health care. This paper provides a review of health coverage in North Carolina before the ACA, the impact the ACA has had on access to health care, and how North Carolina could continue to benefit from "complete" implementation of the ACA.


Assuntos
Patient Protection and Affordable Care Act , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , North Carolina , Estados Unidos
3.
JAMA Netw Open ; 3(11): e2024398, 2020 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-33156347

RESUMO

Importance: Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. Objective: To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA). Design, Setting, and Participants: This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded. Exposure: Section 2713 of the ACA. Main Outcomes and Measures: The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method. Results: The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P < .001). The estimated probability decreased in the middle income group by 9.4%, from 6.4% (95% CI, 6.3%-6.4%) to 5.8% (95% CI, 5.7%-5.8%) (P < .001), and in the highest income group by 1.8%, from 5.6% (95% CI, 5.6%-5.7%) to 5.5% (95% CI, 5.4%-5.5%) (P < .001) in the period after the elimination of cost sharing. Conclusions and Relevance: In this cross-sectional study, the elimination of cost sharing for contraception under the ACA was associated with improvements in contraceptive method prescription fills and a decrease in births among commercially insured women. Women with low income had more precipitous decreases than women with higher income, suggesting that enhanced access to contraception may address well-documented income-related disparities in unintended birth rates.


Assuntos
Coeficiente de Natalidade/tendências , Anticoncepção/economia , Custo Compartilhado de Seguro/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência , Adolescente , Adulto , Anticoncepção/métodos , Estudos Transversais , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Renda/classificação , Renda/tendências , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/normas , Pessoa de Meia-Idade , Pobreza/estatística & dados numéricos , Gravidez , Estados Unidos/epidemiologia , Adulto Jovem
4.
JAMA Netw Open ; 3(11): e2025095, 2020 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-33170263

RESUMO

Importance: Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits. Objective: To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type. Design, Setting, and Participants: This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020. Exposures: Visit paid by Medicaid vs other payment types. Main Outcomes and Measures: Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use. Results: A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02). Conclusions and Relevance: These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Visita a Consultório Médico/estatística & dados numéricos , Cuidado Pós-Natal/normas , Adulto , Aconselhamento , Estudos Transversais , Depressão/diagnóstico , Depressão/prevenção & controle , Serviços de Planejamento Familiar/estatística & dados numéricos , Feminino , Exame Ginecológico/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde/métodos , Acesso aos Serviços de Saúde/normas , Humanos , Cobertura do Seguro/tendências , Programas de Rastreamento/métodos , Visita a Consultório Médico/tendências , Encaminhamento e Consulta/estatística & dados numéricos , Estados Unidos/epidemiologia
5.
Health Aff (Millwood) ; 39(11): 2018-2028, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33030355

RESUMO

The annual Kaiser Family Foundation Employer Health Benefits Survey is the benchmark survey of the cost and coverage of employer-sponsored health benefits in the United States. The 2020 survey was designed and largely fielded before the full extent of the coronavirus disease 2019 (COVID-19) pandemic had been felt by employers. Data collection took place from mid-January through July, with half of the interviews being completed in the first three months of the year. Most of the key metrics that we measure-including premiums and cost sharing-reflect employers' decisions made before the full impacts of the pandemic were felt. We found that in 2020 the average annual premium for single coverage rose 4 percent, to $7,470, and the average annual premium for family coverage also rose 4 percent, to $21,342. Covered workers, on average, contributed 17 percent of the cost for single coverage and 27 percent of the cost for family coverage. Fifty-six percent of firms offered health benefits to at least some of their workers, and 64 percent of workers were covered at their own firm. Many large employers reported having "very broad" provider networks, but many recognized that their largest plan had a narrower network for mental health providers.


Assuntos
Benchmarking , Infecções por Coronavirus , Custo Compartilhado de Seguro/estatística & dados numéricos , Planos de Assistência de Saúde para Empregados , Cobertura do Seguro/estatística & dados numéricos , Pandemias , Pneumonia Viral , Planos de Assistência de Saúde para Empregados/organização & administração , Planos de Assistência de Saúde para Empregados/estatística & dados numéricos , Humanos , Inquéritos e Questionários , Estados Unidos
6.
PLoS One ; 15(10): e0240151, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33052932

RESUMO

As of August 2020, the United States is the global epicenter of the COVID-19 pandemic. Emerging data suggests that "essential" workers, who are disproportionately more likely to be racial/ethnic minorities and immigrants, bear a disproportionate degree of risk. We used publicly available data to build a series of spatial autoregressive models assessing county level associations between COVID-19 mortality and (1) percentage of individuals engaged in farm work, (2) percentage of households without a fluent, adult English-speaker, (3) percentage of uninsured individuals under the age of 65, and (4) percentage of individuals living at or below the federal poverty line. We further adjusted these models for total population, population density, and number of days since the first reported case in a given county. We found that across all counties that had reported a case of COVID-19 as of July 12, 2020 (n = 3024), a higher percentage of farmworkers, a higher percentage of residents living in poverty, higher density, higher population, and a higher percentage of residents over the age of 65 were all independently and significantly associated with a higher number of deaths in a county. In urban counties (n = 115), a higher percentage of farmworkers, higher density, and larger population were all associated with a higher number of deaths, while lower rates of insurance coverage in a county was independently associated with fewer deaths. In non-urban counties (n = 2909), these same patterns held true, with higher percentages of residents living in poverty and senior residents also significantly associated with more deaths. Taken together, our findings suggest that farm workers may face unique risks of contracting and dying from COVID-19, and that these risks are independent of poverty, insurance, or linguistic accessibility of COVID-19 health campaigns.


Assuntos
Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Fatores Socioeconômicos , Infecções por Coronavirus/mortalidade , Demografia/estatística & dados numéricos , Emigrantes e Imigrantes/estatística & dados numéricos , Fazendeiros/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Pandemias , Pneumonia Viral/mortalidade , Estados Unidos
7.
Health Aff (Millwood) ; 39(10): 1743-1751, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33017236

RESUMO

Expansion of Medicaid and establishment of the Children's Health Insurance Program (CHIP) represent a significant success story in the national effort to guarantee health insurance for children. That success is reflected in the high rates of coverage and health care access achieved for children, including those in low-income families. But significant coverage gaps remain-gaps that have been increasing since 2016 and are likely to accelerate with the coronavirus disease 2019 (COVID-19) pandemic and the associated recession. Using National Health Interview Survey data, we found that the proportion of uninsured children was 5.5 percent in 2018. Children continue to face coverage interruptions, and Latino, adolescent, and noncitizen children continue to face elevated risks of being uninsured. Although we note the benefits of a universal, federally financed, single-payer approach to coverage, we also offer two possible reform pathways that can take place within the current multipayer system, aimed at ensuring coverage, access, continuity, and comprehensiveness to move the nation closer to the goal of providing the health care that children need to reach their full potential and to reduce racial and economic inequalities.


Assuntos
Serviços de Saúde da Criança/economia , Saúde da Criança , Children's Health Insurance Program/economia , Disparidades em Assistência à Saúde/economia , Cobertura do Seguro/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Masculino , Medicaid/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde , Pandemias/economia , Pandemias/estatística & dados numéricos , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Pobreza , Fatores Socioeconômicos , Estados Unidos
8.
Health Aff (Millwood) ; 39(10): 1752-1761, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33017237

RESUMO

Safety-net programs improve health for low-income children over the short and long term. In September 2018 the Trump administration announced its intention to change the guidance on how to identify a potential "public charge," defined as a noncitizen primarily dependent on the government for subsistence. After this change, immigrants' applications for permanent residence could be denied for using a broader range of safety-net programs. We investigated whether the announced public charge rule affected the share of children enrolled in Medicaid, the Supplemental Nutrition Assistance Program, and the Special Supplemental Nutrition Program for Women, Infants, and Children, using county-level data. Results show that a 1-percentage-point increase in a county's noncitizen share was associated with a 0.1-percentage-point reduction in child Medicaid use. Applied nationwide, this implies a decline in coverage of 260,000 children. The public charge rule was adopted in February 2020, just before the coronavirus disease 2019 (COVID-19) pandemic began in the US. These results suggest that the Trump administration's public charge announcement could have led to many thousands of eligible, low-income children failing to receive safety-net support during a severe health and economic crisis.


Assuntos
Serviços de Saúde da Criança/organização & administração , Infecções por Coronavirus/prevenção & controle , Assistência Alimentar/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Medicaid/economia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pobreza/estatística & dados numéricos , Adolescente , Criança , Saúde da Criança , Pré-Escolar , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Bases de Dados Factuais , Medo , Feminino , Política de Saúde/legislação & jurisprudência , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Inovação Organizacional , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Formulação de Políticas , Estudos Retrospectivos , Provedores de Redes de Segurança/organização & administração , Estados Unidos
9.
PLoS One ; 15(10): e0240298, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33035265

RESUMO

Many privately insured adults with drug use disorders in the United States do not have health care coverage for drug use treatment. The Affordable Care Act sought to redress this gap by including substance use treatments as essential health benefits under new plans offered. This study used data from 11,732 privately insured adult participants of the 2005-2018 National Survey on Drug Use and Health with drug use disorders to examine trends in drug use treatment coverage and the association of coverage with receiving treatment. 37.6% of the participants with drug use disorders did not know whether their plan covered drug use treatment, with little change over time. Among those who knew, coverage increased modestly between the 2005-2013 and 2014-2018 periods (73.5% vs. 77.5%, respectively, p = .015). Coverage was associated with receiving drug use treatment (adjusted odds ratio = 2.09, 95% confidence interval = 1.61-2.72, p < .001). However, even among participants with coverage, only 13.4% received treatment. Broader coverage of drug use treatment could potentially improve treatment rates.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Estados Unidos , Adulto Jovem
10.
Pediatrics ; 146(5)2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33055226

RESUMO

OBJECTIVES: Seventeen states do not provide Medicaid coverage for neonatal male circumcision, despite American Academy of Pediatrics recommendations supporting access for families that choose it. Our study objectives were to (1) compare state-specific trends in neonatal circumcision to previously established estimates and (2) assess the impact of changes in Medicaid coverage of the procedure. METHODS: The State Inpatient Databases were used to determine rates of neonatal male circumcision in 4 states (CO, FL, MI, and NY) at 4 time points (2001, 2006, 2011, 2016). Neonatal circumcision was defunded by Medicaid in Florida (2003) and Colorado (2011). A multivariable logistic regression model was created to assess associations between patient and state characteristics and odds of neonatal circumcision. RESULTS: Overall, 54.5% of neonates underwent circumcision. States where Medicaid defunded neonatal circumcision revealed a decrease in circumcision rates in subsequent years (47.4% to 37.5% in FL; 61.9% to 52.0% in CO). Neonates with private insurance had higher odds of circumcision compared with those with public insurance (adjusted odds ratio [aOR] 2.23; 95% confidence interval [CI] 2.21-2.25). When Medicaid coverage was available, Black neonates had higher odds of circumcision compared with white neonates (aOR 1.44; 95% CI 1.42-1.46). When Medicaid coverage was not available, Black neonates had lower odds compared with white neonates (aOR 0.40; 95% CI 0.39-0.41). CONCLUSIONS: State-specific data reveal trends in neonatal circumcision similar to previous national estimates. Colorado and Florida revealed 20.9% and 16.0% reductions in neonatal circumcision rates, respectively, after defunding. Black neonates appeared to be disproportionately affected by changes in Medicaid coverage.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid , Afro-Americanos , Estudos de Coortes , Grupo com Ancestrais do Continente Europeu , Humanos , Recém-Nascido , Masculino , Estudos Retrospectivos , Estados Unidos
11.
JAMA Netw Open ; 3(10): e2021876, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33084899

RESUMO

Importance: The association of state-level immigrant policies with uninsurance among Latino youths remains unknown. Objective: To assess the association of state-level immigrant integration and criminalization policies with health insurance coverage among US-born Latino youths by maternal citizenship. Design, Setting, and Participants: This cross-sectional study analyzed secondary data from the American Community Survey, January 1, 2016, to December 31, 2018, for US-born Latino youths (age, ≤17 years) and their mothers (age, 18-64 years) as well as state-level indicators of immigrant integration and criminalization policies (in all 50 states and the District of Columbia). Exposures: Immigrant integration and criminalization policies. Main Outcomes and Measures: The main outcome was maternal reports of youth uninsurance status at the time of the American Community Survey interview. Variation in youth uninsurance by maternal citizenship, state immigrant integration policy context, and state immigrant criminalization policy context were examined. All analyses were conducted with weighted survey data. Results: Of the 226 691 US-born Latino youths (115 431 [50.92%] male; mean [SD] age, 7.66 [4.92] years) included in the study, 36.64% (95% CI, 36.21%-36.92%) had noncitizen mothers. Overall, 7.09% (95% CI, 6.78%-7.41%) of noncitizen mothers reported that their youths were uninsured compared with 4.68% (95% CI, 4.49%-4.88%) of citizen mothers. Of uninsured youths who resided in states with a low level of immigrant integration policies, 9.10% (8.22%-10.06%) had noncitizen mothers and 4.75% (95% CI, 4.19%-5.37%) had citizen mothers; of uninsured youths who resided in states with high criminalization policies, 9.37% (95% CI, 8.90%-9.87%) had noncitizen mothers and 5.91% (95% CI, 5.64%-6.20%) had citizen mothers. In states with few immigrant integration policies, the probability of uninsurance among youths with noncitizen mothers was 3.3% (95% CI, 2.3%-4.4%) higher than that among youths with citizen mothers. Among youths with noncitizen mothers, the difference in the probability of uninsurance between those residing in states with a low level vs a high level of immigrant integration policies was 2.1% (95% CI, 0.6%-3.6%). Among youths residing in states with high levels of immigrant criminalization policies, those with noncitizen mothers had a 2.6% (95% CI, 1.9%-3.0%) higher probability of being uninsured compared with those whose mothers were citizens. Among youths with noncitizen mothers, the difference in the probability of uninsurance between those who resided in a state with a low level vs a state with a high level of immigrant criminalization policies was 1.7% (95% CI, 0.7%-2.7%). Conclusions and Relevance: The findings of this cross-sectional study suggest that among US-born Latino youths, disparities in uninsurance by maternal citizenship are associated with state-level immigrant integration and criminalization policies and that anti-immigrant policies may be associated with disparities in health care access for US-born Latino youths.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Hispano-Americanos/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Mães/estatística & dados numéricos , Políticas , Adolescente , Adulto , Criança , Pré-Escolar , Estudos Transversais , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estados Unidos/etnologia
12.
JAMA Netw Open ; 3(10): e2018728, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33001201

RESUMO

Importance: Medicaid expansion is associated with increased access to health services, increased quality of medical care delivered, and reduced mortality, but little is known about its association with use of long-term care. Objective: To examine the association of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) with long-term care use among newly eligible low-income adults and among older adults whose eligibility did not change. Design, Setting, and Participants: This difference-in-difference cohort study used data from the Health and Retirement Study, a nationally representative longitudinal survey of persons 50 years or older. Long-term care use from 2008 to 2012 was compared with use from 2014 to 2016 among low-income adults aged 50 to 64 years without Medicare coverage residing in states in which Medicaid coverage expanded in 2014 and those living in states without expansion. Low-income adults who were covered by Medicare and were ineligible for expanded Medicaid were also included in the analysis. Data were analyzed from January 15, 2018, to December 31, 2019. Exposures: Residence in a state with Medicaid expansion in 2014. Main Outcomes and Measures: Any home health care use or any nursing home use in 2014 or 2016. All estimates are weighted to account for the Health and Retirement Study sampling design. Results: Among the 891 individuals likely eligible for expanded Medicaid, the mean (SD) age was 55.2 (3.1) years; 534 (53.4%) were women, 482 (49.5%) were married, and 661 (45.9%) were White non-Hispanic. Before the ACA-funded Medicaid expansion, 0.4% (95% CI, -0.3% to 1.1%) in expansion states and 1.0% (95% CI, -0.1% to 2.2%) in nonexpansion states used nursing homes, and 1.9% (95% CI, 0.4%-3.4%) in expansion states and 7.1% (95% CI, 4.7%-9.5%) in nonexpansion states used any formal home care. The ACA-funded Medicaid expansion was associated with an increase of 4.4 percentage points (95% CI, 2.8-6.1 percentage points) in the probability of any long-term care use among low-income, middle-aged adults, with increases in home health use (3.8 percentage points; 95% CI, 2.0-5.6 percentage points) and in any nursing home use (2.1 percentage points; 95% CI, 0.9-3.3 percentage points). Conclusions and Relevance: In this study, ACA-funded Medicaid expansion was associated with an increase in any long-term care use among newly eligible low-income, middle-aged adults, suggesting that the population covered by the Medicaid expansion may have had unmet long-term care needs before expansion.


Assuntos
Acesso aos Serviços de Saúde/economia , Cobertura do Seguro/economia , Seguro Saúde/economia , Assistência de Longa Duração/economia , Medicaid/economia , Patient Protection and Affordable Care Act/economia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estados Unidos
13.
JAMA Netw Open ; 3(10): e2015198, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33026448

RESUMO

Importance: The Patient Protection and Affordable Care Act broadened insurance coverage, partially through voluntary state-based Medicaid expansion. Objective: To determine whether patients with higher-risk prostate cancer residing in Medicaid expansion states were more likely to receive treatment after expansion compared with patients in states electing not to pursue Medicaid expansion. Design, Setting, and Participants: This population-based cohort study included 15 332 patients diagnosed with higher-risk prostate cancer (ie, grade group >2; grade group 2 with prostate-specific antigen levels >10 ng/mL; or grade group 1 with prostate-specific antigen levels >20 ng/mL) from January 2010 to December 2016 aged 50 to 64 years who were candidates for definitive treatment. Patients residing in states that partially expanded Medicaid coverage before 2010 (ie, California and Connecticut) and those with diagnosis not confirmed by histology were excluded. Data were collected from the Surveillance, Epidemiology, and End Results Program. Data were analyzed between August and December 2019. Exposure: State-level Medicaid expansion status. Main Outcomes and Measures: Insurance status before and after expansion, treatment with prostatectomy or radiation therapy (including brachytherapy), treatment trends over time. Results: Of 15 332 patients, 7811 (50.9%) lived in expansion states (mean [SD] age, 59.1 [3.8] years; 5532 [71.9%] non-Hispanic White), and 7521 (49.1%) lived in nonexpansion states (mean [SD] age, 59.0 [3.9] years; 3912 [52.1%] non-Hispanic White). Residence in an expansion state was associated with higher pre-expansion levels of Medicaid coverage (292 [8.1%] vs 161 [3.8%]; odds ratio [OR], 2.12; 95% CI, 1.78 to 2.53) and lower likelihood of being uninsured (136 [3.2%] vs 38 [1.1%]; OR, 0.28; 95% CI, 0.15 to 0.54). After expansion, there was no difference in trends in treatment receipt between expansion and nonexpansion states (change, -0.39%; 95% CI, -0.11% to 0.28%; P = .25). Patients with private or Medicare coverage were more likely to receive treatment vs those with Medicaid or no coverage across racial/ethnic groups (eg, Black patients with coverage: OR, 2.30; 95% CI, 1.68 to 3.10; Black patients with no coverage: OR, 1.48; 95% CI, 1.09 to 2.00; P < .001). Medicaid patients were not more likely to be treated compared with those without insurance (737 [78.8%] vs 435 [79.5%]; OR, 0.97; 95% CI, 0.76 to 1.25). Conclusions and Relevance: In this cohort study, state-level expansion of Medicaid was associated with increased Medicaid coverage for men with higher-risk prostate tumors but did not appear to affect treatment patterns at a population level. This may be related to the finding that Medicaid coverage was not associated with increased treatment rates compared with those without insurance.


Assuntos
Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Medicaid/economia , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/economia , Neoplasias da Próstata/economia , Neoplasias da Próstata/terapia , Planos Governamentais de Saúde/economia , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/estatística & dados numéricos , Planos Governamentais de Saúde/estatística & dados numéricos , Estados Unidos
14.
JAMA Netw Open ; 3(10): e2019869, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33030554

RESUMO

Importance: Millions of Americans gained insurance through the state expansion of Medicaid, but several states with large populations of racial/ethnic minorities did not expand their programs. Objective: To investigate the implications of Medicaid expansion for liver transplant (LT) wait-listing trends for racial/ethnic minorities. Design, Setting, and Participants: A cohort study was performed of adults wait-listed for LT using the United Network of Organ Sharing database between January 1, 2010, and December 31, 2017. Poisson regression and a controlled, interrupted time series analysis were used to model trends in wait-listing rates by race/ethnicity. The setting was LT centers in the United States. Main Outcomes and Measures: (1) Wait-listing rates by race/ethnicity in states that expanded Medicaid (expansion states) compared with those that did not (nonexpansion states) and (2) actual vs predicted rates of LT wait-listing by race/ethnicity after Medicaid expansion. Results: There were 75 748 patients (median age, 57.0 [interquartile range, 50.0-62.0] years; 48 566 [64.1%] male) wait-listed for LT during the study period. The cohort was 8.9% Black and 16.4% Hispanic. Black patients and Hispanic patients were statistically significantly more likely to be wait-listed in expansion states than in nonexpansion states (incidence rate ratio [IRR], 1.54 [95% CI, 1.44-1.64] for Black patients and 1.21 [95% CI, 1.15-1.28] for Hispanic patients). After Medicaid expansion, there was a decrease in the wait-listing rate of Black patients in expansion states (annual percentage change [APC], -4.4%; 95% CI, -8.2% to -0.6%) but not in nonexpansion states (APC, 0.5%; 95% CI, -4.0% to 5.2%). This decrease was not seen when Black patients with hepatitis C virus (HCV) were excluded from the analysis (APC, 3.1%; 95% CI, -2.4% to 8.9%), suggesting that they may be responsible for this expansion state trend. Hispanic Medicaid patients without HCV were statistically significantly more likely to be wait-listed in the post-Medicaid expansion era than would have been predicted without Medicaid expansion (APC, 13.2%; 95% CI, 4.0%-23.2%). Conclusions and Relevance: This cohort study found that LT wait-listing rates have decreased for Black patients with HCV in states that expanded Medicaid. Conversely, wait-listing rates have increased for Hispanic patients without HCV. Black patients and Hispanic patients may have benefited differently from Medicaid expansion.


Assuntos
Grupos Étnicos/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adulto , Grupo com Ancestrais do Continente Africano/estatística & dados numéricos , Idoso , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários/estatística & dados numéricos , Patient Protection and Affordable Care Act , Estados Unidos , Listas de Espera
15.
Med Care ; 58(11): 952-957, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32868693

RESUMO

BACKGROUND: Access to bariatric surgery is restricted by insurers in numerous ways, including by precertification criteria such as 3-6 months preoperative supervised medical weight management and documented 2-year weight history. OBJECTIVES: To investigate if there is an association between the aforementioned precertification criteria, insurance plan type, and the likelihood of undergoing bariatric surgery, after controlling for potential sociodemographic confounders. RESEARCH DESIGN: The study was conducted using the Pennsylvania Health Care Cost Containment Council's data in 5 counties of Pennsylvania in 2016 and records of preoperative insurance requirements maintained by the Temple University Bariatric Surgery Program.Privately insured bariatric surgery patients and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched by sex, race, age group, and zip code (n=1054). Univariate tests and logistic regression analysis were utilized for data analysis. RESULTS: The insurance requirement for 3-6 months preoperative supervised medical weight management was associated with smaller odds of undergoing surgery [odds ratio (OR)=0.459; 95% confidence interval (CI), 0.253-0.832; P=0.010], after controlling for insurance plan type and the requirement for documented weight history.Preferred provider organization (OR=1.422; 95% CI, 1.063-1.902; P=0.018) and fee-for-service (OR=1.447; 95% CI, 1.021-2.050; P=0.038) plans were associated with greater odds of undergoing surgery, compared with health maintenance organization plans, after controlling for the studied precertification requirements. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P=0.132). CONCLUSIONS: There is a need for consideration of insurance benefits design as a determinant of access to bariatric surgery.


Assuntos
Cirurgia Bariátrica/estatística & dados numéricos , Definição da Elegibilidade/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/normas , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Grupos de Populações Continentais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Características de Residência , Fatores Sexuais , Estados Unidos , Adulto Jovem
16.
Med Care ; 58(11): 963-967, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32925457

RESUMO

PURPOSE: Testing for BRCA1/2 mutations has increased among privately insured women in the United States. However, little is known about testing rates or trends among women with Medicaid. We sought to determine whether BRCA1/2 testing rates differed between women with private insurance compared with women with Medicaid in a state where both insurance types cover the test, and to compare testing trends from 2011 to 2015. METHODS: We conducted a retrospective cohort study of medical claims from January 2011 through June 2015. We included Massachusetts women aged 18-64 with private insurance or Medicaid and at least 12 months of continuous enrollment. We used multivariable linear regression to examine the association of insurance type, age, and time with testing rates. RESULTS: Mean monthly BRCA1/2 testing rates were lower among women with Medicaid compared with those with private insurance. Among privately insured women, mean monthly rates rose from 9.3 per 100,000 in 2011 to 18.4 per 100,000 in 2015, while among Medicaid-insured women, rates increased from 3.7 to 14.7. There was no difference in the monthly rate of increase in both groups (P=0.07). In adjusted analyses, rates were lower among Medicaid-insured women (7 fewer tests per month than privately insured women, P<0.001), and differed by age, with women aged 44-54 most likely to receive testing and women 18-34 the least likely. CONCLUSION: BRCA1/2 testing rates were lower among women insured by Medicaid compared with those with private insurance, though rates increased from 2011 to 2015 among both groups of women at a similar rate.


Assuntos
Testes Genéticos/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adolescente , Adulto , Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias da Mama/genética , Feminino , Humanos , Revisão da Utilização de Seguros , Massachusetts , Pessoa de Meia-Idade , Neoplasias Ovarianas/genética , Setor Privado , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
20.
PLoS One ; 15(8): e0236027, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32866152

RESUMO

BACKGROUND: Recently in Ethiopia, there is an increasing movement to implement community based health insurance scheme as integral part of health care financing and remarkable movements has resulted in the spread of the scheme in different parts of the country. Despite such increasing effort, recent empirical evidence shows enrolment has remained low. To identify determinants of enrollment in community based health insurance among households in Tach-Armachiho Woreda, North Gondar, Ethiopia, 2019. METHODS: A community based unmatched case control study was conducted Tach-Armachiho Woreda from March to May 2019 among 262 participants (88 cases and 174 controls with case control ratio of 1:2). Study subjects were selected using multi-stage sampling technique. Data were collected using a pretested, structured interviewer administered questioner. Data were entered to Epi-info 7 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression model were used to see the determinants of enrollment in community based health insurance. Adjusted odds ratio with 95% CI at p-value <0.05 in multivariable logistics regression analysis factors were identified as statistically significantly associated. RESULT: Female headed households (AOR = 2.79, 95% CI = 1.16, 6.69), Increase in Age (AOR = 1.09, 95% CI = 1.05, 1.13) and negative perception towards community based health insurance (AOR = 0.062, 95% CI = .030, .128) were found to be significant predictors. CONCLUSION: This study provides evidence that the decision to enroll in the scheme is shaped by age and a combination of household head sex and perception towards community based health insurance. Implementers aimed at enhancing enrolment ought to act on the bases of this findings.


Assuntos
Seguro de Saúde Baseado na Comunidade/estatística & dados numéricos , Características da Família , Cobertura do Seguro/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Proteínas de Arabidopsis , Estudos de Casos e Controles , Estudos Transversais , Etiópia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proteínas de Ligação a RNA , Inquéritos e Questionários
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