Inclusion of People With Disabilities in Community Health Needs Assessments in Florida, United States.

Community health needs assessments (CHNAs) play a crucial role in identifying health needs of communities. Yet, unique health needs of people with disabilities (PWDs) are often underrecognized in public health practice. In 2010, the Patient Protection and Affordable Care Act (ACA) required the implementation of standardized data collection guidelines, including disability status, among federal agencies. The extent to which guidance from ACA and the U.S. Centers for Disease Control and Prevention has impacted disability inclusion in CHNAs is unknown. This study used a content analysis approach to review CHNAs conducted by local health councils and the top 11 nonprofit hospitals in Florida (n = 77). We coded CHNAs based on mentioning disability in CHNA reports, involving disability-related stakeholders, and incorporating data on disability indicators. Findings indicate that PWDs are widely not included in CHNAs in Florida, emphasizing the need for equitable representation and comprehensive understanding of PWDs in community health planning.

The association between the Patient Protection and Affordable Care Act and healthcare affordability among US adults with intellectual disability.

BACKGROUND: Historically, US adults with intellectual disability (ID) experience worse healthcare access than the general population. However, the implementation of the Patient Protection and Affordable Care Act (ACA) may have reduced disparities in healthcare access. METHODS: Using a pre-ACA 2011-2013 sample and a post-ACA implementation 2014-2016 sample from the National Health Interview Survey data, we examined the association between the ACA's introduction and healthcare access among adults with ID (N = 623). Negative binomial regression models were used to test the association between the ACA and the total number of foregone healthcare services. Binary logistic regression was used to explore whether the ACA's implementation was associated with the increased likelihood of possessing health insurance as well as the decreased likelihood of any and particular measures of foregone healthcare services due to cost. RESULTS: The study provides evidence that the ACA's implementation was associated with the decreased likelihood of the total number and any foregone care services owing to cost. Findings also revealed that the ACA's implementation was associated with expansion of health insurance coverage and decreasing instances of foregone care services for medical care, dental care, specialist visit and mental care among adults with ID. However, persons with ID were still at a higher risk of foregone prescription medicines, follow-up medical care and eyeglasses due to cost in the post-ACA years. CONCLUSIONS: The study provides evidence that healthcare access among Americans with ID improved after the ACA's implementation. However, challenges in access to follow-up care, eyeglasses and prescription medicines persist and require policy solutions, which extend beyond the ACA's provisions.

Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act.

Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in health insurance among AI/AN adults before and after implementation of the ACA.Design: We used data from the American Community Survey from 2008 to 2016 to examine trends in health insurance. We compared to Non-Hispanic Whites and stratified AI/AN adults with and without Indian Health Service (IHS) coverage. We used multivariate regression to evaluate the probability of health insurance post-ACA and included time period and subgroup interaction terms.Results: Public and private health insurance coverage increased post-ACA by 3.17 and 1.24 percentage points, respectively, but the percent uninsured remained high (37.7% of those with IHS coverage and 19.2% of those without). AI/AN in Medicaid Expansion states had a significantly greater percentage point (pp) increase in public insurance (6.31 pp, 95% CI 5.04-7.59) than AI/AN in non-expansion states (p < 0.001). There was a greater increase in private coverage among AI/AN without IHS compared to AI/AN with IHS coverage (p = 0.002).Conclusions: Despite improvements in healthcare insurance coverage for AI/AN, substantial disparities remain. The improvements appeared to be largely driven by Medicaid Expansion. Without specific considerations for AI/AN, future healthcare reforms could intensify health injustices and inequities they face.

Positive impact of the Patient Protection and Affordable Care Act Medicaid expansion on Louisiana women with breast cancer.

BACKGROUND: Louisiana is one of the few Southern states that enacted the Medicaid expansion of the Patient Protection and Affordable Care Act (ACA). To the authors' knowledge, the issue of how this has affected the breast cancer landscape in Louisiana is unknown. The authors have postulated that ACA expansion had a positive impact for Louisiana women diagnosed with breast cancer. METHODS: Data from the Louisiana Tumor Registry regarding 14,640 women aged 20 to 64 years who resided in Louisiana and were diagnosed with American Joint Committee on Cancer stage 0 to stage IV breast cancer between 2012 and 2018 were analyzed. The study period was divided into 2 groups: 1) before ACA expansion (January 1, 2012-May 31, 2016); and 2) after ACA expansion (June 1, 2016-December 31, 2018). The chi-square test and multivariable logistic regression models were used to assess the impact of ACA expansion. A P value <.05 was considered statistically significant. RESULTS: After ACA expansion, the rate of uninsured patients decreased from 5.4% to 3.0% (P < .0001), and the rate of Medicaid recipients increased from 11.6% to 17.7% (P < .0001). The diagnosis of stage I breast cancer increased from 36.8% to 44.7% (P < .0001), whereas the diagnosis of stage III breast cancer decreased from 10.7% to 8.5% (P < .0001). The receipt of radiotherapy after breast-conserving surgery increased from 81.2% to 84.0% (P = .0035), and the receipt of radiotherapy within 90 days increased from 57.2% to 61.7% (P = .0012). After adjustment for sociodemographic and clinical variables, the models demonstrated that ACA expansion decreased the uninsured rate by 48% (odds ratio [OR], 0.52; 95% CI, 0.43-0.63), increased the diagnosis of early-stage disease (stage0 to stage II) by 27% (OR, 1.27; 95% CI, 1.15-1.41), increased receipt of radiotherapy after breast-conserving surgery by 19% (OR, 1.19; 95% CI, 1.03-1.37), and reduced the delay of receipt of radiotherapy by 16% (OR, 0.84; 95% CI, 0.74-0.95). CONCLUSIONS: ACA expansion in Louisiana reduced the uninsured rate, increased the diagnosis of early-stage disease, and increased access to treatment.

Precision medicine testing in ovarian cancer: The growing inequity between patients with commercial vs medicaid insurance.

INTRODUCTION: Precision medicine technologies have significant impact in the care of patients with ovarian cancer. Compared to affluent patients, socioeconomically vulnerable patients are less likely to have access to this testing. There is little data that demonstrate this inequity over time. METHODS: We used the IBM Truven Health MarketScan Research Database to identify patients in the United States who underwent surgery for ovarian cancer between 2011 and 2017. The presence of claims for precision medicine testing within six months of surgery was assessed for each patient. Precision medicine testing included both molecular genetic testing (BRCA limited or full sequencing, somatic and germline testing) as well as ancillary pathology tests (immunohistochemistry, microsatellite instability). Demographic data was extracted. RESULTS: We identified 27,181 patients who met eligibility. Of these, 88.6% had commercial insurance, and 11.4% had Medicaid. While the proportion of patients who underwent precision medicine testing increased over time for both cohorts (47.0% to 66.6% for commercially insured, 41.4% to 57.6% for Medicaid insured, p < 0.0001), the inequity in testing rates widened (5.6% disparity to 9.0%, p < 0.0001). This was driven by growing inequity in germline and somatic genetic testing (7.6% disparity to 21.3%, p < 0.0001). CONCLUSIONS: There is widening inequity in precision medicine testing rates between commercially insured and Medicaid insured poate patients with ovarian cancer.

The effect of the Affordable Care Act dependent coverage provision on HPV vaccine uptake in young adult women, National Health and Nutrition Examination Survey 2007-2016.

The human papillomavirus (HPV) vaccine protects against cancers caused by HPV. The study objective was to examine the effect of the Affordable Care Act (ACA) dependent child coverage provision on HPV vaccination initiation, HPV vaccine completion, HPV infection, and health insurance coverage among young women. Using cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), 2172 female participants were included. The impact of the dependent coverage provision on the four outcomes was examined using difference-in-difference analyses with linear probability regressions, controlling for race/ethnicity, age, income, head of household education, and family employment. ACA exposure group was operationalized by age, with those targeted by the dependent coverage provision (ages 19-25) serving as the intervention group and those similar in age but not targeted (ages 18 and 26) serving as the control group. From 2007 to 2016, HPV vaccine initiation, HPV vaccine completion, and health insurance prevalence increased and HPV infection prevalence decreased. In the difference-in-difference adjusted models, ACA exposure was not associated with HPV vaccine initiation (0.045 percentage points [95% CI -0.087, 0.178]), completion (-0.044 percentage points [95% CI -0.152, 0.063]), HPV 16/18 infection (-0.051 percentage points [95% CI -0.123, 0.021]), or health insurance (0.065 percentage points [95% CI -0.032, 0.162]) among women aged 19 to 25. The dependent coverage provision may not have addressed relevant barriers to HPV vaccination. However, given that the effect of the dependent coverage provision on HPV vaccination and health insurance has been demonstrated previously, small sample size is a concern.

Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act.

One-half of women in the United States use Medicaid during pregnancy. Women living in states that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA) are at risk of losing coverage post partum. We analyzed Medicaid claims and vital statistics for the state of North Carolina for the period 2011 to 2017. North Carolina did not expand Medicaid but did alter Medicaid enrollment to meet ACA requirements. After implementation, enrollment in full Medicaid during pregnancy almost doubled, and enrollment in Medicaid for pregnant women decreased. Full Medicaid offers more comprehensive coverage and does not expire at 60 days post partum, allowing for access to crucial preventive health services including contraception and primary care.

Measuring the impact of the Affordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach.

BACKGROUND: The Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act (ACA), was created to increase access to primary care, improve quality of care, and decrease healthcare costs. A key provision in the law that mandated expansion of state Medicaid programme changed when states were given the option to voluntarily expand Medicaid. Our study sought to measure the impact of ACA Medicaid expansion on preventable hospitalization (PH) rates, a measure of access to primary care. METHODS: We performed an interrupted time series analysis of quarterly hospitalization rates across eight states from 2012 to 2015. Segmented regression analysis was utilized to determine the impact of policy reform on PH rates. RESULTS: The Affordable Care Act's Medicaid expansion led to decreased rates of PH (improved access to care); however, the finding was not significant (coefficient estimate: -0.0059, CI -0.0225, 0.0107, p = 0.4856). Healthcare system characteristics, such as Medicaid spending per enrollee and Medicaid income eligibility, were associated with a significant decrease in rates of PH (improved access to care). However, the Medicaid-to-Medicare fee index (physician reimbursement) and states with a Democratic state legislature had a significant increase in rates of PH (poor access to care). CONCLUSION: Health policy reform and healthcare delivery characteristics impact access to care. Researchers should continue evaluating such policy changes across more states over longer periods of time. Researchers should translate these findings into cost analysis for state policy-makers to make better-informed decisions for their constituents. CONTRIBUTION TO KNOWLEDGE: Ambulatory care-sensitive conditions are a feasible method for evaluating policy and measuring access to primary care. Policy alone cannot improve access to care. Other factors (trust, communication, policy-makers' motivations and objectives, etc.) must be addressed to improve access.

Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans' Association With Viral Suppression.

BACKGROUND: Healthcare delivery changes associated with viral suppression (VS) could contribute to the United States' "Ending the HIV Epidemic" (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states. METHODS: A multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014-2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated. RESULTS: Of the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06-3.53) and engagement in care in 2014 (aPR, 1.16; 1.04-1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs' NNT for an additional person to achieve VS is 20 (14.1-34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28-1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99-1.14) was associated with VS. CONCLUSIONS: Once enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE.

Changes in prostate-specific antigen at the time of prostate cancer diagnosis after Medicaid expansion in young men.

BACKGROUND: The objective of this study was to determine the effect of Medicaid expansion under the Patient Protection and Affordable Care Act (January 1, 2014) on the epidemiology of high-risk prostate-specific antigen (PSA) levels (≥20 ng/mL) at the time of prostate cancer (PCa) diagnosis. The authors hypothesized that better access to care would result in a reduction of high-risk features at diagnosis. METHODS: A retrospective cohort study was performed of 122,324 men aged <65 years who were diagnosed with PCa within the National Cancer Database. Difference-in-difference (DID) analyses adjusting for sociodemographic variables using linear regression compared PSA levels at diagnosis before expansion (2012-2013) and after expansion (2015-2016) between men residing in states that did or did not expand Medicaid. RESULTS: From 2012 to 2016, the proportion of men with PSA levels ≥20 ng/mL increased (from 18.9% to 19.8%) in nonexpansion states and decreased (from 19.9% to 18.2%) in expansion states. Compared with men in nonexpansion states, men in expansion states experienced a decline in PSA ≥20 ng/mL (DID, -2.33%; 95% CI, -3.21% to -1.44%; P < .001). Accordingly, the proportion of men presenting with high-risk disease decreased in expansion states relative to nonexpansion states (DID, -1.25%; 95% CI, -2.26% to 0.25%; P = .015). A similar statistically significant decrease in PSA levels ≥20 ng/mL was noted among black men (DID, -3.11%; 95% CI, -5.25% to 0.96%; P = .005). CONCLUSIONS: In Medicaid expansion states, there was an associated decrease in the proportion of young men presenting with PSA ≥20 ng/mL at the time of PCa diagnosis. These results suggest that Medicaid expansion improved access to PCa screening. Longer term data should assess oncologic outcomes.

The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States.

BACKGROUND: To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States. METHODS: HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis. RESULTS: Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]). CONCLUSIONS: The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion.

The effect of Medicaid expansion among adults from low-income communities on stage at diagnosis in those with screening-amenable cancers.

BACKGROUND: Several states have opted to expand Medicaid under the Patient Protection and Affordable Care Act (ACA), which offers insurance coverage to low-income individuals up to 138% of the federal poverty level. This expansion of Medicaid to a medically vulnerable population potentially can reduce cancer outcome disparities, especially among patients with screening-amenable cancers. The objective of the current study was to estimate the effect of Medicaid expansion on the percentage of adults from low-income communities with screening-amenable cancers who present with metastatic disease. METHODS: Using state cancer registry data linked with block group-level income data, a total of 12,760 individuals aged 30 to 64 years who were diagnosed with incident invasive breast (female), cervical, colorectal, or lung cancer from 2011 through 2016 and who were uninsured or had Medicaid insurance at the time of diagnosis were identified. This sample was probability weighted based on income to reflect potential Medicaid eligibility under the ACA's Medicaid expansion. A multivariable logistic model then was fitted to examine the independent association between the exposure (pre-expansion [years 2011-2013] vs postexpansion [years 2014-2016]) and the outcome (metastatic vs nonmetastatic disease at the time of diagnosis). RESULTS: After adjusting for potential confounders, individuals who were diagnosed postexpansion were found to have 15% lower odds of having metastatic disease compared with those who were diagnosed pre-expansion (adjusted odds ratio, 0.85; 95% confidence interval, 0.77-0.93). As a control, a separate analysis that focused on individuals with private insurance who resided in high-income communities found nonsignificant postexpansion (vs pre-expansion) changes in the outcome (adjusted odds ratio, 1.02; 95% confidence interval, 0.96-1.09). CONCLUSIONS: Medicaid expansion is associated with a narrowing of a critical cancer outcome disparity in adults from low-income communities.

Impact of the Patient Protection and Affordable Care Act on cost-related medication underuse in nonelderly adult cancer survivors.

BACKGROUND: Cost-related medication underuse (CRMU), a measure of access to care and financial burden, is prevalent among cancer survivors. The authors quantified the impact of the Patient Protection and Affordable Care Act (ACA) on CRMU in nonelderly cancer survivors. METHODS: Using National Health Interview Survey data (2011-2017) for cancer survivors aged 18 to 74 years, the authors estimated changes in CRMU (defined as taking medication less than prescribed due to costs) before (2011-2013) to after (2015-2017) implementation of the ACA. Difference-in-differences (DID) analyses estimated changes in CRMU after implementation of the ACA in low-income versus high-income cancer survivors, and nonelderly versus elderly cancer survivors. RESULTS: A total of 6176 cancer survivors aged 18 to 64 years and 4100 cancer survivors aged 65 to 74 years were identified. In DID analyses, there was an 8.33-percentage point (PP) (95% confidence interval, 3.06-13.6 PP; P = .002) decrease in CRMU for cancer survivors aged 18 to 64 years with income <250% of the federal poverty level (FPL) compared with those with income >400% of the FPL. There was a reduction for cancer survivors aged 55 to 64 years compared with those aged 65 to 74 years with income <400% of the FPL (-9.35 PP; 95% confidence interval, -15.6 to -3.14 PP [P = .003]). CONCLUSIONS: There was an ACA-associated reduction in CRMU noted among low-income, nonelderly cancer survivors. The ACA may improve health care access and affordability in this vulnerable population.

The Affordable Care Act Medicaid Expansion Positively Impacted Community Health Centers and Their Patients.

Community health centers (CHCs) provide primary care for underserved children and adults. The Patient Protection and Affordable Care Act (ACA) aimed to strengthen the CHC network by increasing federal funds and expanding Medicaid eligibility. The ACA also aimed to boost preventive and mental health services and to reduce health and healthcare disparities. Here, we summarize our results to-date as experts in investigating the impact of ACA Medicaid expansion on CHCs and the patients they serve. We found the ACA Medicaid expansion increased access to care and preventive services, primarily in Medicaid expansion states. Rates of physical and mental health conditions rose substantially from pre- to post-ACA in expansion states, suggesting underdiagnosis pre-ACA. Disparities in health insurance coverage by race/ethnicity decreased at CHCs, yet some remain. These findings indicate that the ACA Medicaid expansion significantly helped CHCs and patients. Insurance expansion buoyed CHCs' financial viability by increasing reimbursement. Therefore, the ACA Medicaid expansion enhanced the health of underserved patients and repeal would jeopardize these advances for CHCs and their patients.

Trends in guideline-adherent fertility-sparing surgery for early-stage cervical cancer before and after the Affordable Care Act.

OBJECTIVE: To assess trends in guideline-adherent fertility-sparing surgery (GA-FSS) for early-stage cervical cancer relative to Patient Protection and Affordable Care Act (ACA) implementation. METHODS: National Cancer Database patients treated for Stage IA1-IB1 cervical cancer from 2004 to 2016 were included. Multivariable logistic regression was used to determined trends in GA-FSS relative to the ACA and identify patient factors independently associated with GA-FSS. RESULTS: Odds of GA-FSS increased in the post- compared to pre-ACA cohort (aOR = 1.65; 95%CI: 1.34-2.03). Decreasing age, Asian/Pacific Islander race, higher education and income levels, more recent treatment year, and lower clinical stage were independently associated with increased odds of receiving GA-FSS. In the pre- and post-ACA samples, decreasing age (per 1 year age increase; pre-ACA aOR = 0.87, 95%CI:0.85-0.90; post-ACA aOR = 0.85, 95%CI:0.83-0.87), higher education level (top vs. lowest education quartile; pre-ACA aOR = 2.08, 95%CI:1.19-3.65; post-ACA aOR = 2.00, 95%CI:1.43-2.80), and lower clinical stage (stages IA2 [pre-ACA aOR = 0.19, 95%CI:0.09-0.41; post-ACA aOR = 0.29, 95%CI:0.19-0.45] and IB1 [pre-ACA aOR = 0.06, 95%CI:0.06-0.16; post-ACA aOR = 0.16, 95%CI: 0.12-0.20] relative to stage IA1) were independently associated with increased odds of GA-FSS receipt. After the ACA, Asian/Pacific Islander race (aOR = 2.81, 95%CI: 1.81-4.36) and more recent treatment year (Spearman's ρ = 0.0348, p-value = 0.008) were also independently associated with increased odds of GA-FSS receipt. When adjusted for the pre- vs. post-ACA treatment periods, Medicaid patients were less likely to undergo GA-FSS than privately-insured patients (aOR = 1.65; 95%CI:1.34-2.03). CONCLUSIONS: Patients were more likely to receive GA-FSS post-ACA. Though the proportion of publicly-insured women increased after ACA implementation, women on Medicaid remained less likely to receive GA-FSS than women with private insurance.

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study.

PURPOSE: We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion. METHODS: We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county. RESULTS: Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees. CONCLUSIONS: In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.

The Affordable Care Act and Recent Reforms: Policy Implications for Equitable Mental Health Care Delivery.

Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act (ACA) in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article evaluates the impact of the ACA on equitable mental health care delivery according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities.

Dual-Method Contraception Use Among Young Women Pre- and Post-ACA Implementation.

The 2012 implementation of the Patient Protection and Affordable Care Act (ACA) contraceptive coverage mandate removed financial barriers to contraception access for many insured women. Since that time, increases in sexually transmitted disease (STD) rates have been noted, particularly among Black adolescent and young adult women aged 15 to 24 years. It is unclear whether changes in dual-method contraception use (simultaneous use of nonbarrier contraceptive methods and condoms) are associated with the increase in STD rates. A repeated cross-sectional analysis was conducted among adolescent and young adult women to compare pre-ACA data from the 2006-2010 cohort and post-ACA data from the 2013-2015 cohort of the National Survey for Family Growth. A significant decrease in short-acting reversible contraception use (SARC; 78.2% vs. 67.5%; p < .01) and a significant increase in long-acting reversible contraception use (LARC; 8.9% vs. 21.8%; p < .01) were found, but no significant change in dual-method contraception use was found among pre- versus post-ACA SARC users and SARC nonusers (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 0.64-5.46, p = .25), LARC users and LARC nonusers (adjusted odds ratio [AOR]: 1.62, 95% CI: 0.42-6.18, p = .48), or White and Black women (AOR: 1.45, 95% CI: 0.66-3.18, p = .35). There was no direct association between changes in contraception use and decreased condom use and therefore no indirect association between changes in contraception use and increased STD rates. Health care providers should continue promoting consistent condom use. Additional research is needed to understand recent increases in STD rates among Black women in the post-ACA era.

Predictors and Costs of 30-Day Readmissions After Index Hospitalizations for Alcohol-Related Disorders in U.S. Adults.

BACKGROUND: In 2015, the Hospital Readmissions Reduction Program mandated financial penalties to hospitals with greater rates of readmissions for certain conditions. Alcohol-related disorders (ARD) are the fourth leading cause of 30-day readmissions. Yet, there is a dearth of national-level research to identify high-risk patient populations and predictors of 30-day readmission. This study examined patient- and hospital-level predictors for index hospitalizations with principal diagnosis of ARD and predicted the cost of 30-day readmissions. METHODS: The 2014 Nationwide Readmissions Database was used to identify ARD-related index hospitalizations. Multivariable logistic regression was used to estimate patient- and hospital-level predictors for readmissions, and a 2-part model was used to predict the incremental cost conditional upon readmission. RESULTS: In 2014, 285,767 index hospitalizations for ARD were recorded, and 18.9% of ARD-associated hospitalizations resulted in at least one 30-day readmission. Patients who were males, aged 45 to 64 years, Medicaid enrollees, living in urban and low-income areas, or with 1 to 2 comorbidities had high risk of readmission. Index hospitalization costs were higher among readmitted patients ($8,840 vs. $8,036, p < 0.01). Predicted mean costs for readmissions on index stay with ARD were greater among those aged 45 to 64 years ($1,908, p < 0.001), Medicare enrollees ($2,133, p < 0.001), rural residents ($1,841, p < 0.01), living in high-income areas ($1,876, p < 0.001), with 4 or more comorbidities ($2,415, p < 0.001), or admitted in large metropolitan hospitals ($2,032, p < 0.001), with large number of beds ($1,964, p < 0.001), with government ownership ($2,109, p < 0.001), or with low volume of ARD cases ($2,155, p < 0.001). CONCLUSIONS: One in 5 ARD-related index hospitalizations resulted in a 30-day readmission. Overall, costs of index hospitalizations for ARD were $2.3 billion, of which $512 million were spent on hospitalizations that resulted in at least 1 readmission. There is a need to develop patient-centric health programs to reduce readmission rates and costs among ARD patients.

Women's obstetric and reproductive health care discourse in online forums: Perceived access and quality pre- and post-Affordable Care Act.

This corpus-based study examines women's framing of health issues in online forums (MedHelp.org, AphroditeWomensHealth.com, and Connect.MayoClinic.org) prior to, during, and after implementation of the Affordable Care Act (ACA). Since worldviews affect how women describe health issues, their discourse is both a way to see ideology indexed in the forums, as well as how that discourse has been shaped by policy. Posts were collected December 2016-April 2017 and annotated using the UAM (Universidad Autónoma de Madrid) Corpus Tool to examine emergent categories and compare them to three time periods: pre-, during, and post-ACA. Data within posts were coded as to the linguistic moves being made. Three frequent categories of linguistic function in the data were identified: experience-sharing, advice-requesting and offering, and rationale-offering (N = 1268). These linguistic moves were sub-divided into further categories (e.g., under advice requesting, a request for diagnosis), and a discourse-analytical perspective provides insight into the values indexed in each. Before ACA, forum participants cited access, fear, and a history of unhelpful medical visits as obstacles to seeking care. After implementation, obstacles cited were prior unhelpful visits, followed by access, and uncertainty regarding care-seeking appropriateness. While ACA implementation reduced lack of insurance as an obstacle to obtaining healthcare, online forums indicate that patients continue to find doctors' visits unhelpful, instead choosing to seek medical advice from the lay public. Patients' distrust of the medical profession persisted following ACA implementation. There is a need for public health initiatives to improve this relationship in order to augment health care outcomes.