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OBJECTIVES: This study evaluated a collaborative service model between the largest Medicaid managed care organization (MCO) in Texas, Superior HealthPlan, and the affordable housing provider Prospera Housing CommunityServices. STUDY DESIGN: Using a quasi-experimental 2-groups research design, we compared health care outcomes and costs between a sample of 104 participants served by the Prospera+Superior collaborative model and a group of 104 participants who had health care coverage through the Superior HealthPlan Medicaid MCO but did not live atProspera properties (ie, Superior-only group). METHODS: Data from medical claims were analyzed to examine change in outcomes 12 months before and after implementation of the Prospera+Superior collaborative model in 2019. RESULTS: The Prospera+Superior group had a 56% lower rate of emergency department/urgent care visits and spent $2061 less in prescription costs than the Superior-only group after implementation. CONCLUSIONS: These findings provide needed evidence of the clinical and economic value of forming multisector collaborative models between MCOs and other communityproviders. [ABSTRACT FROM AUTHOR]

Background: Young people's ability to use their preferred contraceptive method is an indicator of reproductive autonomy and healthcare access. State policies can hinder or facilitate access to a preferred contraceptive method. Objective: This study compared use of preferred contraceptive method in Texas and California, states with contrasting health policy contexts that impact health insurance coverage and access to subsidized family planning services. Methods: We used baseline survey data from an ongoing cluster randomized controlled trial of sexually active students, assigned female at birth, ages 18–25, at 29 community colleges in Texas and California (N = 1,974). We described contraceptive preferences and use, as well as reasons for nonuse of a preferred method. We conducted multivariable-adjusted mixed-effects logistic regression analyses for clustered data, and then calculated the predicted probability of using a preferred contraceptive method in Texas and California by insurance status. Results: More Texas participants were uninsured than Californians (30% vs. 8%, p<0.001). Thirty-six percent of Texas participants were using their preferred contraceptive method compared to 51% of Californians. After multivariable adjustments, Texas participants had lower odds of using their preferred method (adjusted odds ratio = 0.62, 95% confidence interval = 0.48–0.81) compared to those in California. Texas participants in all insurance categories had a lower predicted probability of preferred method use compared to California participants. In Texas, we found a 12.1 percentage-point difference in the predicted probability of preferred method use between the uninsured (27.5%) and insured (39.6%) (p<0.001). Texans reported financial barriers to using their preferred method more often than Californians (36.7% vs. 19.2%, p<0.001) as did the uninsured compared to the insured (50.9% vs. 18.7%, p<0.001). Conclusion: These findings present new evidence that state of residence plays an important role in young people's ability to realize their contraceptive preference. Young people in Texas, with lower insurance coverage and more limited access to safety net programs for contraceptive care than in California, have lower use of preferred contraception. It has become urgent in states with abortion bans to support young people's access to their preferred methods. [ABSTRACT FROM AUTHOR]

Background Using antibiotics without a prescription is potentially unsafe and may increase the risk of antimicrobial resistance. We evaluated the effect of patient, health system, and clinical encounter factors on intention to use antibiotics without a prescription that were (1) purchased in the United States, (2) obtained from friends or relatives, (3) purchased abroad, or (4) from any of these sources. Methods The survey was performed January 2020–June 2021 in 6 publicly funded primary care clinics and 2 private emergency departments in Texas, United States. Participants included adult patients visiting 1 of the clinical settings. Nonprescription use was defined as use of antibiotics without a prescription; intended use was professed intention for future nonprescription antibiotic use. Results Of 564 survey respondents (33% Black and 47% Hispanic or Latino), 246 (43.6%) reported prior use of antibiotics without a prescription, and 177 (31.4%) reported intent to use antibiotics without a prescription. If feeling sick, respondents endorsed that they would take antibiotics obtained from friends/relatives (22.3% of 564), purchased in the United States without a prescription (19.1%), or purchased abroad without a prescription (17.9%). Younger age, lack of health insurance, and a perceived high cost of doctor visits were predictors of intended use of nonprescription antibiotics from any of the sources. Other predictors of intended use were lack of transportation for medical appointments, language barrier to medical care, Hispanic or Latino ethnicity, and being interviewed in Spanish. Conclusions Patients without health insurance who report a financial barrier to care are likely to pursue more dangerous nonprescription antimicrobials. This is a harm of the US fragmented, expensive healthcare system that may drive increasing antimicrobial resistance and patient harm. [ABSTRACT FROM AUTHOR]

Lung cancer is a major public health concern in Texas. Low dose computed tomography (LDCT) is shown to reduce the risk of dying from lung cancer among high-risk populations. The United States Preventive Services Task Force (USPSTF) endorsed LDCT for lung cancer screening since 2014, and the Centers for Medicare & Medicaid Services started covering the expense since 2015. We used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey to ascertain recent estimates of the proportion of screening-eligible individuals for various sociodemographic subgroups, as well as the LDCT uptake rate among screening-eligible population, for Texas versus other states. The estimated uptake rate among Texans who were eligible for lung cancer screening was around 25% in 2018. Although the rate of lung cancer screening in Texas was higher than the rate reported in the other seven states (average of 11%) that also participated in the lung cancer screening module of the 2018 BRFSS survey, results indicated Texas' lower screening rates in specific vulnerable populations: racial/ethnic minorities and residences without insurance coverage. Greater public and community outreach and communication may improve the use of LDCT among screening-eligible Texans. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to evaluate the Dual Use (DU) Option – a crop insurance policy created by the 2018 Farm Bill – relative to other policies available to dual-purpose annual forage producers. The new policy combines existing rainfall-based policies for annual forage crops and multi-peril policies for grain, allowing coverage for multiple crop uses on the same acres during the same growing season. Design/methodology/approach: The paper uses a simulation model to examine crop insurance choices for a typical Texas dual-purpose wheat farm. The certainty equivalent (CE) of wealth is used to rank choices within and between three insurance plans and to analyze the effects of those choices over a range of producer risk aversion levels and for three cases of yield expectations. Findings: The DU Option is more preferred as risk aversion increases, but it is not universally preferred. Therefore, while the policy can be a viable risk management tool, certain restrictions may be limiting its effectiveness. Practical implications: The findings of this paper can help explain farm-level decision making related to dual-purpose annual forage crop insurance program choices. Originality/value: This paper contributes to the literature by documenting a new crop insurance program made available in the 2018 Farm Bill and provides insights into producers' possible choices by evaluating extensive scenarios. [ABSTRACT FROM AUTHOR]

Motivated by the relatively infrequent but very large price spikes in the day-ahead and real-time energy markets operated by the Electric Reliability Council of Texas, this paper proposes an insurance that a small and risk-averse retailer in Texas (i.e., a retail electric provider (REP)) may buy to prevent financial insolvency caused by inadequate risk management. It also demonstrates the insurance's practical design, pricing, and implementation. As participation in the REP's procurement auction is voluntary, the insurance is mutually beneficial for the REP and the insurance seller. Hence, the proposed insurance is a newly developed wholesale market product that deserves consideration by REPs in Texas and competitive retailers elsewhere. [ABSTRACT FROM AUTHOR]

Objective: To investigate influenza vaccination rates and perceptions underlying vaccine noncompliance. Participants: Participants included undergraduate students (N = 365) at a rural, medium-sized university in Texas. Methods: Students were anonymously surveyed in the spring of 2018 on demographics, insurance status, perceived barriers of influenza vaccination, and vaccination status. Results: Nearly 90% of students had health insurance; however, only 30% of them received the influenza vaccination annually. The top two reasons for non-vaccination were the low perceived threat (20.20%) and having a busy schedule (11.10%). Having health insurance [OR: 2.84, CI: (1.16, 7.0)] and being in the younger age group (18–24) [OR: 1.98, CI: (1.11, 3.54)] were both positively associated with the annual vaccination status. Conclusion: Health education efforts should be focused on vaccination initiatives that increase awareness about the health benefits and ease of access, especially among the older age groups (> =25 years). Information on myths versus facts should also be disseminated. [ABSTRACT FROM AUTHOR]

Insurance churn (changes in coverage) after childbirth is common in the United States, particularly in states that have not expanded Medicaid coverage. Although insurance churn may have lasting consequences for health care access, most research has focused on the initial weeks after a birth. We analyzed data from a cohort study of postpartum Texans with pregnancies covered by public insurance (n = 1,489). Women were recruited shortly after childbirth from eight hospitals in six cities, completing a baseline survey in the hospital and follow-up surveys at 3, 6, and 12 months. We assessed insurance trajectories, health care use, and health indicators over the 12 months after childbirth. We also conducted a content analysis of women's descriptions of postpartum health concerns. A majority of participants (64%) became uninsured within 3 months of the birth and remained uninsured for the duration of the study; 88% were uninsured at some point in the year after the birth. At 3 months postpartum, 17% rated their health as fair or poor, and 13% reported a negative change in their health after the 3-month survey. Women's open-ended responses described financial hardships and other difficulties accessing care for postpartum health issues, which included acute and ongoing conditions, undiagnosed concerns, pregnancy and reproductive health, mental health, and weight/lifestyle concerns. Insurance churn was common among postpartum women with births covered by Medicaid/CHIP and prevented many women from receiving health care. To improve postpartum health and reduce maternal mortality and morbidity, states should work to stabilize insurance coverage for women with low incomes. [ABSTRACT FROM AUTHOR]

This Medical News article discusses a recent court ruling that invalidated the Affordable Care Act's requirement for privately insured patients to have no out-of-pocket costs for certain preventive services and drugs. [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]

Background: The upward trends of vaccine exemptions in Texas are alarming. While HPV vaccine rates in this State are among the lowest nationwide, factors that contribute to the low HPV vaccination uptake among adults remain unknown. In this study, we examined the main reasons for not receiving HPV vaccination among age‐eligible adults. Methods: The Texas health screening survey (2018), a multistage area probability design‐based survey of a representative sample of Texas residents, was used to identify 907 eligible adults (age ≥ 18 years) respondents, including 724 women aged ≤ 26 years in 2007 (≤38 years in 2018), and 183 men aged ≤ 21 years in 2011 (≤28 years in 2018). Participants who reported having never received an HPV shot, where asked the main reason for not receiving the vaccine. Results: Overall, 58.5% (95%CI: 55.1‐62.0) of vaccine eligible adults reported having never received the HPV vaccine. The most commonly reported reasons for not receiving it were: did not know about the vaccine (18.5% (14.9‐22.1)), and provider did not recommend (14.1% (10.9‐17.4)). In contrast, commonly perceived reasons such as: safety concerns (7.2% (4.8‐9.5)), lack of insurance (3.4% (1.7‐5.1), and concerns about increasing sexual activity if vaccinated (0.2% (0.0‐0.5)), were less frequently reported. Conclusion: Among vaccine‐eligible adults, safety and sexuality concerns do not appear to be the prime factors underlying low HPV vaccination rates. Rather than emphasizing them, educational interventions should aim at improving vaccine's knowledge, and enhancing provider recommendations on the necessity of HPV vaccination. [ABSTRACT FROM AUTHOR]

Purpose: Although rates of hospice use have increased over time, insurance plan- and racial/ethnic-based disparities in rates have been reported in the USA. We hypothesized that increased rates of hospice use would reduce or eliminate insurance plan-based disparities and that racial/ethnic disparities would be eliminated in managed care (MC) insurance plans.Methods: We studied the use of hospice care in the final 30 days of life among 40,184 elderly Texas Medicare beneficiaries who died from primary breast, colorectal, lung, pancreas, or prostate cancer between January 1, 2007 and December 31, 2013, using statewide Medicare claims linked to cancer registry data. Rates of hospice use were computed by race/ethnicity and insurance plan (MC or fee-for-service (FFS)). We used logistic regression to account for the impact of confounding factors.Results: Rates of hospice use increased significantly over time, from 68.9% in 2007 to 76.1% in 2013. By 2013, differences in hospice use rates between MC and FFS plans had been reduced from 10% to < 5%. However, after accounting for insurance plan and confounding factors, racial/ethnic minority beneficiaries' hospice use was significantly lower than non-Hispanic white beneficiaries' (p < 0.0001). This disparity was observed among both FFS and MC beneficiaries.Conclusions: Hospice use in the final 30 days of life has increased among elderly cancer patients in Texas, virtually eliminating the difference between FFS and MC insurance plans. Despite these positive trends, racial/ethnic-based disparities persist. These disparities are not explained by confounding factors. Future research should address social and behavioral influences on end-of-life decisions. [ABSTRACT FROM AUTHOR]

• Although vaccination offers protection against influenza, 34% of individuals receive an influenza vaccine each year. • Limited health insurance may contribute to low vaccination rates, particularly in areas with lower insurance coverage. • Among residents of Brazos County who had influenza in December 2017, 38% did not have health insurance. • Only 19% of those without health insurance had influenza vaccination compared to 30% of insured individuals. • Making influenza vaccine more readily accessible to the uninsured should be an objective of public health practice. Lack of health insurance may limit access to influenza vaccination, resulting in higher risk of infection. The Brazos County Health Department obtained medical records summarizing vaccination and health insurance status of all influenza cases occurring in December 2017 (n = 417). The odds of influenza vaccination were estimated for those with public or private health insurance as compared to uninsured individuals using multivariate logistic regression analysis adjusted for age and race. Health insurance coverage among Brazos County residents with influenza was 62.4%. Public and private health insurance was associated with higher odds of influenza vaccination compared to no insurance (aOR: 2.05; 95% CI: 1.00–4.21 and aOR: 1.77; 95% CI: 1.07–2.92, respectively), particularly among adults 18–64 years of age. Influenza vaccination is strongly associated with health insurance. Expansion of programs that facilitate access to health services or provide free influenza vaccines may improve influenza prevention among the uninsured. [ABSTRACT FROM AUTHOR]

Context: States face increasing Medicaid expenditures largely as a result of growing dual-eligible populations. In this article we examine self-reported community-based Medicaid participation among Medicare recipients 65 and older in California and Texas, with a particular focus on the older Mexican-origin population. Methods: We use six waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) covering the period from 1993-94 to 2010-11. Findings: The data reveal relatively high Medicaid participation rates by older individuals of Mexican origin, but significant differences between the two states. At baseline, 30% of older Mexican-origin Medicare beneficiaries in California reported receiving Medicaid compared to 41% in Texas. Conclusions: Despite California's more liberal eligibility criteria, community-dwelling Texans were more likely than Californians to report coverage at some point during the 17-year follow-up. Our data, as well as administrative data, reveal that California classifies nearly all of its communitydwelling Medicaid recipients as "full duals," meaning that they receive full benefits, whereas Texas is more likely to classify similarly poor and disabled individuals as "partial duals," meaning that they receive less coverage, thereby lowering overall program expenditures. Cost containment strategies that restrict access may be especially consequential for vulnerable Hispanic populations. [ABSTRACT FROM AUTHOR]

The article examines issues surrounding the suicide attempt of Albert Benton Shoemake, president of the U.S. Trust and Guaranty Co., and its impact on the insurance sector in Texas in 1956. Topics discussed include the state of the Texan economy after a five-year drought in 1956, impact of this suicide attempt on shareholders and families that relied on Texas insurance, and the account of an investigation into the operation of the U.S. Trust and Guaranty Co. in 1955.

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle--between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing. [ABSTRACT FROM AUTHOR]

Objective: The Patient Protection and Affordable Care Act (ACA) has allowed millions of Americans to obtain coverage. However, many, especially minorities, remain uninsured. With mounting evidence supporting the importance of health insurance literacy (HIL), the purpose of this cross-sectional study is to examine the association between HIL and ACA knowledge.Methods: We conducted 681 in-person interviews with participants at a community health event along the Texas-Mexico border in 2015, after the conclusion of the ACA's second enrollment period. To assess HIL, we used the Health Insurance Literacy Measure, reflecting consumers' confidence to choose, compare, and use health insurance. We assessed ACA knowledge through the following question: "How much would you say you know about this health reform law?" Logistic regression was used to examine the association between HIL and ACA knowledge after controlling for several covariates.Results: Almost 70% of participants knew nothing/very little about the ACA. Multivariate analyses revealed that no/very little ACA knowledge was associated with low levels of confidence "choosing health insurance plans" (OR:0.55; 95%CI:0.40-0.75) (full sample) and "comparing plans" (OR:0.56; 95%CI:0.32-0.96) (U.S.-born sub-sample).Conclusion: No/little ACA knowledge is associated with lower levels of HIL.Practice Implications: Promoting HIL is an essential step towards improving healthcare access. [ABSTRACT FROM AUTHOR]

The article discusses the role of health-system specialty pharmacies in providing patient care services. Topics mentioned include the use of prior authorization by insurance companies as a tool to control medication costs, the decrease in the burden of physicians for outpatient prior authorization, and the technological innovation of prior authorization into electronic medication system.

Latinos have the highest US childhood uninsurance rate of any race/ethnicity, but little is known about effective ways to eliminate this disparity. We evaluated the effects of parent mentors--Latino parents with children covered by Medicaid or the Children's Health Insurance Program--on insuring Latino children in a randomized, controlled, community-based trial of 155 uninsured children conducted in the period 2011-15. Parent mentors were trained to assist families in getting insurance coverage, accessing health care, and addressing social determinants of health. We found that parent mentors were more effective than traditional methods in insuring children (95 percent versus 69 percent), achieving faster coverage and greater parental satisfaction, reducing unmet health care needs, providing children with primary care providers, and improving the quality of well-child and subspecialty care. Children in the parent-mentor group had higher quality of overall and specialty care, lower out-of-pocket spending, and higher rates of coverage two years after the end of the intervention (100 percent versus 70 percent). Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities. [ABSTRACT FROM AUTHOR]

Anecdotal reports and systematic research highlight the prevalence of narrow-network plans on the Affordable Care Act's health insurance Marketplaces. At the same time, Marketplace premiums in the period 2014-16 were much lower than projected by the Congressional Budget Office in 2009. Using detailed data on the breadth of both hospital and physician networks, we studied the prevalence of narrow networks and quantified the association between network breadth and premiums. Controlling for many potentially confounding factors, we found that a plan with narrow physician and hospital networks was 16 percent cheaper than a plan with broad networks for both, and that narrowing the breadth of just one type of network was associated with a 6-9 percent decrease in premiums. Narrow-network plans also have a sizable impact on federal outlays, as they depress the premium of the second-lowest-price silver plan, to which subsidy amounts are linked. Holding all else constant, we estimate that federal subsidies would have been 10.8 percent higher in 2014 had Marketplaces required all plans to offer broad provider networks. Narrow networks are a promising source of potential savings for other segments of the commercial insurance market. [ABSTRACT FROM AUTHOR]

Objective: To explain the association of out-of-pocket (OOP) cost, community-level factors, and individual characteristics on statin therapy nonadherence.Data Sources: BlueCross BlueShield of Texas claims data for the period of 2008-2011.Study Design: A retrospective cohort of 49,176 insured patients, aged 18-64 years, with at least one statin refill during 2008-2011 was analyzed. Using a weighted proportion of days covered ratio, differences between adherent and nonadherent groups are assessed using chi-squared tests, t-tests, and a clustered generalized linear model with logit link function.Principal Findings: Statin therapy adherence, measured at 48 percent, is associated with neighborhood-level socioeconomic factors, including race/ethnicity, educational attainment, and poverty level. Individual characteristics influencing adherence include OOP medication cost, gender, age, comorbid conditions, and total health care utilization.Conclusions: This study signifies the importance of OOP costs as a determinant of adherence to medications, but more interestingly, the results suggest that other socioeconomic factors, as measured by neighborhood-level variables, have a greater association on the likelihood of adherence. The results may be of interest to policy makers, benefit designers, self-insured employers, and provider organizations. [ABSTRACT FROM AUTHOR]

Because of their expertise, physiatrists provide disability insurance assistance for cancer survivors. In this brief report, we perform a descriptive retrospective analysis of all new (354) outpatient physiatry consultations from January 1,2009, to December 31,2013, at a National Cancer Institute Comprehensive Cancer Center. Disability and/or work accommodations were brought up at some point with the physiatrist during the duration of their care for 131 (37%) of 354 patients. More than 90% of the discussions took place during the first visit. Of those patients who had a documented disability/employment discussion, 58 (44.3%) of 131 patients were originally referred for disability assistance specifically, and 58 (44.3%) of 131 also had disability insurance paperwork completed by the physiatrist. Outcomes of initial physiatry disability insurance assistance were 45 (77.6%) of 58 approved/renewed, 5 (8.6%) of 58 denied, and 8 (13.8%) of 58 unknown/died during the disability application process. The median form size was 33 (SD, 25.95) items. This study is the first of its kind and provides an initial look at work-related discussions and support with disability insurance paperwork as a specific intervention provided by physiatrists at a cancer center. The results are compelling and demonstrate that physiatrists frequently provide these interventions. These interventions take considerable time and effort but are generally successful. [ABSTRACT FROM AUTHOR]

Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA's coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in "excellent" self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health. [ABSTRACT FROM AUTHOR]

The impact of the Affordable Care Act (ACA) on HIV care patients, aged 18–64, was evaluated in three jurisdictions with Medicaid expansion (Chicago, New York State, and Washington) and three jurisdictions without Medicaid expansion (Georgia, Texas, and Virginia) using data from the Medical Monitoring Project. Multivariate regression models were used to evaluate insurance status that was reported pre- and post-ACA; self-reported impact of ACA on HIV care was explored with descriptive statistics. The likelihood of having insurance was significantly greater post-ACA compared to pre-ACA in Chicago (aRR = 1.33, 95%CI = 1.20, 1.47), Washington (aRR = 1.15, 95%CI = 1.08, 1.22), and Virginia (aRR = 1.14, 95%CI = 1.00, 1.29). In Washington and Chicago, the likelihood of being Medicaid-insured was greater post-ACA compared to pre-ACA implementation (Chicago: aRR = 1.25, 95%CI = 1.03,1.53; Washington: aRR = 1.66 95% CI = 1.30, 2.13). No other significant differences were observed. Only a subset of HIV care patients (range: 15–35%) reported a change in insurance that would have coincided with the implementation of ACA; and within this subset, a change in medical care costs was the most commonly noted issue. In conclusion, the influence of ACA on insurance coverage and other factors affecting HIV care likely varies by jurisdiction. [ABSTRACT FROM PUBLISHER]

Objective To determine the mean cervical cancer medical care costs for patients enrolled in commercial insurance in Texas. Cost is represented by insurer and patient payments for care. Methods We estimated the mean medical care costs during the first 2 years after the index diagnosis date for patients with cervical cancer (cases). Cases were identified using claims-based International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9), diagnosis codes and matched to controls without a claims-based ICD-9 code for cancer using a 2-step propensity score matching method. Index dates for the cases were randomly assigned to potential controls, and cases and controls were matched by index date. Data for cancer cases and controls were obtained from the de-identified 2011–2014 U.S. MarketScan databases. A generalized linear model was employed to compute the cost for censored months during the 2-year follow-up period. Differential costs were assessed by subtracting the medical costs incurred by controls from those incurred by cases. Results During 2011–2014, 475 commercially insured Texas patients with newly diagnosed cervical cancer met the inclusion criteria. The first-year and second-year mean medical costs were $60,828 and $37,721 for cases and $9982 and $10,066 for controls, respectively. The differential costs of cervical cancer for the first and second years were $50,846 and $27,656, respectively. The major correlates of higher monthly cervical cancer costs were higher Charlson Comorbidity Index score during 6 months period prior to diagnosis, higher healthcare costs between 6 months and 3 months prior to diagnosis, and residence in the western region of Texas. Costs for cervical cancer patients decreased steeply between month 1 and month 5 after diagnosis and then were stable, while costs for the control group were stable throughout the follow-up period. Conclusions Mean direct medical costs associated with cervical cancer in Texas were substantial. These data will serve as key cost parameters in models of costs associated with human papillomavirus (HPV)-related cancers in Texas and the economic evaluation of HPV vaccination dissemination in Texas. [ABSTRACT FROM AUTHOR]

Aims To examine the conditions under which Screening, Brief Intervention and Referral to Treatment (SBIRT) programs can be sustained by health insurance payments. Design A mathematical model was used to estimate the number of patients needed for revenues to exceed costs. Setting Three medical settings in the United States were examined: in-patient, out-patient and emergency department. Components of SBIRT were delivered by combinations of health-care practitioners (generalists) and behavioral health specialists. Participants Practitioners in seven SBIRT programs who received grants from the US Substance Abuse and Mental Health Services Administration (SAMHSA). Measurements Program costs and revenues were measured using data from grantees. Patient flows were measured from administrative data and adjusted with prevalence and screening estimates from the literature. Findings SBIRT can be sustained through health insurance reimbursement in out-patient and emergency department settings in most staffing mixes. To sustain SBIRT in in-patient programs, a patient flow larger than the national average may be needed; if that flow is achieved, the range of screens required to maintain a surplus is narrow. Sensitivity analyses suggest that the results are very sensitive to changes in the proportion of insured patients. Conclusions Screening, Brief Intervention and Referral to Treatment programs in the United States can be sustained by health insurance payments under a variety of staffing models. Screening, Brief Intervention and Referral to Treatment programs can be sustained only in an in-patient setting with above-average patient flow (more than 2500 screens). Screening, Brief Intervention and Referral to Treatment programs in out-patient and emergency department settings can be sustained with below-average patient flows (fewer than 125 000 out-patient visits and fewer than 27 000 emergency department visits). [ABSTRACT FROM AUTHOR]

Objectives.To examine the effects of the Affordable Care Act’s (ACA’s) Marketplace on Texas residents and determine which population subgroups benefited the most and which the least. Methods. We analyzed insurance coverage rates among nonelderly Texas adults using the Health Reform Monitoring Survey-Texas from September 2013, just before the first open enrollment period in the Marketplace, through March 2016. Results. Texas has experienced a roughly 6–percentage-point increase in insurance coverage (from 74.7% to 80.6%; P= .012) after implementation of the major insurance provisions of the ACA. The 4 subgroups with the largest increases in adjusted insurance coverage between 2013 and 2016 were persons aged 50 to 64 years (12.1 percentage points; P = .002), Hispanics (10.9 percentage points;P = .002),persons reporting fair or poor health status (10.2 percentage points; P = .038), and those with a high school diploma as their highest educational attainment (9.2 percentage points; P = .023). Conclusions. Many population subgroups have benefited from the ACA’s Marketplace, but approximately 3 million Texas residents still lack health coverage. Adopting the ACA’s Medicaid expansion is a means to address the lack of coverage. [ABSTRACT FROM AUTHOR]

Changes in insurance coverage over time, or "churning," may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a "private option" expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months--a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts. [ABSTRACT FROM AUTHOR]

The author reflects on the effect of uninsurance and health reform on a family in Texas. Topics covered include the depiction of a family's life behind the politics of reform and the consequences of political inaction, the reason behind the rejection of a couple's Medicaid application and the state's decision not to adopt the Affordable Care Act's (ACA) Medicaid expansion.

Objectives. To compare access to care and perceived health care quality by insurance type among low-income adults in 3 southern US states, before Medicaid expansion under the Affordable Care Act. Methods. We conducted a telephone survey in 2013 of 2765 low-income US citizens, aged 19 to 64 years, in Arkansas, Kentucky, and Texas. We compared 11 measures of access and quality of care for respondents with Medicaid, private insurance, Medicare, and no insurance with adjustment for sociodemographics and health status. Results. Low-income adults with Medicaid, private insurance, and Medicare reported significantly better health care access and quality than uninsured individuals. Medicaid beneficiaries reported greater difficulty accessing specialists but less risk of high out-ofpocket spending than those with private insurance. For other outcomes, Medicaid and private coverage performed similarly. Conclusions. Low-income adults with insurance report significantly greater access and quality of care than uninsured adults, regardless of whether they have private or public insurance. Access to specialty care in Medicaid may require policy attention. Public Health Implications. Many states are still considering whether to expand Medicaid under the Affordable Care Act and whether to pursue alternative models for coverage expansion. Our results suggest that access to quality health care will improve under the Affordable Care Act's coverage expansions, regardless of the type of coverage. [ABSTRACT FROM AUTHOR]

Background: Silent-members are members of a medical health plan who submit no claims for healthcare services in a benefit year despite 12 months of continuous-enrollment. This study was conducted to evaluate the future expenditure risk of commercial-insured members who avoid all medical care despite coverage. In order to determine if the silent-members were at greater risk, we compared them to members who received care in the anchor year (2009) but had low-expenditures. The low-expenditure members were assumed to represent persons without significant medical conditions and without care-avoidance behaviors. We examined the claims experience of a cohort of silent members in the 2 years after the silent year (2009) and compared it with the corresponding claims experience for a cohort of low-expenditure members from the same anchor year (2009).Methods: Members of commercial health plans (BCBS of Texas) were selected based on continuous-enrollment in 2009. Two sub-groups were identified based on annual claims expenditure: Care avoiders were members with 12 months continuous-enrollment and no medical claims, and are thus referred to as "silent members" in the insurance industry. Low-Expenditure members were those with 12 months continuous-enrollment and total PMPY (per member per year) annual medical claims expenditure in the lowest 10th percentile of members with claims experience. "Low-expenditure" members served as a comparison group to the "silent members", under the assumption that such claimants were using benefits for minor healthcare issues as needed. Key variables were enrollment and expenditures. Enrollment data identified demographics and continuous-enrollment. Medical claims data were used to calculate utilization and expenditures. All claims data were de-identified and no consent was required, as approved by the Institutional Review Board. No research involved human subjects. Multivariate logistic regression models were applied.Results: Silent members who seek care in subsequent years have a greater probability of becoming high-expenditure claimants than those with low-expenditure experience.Conclusions: For silent members who subsequently seek treatment, the probability of becoming high-expenditure is significantly greater than low-expenditure members from the anchor year. The implications of future high costs for silent members who become claimants may support the need for additional research to address the risks of care avoidance behaviors. [ABSTRACT FROM AUTHOR]

Background An emerging literature reports that women who reside in socioeconomically deprived communities are less likely to adhere to mammography screening. This study explored associations between area-level socioeconomic measures and mammography screening among a racially and ethnically diverse sample of women in Texas. Methods We conducted a cross-sectional, multilevel study linking individual-level data from the 2010 Health of Houston Survey and contextual data from the U.S. Census. Women ages 40 to 74 years ( n = 1,541) were included in the analyses. We examined tract-level poverty, unemployment, education, Hispanic and Black composition, female-headed householder families, and crowding as contextual measures. Using multilevel logistic regression modeling, we compared most disadvantaged tracts (quartiles 2–4) to the most advantaged tract (quartile 1). Results Overall, 64% of the sample was adherent to mammography screening. Screening rates were lower ( p < .05) among Hispanics, those foreign born, women aged 40 to 49 years, and those with low educational attainment, unemployed, and without health insurance coverage. Women living in areas with high levels of poverty (quartile 2 vs. 1: odds ratio [OR], 0.50; 95% CI, 0.30–0.85), Hispanic composition (quartile 3 vs. 1: OR, 0.54; 95% CI, 0.32–0.90), and crowding (quartile 4 vs. 1: OR, 0.53; 95% CI, 0.29–0.96) were less likely to have up-to-date mammography screening, net of individual-level factors. Conclusion Our findings highlight the importance of examining area-level socioeconomic inequalities in mammography screening. The study represents an advance on previous research because we examined multiple area measures, controlled for key individual-level covariates, used data aggregated at the tract level, and accounted for the nested structure of the data. [ABSTRACT FROM AUTHOR]

Background: Tobacco smoke exposure increases breathing problems of children. Texas Children's Health Plan is a Managed Medicaid and Children's Health Insurance Program (CHIP) managed care provider. The aim of this study is to determine associations among tobacco smoke exposure, asthma prevalence, and asthma health-care utilization.Methods: Texas Children's Health Plan conducts an annual survey of members who have a physician visit. Questions were added to the survey in March 2010 about asthma and tobacco smoke exposure. Survey results for children < 18 years of age were matched to health plan claims data for the 12 months following the date of the physician visit.Results: A total of 22,470 parents of unique members/patients from birth to < 18 years of age participated in the survey. More whites than African Americans or Hispanics report that the child's mother is a smoker (19.5% vs 9.1% and vs 2.3%, respectively; P < .001). Compared with children whose mother does not smoke, parent report of asthma diagnosis and claims for dispensing of short-acting beta agonist medication are greater if the mother is a smoker (adjusted OR, 1.20 [95% CI, 1.03-1.40] and 1.24 [95% CI, 1.08-1.42], respectively). In contrast to Medicaid, in which there are no out-of-pocket costs, the CHIP line of business requires copays for ED visits. ED visits are influenced by maternal smoking only in the CHIP line of business (adjusted OR, 4.40; 95% CI, 1.69-11.44).Conclusion: Maternal smoking increases risk for asthma diagnosis and prescription of asthma quick relief medication. Maternal smoking predicted asthma-related ED visits only for the CHIP line of business. [ABSTRACT FROM AUTHOR]

Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the "private option"). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November-December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky's traditional Medicaid expansion and Arkansas's private option, which suggests that both approaches improved access among low-income adults. [ABSTRACT FROM AUTHOR]

The article reports on the ruling by the U.S. Supreme Court as of September 2021 in the case California v. Texas, in which the Affordable Care Act (ACA) was upheld. Also cited are the expansion of the law by the administration of President Joe Biden, and the growing marketplace enrollment due to the broad COVID-19 special enrollment period (SEP) and enhanced premium tax credits under the American Rescue Plan Act (ARPA).

Using data from the 2008 Cross-Border Utilization of Health Care Survey, we examined the relationship between United States (US) health insurance coverage plans and the use of health care services in Mexico by US residents of the US-Mexico border region. We found immigrants were far more likely to be uninsured than their native-born counterparts (63 vs. 27.8 %). Adults without health insurance coverage were more likely to purchase medications or visit physicians in Mexico compared to insured adults. However, adults with Medicaid coverage were more likely to visit dentists in Mexico compared to uninsured adults. Improving health care access for US residents in the southwestern border region of the country will require initiatives that target not only providing coverage to the large uninsured population but also improving access to health care services for the large underinsured population. [ABSTRACT FROM AUTHOR]

An interview with James I. Rodriguez, fellow of The American College of Healthcare Executives (FACHE) and Chief Executive Officer (CEO) of TexHealth Central Texas, is presented. When asked about events in his career leading to success, he refers to a few key work experiences. Rodriguez believes that the multi-share health plan is a viable solution to help small businesses to provide health insurance coverage for employees. He comments on the role of accountable care organizations (ACOs).

There are large differences in US health insurance coverage by racial and ethnic groups, yet there have been no estimates to date on how implementation of the Affordable Care Act will affect the distribution of coverage by race and ethnicity.We used a microsimulation model to show that racial and ethnic differentials in coverage could be greatly reduced, potentially cutting the eight-percentage-point black-white differential in uninsurance rates by more than half and the nineteen-percentage-point Hispanic-white differential by just under one-quarter. However, blacks and Hispanics are still projected to remain more likely to be uninsured than whites. Achieving low uninsurance under the Affordable Care Act will depend on effective state policies to attain high enrollment in Medicaid and the Children's Health Insurance Program and the new insurance exchanges. Coverage gains among Hispanics will probably depend on adoption of strategies that address language and related barriers to enrollment and retention in California and Texas, where almost half of Hispanics live. If uninsurance is reduced to the extent projected in this analysis, sizable reductions in long-standing racial and ethnic differentials in access to health care and health status are likely to follow. [ABSTRACT FROM AUTHOR]

Screening and brief intervention (SBI) in health care settings is an evidence-based practice for substance misuse. The Uniform Accident and Sickness Policy Provision Law (UPPL) discourages providers from carrying out SBI by allowing insurers in 26 states to refuse coverage for injuries resulting from intoxication. This project used a qualitative case study methodology to understand how policy-advocacy communication may have impacted the success of UPPL repeal efforts in Texas. Results showed bill progress could have been impeded due to less-effective communication from advocates. These findings suggest the quality of communication may influence the success of evidence-based policy-advocacy for UPPL repeal. [ABSTRACT FROM AUTHOR]

Ying AK, Lairson DR, Giardino AP, Bondy ML, Zaheer I, Haymond MW, Heptulla RA. Predictors of direct costs of diabetes care in pediatric patients with type 1 diabetes. Objective: This study examines factors that predict elevated direct costs of pediatric patients with type 1 diabetes. Methods: A cohort of 784 children with type 1 diabetes at least 6 months postdiagnosis and managed by pediatric endocrinologists at Texas Children's Hospital were included in this study. Actual reimbursed costs from January 2004 to December 2005 were obtained. Medication and supply costs were based on estimates from insulin dosage and type of insulin regimen prescribed, respectively. We examined utilization of care, total diabetes-related direct medical costs, and predictors of direct costs and hospitalization. Results: Annually, 7% (58/784) of patients (excluding initial hospitalization at diagnosis) had a diabetes-related hospitalization and median length of stay was days. Mean total diabetes-related direct cost per person-year was $4730 [95% confidence interval (CI), 4516-4944]. Supplies accounted for 38% and medications 33% of costs, respectively. Older age, hemoglobin A (HbA) > 8.5%, use of a multi-injection or pump regimen, living in a non-married household, and female gender were associated with higher annual costs. HbA > 8.5%, living in a non-married household, and female gender increased the odds of a diabetes-related hospitalization. Discussion: Better metabolic control in patients with type 1 diabetes was associated with lower direct medical costs and lower odds of hospitalization. Marital status of the primary caregiver, irrespective of type of insurance, impacts the patient's healthcare costs and risk of hospitalization. This large single-center US study analyzes cost distribution in children with diabetes and is informative for payers and providers focused on effective management and improving healthcare costs. [ABSTRACT FROM AUTHOR]

There is wide variation in long-term acute care hospital (LTACH) use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain. Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers. Multicenter retrospective observational cohort. Consecutive hospitalized Medicare beneficiaries transferred to an LTACH from 2017 to 2018 from an accountable care organization in Texas. The primary outcome was clinical appropriateness of transfer ascertained by 2 physician reviewers. We abstracted patients' characteristics and primary reasons for transfer. We examined the positive predictive value (PPV) of meeting Medicare criteria for full LTACH payment [preceding intensive care unit (ICU) stay ≥3 days or prolonged mechanical ventilation] for identifying appropriate transfers, and how this differed if Medicare adopted an 8-day minimum ICU stay criterion recommended by the Medicare Payment Advisory Commission (MedPAC). Of 105 LTACH transfers, 33 (31.4%) were clinically appropriate. The most common reason among appropriate transfers was respiratory care (58%), but 42% had other indications. Inappropriate transfers most commonly were for wound care (28%), intravenous medication infusions (28%), or patient (17%) and physician preference (26%). The PPV for meeting Medicare LTACH payment criteria was 55%. The PPV improved to 77% if Medicare adopted the 8-day minimum ICU stay criterion, with only a modest absolute increase in appropriate transfers not meeting the more stringent criteria (12% to 17%). Two-thirds of LTACH transfers in a high-LTACH-use region are clinically inappropriate, and are most commonly transferred for wound care, intravenous infusions, or patient and physician preference. Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers. Adoption of MedPAC's recommended 8-day minimum ICU stay criterion could safely reduce inappropriate transfers, although generalizability to low LTACH-use regions is uncertain. [ABSTRACT FROM AUTHOR]

The authors analyzed ethnic/racial disparities in healthcare access and length of stay from a defined population of individuals seeking medical detoxification services at a hospital in Texas. Results indicated Blacks were more likely to be insured compared with Whites, mostly by public insurance, but this did not hold for Hispanics, who were about three times more likely to be uninsured compared with Blacks. In addition, the authors observed lower median of length of stay in the Medicaid category among Hispanics. These results can be explained by aggressive case management, sociocultural barriers, or discriminatory practices, both intentional and unintentional. [ABSTRACT FROM AUTHOR]

The article offers updates on Affordable Care Act (ACA) litigation issues in the U.S. as of February 2020. Topics covered include whether insurers are entitled to over 12 billion U.S. dollars in unpaid risk-corridor payments from 2014 to 2016, whether the ACA's contraceptive mandate violates the Religious Freedom Restoration Act, and the expansive end-of-year spending package of U.S. Congress.

The article provides an update on the ruling from the Fifth Circuit Court of Appeals on the status of the Affordable Care Act as of October 2019. Topics covered include reports issued by the U.S. Department of Health and Human Services on the risk adjustment program, a decline in individual-market enrollment among unsubsidized consumers since 2016, and the estimated number of people in 50 states and the District of Columbia that affectuated their 2019 Marketplace coverage as of February 2019.

Presents a comparison of the Galveston Plan of Galveston, Texas and the Social Security in the United States based on different earner and family scenarios. How the Galveston Plan is financed; Benefits provided; Effects of inflation.