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A growing body of research documents positive long-term impacts of public health insurance that go far beyond improving recipients' health. In this study, we expand the analysis to assess whether expanding Medicaid coverage generates reductions in crime. We find that increased Medicaid eligibility during childhood generates significant reductions in crime in early adulthood. Cohorts who experienced expanded Medicaid eligibility during childhood had significantly fewer arrests for property crime, drug-related crime, and driving under the influence in early adulthood. The effects are concentrated among males, are larger for Blacks than whites, and larger for eligibility experienced later in childhood. [End Page 1741] [ABSTRACT FROM AUTHOR]

Context Methods Findings Conclusions Policy Points A large population of incarcerated people may be eligible for prerelease and transition services under the new Medicaid Reentry Section 1115 Demonstration Opportunity. We estimated the largest relative population increases in Medicaid coverage from the opportunity may be expected in smaller and more rural states. We found that mental illness, hepatitis C, and chronic kidney disease prevalence rates were sufficiently high among incarcerated populations to likely skew overall Medicaid population prevalence of these diseases when prerelease and transition services are expanded, implying the need for planning of additional data exchange and service delivery infrastructure by state Medicaid plans. A large population of incarcerated people may be eligible for prerelease and transition services under the new Medicaid Reentry Section 1115 Demonstration Opportunity. We estimated the largest relative population increases in Medicaid coverage from the opportunity may be expected in smaller and more rural states. We found that mental illness, hepatitis C, and chronic kidney disease prevalence rates were sufficiently high among incarcerated populations to likely skew overall Medicaid population prevalence of these diseases when prerelease and transition services are expanded, implying the need for planning of additional data exchange and service delivery infrastructure by state Medicaid plans. As states expand prerelease and transition services for incarcerated individuals under the Medicaid Reentry Section 1115 Demonstration Opportunity, we sought to systematically inform Medicaid state and plan administrators regarding the population size and burden of disease data available on incarcerated populations in both jails and prisons in the United States.We analyzed data on eligibility criteria for new Medicaid prerelease and transition services based on incarceration length and health conditions across states. We estimated the potentially eligible populations in prisons and jails, considering various incarceration lengths and health status requirements. We also compared disease prevalence in the incarcerated population with that of the existing civilian Medicaid population.We found that rural and smaller states would experience a disproportionately large proportion of their Medicaid populations to be eligible for prerelease and transition services if new Medicaid eligibility rules were broadly applied. Self‐reported psychological distress was notably higher among incarcerated individuals compared with those currently on Medicaid. The prevalence rates of previously diagnosed chronic hepatitis C and kidney disease were also much higher in the incarcerated population than the existing civilian Medicaid population.We estimated large volumes of potentially Medicaid‐eligible entrants as coverage policy changes take effect over the coming years, particularly impacting smaller and more rural states. Our findings reveal very high disease prevalence rates among the incarcerated population subject to new Medicaid coverage, including specific chronic, infectious, and behavioral health conditions that state Medicaid programs, health plans, and providers may benefit from advanced planning to address. [ABSTRACT FROM AUTHOR]

Objective: The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment. Data Sources and Study Setting: Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions. Study Design: Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline‐recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five‐year waiting period for pregnant immigrants to access Medicaid. Data Collection/Extraction Methods: Survey responses from 35,779 postpartum individuals with self‐reported Hispanic ethnicity who gave birth during 2016–2020. Principal Findings: Compared to English‐speaking Hispanic people, Spanish‐speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage‐point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage‐point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish‐speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage‐point lower prenatal care adequacy, but 1.3 (95% CI:−1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage‐point higher postpartum care quality than English‐speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage‐points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage‐points higher. Conclusions: Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish‐speaking and English‐speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth. [ABSTRACT FROM AUTHOR]

Interest in home-based care is increasing among Medicare Advantage plans, but information on the characteristics of homebound beneficiaries is limited. This study examines the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national plan. Visual Abstract. Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan: Interest in home-based care is increasing among Medicare Advantage plans, but information on the characteristics of homebound beneficiaries is limited. This study examines the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national plan. Background: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown. Objective: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan. Design: Cross-sectional. Setting: National MA plan. Participants: Humana MA beneficiaries in 2022 (n  = 2 435 519). Measurements: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status. Results: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]). Limitation: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability. Conclusion: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries. Primary Funding Source: Humana, under a collaborative research agreement with Johns Hopkins University. [ABSTRACT FROM AUTHOR]

Background: Alzheimer's disease and related dementias (ADRD) prevalence varies geographically in the United States. Objective: To assess whether the geographic variation of ADRD in Central Appalachia is explained by county-level sociodemographics or access to care. Methods: Centers for Medicare and Medicaid Services Public Use Files from 2015– 2018 were used to estimate county-level ADRD prevalence among all fee-for-service (FFS) beneficiaries with≥1 inpatient, skilled nursing facility, home health agency, hospital outpatient or Carrier claim with a valid ADRD ICD-9/10 code over three-years in Central Appalachia (Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia). Negative binomial regression was used to estimate prevalence overall, by Appalachian/non-Appalachian designation, and by rural/urban classification. Models were then adjusted for county-level: 1) FFS demographics (age, gender, and Medicaid eligibility), comorbidities; 2) population sociodemographics (race/ethnicity, education, aging population distribution, and renter-occupied housing); and 3) diagnostic access (PCP visits, neurology visits, and imaging scans). Results: Across the 591 counties in the Central Appalachian region, the average prevalence of ADRD from 2015– 2018 was 11.8%. ADRD prevalence was modestly higher for Appalachian counties both overall (PR: 1.03; 95% CI: 1.02, 1.04) and after adjustment (PR: 1.02; 95% CI: 1.00, 1.03) compared to non-Appalachian counties. This difference was similar among rural and urban counties (p = 0.326) but varied by state (p = 0.004). Conclusions: The relative variation in ADRD prevalence in the Appalachian region was smaller than hypothesized. The case mixture of the dual eligible population, accuracy of the outcome measurement, and impact of educational attainment in this region may contribute to this observation. [ABSTRACT FROM AUTHOR]

This article explores the racial and ethnic disparities in healthcare access and satisfaction among older adults in the United States. It specifically focuses on the impact of Medicare Advantage (MA) compared to Traditional Medicare (TM) on healthcare equity. The study finds that Black and Hispanic older adults face challenges in obtaining necessary care and experience more hospitalizations for chronic conditions compared to White older adults. The research also reveals disparities in satisfaction with care, access, and costs between different racial and ethnic groups in MA and TM. The findings emphasize the importance of addressing these disparities and improving healthcare experiences for Black and Hispanic beneficiaries in Medicare. [Extracted from the article]

This paper studies how better access to public health insurance affects infant mortality during pandemics. The analysis combines cross-state variation in mandated eligibility for Medicaid with two influenza pandemics that arrived shortly before and after the program's introduction in 1965. We find that better access to public health insurance in high-eligibility states substantially reduced pandemic infant mortality. The reductions in pandemic infant mortality are too large to be attributable solely to new Medicaid recipients, suggesting that expanded access to public health insurance helped mitigate disease transmission among the broader population. [ABSTRACT FROM AUTHOR]

This correction notice addresses errors in the author group, abstract, and text of an article titled "Medicaid expansion and the mental health of spousal caregivers" published in the Review of Economics of the Household. The correct author order is Joan Costa-Font, Nilesh Raut, and Courtney H. Van Houtven. The abstract has been revised to accurately reflect the study's findings, which indicate that Medicaid expansion under the Affordable Care Act reduced depressive symptoms among spousal caregivers. The article explores the policy impact of Medicaid expansion using longitudinal evidence from the Health and Retirement Study. The corrected version of the article is available online. [Extracted from the article]

Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD. [ABSTRACT FROM AUTHOR]

In 2014, the Affordable Care Act (ACA) expanded the role of Medicaid by encouraging states to increase eligibility for lower-income adults. As of 2024, 10 states had not adopted the expanded eligibility provisions of the ACA, possibly due to concerns about the state's share of spending. Using the Medical Expenditure Panel Survey (MEPS), we documented how health care utilization, expenditures, and the overall health status of newly eligible enrollees compare with enrollees who would have been eligible under their states' rules before the ACA. Our estimates suggest that, during 2014–16, newly eligible Medicaid enrollees had worse health and greater utilization and expenditures than previously eligible enrollees. However, during 2017–19, newly and previously eligible enrollees had comparable per capita health expenditures across six types of health spending. We find some evidence that changes in Medicaid enrollment composition muted observed differences between eligibility groups. [ABSTRACT FROM AUTHOR]

Interactions between redistributive policies can confront low‐income households with complicated choices. We study one such interaction, namely the relationship between Medicaid eligibility thresholds and the minimum wage. A minimum wage increase reduces the number of hours a low‐skilled individual can work while retaining Medicaid eligibility. We show that the empirical and welfare implications of this interaction can depend crucially on the relevance of labor market frictions. Absent frictions, affected workers may maintain Medicaid eligibility through small reductions in hours of work. With frictions, affected workers may lose Medicaid eligibility unless they leave their initial job. Empirically, we find that workers facing this scenario became less likely to participate in Medicaid, less likely to work, and more likely to spend time looking for new jobs, including search while employed. The observed outcomes suggest that low‐skilled workers face substantial labor market frictions. Because adjustment is costly, tinkering with safety net program parameters that determine the location of program eligibility notches can be harmful to beneficiaries. [ABSTRACT FROM AUTHOR]

Background: Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. Objective: We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. Design: Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. Participants: 512,744 low-income adults aged 20–64 in the 2011–2019 Behavioral Risk Factor Surveillance System. Main Measures: Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. Key Results: Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. Conclusions: Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions. [ABSTRACT FROM AUTHOR]

We study enrollment, medical service utilization, and incurred expenses of individual comprehensive and Medicaid managed care plans in states with or without Medicaid expansion adopted at the Affordable Care Act (ACA) early stage 2014–2016. To make healthcare services more accessible, 27 states expanded Medicaid eligibility to cover nearly‐poor non‐elderly adults who have had incomes between 100% and 138% of federal poverty level in 2014. In non‐expansion states, early enrollees in this income cohort had to choose individual market plans rather than Medicaid. Early enrollees' enrollment choices and their health status have had a great impact on the individual market premiums and Medicaid spending. We examined health insurers' annual regulatory filings with the National Association of Insurance Commissioners for 2013–2016 and found that: First, individual comprehensive insurance enrollment grew much faster in states not expanding Medicaid eligibility. Second, after incorporating early enrollees, per member per month (PMPM) medical service utilization and expenses of individual comprehensive insurance grew much faster in non‐expansion states. Third, among major types of medical utilization and expense measures, PMPM hospital inpatient days and PMPM prescription drug expenses increased substantially since 2014. Finally, Medicaid beneficiaries generated more PMPM medical utilization and expenses in expansion states. [ABSTRACT FROM AUTHOR]

Background: Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. Objective: Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). Design: Cross-sectional study using ordinary least squares regression controlling for patient and community factors. Participants: Medicare fee-for-service patients enrolled from 2015–2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. Main Measures: Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018–2022. Key Results: Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). Conclusions: Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments. [ABSTRACT FROM AUTHOR]

Medicaid is the largest payer of long-term services and supports (LTSS) and millions of older Americans rely on this means-tested program, especially during late life. There has been longstanding concern that wealthy older adults may be accessing the program by opportunistically divesting assets in order to qualify for coverage rather than by having high medical or LTSS expenses on which they spend down their resources to eligibility levels. Few current studies analyze this question longitudinally. Thus, questions remain about whether states need to tighten asset eligibility rules to prevent opportunistic asset divestiture. This analysis explores robust longitudinal data to determine the extent to which older, wealthier Americans accessing Medicaid do so by engaging in opportunistic asset transfer. Our findings demonstrate that this may occur among a relatively small proportion of wealthy people, and that tightening Medicaid eligibility criteria would likely have only a very modest impact on program expenditures. [ABSTRACT FROM AUTHOR]

Background: As part of the Patient Protection and Affordable Care Act, some states expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty line. While this resulted in an increased proportion of insured residents, its impact on the diagnosis and treatment of hepatopancreaticobiliary (HPB) cancers has not been studied. Study Design: The National Cancer Database (NCDB) from 2010 to 2017 was used. Patients diagnosed with HPB malignancies in states which expanded in 2014 were compared to patients in non-expansion states. Subset analyses of patients who underwent surgery and those in high-risk socioeconomic groups were performed. Outcomes studied included initiation of treatment within 30 days of diagnosis, stage at diagnosis, care at high volume or academic center, perioperative outcomes, and overall survival. Adjusted difference-in-differences analysis was performed. Results: A total of 345,684 patients were included, of whom 55% resided in non-expansion states and 54% were diagnosed with pancreatic cancer. Overall survival was higher in states with Medicaid expansion (HR.90, 95% CI [.88-.92], P <.01). There were also better postoperative outcomes including 30-day mortality (.67 [.57-.80], P <.01) and 30-day readmissions (.87 [.78-.97], P =.02) as well as increased likelihood of having surgery in a high-volume center (1.42 [1.32-1.53], P <.01). However, there were lower odds of initiating care within 30 days of diagnosis (.77 [.75-.80], P <.01) and higher likelihood of diagnosis with stage IV disease (1.09 [1.06-1.12], P <.01) in expansion states. Conclusion: While operative outcomes and overall survival from HPB cancers were better in states with Medicaid expansion, there was no improvement in timeliness of initiating care or stage at diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: Pregnant beneficiaries in the two primary Medicaid eligibility categories, traditional Medicaid and pregnancy Medicaid, have differing access to care especially in the preconception and postpartum periods. Pregnancy Medicaid has higher income limits for eligibility than traditional Medicaid but only provides coverage during and for a limited time period after pregnancy. Our objective was to determine the association between type of Medicaid (traditional Medicaid and pregnancy Medicaid) on receipt of outpatient care during the perinatal period. Methods: This retrospective cohort study compared outpatient visits using linked birth certificate and Medicaid claims from all Medicaid births in Oregon and South Carolina from 2014 through 2019. Pregnancy Medicaid ended 60 days postpartum during the study. Our primary outcome was average number of outpatient visits per 100 beneficiaries each month during three perinatal time points: preconceputally (three months prior to conception), prenatally (9 months prior to birthdate) and postpartum (from birth to 12 months). Results: Among 105,808 Medicaid-covered births in Oregon and 141,385 births in South Carolina, pregnancy Medicaid was the most prevelant categorical eligibility. Traditional Medicaid recipients had a higher average number of preconception, prenatal and postpartum visits as compared to those in pregnancy Medicaid. Discussion: In South Carolina, those using traditional Medicaid had 450% more preconception visits and 70% more postpartum visits compared with pregnancy Medicaid. In Oregon, those using traditional Medicaid had 200% more preconception visits and 29% more postpartum visits than individuals using pregnancy Medicaid. Lack of coverage in both the preconception and postpartum period deprive women of adequate opportunities to access health care or contraception. Changes to pregnancy Medicaid, including extended postpartum coverage through the American Rescue Plan Act of 2021, may facilitate better continuity of care. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Time spent at home may aid in understanding recovery following traumatic brain injury (TBI) among older adults, including those with Alzheimer's disease and related dementias (ADRD). We examined the impact of ADRD on recovery following TBI and determined whether socioeconomic disadvantages moderated the impact of ADRD. METHODS: We analyzed Medicare beneficiaries aged ≥65 years diagnosed with TBI in 2010–2018. Home time was calculated by subtracting days spent in a care environment or deceased from total follow‐up, and dual eligibility for Medicaid was a proxy for socioeconomic disadvantage. RESULTS: A total of 2463 of 20,350 participants (12.1%) had both a diagnosis of ADRD and were Medicaid dual‐eligible. Beneficiaries with ADRD and Medicaid spent markedly fewer days at home following TBI compared to beneficiaries without either condition (rate ratio 0.66; 95% confidence interval [CI] 0.64, 0.69). DISCUSSION: TBI resulted in a significant loss of home time over the year following injury among older adults with ADRD, particularly for those who were economically vulnerable. Highlights: Remaining at home after serious injuries such as fall‐related traumatic brain injury (TBI) is an important goal for older adults.No prior research has evaluated how ADRD impacts time spent at home after TBI.Older TBI survivors with ADRD may be especially vulnerable to loss of home time if socioeconomically disadvantaged.We assessed the impact of ADRD and poverty on a novel DAH measure after TBI.ADRD‐related disparities in DAH were significantly magnified among those living with socioeconomic disadvantage, suggesting a need for more tailored care approaches. [ABSTRACT FROM AUTHOR]

Background: The rates of suicide and opioid use disorder (OUD) among pregnant and postpartum women continue to increase. This research characterized OUD and suicide attempts among Medicaid-enrolled perinatal women and examined prenatal OUD diagnosis as a marker for postpartum suicide attempts. Methods: Data from Oregon birth certificates, Medicaid eligibility and claims files, and hospital discharge records were linked and analyzed. The sample included Oregon Medicaid women aged 15–44 who became pregnant and gave live births between January 2008 and January 2016 (N = 61,481). Key measures included indicators of suicide attempts (separately for any means and opioid poisoning) and OUD diagnosis, separately assessed during pregnancy and the one-year postpartum period. Probit regression was used to examine the overall relationship between prenatal OUD diagnosis and postpartum suicide attempts. A simultaneous equations model was employed to explore the link between prenatal OUD diagnosis and postpartum suicide attempts, mediated by postpartum OUD diagnosis. Results: Thirty-three prenatal suicide attempts by any means were identified. Postpartum suicide attempts were more frequent with 58 attempts, corresponding to a rate of 94.3 attempts per 100,000. Of these attempts, 79% (46 attempts) involved opioid poisoning. A total of 1,799 unique women (4.6% of the sample) were diagnosed with OUD either during pregnancy or one-year postpartum with 53% receiving the diagnosis postpartum. Postpartum suicide attempts by opioid poisoning increased from 55.5 per 100,000 in 2009 to 105.1 per 100,000 in 2016. The rate of prenatal OUD also almost doubled over the same period. Prenatal OUD diagnosis was associated with a 0.15%-point increase in the probability of suicide attempts by opioid poisoning within the first year postpartum. This increase reflects a three-fold increase compared to the rate for women without a prenatal OUD diagnosis. A prenatal OUD diagnosis was significantly associated with an elevated risk of postpartum suicide attempts by opioid poisoning via a postpartum OUD diagnosis. Conclusions: The risk of suicide attempt by opioid poisoning is elevated for Medicaid-enrolled reproductive-age women during pregnancy and postpartum. Women diagnosed with prenatal OUD may face an increased risk of postpartum suicides attempts involving opioid poisoning. [ABSTRACT FROM AUTHOR]

Position: The Society for Maternal-Fetal Medicine supports federal and state policies that expand Medicaid eligibility and extend Medicaid coverage through 12 months postpartum to address the maternal morbidity and mortality crisis and improve health equity. Access to coverage is essential to optimize maternal health following pregnancy and childbirth and avoid preventable causes of maternal morbidity and mortality that extend throughout the first year postpartum. The Society opposes policies such as work requirements or limitations on coverage for undocumented individuals that unnecessarily impose restrictions on Medicaid eligibility. [ABSTRACT FROM AUTHOR]

Using data from the Current Population Survey's Merged Outgoing Rotation Groups, the authors examine whether greater Medicaid generosity encourages people to switch toward better quality occupations. Exploiting variation in Medicaid eligibility expansions for children across states during the 1990s and early 2000s, they find that a one standard deviation increase in Medicaid infant income thresholds increased the likelihood that working parents move to a new occupation by 1.6 percentage points or 3.3%. Findings show that these effects are larger for those below 150% of the poverty line and for married parents who were not benefiting from Medicaid prior to the expansions. In addition, findings indicate that Medicaid generosity also increased mobility toward occupations with higher average wages and higher educational requirements. This article contributes to the literature on job lock by showing that access to public health insurance not only increases employment and job switches but also encourages occupational upgrading. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the incidence rate and factors associated with fractures among adults with ankylosing spondylitis (AS). Methods: We performed a retrospective cohort study with data from the Rheumatology Informatics System for Effectiveness registry linked to Medicare claims from 2016 to 2018. Patients were required to have two AS International Classification of Diseases codes 30 or more days apart and a subsequent Medicare claim. Then, 1 year of baseline characteristics were included, after which patients were observed for fractures. First, we calculated the incidence rate of fractures. Second, we constructed logistic regression models to identify factors associated with the fracture, including age, sex, race and ethnicity, body mass index, Medicare/Medicaid dual eligibility, area deprivation index, Charlson comorbidity index, smoking status, osteoporosis, historical fracture, and use of osteoporosis treatment, glucocorticoids, and opioids. Results: We identified 1,426 adults with prevalent AS. Mean ± SD age was 69.4 ± 9.8 years, 44.3% were female, and 77.3% were non‐Hispanic White. Fractures occurred in 197 adults with AS. The overall incidence rate of fractures was 76.7 (95% confidence interval [CI] 66.4–88.6) per 1,000 person‐years. Older age (odds ratio [OR] 2.8, 95% CI 1.39–5.65), historical fracture (OR 5.24, 95% CI 3.44–7.99), and use of more than 30 mg morphine equivalent (OR 1.86, 95% CI 1.08–3.19) conferred increased odds of fracture. Conclusions: In this large sample of Medicare beneficiaries with AS, increasing age, historical fracture, and use of opioids had higher odds of fracture. Men and women were equally likely to have a fracture. Because opioid use was associated with fracture in AS, this high‐risk population should be considered for interventions to mitigate risk. [ABSTRACT FROM AUTHOR]

Rates of neonatal abstinence syndrome (NAS) resulting from opioid misuse are rising. However, policies to treat opioid misuse during pregnancy are unclear. We apply a difference‐in‐differences design to national pediatric discharge records to examine the effects of state Medicaid policies on NAS. Among states in which Medicaid covered two clinically‐recommended medications for treating opioid misuse (buprenorphine, methadone), the Affordable Care Act's Medicaid expansion reduced Medicaid‐covered NAS hospitalizations. Medicaid expansion did not affect NAS hospitalizations in other expansion states. These findings imply a nuanced relationship between Medicaid policy and NAS that should be considered in addressing opioid misuse among pregnant women. [ABSTRACT FROM AUTHOR]

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population. [ABSTRACT FROM AUTHOR]

Early and adequate prenatal care is important to the health of Mississippi's mothers and children. Presumptive Eligibility for Pregnant Women is a potential Medicaid policy which would support immediate care for pregnant women. Policies that support Presumptive Eligibility of Pregnant Women may improve access to prenatal care services in Mississippi. [ABSTRACT FROM AUTHOR]

Objectives: Medicaid and the Children's Health Insurance Program (CHIP) provide health insurance coverage to more than 90 million Americans as of early 2023. There is substantial variation in eligibility criteria, application procedures, premiums, and other programmatic characteristics across states and over time. Analyzing changes in Medicaid policies is important for state and federal agencies and other stakeholders, but such analysis requires data on historical programmatic characteristics that are often not available in a form ready for quantitative analysis. Our objective is to fill this gap by synthesizing existing qualitative policy data to create a new data resource that facilitates Medicaid policy research. Data description: Our source data were the 50-state surveys of Medicaid and CHIP eligibility, enrollment, and cost-sharing policies, and budgets conducted near annually by KFF since 2000, which we coded through 2020. These reports are a rich source of point-in-time information but not operationalized for quantitative analysis. Through a review of the measures captured in the KFF surveys, we developed five Medicaid policy domains with 122 measures in total, each coded by state-quarter—1) eligibility (28 measures), 2) enrollment and renewal processes (39 measures), 3) premiums (16 measures), 4) cost-sharing (26 measures), and 5) managed care (13 measures). [ABSTRACT FROM AUTHOR]

Background: Patient affordability is an important nonclinical consideration for treatment access among patients with schizophrenia. Objective: This study evaluated and measured out-of-pocket (OOP) costs for antipsychotics (APs) among Medicaid beneficiaries with schizophrenia. Methods: Adults with a schizophrenia diagnosis, ≥ 1 AP claim, and continuous Medicaid eligibility were identified in the MarketScan® Medicaid Database (1 January 2018–31 December 2018). OOP AP pharmacy costs ($US 2019) were normalized for a 30-day supply. Results were descriptively reported by route of administration [ROA; orals (OAPs), long-acting injectables (LAIs)], generic/branded status within ROAs, and dosing schedule within LAIs. The proportion of total (pharmacy and medical) OOP costs AP-attributable was described. Results: In 2018, 48,656 Medicaid beneficiaries with schizophrenia were identified (mean age 46.7 years, 41.1% female, 43.4% Black). Mean annual total OOP costs were $59.97, $6.65 of which was AP attributable. Overall, 39.2%, 38.3%, and 42.3% of beneficiaries with a corresponding claim had OOP costs > $0 for any AP, OAP, and LAI, respectively. Mean OOP costs per patient per 30-day claim (PPPC) were $0.64 for OAPs and $0.86 for LAIs. By LAI dosing schedule, mean OOP costs PPPC were $0.95, $0.90, $0.57, and $0.39 for twice-monthly, monthly, once-every-2-months, and once-every-3-months LAIs, respectively. Across ROAs and generic/branded status, projected OOP AP costs per-patient-per-year for beneficiaries assumed fully adherent ranged from $4.52 to $13.70, representing < 25% of total OOP costs. Conclusion: OOP AP costs for Medicaid beneficiaries represented a small fraction of total OOP costs. LAIs with longer dosing schedules had numerically lower mean OOP costs, which were lowest for once-every-3-months LAIs among all APs. [ABSTRACT FROM AUTHOR]

A 2015 policy change substantially increased the administrative burden involved in accessing health insurance for Pacific Islander immigrants in Hawaii. We examine the heterogeneous health-care use effects of this policy, which revoked Medicaid eligibility for these migrants and replaced it with access to subsidized private health insurance. Using data on the universe of hospitalizations and emergency room visits in Hawaii, we classify individuals as high or low risk based on their use in a baseline period. We then use a difference-indifferences strategy to estimate the effects of the policy on use, separately for low-risk and high-risk groups. The policy exacerbated health inequality: high-risk individuals experienced larger reductions in total use and larger increases in uninsured use. [ABSTRACT FROM AUTHOR]

Along with the late 1980s Medicaid expansion for pregnant women and children, states implemented multiple reforms to reduce administrative burdens and facilitate access to Medicaid and prenatal care. We use National Vital Statistics birth data from 1985 to 1994 and a difference-in-discontinuities approach to compare the effectiveness of these reforms for improving infant health and access to prenatal care. Results indicate that combinations of reforms to reduce administrative burdens increased Medicaid enrollment and improved infant health nearly as much as Medicaid expansion. In most cases, these reforms yield larger benefits for racially and socioeconomically marginalized mothers, but targeted reforms could better address unequal barriers and further improve equality. Benefits of the reforms are larger in states with more physicians per capita, particularly for marginalized mothers. Overall, results suggest that combined policy responses to reduce multiple burdens at the same time are needed to address unequal barriers. [ABSTRACT FROM AUTHOR]

I study how credit and default affect optimal health insurance, constructing a life‐cycle model of health investment with a strategic default option on emergency room bills and financial debts. The model is calibrated to the U.S. economy and used to compare the optimal policy for Medicaid by the availability of the default option and credit. I find that strategic default induces the optimal policy to be more redistributive. With (Without) the option, the optimal income threshold for Medicaid eligibility is 44% (25%) of the average income. In these findings, the interaction between strategic default and preventative medical spending is important. [ABSTRACT FROM AUTHOR]

Medicaid eligibility expansion, though not directly applicable to children, has been associated with improved access to care in children with cancer, but associations with overall survival are unknown. Data for children ages 0 to 14 years diagnosed with cancer from 2011 to 2018 were queried from central cancer registries data covering cancer diagnoses from 40 states as part of the Centers for Disease Control and Prevention's National Program of Cancer Registries. Difference-in-differences analyses were used to compare changes in 2-year survival from 2011-2013 to 2015-2018 in Medicaid expansion relative to nonexpansion states. In adjusted analyses, there was a 1.50 percentage point (95% confidence interval = 0.37 to 2.64) increase in 2-year overall survival after 2014 in expansion relative to nonexpansion states, particularly for those living in the lowest county income quartile (difference-in-differences  = 5.12 percentage point, 95% confidence interval = 2.59 to 7.65). Medicaid expansion may improve cancer outcomes for children with cancer. [ABSTRACT FROM AUTHOR]

Objective: To inform efforts to improve equity in the quality of behavioral health care by examining income‐related differences in performance on HEDIS behavioral health measures in Medicare Advantage (MA) plans. Data Sources and Study Setting: Reporting Year 2019 MA HEDIS data were obtained and analyzed. Study Design: Logistic regression models were used to estimate differences in performance related to enrollee income, adjusting for sex, age, and race‐and‐ethnicity. Low‐income enrollees were identified by Dual Eligibility for Medicare and Medicaid or receipt of the Low‐Income Subsidy (DE/LIS). Models without and with random effects for plans were used to estimate overall and within‐plan differences in measure performance. Heterogeneity by race‐and‐ethnicity in the associations of low‐income with behavioral health quality were examined using models with interaction terms. Data Collection/Extraction Methods: Data were included for all MA contracts in the 50 states and the District of Columbia that collect HEDIS data. Principal Findings: For six of the eight measures, enrollees with DE/LIS coverage were more likely to have behavioral health conditions that qualify for HEDIS measures than higher income enrollees. In mixed‐effects logistic regression models, DE/LIS coverage was associated with statistically significantly worse overall performance on five measures, with four large (>5 percentage point) differences (−7.5 to −11.1 percentage points) related to follow‐up after hospitalization and avoidance of drug‐disease interactions. Where the differences were large, they were primarily within‐plan rather than between‐plan. Interactions between DE/LIS and race‐and‐ethnicity were statistically significant (p < 0.05) for all measures; income‐based quality gaps were larger for White enrollees than for Black or Hispanic enrollees. Conclusions: Low income is associated with lower performance on behavioral health HEDIS measures in MA, but these associations differ across racial‐and‐ethnic groups. Improving care integration and addressing barriers to care for low‐income enrollees may improve equity across income levels in behavioral health care. [ABSTRACT FROM AUTHOR]

Policy makers are increasingly investing in programs focused on identifying and addressing the nonmedical needs of high-utilizing Medicaid beneficiaries, yet little is known about these programs' implementation. This study provides an overview of early progress in and strategies used to implement California's Whole Person Care (WPC) Pilot Program, a $3 billion Medicaid Section 1115(a) waiver demonstration project focused on improving the integrated delivery of health, behavioral health, and social services for Medicaid beneficiaries who use acute and costly services in multiple service sectors. WPC pilots reported significant progress in developing partnerships, data-sharing infrastructure, and services needed to coordinate care for identified patient populations. We also identified major barriers to WPC implementation, such as difficulty identifying and engaging eligible beneficiaries and the lack of affordable housing. Our findings offer insights to leaders and policy makers interested in testing new approaches for improving the health and well-being of medically and socially complex patients.

Introduction: Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion. Aims: To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark. Methods: Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses. Results: Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups. Conclusions: Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence. [ABSTRACT FROM AUTHOR]

Tropical cyclones (TCs) pose a significant threat to human health, and research is needed to identify high-risk subpopulations. We investigated whether hospitalization risks from TCs in Florida (FL), United States, varied across individuals and communities. We modeled the associations between all storms in FL from 1999 to 2016 and over 3.5 million Medicare hospitalizations for respiratory (RD) and cardiovascular disease (CVD). We estimated the relative risk (RR), comparing hospitalizations during TC-periods (2 days before to 7 days after) to matched non-TC-periods. We then separately modeled the associations in relation to individual and community characteristics. TCs were associated with elevated risk of RD hospitalizations (RR: 4.37, 95% CI: 3.08, 6.19), but not CVD (RR: 1.04, 95% CI: 0.87, 1.24). There was limited evidence of modification by individual characteristics (age, sex, or Medicaid eligibility); however, risks were elevated in communities with higher poverty or lower homeownership (for CVD hospitalizations) and in denser or more urban communities (for RD hospitalizations). More research is needed to understand the potential mechanisms and causal pathways that might account for the observed differences in the association between tropical cyclones and hospitalizations across communities. Tropical cyclones pose a significant threat to human health. Here, authors show associations between tropical cyclones and risk of cause-specific hospitalizations, with elevated risks according to neighborhood-level poverty, homeownership and urbanicity. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of chronic and occasional opioid use and identify risk factors of opioid use among persons with knee osteoarthritis (OA). Methods: We used the Medicare Current Beneficiary Survey to select a knee OA cohort. We obtained data on demographics characteristics, marital status, comorbidities, insurance, and prescription medication coverage from survey data and linked Medicare claims. We included all prescribed medication records classified as opioid under the First Databank therapeutic antiarthritics or analgesics categories. We stratified individuals with knee OA into 3 opioid use groups: 1) nonusers (0 prescriptions/year), 2) occasional users (1–5 prescriptions/year), and 3) chronic users (6+ prescriptions/year). We built multivariable logistic regression models using a generalized estimating equation to determine correlates of chronic opioid use. Results: Among 3,549 Medicare beneficiaries with knee OA and a mean ± SD age of 78 ± 7 years, 68% were female, 9% were chronic users, and 21% used opioids occasionally. Multivariable analysis showed that non‐Hispanic ethnicity (odds ratio [OR] 4.8, 95% confidence interval [95% CI] 2.2–10.2), divorced status (vs. married; OR 2.3, 95% CI 1.5–3.5), Medicaid eligibility (OR 1.9, 95% CI 1.3–2.7), depression (OR 1.9, 95% CI 1.5–2.5), chronic obstructive pulmonary disease (OR 1.9, 95% CI 1.4–2.5), and inability to walk without assistive devices (vs. no difficulty walking; OR 2.4, 95% CI 1.5–3.7) were independently associated with chronic opioid use. Conclusion: A total of 9% of persons with knee OA use opioids chronically. Efforts to find nonopioid regimens for treating knee OA pain should be tailored to patients at high risk for chronic use. [ABSTRACT FROM AUTHOR]

Objective: To examine the limitations of peer grouping and associated challenges measuring social risk in Medicare's Hospital Readmission Reduction Program (HRRP). Under peer grouping, hospitals are divided into quintiles based on the proportion of a hospital's Medicare inpatients with Medicaid ("dual share"). This approach was implemented to address concerns that the HRRP unfairly penalized hospitals that disproportionately serve disadvantaged patients. Data: Public data on hospitals in the HRRP. Design: We examined the relationship between hospital dual share and readmission rates within peer groups; changes in hospitals' peer group assignments, readmission rates, and penalties; and the relationship between state Medicaid eligibility rules and peer groups. Data Collection: Public data on hospital characteristics and readmission rates for 3119 hospitals from 2019 to 2020. Principal Findings: The proportion of dual inpatients among hospitals of the same peer group varied by as much as 69 percentage points (ppt). Within peer groups, a one ppt increase in dual share was associated with a 0.01 ppt increase in the difference from the median readmission rate (p < 0.001). From 2019 to 2020, 8.8% of hospitals switched peer groups. Compared to hospitals that did not switch, those moving to a lower peer group had a higher mean penalty in 2020 (0.096 ppt; p = 0.006); those moving to a higher group had a lower mean penalty (−0.06 ppt; p = 0.079). However, changes in penalties did not correspond to changes in readmission rates. Hospitals in states with higher Medicaid income eligibility limits were more likely to be in higher peer groups. Conclusions: Peer grouping is limited in the extent to which it accounts for differences in hospitals' patient populations, and it may not fully insulate hospitals from penalties linked to changes in patient mix. These problems arise from the construction of peer groups and the measure of social risk used to define them. [ABSTRACT FROM AUTHOR]

Because Medicare beneficiaries can qualify for Medicaid through several pathways, duals who newly enroll in Medicaid may have experienced various financial and/or health changes that impact their Medicaid eligibility. Alternatively, new enrollment could reflect changes in awareness of the program among those previously eligible. Using monthly enrollment data linked to Health and Retirement Study survey data, we examine financial and health changes that occur around the time new Medicaid participants enter the program, and we compare those with changes experienced by both those continuously enrolled in Medicaid and those not enrolled. We find that Medicaid entry is often timed with a marked increase in out-of-pocket medical expenses, a substantial decrease in assets for some, and increases in activities of daily living (ADL) limitations. We also observe financial changes among persons continuously enrolled in Medicaid. Our results inform discussions about Medicaid eligibility policies and potential gaps in the protection that Medicaid offers from financial risk. [ABSTRACT FROM AUTHOR]

Background: Medicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. No studies have used long-run data to assess the recent use of the program by beneficiaries.Objective: To assess patterns of short- and long-term enrollment among beneficiaries, using a 10-year longitudinal panel of Michigan Medicaid eligibility data.Design: Primary analyses assessing trends in Medicaid enrollment among cohorts of existing and new beneficiaries.Setting: Administrative records from Michigan Medicaid for the period 2011 to 2020.Participants: 3.97 million Medicaid beneficiaries.Measurements: Short- and long-term enrollment in the program.Results: The sample includes 3.97 million unique beneficiaries enrolled at some point between 2011 and 2020. Among a cohort of 1.23 million beneficiaries enrolled in 2011, over half (53%) were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period (67%) on Medicaid. These beneficiaries, however, experienced substantial lapses in coverage, as only 25% were continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period.Limitation: Primary estimates from a single state.Conclusion: For many beneficiaries, Medicaid has served as their primary source of coverage for at least a decade. This pattern would justify increasing investments in the program to improve long-term health outcomes.Primary Funding Source: Self-funded. [ABSTRACT FROM AUTHOR]

We examine multigenerational impacts of positive in utero health interventions using a new research design that exploits sharp increases in prenatal Medicaid eligibility that occurred in some states. Our analyses are based on US Vital Statistics natality files, which enables linkages between individuals' early life Medicaid exposure and the next generation's health at birth. We find evidence that the health benefits associated with treated generations' early life program exposure extend to later offspring. Our results suggest that the returns on early life health investments may be substantively underestimated. (JEL I12, I13, I18, I38, J13, J16) [ABSTRACT FROM AUTHOR]

This paper examines the incidence of the cost burden associated with expanding public health insurance to low‐income adults in the context of the Affordable Care Act. Using data from the Medical Expenditures Panel Survey (MEPS), I exploit exogenous variation in Medicaid eligibility rules across states, income groups and time. I find that public insurance eligibility reduced mean out‐of‐pocket spending by 19.6 percent among targeted households, but it did not causally increase total expenditures among beneficiaries. Rather, Medicaid expansion shifted the burden of payment from eligible households and private insurance (21.5 percent reduction) to taxpayers in the form of public insurance (46.6 percent increase). The efficiency of these public funds can be summarized by a mean Marginal Value of Public Funds of 0.70 in the full sample, 0.99 among households with at least one pre‐existing condition, and 1.26 in states with an above‐median number of public hospitals. [ABSTRACT FROM AUTHOR]

Spending on care for cancer patients can be substantial and has continued to increase in recent years. Radiation treatments (RT) are a vital component of cancer care, and as alternative payment models are being employed and more advanced RT modalities are utilized, more information is needed regarding variation in RT spending. We aimed to describe trends in RT spending over time and identify potential drivers of practice-level variation in spending. Using 2009-2020 national Medicare claims, we identified patients with cancer enrolled in fee-for-service Medicare undergoing RT and examined RT-specific spending during the 90 days following RT initiation. The unit of analysis was a 90-day RT episode triggered by RT initiation. In unadjusted analyses, we summed RT-specific episode standardized spending by cancer type over time. RT episodes were categorized by type of technology (2D/3D conventional, intensity-modulated, stereotactic, proton, brachytherapy) based on the majority of fractions within the 90-day episode. We characterized variation in practice-level RT-specific spending and assessed the extent to which variation was explained by patient demographic and clinical factors and geographic region. We estimated linear regression models that included random effects for each practice to understand practice-level variation in standardized RT-specific spending and sequentially added variables to control for year, patient demographic and clinical characteristics (sex, race and ethnicity, Medicaid eligibility, cancer type, and patient risk based on Hierarchical Condition Categories), and hospital referral region. From 2009-2020, 1,898,864 beneficiaries with cancer initiated 2,149,385 90-day RT episodes at 2,150 practices. Mean (standard deviation) RT-specific spending for a 90-day episode was $13,683 ($8,628). RT-specific per-episode spending increased over time ($12,978 in 2009 to $13,689 in 2020), while the median number of fractions per episode decreased (25 in 2009, 16 in 2020). The proportion of RT episodes of intensity-modulated RT, stereotactic RT, and proton RT increased, while use of 2D/3D conventional RT decreased. Use of brachytherapy remained stable. Practice-level per-episode spending variation (standard deviation $2,882) remained high even after adjusting for patient demographic and clinical characteristics and geographic region. 90-day RT per-episode spending has increased over time. We identified substantial variation in practice-level RT per-episode spending for cancer patients that is not strongly driven by patient characteristics or geographic region. Further investigations are needed to elucidate practice-level factors associated with spending, as alternative payment models in oncology care typically are implemented at the practice level. [ABSTRACT FROM AUTHOR]