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1.
PLoS One ; 15(1): e0222387, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31978141

RESUMO

In order to gain insights into how the effects of the uneven adoption of Medicaid expansion varies across the rural/urban spectrum and between racial/ethnic groups in the United States, this research used the fertility question in the 2011-2015 American Community Survey to link infants' records to their mothers' household health insurance status. This preliminary exploration of the Medicaid expansion used logistic regression to examine the probability that an infant will be born without health insurance coverage. Overall, the states that adopted Medicaid expansion improved the health insurance coverage for households with infants. However, rural households with infants report lower percentages of coverage than urban households with infants. Furthermore, the rural/urban gap in health insurance coverage is wider in states that adopted the Medicaid expansion. Additionally, Hispanic infants remain significantly less likely to have health insurance coverage compared to Non-Hispanic White infants. Understanding infant health insurance coverage across ethnic/racial groups and the rural/urban spectrum will become increasingly important as the U.S. population transitions to a minority-majority and also becomes more urban. Although not a perfect solution, our findings showed that the Medicaid expansion of health insurance coverage had a mainly overall positive effect on the percentage of U.S. households with infants who have health insurance coverage.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adulto , Grupos de Populações Continentais/estatística & dados numéricos , Grupos Étnicos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu , Feminino , Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde , Hispano-Americanos , Humanos , Lactente , Cobertura do Seguro , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Patient Protection and Affordable Care Act/estatística & dados numéricos , População Rural , Estados Unidos/epidemiologia
2.
Med Care ; 57(10): 788-794, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31513138

RESUMO

BACKGROUND: Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. OBJECTIVES: To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. RESEARCH DESIGN: A retrospective cohort study. SUBJECTS: Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. MEASURES: Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. RESULTS: The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18-0.19] and returning insured (OR, 0.22; 95% CI, 0.22-0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01-2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. CONCLUSIONS: Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Continuidade da Assistência ao Paciente , Feminino , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/legislação & jurisprudência , Masculino , Medicaid/legislação & jurisprudência , Pessoa de Meia-Idade , Oregon , Estudos Retrospectivos , Estados Unidos
3.
Surgery ; 166(5): 820-828, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31402131

RESUMO

BACKGROUND: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery. METHODS: A total of 47,974 nonelderly adult bariatric surgical patients (ages 18-64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates. RESULTS: The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P < .001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states. CONCLUSION: The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery.


Assuntos
Cirurgia Bariátrica/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Obesidade Mórbida/cirurgia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Populações Vulneráveis/estatística & dados numéricos , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Cirurgia Bariátrica/economia , Cirurgia Bariátrica/legislação & jurisprudência , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicaid/economia , Medicaid/legislação & jurisprudência , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Grupos Minoritários/estatística & dados numéricos , Obesidade Mórbida/economia , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
4.
Med Care ; 57(8): 567-573, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31299024

RESUMO

BACKGROUND: Every year, millions of Americans lose their health insurance and remain uninsured for various reasons, potentially impacting access to medical services. OBJECTIVE: To examine trends in health insurance loss in the periods shortly before and after implementation of Patient Protection and Affordable Care Act (ACA) and to assess the association of past-year health insurance loss with access to health services and medications. RESEARCH DESIGN AND SUBJECTS: Trends in health insurance loss were examined in 176,961 nonelderly adult participants of the National Health Interview Survey 2011-2017-a representative cross-sectional annual survey of US general population. Multivariable logistic regression models were used to examine access to health services and medications. MEASURES: Loss of private insurance or Medicaid in the past year; use of emergency room services and hospitalizations; contact with medical providers; affording medical care or medications; cost-related medication nonadherence. RESULTS: Private health insurance loss decreased from 3.9%-4.0% in 2011-2013 to 2.7% to 3.1% in 2014-2017 (P<0.001); Medicaid loss decreased from 8.5%-8.9% to 4.6%-6.4% in this period (P<0.001). Nevertheless, as late as 2017, ∼6 million uninsured adults reported having lost private insurance or Medicaid in the past year. Loss of either type of health insurance was associated with lower odds of accessing medical providers, but higher odds of not affording medical care and poor adherence to medication regimens to save costs. CONCLUSIONS: Implementation of ACA was associated with lower risk of health insurance loss. Nevertheless, health insurance loss remains a major barrier to accessing health services and prescribed medications.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/legislação & jurisprudência , Hospitalização/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/legislação & jurisprudência , Modelos Logísticos , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/legislação & jurisprudência , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
5.
Am J Public Health ; 109(9): 1233-1235, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318586

RESUMO

Objectives. To evaluate the effect of the Affordable Care Act (ACA) on US veterans' access to care.Methods. We used US Behavioral Risk Factor Surveillance System data to compare measures of veterans' coverage and access to care, including primary care, for 3-year periods before (2011-2013) and after (2015-2017) ACA coverage provisions went into effect. We used difference-in-differences analyses to compare changes in Medicaid expansion states with those in nonexpansion states.Results. Coverage increased and fewer delays in care were reported in both expansion and nonexpansion states after 2014, with larger effects among low socioeconomic status (SES) and poor health subgroups. Coverage increases were significantly larger in expansion states than in nonexpansion states. Reports of cost-related delays, no usual source of care, and no checkup within 12 months generally improved in expansion states relative to nonexpansion states, but improvements were small; changes were mixed among veterans with low SES or poor health.Conclusions. Increases in insurance coverage among nonelderly veterans after ACA coverage expansions did not consistently translate into improved access to care. Additional study is needed to understand persisting challenges in veterans' access to care.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Sistema de Vigilância de Fator de Risco Comportamental , Humanos , Pessoa de Meia-Idade , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto Jovem
6.
Am J Public Health ; 109(9): 1236-1242, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318591

RESUMO

Objectives. To determine whether the 2014 Affordable Care Act Medicaid expansion affected well-being in the low-income and general adult US populations.Methods. We obtained data from adults aged 18 to 64 years in the nationally representative Gallup-Sharecare Well-Being Index from 2010 to 2016 (n = 1 674 953). We used a difference-in-differences analysis to compare access to and difficulty affording health care and subjective well-being outcomes (happiness, sadness, worry, stress, and life satisfaction) before and after Medicaid expansion in states that did and did not expand Medicaid.Results. Access to health care increased, and difficulty affording health care declined following the Medicaid expansion. Medicaid expansion was not associated with changes to emotional states or life satisfaction over the study period in either the low-income population who newly gained health insurance or in the general adult population as a spillover effect of the policy change.Conclusions. Although the public health benefits of the Medicaid expansion are increasingly apparent, improved population well-being does not appear to be among them.Public Health Implications. Subjective well-being indicators may not be informative enough to evaluate the public health impact of expanded health insurance.


Assuntos
Nível de Saúde , Cobertura do Seguro/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adulto , Humanos , Medicaid , Pessoa de Meia-Idade , Saúde Pública , Qualidade de Vida , Estados Unidos/epidemiologia
7.
Am J Public Health ; 109(9): 1243-1248, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318597

RESUMO

Objectives. To examine whether the expansion of Medicaid under the Affordable Care Act (ACA) decreased the prevalence of severe food insecurity.Methods. With data on adult respondents to the Food Security Supplement to the Current Population Survey in US states for the years 2010 to 2013 and 2015 to 2016, I used a difference-in-difference design to compare trends in very low food security (VLFS) among low-income childless adults in states that did and did not expand Medicaid in 2014 under the ACA.Results. Among low-income, nonelderly childless adults, VLFS rose from 17.4% before ACA to 17.5% after ACA in nonexpansion states, and fell from 17.6% to 15.9% in expansion states. In difference-in-difference analysis, Medicaid expansion was associated with a significant adjusted 2.2-percentage-point decline in rates of VLFS, equivalent to a 12.5% relative reduction.Conclusions. The improvement in food security after the ACA's health insurance expansion suggests that health insurance provision has spillover effects that reduce other dimensions of poverty.Public Health Implications. Providing free or low-cost health insurance coverage may free up household funds, reducing food insecurity and improving this important social determinant of health.


Assuntos
Abastecimento de Alimentos/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza , Estados Unidos , Adulto Jovem
8.
JAMA Netw Open ; 2(6): e195529, 2019 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-31199444

RESUMO

Importance: Physical abuse and neglect affect a significant number of children in the United States. The 2014 Medicaid expansion, in which several states opted to expand their Medicaid programs, is associated with parental financial stability and access to mental health care. Objective: To determine whether Medicaid expansion is associated with changes in physical abuse and neglect rates. Design, Setting, and Participants: This ecological study used state-level National Child Abuse and Neglect Data Systems (NCANDS) data from January 1, 2010, through December 31, 2016, to compare the change in physical abuse and neglect rates in states that chose to expand Medicaid vs those that did not. All cases of physical abuse and neglect of children younger than 6 years during the study period that were referred to state-level Child Protective Services and screened in for further intervention after having met a maltreatment risk threshold were included. Cases with only documented sexual or emotional abuse were excluded. A difference-in-difference analysis was conducted from April 12, 2018, through March 26, 2019. Exposures: State-level Medicaid expansion status. Main Outcomes and Measures: Incidence rate of screened-in referrals for physical abuse or neglect per 100 000 children younger than 6 years per year by state. Results: Data were analyzed for 31 states and the District of Columbia that expanded Medicaid and 19 states that did not during the study period, with baseline neglect counts of 646 463 and 388 265, respectively. After Medicaid expansion, 422 fewer cases of neglect per 100 000 children younger than 6 years (95% CI, -753 to -91) were reported each year after adjusting for confounders for comparison of postexpansion and preexpansion rates in states that expanded Medicaid contrasting with the change during that time in nonexpansion states. From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9% (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did. No associations were found between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates. Conclusions and Relevance: Medicaid expansion was associated with a reduction in the reported child neglect rate, but not the physical abuse rate. These findings suggest that expanding Medicaid may help prevent child neglect.


Assuntos
Maus-Tratos Infantis/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Abuso Físico/estatística & dados numéricos , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Cobertura do Seguro/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estados Unidos/epidemiologia
9.
Public Health Rep ; 134(4): 417-422, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31170025

RESUMO

OBJECTIVES: Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services. METHODS: We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education. RESULTS: We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03). CONCLUSIONS: The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.


Assuntos
Trocas de Seguro de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/legislação & jurisprudência , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Adulto , Feminino , Humanos , Illinois , Pessoa de Meia-Idade , Estados Unidos , Neoplasias do Colo do Útero/terapia
10.
Cancer Control ; 26(1): 1073274819845874, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31067985

RESUMO

BACKGROUND: Prior data suggests that breast cancer screening rates are lower among women in the Appalachian region of the United States. This study examined the changes in breast cancer screening before and after the implementation of the Affordable Care Act Medicaid expansion, in Appalachia and non-Appalachia states. METHODS: Data from the Behavioral Risk Factor Surveillance System between 2003 and 2015 were analyzed to evaluate changes in breast cancer screening in the past 2 years among US women aged 50-74 years. Multivariable adjusted logistic regression and generalized estimating equation models were utilized, adjusting for sociodemographic, socioeconomic, and health-care characteristics. Data were analyzed for 2 periods: 2003 to 2009 (pre-expansion) and 2011 to 2015 (post-expansion) comparing Appalachia and non-Appalachia states. RESULTS: The prevalence for of self-reported breast cancer screening in Appalachia and non-Appalachia states were 83% and 82% ( P < .001), respectively. In Appalachian states, breast cancer screening was marginally higher in non-expanded versus expanded states in both the pre-expansion (relative risk [RR]: 1.002, 95% confidence interval [CI]: 1.002-1.003) and post-expansion period (RR: 1.001, 95% CI: 1.001-1.002). In non-Appalachian states, screening was lower in non-expanded states versus expanded states in both the pre-expansion (RR: 0.98, 95% CI: 0.97-0.98) and post-expansion period (RR: 0.95, 95% CI: 0.95-0.96). There were modest 3% to 4% declines in breast cancer screening rates in the pos-texpansion period regardless of expansion and Appalachia status. CONCLUSIONS: Breast cancer screening rates were higher in Appalachia versus non-Appalachia US states and higher in expanded versus nonexpanded non-Appalachia states. There were modest declines in breast cancer screening rates in the post-expansion period regardless of expansion and Appalachia status, suggesting that more work may be needed to reduce administrative, logistical, and structural barriers to breast cancer screening services.


Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/estatística & dados numéricos , Mamografia/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Idoso , Região dos Apalaches , Sistema de Vigilância de Fator de Risco Comportamental , Feminino , Humanos , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Fatores de Risco , Classe Social , Estados Unidos
11.
BMC Health Serv Res ; 19(1): 291, 2019 May 08.
Artigo em Inglês | MEDLINE | ID: mdl-31068205

RESUMO

BACKGROUND: The Affordable Care Act expanded Medicaid and increased federal funding for Community Health Centers (CHCs). To examine the role of Medicaid coverage on care patterns for those with available safety net care, we assessed differences in access to care for CHC patients with continuous Medicaid coverage vs. gaps in insurance coverage in the last year. METHODS: We used data on adult respondents from the 2014 Health Center Patient Survey (N = 1720) with continuous Medicaid coverage vs. those with some period without insurance coverage in the last 12 months. We examined reported need for any medical care, mental health care, prescription drugs, dental care, and referrals for care outside of the CHC in the last 12 months, and reports of being delayed or unable to get needed care by insurance status. We used logistic regression to assess the association between insurance status and care access, adjusting for patient characteristics. RESULTS: Patients with insurance gaps and continuous Medicaid coverage reported similar levels of need for most types of care in the last 12 months, but those with insurance gaps were significantly more likely to report having difficulty obtaining medical care, prescription drugs, dental care, and completing outside referrals. Of those with incomplete referrals for care outside of the CHC, patients with insurance gaps were more likely than those with continuous Medicaid to cite cost or insurance-related reasons for not following up (70% vs. 19%, p < 0.01). CONCLUSIONS: Having continuous Medicaid coverage appeared to mitigate barriers to care for CHC patients compared to having intermittent or no insurance coverage over the last year. Policies that increase disruptions in Medicaid coverage could adversely impact access to care, even among those with available safety net care.


Assuntos
Centros Comunitários de Saúde , Acesso aos Serviços de Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adulto , Centros Comunitários de Saúde/estatística & dados numéricos , Grupos Étnicos , Feminino , Pesquisa sobre Serviços de Saúde , Disparidades nos Níveis de Saúde , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição , Estados Unidos , Adulto Jovem
12.
Curr HIV/AIDS Rep ; 16(1): 105-112, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30762215

RESUMO

PURPOSE OF REVIEW: Passage of the Affordable Care Act (ACA) in 2010 and subsequent Medicaid expansion has influenced access to HIV treatment and care in the USA. This review aims to evaluate whether the implementation of these policies has impacted progress toward UNAIDS 90-90-90 goals. RECENT FINDINGS: Preliminary evidence has emerged suggesting that the ACA and Medicaid expansion has increased the likelihood of HIV testing and diagnosis, reduced the number of people unaware of HIV infection, and increased the number of people on antiretroviral therapy (ART) who are virally suppressed. While the ACA is associated with some progress toward 90-90-90 goals, more years of data after policy implementation are needed for robust analysis. Methods including difference-in-differences, instrumental variables, and propensity scores are recommended to minimize bias from unmeasured confounders and make causal inference about non-random Medicaid expansion among states.


Assuntos
Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Antirretrovirais/uso terapêutico , Objetivos , Humanos , Cobertura do Seguro , Seguro Saúde , Estados Unidos
13.
Drug Alcohol Depend ; 197: 115-119, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30802735

RESUMO

OBJECTIVES: To explore whether the Affordable Care Act (ACA) enactment is associated with changes in the proportion of discharge against medical advice (DAMA) among hospitalizations due to substance use disorders (SUDs). METHODS: Data were drawn from the 2012-2015 National Inpatient Samples. The sample comprised hospitalizations with a principal diagnosis of SUD (i.e., SUD-involved hospitalization) for patients aged 18-64 years (unweighted N = 287,629). Interrupted time series analyses were conducted to evaluate the effect of the ACA on monthly proportions of DAMA among SUD-involved hospitalizations. RESULTS: Overall, approximately 11% of SUD-involved hospitalizations were DAMA. DAMA was most frequently found among hospitalizations for primary opioid use disorder (pre-ACA: 16.4%; post-ACA: 17.2%). Despite the increase in the Medicaid coverage after ACA enactment, there was no significant change in the proportion of DAMA before and after ACA periods across various demographic groups and clinical conditions. Time series analyses also indicated no significant trend effect on the proportion of DAMA during the pre- and post-ACA months. CONCLUSIONS: As many as 1 in 10 SUD-involved hospitalizations were considered as DAMA. Concerted efforts are needed to enhance insurance benefits for SUDs and patients' knowledge of SUD treatment benefits in order to increase SUD treatment engagement and completion and to reduce DAMA, especially for substance-using patients with Medicaid or opioid use disorder.


Assuntos
Medicaid/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Alta do Paciente/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Humanos , Pacientes Internados/psicologia , Análise de Séries Temporais Interrompida , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Adulto Jovem
14.
Acad Med ; 94(7): 931-933, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30801272

RESUMO

Reflecting on the 2018 U.S. midterm elections, it is clear that health care coverage once again played an important role. This prompted the authors to look back on their 2016 bike listening tour across the country when they asked people about their views on the Affordable Care Act. Through those conversations, the authors observed that a common thread was the rampant misunderstanding of health insurance coverage and the central role that politicians had in the creation of policy. In this Invited Commentary, the authors explore the results of the 2018 election, particularly in the rural northern areas where they toured in 2016, and the contradictions between what people say they want, what the candidates say they support, and what the facts actually show. They offer suggestions for the role physicians might play with patients in correcting misunderstandings about the health care system and the policies that shape it. Patients do not always make decisions as physicians do. As opposed to evidence and data, they might rely on personal experiences and stories. The authors suggest that physicians might be able to help patients use these stories to inform their decisions, and to help them understand the connection between their personal health care experiences and the votes they cast in elections.


Assuntos
Pacientes/psicologia , Política , Qualidade da Assistência à Saúde/normas , Financiamento da Assistência à Saúde , Humanos , Patient Protection and Affordable Care Act/organização & administração , Patient Protection and Affordable Care Act/normas , Patient Protection and Affordable Care Act/estatística & dados numéricos , Pacientes/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados Unidos
15.
Matern Child Health J ; 23(8): 1008-1024, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30631992

RESUMO

Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)-the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0-17 years in Massachusetts compared to children in other New England states. The National Survey of Children's Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts's enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = - 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.


Assuntos
Reforma dos Serviços de Saúde/métodos , Acesso aos Serviços de Saúde/normas , Cobertura do Seguro/normas , Adolescente , Criança , Pré-Escolar , Feminino , Reforma dos Serviços de Saúde/normas , Reforma dos Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Lactente , Cobertura do Seguro/estatística & dados numéricos , Masculino , Massachusetts , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/organização & administração , Patient Protection and Affordable Care Act/estatística & dados numéricos
16.
Matern Child Health J ; 23(5): 657-666, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30600517

RESUMO

Objectives We examine trends in prescription contraceptive sales following the Affordable Care Act's (ACA) zero-copayment contraceptive coverage mandate in areas more likely to be affected by the provision relative to areas less likely to be affected. Methods Before the ACA, several states had their own contraceptive insurance coverage mandates. Using a national prescription claims database combined with wholesaler institutional sales activity from January 2008 through June 2014, we compare sales of the intrauterine device (IUD), implant, injectable, pill, ring, and patch in states that had a state-level insurance coverage mandate before the ACA to states that did not. Results Overall, our results imply the ACA increased sales of prescription contraceptives, with stronger effects for some methods than others. Specifically, we find the ACA increased sales of injectable contraceptives, but had no significant impact on sales of the IUD, implant, pill, or patch in states without a state-level mandate before the ACA relative to states that had a state-level mandate. We also find suggestive evidence of a reduction in sales of the ring. Conclusions for Practice Demand responses to changes in out-of-pocket expenses for contraception vary across methods. Eliminating copays could promote the use of contraceptives, but is not the only approach to increasing contraceptive utilization.


Assuntos
Comércio/estatística & dados numéricos , Anticoncepcionais/uso terapêutico , Patient Protection and Affordable Care Act/estatística & dados numéricos , Comércio/economia , Anticoncepção/economia , Anticoncepção/instrumentação , Anticoncepção/métodos , Anticoncepcionais/economia , Gastos em Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/tendências , Patient Protection and Affordable Care Act/economia , Prescrições/economia , Prescrições/estatística & dados numéricos , Estados Unidos
17.
Health Serv Res ; 54 Suppl 1: 307-316, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30378119

RESUMO

OBJECTIVE: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on disparities in insurance coverage after three years. DATA SOURCE: The 2011-2016 waves of the American Community Survey (ACS), with the sample restricted to nonelderly adults. DESIGN: We estimate a difference-in-difference-in-differences model to separately identify the effects of the nationwide and Medicaid expansion portions of the ACA using the methodology developed in the recent ACA literature. The differences come from time, state Medicaid expansion status, and local area pre-ACA uninsured rates. In order to focus on access disparities, we stratify our sample separately by income, race/ethnicity, marital status, age, gender, and geography. PRINCIPAL FINDINGS: After three years, the fully implemented ACA eliminated 43% of the coverage gap across income groups, with the Medicaid expansion accounting for this entire reduction. The ACA also reduced coverage disparities across racial groups by 23%, across marital status by 46%, and across age-groups by 36%, with these changes being partly attributable to both the Medicaid expansion and nationwide components of the law. CONCLUSIONS: The fully implemented ACA has been successful in reducing coverage disparities across multiple groups.


Assuntos
Grupos Étnicos/estatística & dados numéricos , Reforma dos Serviços de Saúde , Disparidades em Assistência à Saúde/etnologia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/tendências , Estados Unidos
18.
J Healthc Qual ; 41(1): 49-58, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29280779

RESUMO

Under the Affordable Care Act (ACA), more women are insured with Medicaid, which should improve healthcare access. We sought to determine whether there are survival differences among patients with breast cancer undergoing surgery at facilities with varying proportions of Medicaid patients. We used New York State (NYS) Vital Statistics death records data linked with NYS discharge inpatient and ambulatory surgery databases to examine 90-day survival after surgery from 2008 to 2013. We used all Medicaid discharges to calculate and create quintiles of facilities based on Medicaid volume. We calculated survival hazard ratios using a marginal Cox model controlling for clustering of patients within hospitals, age, race, insurance, year of surgery, and comorbidities. Women who received surgery in facilities with the highest quintile of Medicaid volume had higher 90-day mortality (2.1% vs. 0.07%, p < .001) compared with those treated in facilities with lowest Medicaid volume, even after adjusting for multiple confounders. Consequently, although the ACA may improve access, healthcare quality remains questionable because patients treated at facilities with high proportions of Medicaid volume appear to have worse 90-day survival, likely due to quality of surgical and postsurgical care. Policymakers must ensure that quality of care is not negatively impacted by programs to reduce costs.


Assuntos
Neoplasias da Mama/mortalidade , Neoplasias da Mama/cirurgia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , New York , Estados Unidos
19.
Mil Med ; 184(1-2): e76-e82, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29697846

RESUMO

Introduction: Prior to the Affordable Care Act, as many as 1.3 million veterans lacked health insurance. With the passage of the Affordable Care Act, veterans now have new pathways to coverage through Medicaid expansion in those states that chose to expand Medicaid and through private coverage options offered through the Health Insurance Marketplace. We examined the impact of the ACA on health insurance coverage for veterans in expansion and non-expansion states and for urban and rural veterans. Methods: We examined changes in veterans' health insurance coverage following the first year of the ACA, focusing on whether they lived in an urban or rural area and whether they live in a Medicaid expansion state. We used data on approximately 200,000 non-elderly community-dwelling veterans, obtained from the 2013-2014 American Community Survey and estimated differences in the adjusted probability of being uninsured between 2013 and 2014 for both urban and rural areas. Adjusted probabilities were computed by fitting logistic regressions controlling for age, gender, race, marital status, poverty status, education, and employment. Results: There were an estimated 10.1 million U.S. non-elderly veterans in 2013; 82% lived in predominantly urban areas (8.3 million), and the remaining 18% (1.8 million) lived in predominately rural areas. Most veterans lived in the South (43.6%), and rural veterans were more likely to be Southerners than their urban counterparts. On every marker of economic well-being, rural veterans fared worse than urban veterans. They had a statistically significant higher chance of having incomes below 138% of FPG (20.0% versus 17.0%), of being out of the labor force (29.1% versus 23.0%), and of having no more than a high school education (39.6% versus 28.8%). Rural veterans were also more likely to experience at least one functional limitation. Overall, veterans in Medicaid expansion states experienced a significantly larger increase in insurance compared to veterans living in non-expansion states. For rural veterans in Medicaid expansion states, the increase in insurance was 3.5 percentage points, compared with 1.2 percentage points in non-expansion states. Conclusion: Our analysis found a substantial 24% relative decline in the rate of uninsurance for U.S. Veterans, from 9.3 to 7.1% between 2013 and 2014. We found that coverage gains in rural areas were due to gains in Medicaid and individual market coverage. Residence in a Medicaid expansion state was particularly influential for rural veterans - the increase in the insured rate was three times larger in Medicaid expansion states versus non-expansion states. The ACA has had a positive and significant impact on the ability of U.S. Veterans to obtain health insurance coverage specifically for low-income veterans living in rural areas. The poverty rate among Veterans is rising and is particularly an issue for the more recent Gulf War veterans. Providing affordable and accessible health insurance options is part of our commitment to those who have served our country. Our analysis also presents yet another reason for the 17 non-expansion states to consider a Medicaid expansion.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Cobertura do Seguro/normas , Seguro Saúde/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/organização & administração , Patient Protection and Affordable Care Act/estatística & dados numéricos , População Rural/estatística & dados numéricos , Estados Unidos , População Urbana/estatística & dados numéricos
20.
Issue Brief (Commonw Fund) ; 2018: 1-13, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-30457752

RESUMO

Issue: In 2017, health insurance marketplaces in some states were thriving, while those in other states were struggling. What explains these differences? Goal: Identify factors that explain differences in issuers' participation levels in state insurance marketplaces. Methods: Analysis of the Robert Wood Johnson Foundation's HIX Compare dataset, and the National Association of Insurance Commissioners' 2010 Supplemental Health Care Exhibit Report. Findings and Conclusions: State policies and insurance regulations were key factors affecting the number of issuers participating in the marketplaces in 2017. Marketplaces run by states had more issuers than states that rely on the federally facilitated marketplace. States with fewer than four issuers tended to have policies in place that could have been destabilizing--for example, permitting the sale of plans not compliant with the Affordable Care Act's requirements regarding essential health benefits or guaranteed issue. Consumers in states that did not take steps to enforce these insurance market reforms still benefited from their protections, however; they were just enforced at the federal level. States with more issuers were also more likely to have expanded Medicaid. States with fewer issuers tended to be rural and have smaller populations, more concentrated hospital markets, and lower physician-to-population ratios.


Assuntos
Trocas de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Governo Estadual , Demografia , Reforma dos Serviços de Saúde , Política de Saúde , Humanos , Pessoas sem Cobertura de Seguro de Saúde , População Rural , Fatores Socioeconômicos
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