High-volume buprenorphine prescribers: Examining state policy contexts.

Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity?

1502 Background: Medicaid expansion under the Affordable Care Act (ACA) is associated with increased insurance coverage and early stage at diagnosis among patients with cancer. Whether these gains translate to improved survival is largely unknown, however. This study examines changes in one-year survival rates among persons newly diagnosed with cancer following the ACA Medicaid expansion. Methods: Patients aged 18-62 years from 41 population-based state cancer registries diagnosed pre-(2010-2012) and post-(2014-2016) ACA Medicaid expansion were followed through October 1, 2013 and December 31, 2016, respectively. Difference-in-differences (DD) analysis was conducted to estimate changes in one-year overall and cause-specific survival rates associated with Medicaid expansion, adjusting for age group, sex, race/ethnicity, area-level poverty, urban/rural status and region. Stratified analysis was conducted by cancer type, sex and area-level poverty. Results: A total of 2,537,818 patients diagnosed with cancer were included from Medicaid expansion (N = 1,492,729) and non-expansion (N = 1,045,089) states. During follow-up, 291,854 patients died including 246,660 deaths from cancer. The one-year overall survival rate (%) increased from 88.1 pre-ACA to 89.1 post-ACA in Medicaid expansion states and from 85.6 to 86.4 in non-expansion states for both sexes combined, resulting in a net increase of 0.4 (95%CI = 0.3-0.6) in expansion states after adjusting for sociodemographic factors. By cancer site and for both sexes combined, the increase in adjusted one-year overall survival in expansion states versus non-expansion states was greater for cancers of lung (DD = 1.6; 95%CI = 0.8-2.5), pancreas (DD = 2.2; 95%CI = 0.5-3.9) and liver (DD = 3.4; 95%CI = 1.7-5.1); as were the increases for cervix (DD = 1.3; 95%CI = 0.1-2.5), melanoma (DD = 0.4;95%CI = 0.04-0.9), non-Hodgkin lymphoma (DD = 1.2; 95%CI = 0.1-2.2) and esophagus (DD = 7.1; 95%CI = 0.5-13.7) among women. The improvement in one-year overall survival was larger among patients residing in the poorest areas (DD = 0.7; 95%CI = 0.3-1.1) compared to those in the richest areas (DD = 0.2; 95%CI = -0.2 to 0.5), leading to a narrowing survival disparity by area-level poverty. Patterns in one-year cause-specific survival were similar. Conclusions: Medicaid expansion was associated with greater increase in one-year overall survival rates, largely driven by the improvements in survival for cancer types with poor prognosis, suggesting improved access to timely and effective treatments. Furthermore, the increase was largest in poorest areas, highlighting the promising role of Medicaid expansion in reducing health disparities. Future studies should monitor changes in longer-term health outcomes following the ACA.

California has a long tradition of providing publicly funded family planning services to low-income residents. The Affordable Care Act (ACA) increased contraceptive coverage in 2012, and in January2014 it extended Medicaid eligibility by increasing the income cut-off from 100percent to 138percent of the federal poverty level and allowing individuals without dependent children to enroll. We assessed the impact of the ACA's Medicaid expansion on low-income Californian women's receipt of health insurance and needed health care, including contraceptive counseling and prescription contraception, using data for the period 2013-16 from 4,567 women ages 18-44 with low incomes (less than 138percent of poverty). After the ACA expansion, the proportion of uninsured low-income women in California decreased significantly, while the share enrolled in Medicaid increased. However, the proportion of the women who reported using health care and family planning services remained unchanged. Despite the ACA's explicit attention to contraceptive services, improvements in the delivery of family planning services have yet to be fully realized in California.

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

BackgroundUnmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs.MethodsExploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012–2017. The analytic sample included 2054 CHC-year observations.ResultsCompared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01).ConclusionsMedicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Materials and Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.

ABSTRACTThe Affordable Care Act (ACA) has been heralded as a major policy change that is expected to transform the delivery of substance use disorder (SUD) treatment. Few studies have reported on the perceived impacts of ACA from the perspectives of SUD treatment providers, such as physicians who prescribe buprenorphine to patients with opioid use disorder. The present study describes buprenorphine prescribers’ perceptions regarding impacts of the ACA on the delivery of buprenorphine and examines whether state-level approaches to implementing ACA are associated with its perceived impacts. Data are drawn from a national sample of current buprenorphine prescribers (n = 1,174) who were surveyed by mail. On average, buprenorphine prescribers reported ambivalence regarding the impacts of the ACA, as indicated by a mean of 2.75 (SD = 0.69) on a scale that ranged from 1 (“strongly disagree”) to 5 (“strongly agree”). A multi-level mixed-effects regression model indicated that physicians practicing in states that were supportive of ACA, as indicated by adopting both the Medicaid expansion and implementing a state-based health insurance exchange, had more positive perceptions of the ACA than physicians in states that had declined both of these policies. This study suggests that state approaches to ACA may be associated with varied impacts.

This study addresses the lack of research on Medicaid expansion's impact on melanoma staging, treatment utilization, and outcomes by evaluating its effects under the Affordable Care Act (ACA), particularly focusing on staging at diagnosis, treatment use, and 3-year mortality outcomes. The objective is to determine whether Medicaid expansion led to earlier melanoma diagnosis and improved survival rates among non-elderly adults (ages 40-64) by analyzing data from the National Cancer Database (NCDB). A total of 12,667 patients, aged 40-64, diagnosed with melanoma from 2010 to 2020 were identified using the NCDB. Difference-in-difference (DID) analysis was performed to analyze tumor staging at presentation between Medicaid expansion states and non-Medicaid expansion states both prior to the expansion and after the expansion. Of the total patients, 2307 were from the pre-expansion time period residing in Medicaid expansion states (MES) and 1804 in non-Medicaid expansion states. In the post-expansion time period there were 5571 residing in the MES and 2985 in the non-MES. DID analysis revealed a decrease in stage IV melanoma at diagnosis (DID -0.222, p < 0.001) between MES and non-MES before and after Medicaid expansion. After expansion, in stage IV, the occurrence of primary surgery was 0.42 in non-MES and 0.44 (difference 0.02); DID analysis was not statistically significant. The use of immunotherapy in MES was significantly higher than in non-MES after expansion (p < 0.001), although DID analysis did not reveal a statistically significant difference. DID analysis showed a statistically significant decrease in 3-year mortality (DID -0.05, p = 0.001) between MES and non-MES before and after Medicaid expansion. This study revealed the positive impact of the ACA's Medicaid expansion on melanoma stage at presentation, highlighting the importance of public health policies in reducing disparities in mortality rates and early-stage diagnoses. Future research should explore additional barriers to care and evaluate the long-term outcomes of Medicaid expansion to optimize cancer care for vulnerable populations.

We examine the effect of the Medicaid expansions under the 2010 Patient Protection and Affordable Care Act (ACA) on consumer financial outcomes using data from a major credit reporting agency for a large, national sample of adults. We employ the synthetic control method to compare individuals living in states that expanded Medicaid to those that did not. We find that the Medicaid expansions significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies among those residing in zip codes with the highest share of low-income, uninsured individuals. Our estimates imply a reduction in collection balances of approximately $1,140 among those who gain Medicaid coverage due to the ACA. Our findings suggest that the ACA Medicaid expansions had important financial impacts beyond health care use.

The access to care benefits of Affordable Care Act (ACA) Medicaid expansions are important for 45–64-year-old adults who are living below 100% of the Federal Poverty Level, a particularly vulnerable group in the United States (US). Gaining coverage from Medicaid expansions should improve access to healthcare and affect social determinants of health, including financial behavior. We analyzed data from 2009 to 2018 from the National Financial Capability Survey (NFCS) and utilize a difference-in-differences model to compare outcomes changes in states with and without expansion before and after the ACA Medicaid expansions. Overall, Medicaid expansion was associated with increased healthcare access for 45–64-year-olds, potentially resulting in better healthcare experience. Results indicate effects of the Medicaid expansion on the financial behavior of 45–64-year-olds, with evidence of credit card bills being paid in full, higher banking activities, and better financial preparedness. These findings have important implications for financial regulators and healthcare policymakers.

Expanding eligibility for Medicaid was a central goal of the Affordable Care Act (ACA), which continues to be debated and discussed at the state and federal levels as further reforms are considered. In an effort to provide a synthesis of the available research, we systematically reviewed the peer-reviewed scientific literature on the effects of Medicaid expansion on the original goals of the ACA. After analyzing seventy-seven published studies, we found that expansion was associated with increases in coverage, service use, quality of care, and Medicaid spending. Furthermore, very few studies reported that Medicaid expansion was associated with negative consequences, such as increased wait times for appointments-and those studies tended to use study designs not suited for determining cause and effect. Thus, there is evidence to document improvements in several areas of health care delivery following the ACA Medicaid expansion. We outline areas for future research that can further reduce current knowledge gaps.

The Patient Protection and Affordable Care Act (ACA) of 2010 substantially expanded the availability of health insurance coverage, particularly for adults with disabilities. One notable change was the option for states to offer Medicaid coverage to adults with household incomes that were below 138% of the federal poverty line; most but not all states expanded Medicaid to this population. This article investigates whether states that expanded Medicaid coverage through the ACA in 2014—the first year that expansion was possible under the ACA, and the year that most states opted to expand—experienced differential changes in the employment rate of adults with disabilities relative to states that did not expand Medicaid. Using nationally representative data from the American Community Survey, we do not find evidence that the postexpansion employment trend in Medicaid expansion states was significantly different from that trend in states that did not expand Medicaid.

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

10011 Background: Little is known about whether Medicaid expansion under the Affordable Care Act (ACA) affected insurance coverage among adult survivors of childhood cancer, a population at high-risk for poor health outcome. We addressed this gap by evaluating the association between ACA Medicaid expansion and Medicaid enrollment among participants in the Childhood Cancer Survivor Study (CCSS). Methods: The CCSS cohort of 5-year survivors of childhood cancer was linked to administrative Medicaid insurance data in 2010-2016. We identified 13,895 adult survivors (aged 18-64 years) diagnosed with cancer under age 21 and between 1970 and 1999. Outcomes included (1) percentage with any Medicaid enrollment by year; and (2) Medicaid-covered days (number of days when a survivor was enrolled in Medicaid) during each year. Multivariable difference-in-differences (DD) models were used to examine outcome changes pre vs. post ACA Medicaid expansion, in expansion- vs. non-expansion states, adjusting for age, sex, race/ethnicity, income, education, and chronic conditions. Multivariable models were conducted overall and then stratified by cancer type, race/ethnicity, income, and education. Results: Medicaid enrollment rates increased more in expansion states (17.6% pre-expansion to 24.1% post-expansion) than non-expansion states (16.4% to 16.9%), leading to a net increase in enrollment of 6.6 percentage points (ppt; 95% CI = 5.5-7.7) in the multivariable DD model. Multivariable DD model showed a net increase of 18.4 days (95% CI = 13.8-23.1) in Medicaid-covered days in expansion states relative to non-expansion states. The expansion-associated increase in Medicaid enrollment rates was greatest among survivors of leukemia (multivariable DD estimate: 8.9 ppt, 95% CI = 6.9-11.0) and non-Hodgkin lymphoma (8.0 ppt, 95% CI = 5.0-10.9). Greater increases in Medicaid enrollment were seen in non-Hispanic Black (13.5 ppt, 95% CI = 8.0-19.1) and Hispanic survivors (15.8 ppt, 95% CI = 10.6-21.0) than non-Hispanic White peers (5.1 ppt; 95% CI = 4.0-6.2); in survivors with &lt; $20K household income (11.7 ppt, 95% CI = 8.9-14.4) compared to those with ≥$60K household income (2.9 ppt, 95% CI = 1.6-4.2); and in survivors with high school or lower education (9.3 ppt, 95% CI = 6.9-11.8) compared to those with a college or higher degree (3.9 ppt, 95% CI = 2.6-5.3). Similar patterns were observed across survivor subgroups when examining Medicaid-covered days. Conclusions: We provide the first evidence on increased Medicaid enrollment and longer coverage duration among adult survivors of childhood cancer following Medicaid expansion, with greater increases seen among survivors of underrepresented racial/ethnic populations, those with low socioeconomic status, and high medical need survivors.

We welcome the letter by Chen and Parikh (1) sharing their perspective on our study (2) and presenting their recent work on the association of the Affordable Care Act (ACA) Medicaid expansion with dilated eye exams (3). Joint efforts by providers and patients are vital for successful diabetes management, and the ACA Medicaid expansion could expand the utilization of routine checkups for diabetes care. Through increased access to medical providers and increased attention to self-monitoring behaviors, we believe that the ACA could be leading to important improvements in diabetes management (4). In response to the integrated diabetes management strategy, our research identified diabetes care activities led by providers, such as doctor visits, …