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Importance: Sexual minority (ie, people who self-identify as gay, lesbian, bisexual, and other nonheterosexual identities) and gender minority (ie, people who self-identify as transgender, nonbinary, or other noncisgender identities) adults report worse health outcomes compared with heterosexual and cisgender adults, respectively. Although social risk factors (SRFs; eg, housing instability) are associated with health outcomes, little is known about the prevalence of SRFs among sexual and gender minority adults., Objective: To examine differences in the prevalence of SRFs by sexual orientation and gender identity among adults., Design, Setting, and Participants: This cross-sectional study used Behavioral Risk Factor Surveillance System data collected from January 2022 to February 2023 for adults aged 18 years or older residing in 22 US states., Exposure: Self-reported sexual orientation and gender identity., Main Outcomes and Measures: Outcome measures were dissatisfaction with life, lack of emotional support, social isolation, employment loss in the past 12 months, Supplementary Nutrition Assistance Program participation in the past 12 months, insufficient food, inability to pay bills, inability to pay utilities, lack of transportation, and stress. Survey weights were applied. Multivariable linear regression models were used to measure the association between sexual orientation and gender identity for each outcome., Results: The study sample comparing outcomes by sexual orientation included 178 803 individuals: 84 881 men (48.5%; 92.9% heterosexual; 7.1% sexual minority) and 93 922 women (51.5%; 89.4% heterosexual; 10.6% sexual minority). The study sample comparing outcomes by gender identity included 182 690 adults (99.2% cisgender; 0.8% gender minority). Of sexual minority women, 58.1% reported at least 1 SRF compared with 36.5% of heterosexual women. Sexual minority women were significantly more likely to report social isolation (difference, 7.4 percentage points [PP]; 95% CI, 4.9-10.0 PP) and stress (difference, 12.2 PP; 95% CI, 9.8-14.7 PP) compared with heterosexual women. A greater proportion of sexual minority men (51.1%) reported at least 1 SRF than heterosexual men (34.0%); the largest magnitudes of inequity were in dissatisfaction with life (difference, 7.9 PP; 95% CI, 5.8-10.1 PP) and stress (difference, 6.7 PP; 95% CI, 4.5-8.9 PP). Of gender minority adults, 64.1% reported at least 1 SRF compared with cisgender adults (37.1%). Gender minority adults were significantly more likely to report social isolation (difference, 14.8 PP; 95% CI, 9.9-19.7 PP) and stress (difference, 17.0 PP; 95% CI, 11.9-22.1 PP)., Conclusions and Relevance: In this cross-sectional study, sexual and gender minority adults were significantly more likely to report multiple SRFs. These findings suggest that policies and community-based systems to advance socioeconomic equity among sexual and gender minority adults are critical.

Importance: Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US., Objectives: To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences., Design, Setting, and Participants: This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months' post partum. Data were collected from January 1, 2021, to March 31, 2022., Exposures: Demographic, social, clinical, and birth characteristics that have been associated with patients' health care experiences., Main Outcomes and Measures: Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs., Results: The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being "ignored, refused request for help, or failed to respond in a timely manner" (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous., Conclusions and Relevance: This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Antipoverty policies have the potential to improve mental health. We conducted a randomized trial (Paycheck Plus Health Study Randomized Controlled Trial, New York, New York) to investigate whether a 4-fold increase in the Earned Income Tax Credit for low-income Americans without dependent children would reduce psychological distress relative to the current federal credit. Between 2013 and 2014, a total of 5,968 participants were recruited; 2,997 were randomly assigned to the treatment group and 2,971 were assigned to the control group. Survey data were collected 32 months postrandomization (n = 4,749). Eligibility for the program increased employment by 1.9 percentage points and after-bonus earnings by 6% ($635/year), on average, over the 3 years of the study. Treatment was associated with a marginally statistically significant decline in psychological distress, as measured by the 6-item Kessler Psychological Distress Scale, relative to the control group (score change = -0.30 points, 95% confidence interval (CI): -0.63, 0.03; P = 0.072). Women in the treated group experienced a half-point reduction in psychological distress (score change = -0.55 points, 95% CI: -0.97, -0.13; P = 0.032), and noncustodial parents had a 1.36-point reduction (95% CI: -2.24, -0.49; P = 0.011). Expansion of a large antipoverty program to individuals without dependent children reduced psychological distress for women and noncustodial parents-the groups that benefitted the most in terms of increased after-bonus earnings., (© The Author(s) 2022. Published by Oxford University Press.)

Importance: Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage., Objective: To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015., Design, Setting, and Participants: This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021., Exposures: Health insurance through Colorado Medicaid or Colorado's state-based Marketplace., Main Outcomes and Measures: Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders., Results: Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04)., Conclusions and Relevance: In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Importance: Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown., Objective: To compare maternal coverage and care by Medicaid vs marketplace eligibility., Design, Setting, and Participants: A retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey., Exposures: Eligibility for Medicaid or marketplace coverage under the Affordable Care Act., Main Outcomes and Measures: Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use., Results: The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified., Conclusions and Relevance: In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

Importance: The Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option., Objective: To assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado., Design Setting and Participants: Using 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020., Main Outcome and Measures: The main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage., Results: The primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively., Conclusions and Relevance: In this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements., Competing Interests: Conflict of Interest Disclosures: Dr Sommers is currently on leave from Harvard and serving in the US Department of Health and Human Services; however, this article was conceived and drafted while Dr Sommers was employed at the Harvard School of Public Health, and the findings and views in this article do not reflect the official views or policy of the Department of Health and Human Services., (Copyright 2021 Bhanja A et al. JAMA Health Forum.)

Importance: There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical., Objective: To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance., Design, Setting, and Participants: This cross-sectional study used a propensity score-matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL., Exposures: Health insurance through Colorado Medicaid or Colorado's state-based Marketplace., Main Outcomes and Measures: The primary analytical approach was a multivariate regression analysis of the propensity score-matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care-sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score-matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020., Results: The propensity score-matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P < .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P < .001). No differences in ambulatory care-sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P < .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P < .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid., Conclusions and Relevance: In this cross-sectional propensity score-matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.

Objective: To evaluate the effect of Medicaid coverage on dental care outcomes, a major health concern for low-income populations., Data Sources: Primary and secondary data on health care use and outcomes for participants in Oregon's 2008 Medicaid lottery., Study Design: We used the lottery's random selection to gauge the causal effects of Medicaid on dental care needs, medication, and emergency department visits for dental care., Data Collection: Data were collected for lottery participants over 2 years, including mail surveys (N = 23,777) and in-person questionnaires (N = 12,229). Emergency department (ED) records were matched to lottery participants in Portland (N = 24,646)., Principal Findings: Medicaid coverage significantly reduced the share of respondents who reported needing dental care (-9.8 percentage points, p < .001) or having unmet dental care needs (-13.5 percentage points, p < 0.001). Medicaid doubled the share visiting the ED for dental care (+2.6 percentage points, p = .003) and the use of anti-infective medications often prescribed for dental care, but it had no detectable effect on uncovered dental care or out-of-pocket spending., Conclusions: Expansion of Medicaid covering emergency dental care substantially reduced unmet need for dental care, increasing ED dental visits and medication use, while not changing patient use of uncovered dental services., (© Health Research and Educational Trust.)