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Medicare is a primary source of health insurance coverage for several million people younger than age sixty-five who have long-term disabilities. This analysis compared measures of access to care, cost concerns, and satisfaction with care for beneficiaries younger than age sixty-five versus those ages sixty-five and older, using the 2019 Medicare Current Beneficiary Survey. We also compared beneficiaries in traditional Medicare with those in Medicare Advantage, given that a growing share of younger beneficiaries with disabilities are enrolled in private plans. We found that Medicare beneficiaries younger than age sixty-five reported worse access to care, more cost concerns, and lower satisfaction with care than beneficiaries ages sixty-five and older, regardless of their type of Medicare coverage. Among beneficiaries younger than age sixty-five in traditional Medicare, the share reporting cost concerns was highest among those without supplemental coverage. All of these differences were statistically significant. Addressing gaps in coverage for people with disabilities could improve experiences for this often-overlooked segment of the Medicare population. [ABSTRACT FROM AUTHOR]

Despite Medicaid's importance as a payer and source of coverage for mental health care, relatively little is known about how prevalence, access, and quality might vary among Medicaid beneficiaries. This study used national Medicaid data from 2018 to assess regional variations in emergency department (ED) visits for mental health conditions, a measure that may reflect unmet needs for behavioral health care. We found substantial variations, with rates in the region with the highest visit rates eight times higher than those in the region with the lowest rates. Many regions with high rates of ED visits for mental health conditions also had high rates of outpatient mental health use. Regional patterns differed substantially, with some regions exhibiting high rates of ED visits related to anxiety but low rates for schizophrenia and vice versa. The presence of large variations in ED visits for mental health conditions, with substantial differences in the composition across regions, suggests a need for context-specific solutions, including assessments of the ways in which mental health benefits are structured at the state Medicaid agency level and of differences in provider accessibility and an understanding of the types of mental illness underlying high rates of use. [ABSTRACT FROM AUTHOR]

Medicaid expansions under the Affordable Care Act (ACA) dramatically increased access to insurance coverage. We examined whether the 2014 ACA Medicaid expansions also mitigated existing racial or ethnic disparities in preventable hospitalizations and emergency department (ED) visits. Using inpatient data from twenty-nine states and ED data from twenty-six states for the period 2011-18, we found that Medicaid expansions decreased disparities in preventable hospitalizations and ED visits between non-Hispanic Black and White nonelderly adults by 10 percent or more. There were no significant effects on disparities between Hispanic and non-Hispanic White nonelderly adults, possibly reflecting lower baseline differences and, separately, persisting coverage disparities. These findings highlight sustained improvements in community-level care for non-Hispanic Black populations, who historically lack access to care. Our findings also suggest access barriers experienced by Hispanic adults that need to be addressed beyond Medicaid eligibility expansion. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) Medicaid expansions increased preconception and postpartum insurance coverage among low-income birthing people, leading to greater use of outpatient care. In this study we evaluated whether the expansions affected rates of postpartum hospitalization. Our analyses took advantage of underused longitudinal hospital data from the period 2010-17 to examine hospitalizations after childbirth. We compared changes in hospitalizations among birthing people with a Medicaid-flnanced delivery in states that did and did not expand Medicaid under the ACA. We found a 17 percent reduction in hospitalizations during the first sixty days postpartum associated with the Medicaid expansions and some evidence of a smaller decrease in hospitalizations between sixty-one days and six months postpartum. Our findings indicate that expanding Medicaid coverage led to improved postpartum health for low-income birthing people. [ABSTRACT FROM AUTHOR]

In 2022 the average annual premium for family health insurance coverage was $22,463, which is similar to the $22,221 reported in 2021. On average, covered workers contributed $1,327 for single coverage and $6,106 for family coverage. Among covered workers enrolled in a plan with a general annual deductible, the average deductible for single coverage was $1,763. Almost half of large employers reported an increase from 2021 in the share of employees using mental health services. The 2022 survey asked employers about the breadth of their provider networks, especially for those using services for mental health and substance use disorders. Employers were less likely to report that their plan with the largest enrollment was very broad for mental health services than for providers overall. Fewer employers thought that their plan had a sufficient number of behavioral health providers versus primary care providers to provide timely access to enrollees. [ABSTRACT FROM AUTHOR]

We examined changes in health insurance coverage and access to and use of health care among adult (ages 18-64) Latinos in the US before (2007-13) and after (2014-16) implementation of the main provisions of the Affordable Care Act. Data from the California Health Interview Survey were used to compare respondents in the two periods. We used multivariable and decomposition regression analyses to investigate the role of documentation status in access disparities between Mexicans and other Latinos in California. Our findings show that after the implementation of these provisions in California, insurance coverage increased for US- and foreign-born Latinos, including undocumented Latinos. Our decomposition analyses show that after implementation, disparities between Mexicans and other Latinos declined with respect to having coverage and a usual source of care. Without the implementation of these provisions in 2014, these disparities would have been 5.76 percent and 0.31 percent larger, respectively. In contrast, legal documentation status was positively associated with disparities between Mexicans and other Latinos in having coverage and physician visits. If Mexican Latinos had had the same share of undocumented immigrants as other Latinos, disparities in health insurance coverage would have declined by 24.17 percent.

Policy makers are pursuing strategies to integrate Medicare and Medicaid coverage for people enrolled in both programs, who are known as dual eligibles. Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans that exclusively serve this population, with several features intended to enhance care and facilitate integration with Medicaid. This study compared access to, use of, and satisfaction with care among dual eligibles enrolled in D-SNPs versus those enrolled in two other forms of Medicare coverage: other Medicare Advantage (MA) plans not exclusively serving dual eligibles and traditional Medicare. Compared with those in traditional Medicare, dual eligibles generally reported greater access to care, preventive service use, and satisfaction with care in D-SNPs. However, we found fewer differences in these outcomes among dual eligibles in D-SNPs versus other MA plans. Compared with non- Hispanic White dual eligibles, dual eligibles of color (for example, those identifying as Black or Hispanic) were less likely to report receiving better care in D-SNPs versus other Medicare coverage. These findings suggest that D-SNPs altogether have not provided consistently superior or more equitable care, and they highlight areas where federal and state policy could strengthen incentives for D-SNPs to improve care. [ABSTRACT FROM AUTHOR]

To understand the current state of prediabetes burden and treatment in the US, we examined recent trends in prediabetes prevalence, testing, and access to preventive resources. We estimated 13.5 percent prevalence of diagnosed prediabetes in the overall US adult population, using national survey data. Although prediabetes prevalence increased by 4.8 percentage points from 2010 to 2020, access to preventive resources remained low. The most effective intervention for diabetes prevention, known as the National Diabetes Prevention Program, remained woefully undersupplied and underused. There are only 2,098 National Diabetes Prevention Program--recognized providers nationally, and only 3 percent of adults with prediabetes have participated in the program. We suggest three actions to augment prevention efforts: increase payment for prevention interventions to avoid supply distortions, improve data integration and patient follow-up, and extend coverage and broaden access for preventive interventions. These actions, which would require policy-level changes, could lower the barriers to prevention. [ABSTRACT FROM AUTHOR]

Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment. [ABSTRACT FROM AUTHOR]

Assisted living communities are the final home for many of their residents, most of whom are older, frail, and cognitively or functionally impaired. Yet little is known about end-of-life care in this setting. We examined associations of both death at home and home hospice care with individual characteristics, such as race or ethnicity and dual Medicare-Medicaid enrollment; community characteristics; and the stringency of state-level assisted living regulations. Of the 100,783 fee-for-service Medicare beneficiaries residing in 16,560 assisted living communities who died in 2018-19, almost 60 percent died at home, 84 percent of them with home hospice. In predicting the likelihood of death at home, dual Medicare-Medicaid enrollment was more important than race or ethnicity; in contrast, race was a stronger predictor than dual enrollment for hospice care at death. Residents were less likely to die at home or with home hospice in states with lower regulatory stringency regarding assisted living communities. These findings may help inform efforts to ensure equitable access to desired end-of-life care in this setting and suggest an important role for state-level regulation. [ABSTRACT FROM AUTHOR]

The South Korean National Health Insurance scheme has lacked sufficient coverage scope (services covered) and depth (costs covered) since it achieved national coverage in 1989. The government implemented two separate welfare plans (2004-08 and 2009-12) to improve the financial protection of National Health Insurance by mainly focusing on costs covered. The third plan (initiated in 2013) was the most comprehensive, addressing both scope and depth. We evaluated the impact of this benefit expansion policy for four categories of major disease (cancer, cardiac disease, cerebrovascular disease, and rare diseases) on catastrophic health expenditures, impoverishment, and unmet need. Using 2012-17 Korean Health Panel Survey data, we performed difference-in-differences analyses and triple-difference analyses to examine the differential impact of policy across income groups. The policy reduced catastrophic health expenditures among beneficiary households across almost all postpolicy years. However, there was no average effect on reducing household impoverishment or unmet need. The policy had mixed effects by income but did not generally favor low-income households. To provide stronger financial protection, the policy must address issues beyond expanding coverage, such as provider payment structure. In addition, special policy measures for low-income households need to be adopted. [ABSTRACT FROM AUTHOR]

There is a tremendous public health need to identify potentially lethal cancers at earlier stages, when there is a greater chance for improved survival. Although in the US there are currently screening recommendations for only five cancers (breast, colorectal, cervical, lung, and prostate), new tests can screen for up to fifty cancers simultaneously based on a simple blood draw. However, these multicancer screening tests (also called "liquid biopsy" tests) will also present challenges to payers because of intrinsic features of the tests and the complexity of payer coverage assessments for screening tests. We describe these considerations while also offering potential solutions that can inform payers' decision making if these tests prove to be beneficial. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has illuminated and amplified the harsh reality of health inequities experienced by racial and ethnic minority groups in the United States. Members of these groups have disproportionately been infected and died from COVID-19, yet they still lack equitable access to treatment and vaccines. Lack of equitable access to high-quality health care is in large part a result of structural racism in US health care policy, which structures the health care system to advantage the White population and disadvantage racial and ethnic minority populations. This article provides historical context and a detailed account of modern structural racism in health care policy, highlighting its role in health care coverage, financing, and quality. [ABSTRACT FROM AUTHOR]

Addressing health inequities for racial and ethnic minority populations is challenging. After passage of the Affordable Care Act, Michigan launched its Healthy Michigan Plan, which expanded Medicaid eligibility in the state. Our evaluation of the expansion provided the opportunity to study its impact on racial and ethnic minority groups, including Arab American and Chaldean American enrollees, an understudied population. Using data from telephone surveys collected in 2016, 2017, and 2018, we conducted an analysis to study the plan's impact on access to a regular source of care and health status among racial and ethnic minority groups. More than 90 percent of respondents of all racial and ethnic groups reported having a regular source of care after plan enrollment compared with 74.4 percent before enrollment. Respondents who identified as non-Hispanic White, African American, and Hispanic reported improvements in health status after plan enrollment. Our study demonstrates the potential of health insurance access to narrow health inequities between racial and ethnic groups. [ABSTRACT FROM AUTHOR]

Insurance disruptions before, during, and after pregnancy are common in the United States, but little is known about the enrollment patterns of pregnant people in the Affordable Care Act Marketplaces. Data from the Pregnancy Risk Assessment Monitoring System from the period 2016-18 show that among respondents enrolled in Marketplace coverage, approximately one-third reported continuous Marketplace enrollment from preconception through the postpartum period. Compared with respondents who were continuously enrolled in Marketplace coverage from preconception through postpartum, respondents who enrolled in Marketplace plans during pregnancy had a 10.8 percent lower rate of adequate prenatal care, a 6.4 percent lower rate of timely prenatal care initiation, and a 13.2 percent lower rate of having twelve or more prenatal care visits. Policies that promote continuity of coverage during pregnancy, such as designating pregnancy as a qualifying event for a Marketplace open enrollment period, may enable pregnant people to enroll in Marketplace coverage early in their pregnancies and thus enhance access to prenatal care. [ABSTRACT FROM AUTHOR]

One in five pregnant or postpartum people has a diagnosed mood or anxiety disorder, which are the most common mental health illnesses that occur during the perinatal period. Untreated perinatal mental health conditions, encompassing pregnancy and the first five years of a child's life, carry a societal burden of $14 billion per year in the US. This overview article describes the prevalence of perinatal mental health conditions; the implications of those conditions; and associated barriers to screening, treatment, and bias associated with mental health conditions. We offer six policy opportunities designed to overcome the barriers and support overall sexual and reproductive health: extending Medicaid coverage through twelve months postpartum; redesigning care and reimbursement through co-location of services; establishing coverage for home visiting and peer support programs; enhancing telehealth policies that support access and coverage beyond the COVID-19 pandemic; enhancing data, research, and accountability; and enacting social and economic policies that support families. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic precipitated an unemployment crisis in the US that surpassed the Great Recession of 2007-09 within the first three months of the pandemic. This article builds on the limited early evidence of the relationship between the pandemic and health insurance coverage, using county-level unemployment and Medicaid enrollment data from North Carolina, a large state that did not expand Medicaid. We used linear and county fixed effects models to assess this relationship, accounting for county-level social vulnerability, physical and virtual access to Medicaid enrollment, and COVID-19 case burden. Using data from January 2018 through August 2020, we estimated that the passthrough rate--the share of unemployed people who gained Medicaid coverage--was approximately 15 percent statewide but higher in more socially vulnerable counties. This low passthrough rate during a period of increased unemployment resulting from the COVID-19 pandemic means that Medicaid was unable to completely fulfill its countercyclical role, in which it grows to meet greater need during periods of widespread economic hardship, because of North Carolina's stringent Medicaid eligibility criteria. Working toward greater adoption of Medicaid expansion may help ensure that the US is better prepared for the next crisis by ensuring access to health insurance coverage. [ABSTRACT FROM AUTHOR]

Puerto Rico is a US territory and a popular destination for Latino immigrants in the Caribbean. Even with few language and cultural barriers, however, many Latino immigrants in Puerto Rico are uninsured. Using data from the 2014--19 Puerto Rico Community Survey, we examined inequities in health insurance coverage for non--Puerto Rican Latinos ages 18--64 living in Puerto Rico according to citizenship status and Latino subgroup (Dominican, Cuban, Mexican, and other Latino). After controlling for potential confounders, we found that noncitizen Dominicans had a significantly lower probability of having any health insurance (57.2 percent) and having any private insurance (31.5 percent). Regardless of similarities in culture and language, Latino immigrants on the island, particularly Dominicans, experience major health insurance coverage inequities. Considering that Puerto Rico's immigration system is regulated by US federal statute, both federal and local policy makers should acknowledge and focus on reducing these immigrant disparities in health insurance coverage. [ABSTRACT FROM AUTHOR]

Immigrant children in the US have very limited health insurance coverage and health care access. Immigration status is not static: Census data show that the majority of census respondents who enter as noncitizen children eventually become citizens. Eligibility restrictions that prevent noncitizen children from being publicly insured can contribute to their experiencing poorer health and higher medical costs in their adult lives. We isolate the impact of lack of citizenship from socioeconomic factors by comparing citizen and noncitizen siblings living in mixed-status families, using fixed-effects models to net out socioeconomic factors shared within families. Lacking citizenship increased a child's risk of being uninsured and lowered by 26 percentage points the chances that they would have Medicaid or Children's Health Insurance Program coverage. Noncitizen children had significantly more delays in needed medical care because of cost, primarily mediated by the lack of insurance coverage. The US should reexamine policies that exclude noncitizen children from public health insurance programs. [ABSTRACT FROM AUTHOR]

Between 2010 and 2019 the number of Mexican immigrants in the US declined by almost 780,000, or 7 percent. Repatriated migrants either return voluntarily to Mexico (returnees) or are forcibly removed from the US (deportees). As repatriated migrants navigate their return, access to health care in Mexico becomes a pressing need. Lack of a valid form of identification, limited awareness of services, and social stigma, among other factors, restrict health coverage in Mexico for return migrants. This study examined differences in health insurance coverage in Mexico between Mexican-born deportees and returnees from the US in a five-year period and a reference population of Mexican-born residents (nonmigrants and returnees who had been back in Mexico for five years or longer). Using data from Mexico's National Survey of Demographic Dynamics from 2014 and 2018, we found that 74.0 percent of voluntary returnees and 67.5 percent of deportees had health insurance, compared with 88.4 percent of the reference population, after adjustment for socioeconomic and demographic differences. Policy makers from federal, state, and local governments and community organizations need to improve the reintegration of repatriated migrants by reducing bureaucratic hurdles, preparing returnees and deportees for their return to Mexico, and strengthening health coverage options for return migrants. [ABSTRACT FROM AUTHOR]

Since the 1960s the immigrant population in the United States has increased fourfold, reaching 44.7 million, or 13.7 percent of the US population, in 2018. The shifting immigrant demography presents several challenges for US health policy makers. We examine recent trends in immigrant health and health care after the Great Recession and the nationwide implementation of the Affordable Care Act. Recent immigrants are more likely to have lower incidence of chronic health conditions than other groups in the US, although these differences vary along the citizenship and documentation status continuum. Health care inequities among immigrants and US-born residents increased after the Great Recession and later diminished after the Affordable Care Act took effect. Unremitting inequities remain, however, particularly among noncitizen immigrants. The number of aging immigrants is growing, which will present a challenge to the expansion of coverage to this population. Health care and immigration policy changes are needed to integrate immigrants successfully into the US health care system. [ABSTRACT FROM AUTHOR]

The article presents a systematic review comparing the performance of Medicare Advantage (MA) and traditional Medicare in the U.S. Based on the results, MA was linked to lesser hospital admissions and emergency department visits and more preventive care visits than traditional Medicare. Other topics include the differences between MA and traditional Medicare in areas like payment models.

Social discourse about the opioid crisis in the US has focused on White populations, even though opioid-related deaths have grown at a higher rate among people of color than among non-Hispanic White people in recent years. Medications for opioid use disorder (OUD) are the gold standard for treating OUD and preventing overdose but are underused among people with OUD, with disproportionately low treatment initiation and retention among people of color. Methadone, which is highly stigmatized and has a more burdensome treatment regimen, is the predominant medication for OUD available to people of color. To address disparities in the initiation and retention of treatment using medication for OUD, policy makers should consider strategies such as Medicaid expansion, increased grant funding for federally qualified health centers to provide buprenorphine treatment, retention of temporary telehealth policies that allow remote buprenorphine induction, and regulatory changes to allow methadone treatment in office-based practices. [ABSTRACT FROM AUTHOR]

Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004-16. The main outcomes were survival at one, two, and five years for sixteen cancer types in 1,206,821 patients. We found that uninsured patients ages 60-64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66-69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5-17 percent lower than that among older Medicare patients. We conclude that survival after a diagnosis of cancer is considerably lower in younger uninsured patients than in older Medicare patients. Expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US. [ABSTRACT FROM AUTHOR]

In October 2021, the American Academy of Pediatrics and other groups declared a national emergency in child and adolescent mental health. Despite this, pediatric mental health services remain largely inaccessible for many families. A major factor contributing to the lack of access is phantom networks, which are insurance company rosters of in-network mental health providers who, in reality, don't see patients in the network. Phantom networks compound barriers to mental health care for children and adolescents. This is particularly problematic for youth, many of whom use Medicaid, who seek time-sensitive care for severe psychiatric conditions such as psychosis or suicidality. We call on US policy makers to support nationwide legislation that establishes high-quality oversight processes for in-network provider lists. [ABSTRACT FROM AUTHOR]

It is likely that 2021 will be a dynamic year for US health care policy. There is pressing need and opportunity for health reform that helps achieve better access, affordability, and equity. In this commentary, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we draw on our collective backgrounds in health financing, delivery, and innovation to offer consensus-based policy recommendations focused on health costs and financing. We organize our recommendations around five policy priorities: expanding insurance coverage, accelerating the transition to value-based care, advancing home-based care, improving the affordability of drugs and other therapeutics, and developing a high-value workforce. Within each priority we provide recommendations for key elected officials and political appointees that could be used as starting points for evidence-based policy making that supports a more effective, efficient, and equitable health system in the US. [ABSTRACT FROM AUTHOR]

The US has experienced a series of epidemics during the past five decades. None has tested the nation's resilience like the coronavirus disease 2019 (COVID-19) pandemic, which has laid bare critical weaknesses in US pandemic preparedness and domestic leadership and the nation's decline in global standing in public health. Pandemic response has been politicized, proven public health measures undermined, and public confidence in a science-based public health system reduced. This has been compounded by the large number of citizens without ready access to health care, who are overrepresented among infected, hospitalized, and fatal cases. Here, as part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we review the US approach to pandemic preparedness and its impact on the response to COVID-19. We identify six steps that should be taken to strengthen US pandemic resilience, strengthen and modernize the US health care system, regain public confidence in government leadership in public health, and restore US engagement and leadership in global partnerships to address future pandemic threats domestically and around the world. [ABSTRACT FROM AUTHOR]

Countries around the world have committed to achieving universal health coverage as part of the Sustainable Development Goals agreed upon by all United Nations members, intended to be achieved by 2030. But important population groups such as older adults are rarely examined as part of Sustainable Development Goals monitoring and evaluation efforts. This study uses recent (2014-16) high-quality, individual-level data from several aging cohorts representing more than 100,000 adults ages fifty and older in twenty-three high- and middle-income countries. After individual characteristics and health needs were controlled for, national rates varied up to tenfold for poor access (no doctor visit) and threefold for potential overutilization (fifteen or more doctor visits and multiple hospitalizations) in the past year. Catastrophic expenditures (25 percent or more of household income spent out of pocket on health care) averaged 9 percent, with the highest rates observed in middle-income countries and among sicker populations in some high-income countries. Strengthening universal health coverage for older adults will require greater tailoring and targeting of benefits to meet this population's health needs while protecting them from catastrophic health expenditures. [ABSTRACT FROM AUTHOR]

With the implementation of the Affordable Care Act (AGO, millions of low-income adults gained health coverage. We examined how the ACA's expansion of Medicaid eligibility affected dental coverage and the use of oral health services among low-income adults, using data from the National Health Interview Survey from the period 2010-18. We found that the ACA increased rates of dental coverage by 18.9 percentage points in states that provide dental benefits through Medicaid. In terms of utilization, expansion states that provide dental benefits saw the greatest increase in people having a dental visit in the past year (7.2 percentage points). However, there was no significant change in the overall share of people who had a dental visit in the past year, although the expansion was associated with a significant increase in this metric among White adults. The expansion was also associated with a 1.4-percentage-point increase in complete teeth loss, which may be a marker of both poor oral health and the potential gaining of access to dental services (with subsequent tooth extractions). Our findings suggest that in addition to expanded coverage, policies need to tackle other barriers to accessing dental care to improve population oral health. [ABSTRACT FROM AUTHOR]

The period before pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. We evaluated whether increased access Wisconsinto health insurance under the Affordable Care Act Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and nonexpansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures. [ABSTRACT FROM AUTHOR]

More than 55,000 children die each year in the United States, and hospice is used for very few of them at the end of their lives. Nearly one-third of pediatric deaths are a result of chronic, complex conditions, and the majority of these children are enrolled in Medicaid because of disability status or the severity of their disease. Changes in Medicaid/ Children's Health Insurance Program regulations under Section 2302 of the Affordable Care Act require all state Medicaid plans to finance curative and hospice services for children. The section enables the option for pediatric patients to continue curative care while enrolled in hospice. We examined state-level implementation of concurrent care for Medicaid beneficiaries and found significant variability in guidelines across the US. The implementation of concurrent care has fostered innovation yet has added barriers to how pediatric concurrent care has been implemented. [ABSTRACT FROM AUTHOR]

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

Policy makers and parents should share a goal that all children have opportunities to thrive, regardless of their circumstances at birth. Studies that focus on socioeconomic measures of opportunities for thriving measure intergenerational mobility, or the extent to which children's outcomes can diverge from those of their parents. We bring this focus to the study of children's health by estimating intergenerational health mobility during early childhood in a national sample. We find that children in families characterized as minorities, those without health insurance, or those with low socioeconomic status experience less upward health mobility and greater downward health mobility. We also show that community characteristics may shape health mobility. For example, children growing up in places with high proportions of uninsured residents are less likely to experience upward health mobility and more likely to experience downward health mobility. These descriptive findings may allow new insights into ways in which children's health can be decoupled from their circumstances at birth. [ABSTRACT FROM AUTHOR]

In June 2018 Arkansas became the first US state to implement work requirements in Medicaid, requiring adults ages 30-49 to work twenty hours a week, participate in "community engagement" activities, or qualify for an exemption to maintain coverage. By April 2019, when a federal judge put the policy on hold, 18,000 adults had already lost coverage. We analyze the policy's effects before and after these events, using a telephone survey performed in late 2019 of 2,706 low-income adults in Arkansas and three control states compared with data from 2016 and 2018. We have four main findings. First, most of the Medicaid coverage losses in 2018 were reversed in 2019 after the court order. Second, work requirements did not increase employment over eighteen months of follow-up. Third, people in Arkansas ages 30-49 who had lost Medicaid in the prior year experienced adverse consequences: 50 percent reported serious problems paying off medical debt, 56 percent delayed care because of cost, and 64 percent delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year. Finally, awareness of the work requirements remained poor, with more than 70 percent of Arkansans unsure whether the policy was in effect. [ABSTRACT FROM AUTHOR]

New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eighty-three thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients. [ABSTRACT FROM AUTHOR]

We assessed the effects of female political representation on mortality among children younger than age five in Brazil and the extent to which this effect operates through coverage with conditional cash transfers and primary care services. We combined data on under-five mortality rates with data on women elected as mayors or representatives in state and federal legislatures for 3,167 municipalities during 2000-15. Results from fixed-effects regression models suggest that the election of a female mayor and increases in the shares of women elected to state legislatures and to the federal Chamber of Deputies to 20 percent or more were significantly associated with declines in under-five mortality. Increasing the political representation of women was likely associated with beneficial effects on child mortality through pathways that expanded access to primary health care and conditional cash transfer programs. [ABSTRACT FROM AUTHOR]

The article discusses the Medicaid coverage gap created by the U.S. Supreme Court's landmark decision in National Federation of Independent Business v. Sebelius. Topics covered include the effect of the decision on the nation's poorest working-age adults, the various options for closing the gap, and the Affordable Care Act's pluralistic approach to insurance coverage.

The Affordable Care Act (ACA) significantly improved health insurance coverage in the US, but too many Americans remain under- or uninsured. This article examines federal strategies under consideration that build on the ACA to extend comprehensive coverage to all low-income Americans and increase coverage affordability for middle-income Americans. For low-income Americans these policy options include extending the enhanced match rate offered to states that expanded eligibility for Medicaid in the early years of the ACA to states that have not yet expanded Medicaid and increasing Marketplace cost-sharing subsidies. To address the issue of affordability for middle-income Americans, this article considers options for lowering premiums (for example, extending tax credits to people with incomes above the current eligibility threshold, increasing the generosity of tax credits for those currently eligible, and making reinsurance permanent), lowering cost sharing (such as tying premium tax credits to the second-lowest-cost gold plan rather than the equivalent silver plan and extending federal assistance for cost sharing to people with incomes above the current threshold), and establishing a public option. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All. [ABSTRACT FROM AUTHOR]

Women of working age (ages 19-64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women's experiencing uninsurance, underinsurance, and increased financial burdens related to obtaining health care. This literature review summarizes evidence on the law's effects on women's health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes. Despite major progress after the Affordable Care Act's implementation, barriers to coverage, access, and affordability remain, and serious threats to women's health still exist. Highlighting the law's effects on women's health is critical for informing future policies directed toward the continuing improvement of women's health care and health. [ABSTRACT FROM AUTHOR]

The Affordable Care Act's Medicaid expansion provided insurance coverage to many low-income adults with substance use disorders, but it is unclear whether this led to more people receiving treatment. We used the Treatment Episode Data Set and a difference-in-differences approach to compare annual rates of specialty treatment admissions in expansion versus nonexpansion states in the period 2010-17. We found that admissions to treatment steadily increased in the four years after Medicaid expansion, with 36 percent more people entering treatment by the fourth expansion year in expansion states compared to nonexpansion states. Changes were largest for people entering intensive outpatient programs and those seeking medication treatment for opioid use disorder. The share of admissions paid for by Medicaid increased 23 percentage points in expansion states compared to nonexpansion states, largely displacing treatment paid for by state and local governments. The gradual increase in specialty substance use disorder treatment admissions after Medicaid expansion may reflect improving capacity and access to care. [ABSTRACT FROM AUTHOR]

The vision of the Affordable Care Act (ACA) for a reformed individual health insurance market included requirements and incentives for insurers to manage risk instead of avoiding it, minimum standards for coverage adequacy, income-related subsidies, managed competition through health insurance Marketplaces, and new programs to promote insurer competition. Against this vision, we assessed how insurance markets evolved between 2014 and 2019, using metrics such as premium changes, insurer participation, and enrollment. We also assessed how federal and state policy choices during the implementation of the ACA may have affected market performance. The article closes with an assessment of recent federal-level policy choices and the evidence to date about their effect on insurance markets, together with a discussion of how market experience under the ACA can inform policy makers who seek to further expand consumers' access to affordable, comprehensive coverage. [ABSTRACT FROM AUTHOR]

Large disparities in health insurance coverage and access to health services have long persisted in the US health care system. We considered how the insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups. Because coverage increased more for non-Hispanic blacks and Hispanics than for non-Hispanic whites, disparities in coverage have decreased. Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites. [ABSTRACT FROM AUTHOR]

The Affordable Care Act was designed to provide financial protection to Americans in their use of the health care system. This required addressing two intertwined problems: cost barriers to accessing coverage and care, and barriers to comprehensive risk protection provided by insurance. We reviewed the evidence on whether the law was effective in achieving these goals. We found that the Affordable Care Act generated substantial, widespread improvements in protecting Americans against the financial risks of illness. The coverage expansions reduced uninsurance rates, especially relative to earlier forecasts; improved access to care; and lowered out-of-pocket spending. The insurance market reforms also made it easier for people to get and stay enrolled in coverage and ensured that those who were insured had true financial risk protection. But subsequent court decisions and congressional and executive branch actions have left millions uninsured and allowed the risk of inadequate insurance to resurface. [ABSTRACT FROM AUTHOR]

The article discusses the gaps in access to opioid use disorder treatment for Medicare beneficiaries. Topics mentioned include the National Survey of Substance Abuse Treatment Services, whether a substance use disorder treatment program accepted any type of Medicare insurance and offered buprenorphine or injectable naltrexone, and U.S. counties with at least one treatment program that accepted Medicare and offered buprenorphine or injectable naltrexone in 2016.

Australian health policy has prioritized efforts to close the ten-year life expectancy gap between indigenous and nonindigenous Australians, a disparity largely driven by cardiovascular disease and diabetes. Because out-of-pocket spending poses a barrier to accessing medications for chronic conditions, in 2010 the Australian government reduced or eliminated medication copayments for indigenous people with chronic disease or risk factors for chronic disease. In this quasiexperimental study we found that the copayment reductions were associated with a 39 percent relative increase in the use of medications and a 61 percent reduction in out-of-pocket spending. Among indigenous Australians who qualified for the largest copayment reductions, overall use of medications increased by 156 percent--including increases of 26-109 percent in the use of lipid-lowering, hypertension, and diabetes medications. These findings suggest that Australia's novel strategy of targeted copayment reductions improved access to prescription medications among indigenous Australians, a population with a high burden of chronic conditions and marked social disadvantage. [ABSTRACT FROM AUTHOR]

Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (-1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits--even for those with established access to safety-net care. [ABSTRACT FROM AUTHOR]

Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program. [ABSTRACT FROM AUTHOR]

Coverage disruptions and coverage loss occur frequently among Medicaid enrollees and are associated with delayed health care access and reduced medication adherence. Little is known about the effect on churning of the expansion of eligibility for Medicaid under the Affordable Care Act (ACA), which had the potential to reduce coverage disruptions as a result of increased outreach and more generous income eligibility criteria. We used a difference-in-differences framework to compare rates of coverage disruption in expansion versus nonexpansion states, and in subgroups of states that used alternative expansion strategies. We found that among low-income Medicaid beneficiaries ages 19-64, disruption in coverage decreased 4.3 percentage points in the post-ACA period in expansion states compared to nonexpansion states, and there was a similar decrease in the share of people who experienced a period without any insurance. Men, people of color, and those without chronic illnesses experienced the largest improvements in coverage continuity. Coverage disruptions declined in both traditional expansion states and those that used Section 1115 waivers for expansion. Our quasi-experimental study provides the first nationwide evidence that Medicaid expansion led to decreased rates of coverage disruption. We estimate that half a million fewer adults experienced an episode of churning annually. [ABSTRACT FROM AUTHOR]

Spending on health care in the United States amounted to 17.9 percent of gross domestic product in 2017. Households paid for this care through out-of-pocket medical spending and a complex mix of out-of-pocket premiums, employer premium contributions, taxes, and subsidies that combined to finance private employer-sponsored insurance, nongroup insurance, and multiple public insurance programs. Our analysis examined the impact of this complex system of health care financing on households in the period 2005-16, tracking how economic and policy changes affected incidence--that is, the amount paid to finance health care, either directly or indirectly, by households as a share of their pretax income. Health care financing was regressive at the start of our study period, with households in the bottom 20 percent of income paying 26.8 percent of their income compared to about half that amount for those with income in the top 1 percent. By 2016 incidence had become approximately proportional (the same percentage across all income levels). In part, these results reflect increases in coverage through Medicaid and the Affordable Care Act Marketplaces, which are progressively financed through the federal tax system. [ABSTRACT FROM AUTHOR]