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Policy PointsWe examined the effect of the Paid Family Leave policy (PFL) and Paid Sick Leave policy (PSL) on care provision to older parents.We found that PSL adoption led to an increase in care provision, an effect mainly attributable to respondents in states/periods when PSL and PFL were concurrently offered. Some of the strongest effects were found among women and unpartnered adult children.PFL adoption by itself was not associated with care provision to parents except when PFL also offered job protection.Paid leave policies have heterogeneous effects on eldercare and their design and implementation should be carefully considered. Context: Family caregivers play a critical role in the American long‐term care system. However, care responsibilities are known to potentially conflict with paid work, as about half of family caregivers are employed. The federal Family and Medical Leave Act passed by the US Congress in 1993 provides a nonuniversal, unpaid work benefit. In response, several states and localities have adopted the Paid Family Leave policy (PFL) and Paid Sick Leave policy (PSL) over the last two decades. Our objective is to examine the effect of these policies on the probability of personal care provision to older parents. Methods: This study used longitudinal data from the Health and Retirement Study (1998‐2020). Difference‐in‐differences regression models were estimated to examine associations between state‐ and local‐level PFL and PSL mandates and personal care provision to older parents. We analyzed heterogeneous effects by the type of paid leave exposure (provision of job protection with PFL and availability of both PSL and PFL [with or without job protection] concurrently). We also examined results for different population subgroups. Findings: PSL implementation was associated with a four‐ to five‐percentage point increase in the probability of personal care provision. These effects were mainly attributable to respondents in states/periods when PSL and PFL were concurrently offered. The strongest effects were found among adult children who were employed at baseline, women, younger, unpartnered, and college educated. PFL implementation by itself was not associated with care provision to parents except when the policy also offered job protection. Conclusions: Paid leave policies have heterogeneous impacts on personal care provision, potentially owing to differences in program features, variation in caregiving needs, and respondent characteristics. Overall, the results indicate that offering paid sick leave and paid family leave, when combined with job protection, could support potential family caregivers. [ABSTRACT FROM AUTHOR]

Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states' expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states. [ABSTRACT FROM AUTHOR]

The article offers information on the development of a model for Medicaid Managed Care (MMC) enacted by Kentucky in 2021 designed to avoid a complete reversal of the Medicaid drug benefit from an MMC model to a purely Medicaid fee-for-service (FFS) model. Topics covered include how the pharmacy benefit manager (PBM) reform legislation disrupted the vertically aligned PBM industry, a summary of the PBM reform elements, and the goal of the model to preserve the intent of the 340B program.

Context: Previous studies show that nonprofit hospital spending on charity care declined in Medicaid expansion states. We test whether state community benefit regulations mitigated the decline in charity care spending. Methods: We use a fixed effects model to evaluate the association between state regulations and nonprofit hospital community benefit spending and its subcategories as a share of total expenses in Medicaid expansion states. We obtained community benefit spending data from the Internal Revenue Service Form 990 Schedule H filings of 1,738 hospitals in 44 states and the District of Columbia from 2010 to 2017. We determine the stringency of state regulations by comparing the provisions of state and federal requirements based on regulation information compiled by the Hilltop Institute. Findings: State minimum community benefit requirements are associated with increased community benefit and charity care spending by nonprofit hospitals in Medicaid expansion states. Conclusions: States that imposed minimum community benefit requirements on nonprofit hospitals did not experience a decline in charity care spending after Medicaid expansion. The results suggest state minimum community benefit rules may expand the provision of community benefit and charitable care spending. [ABSTRACT FROM AUTHOR]

The article discusses that Medicaid expansion falls within adaptive accumulation in which profit streams can be secured. It presents a policy case in which the neoliberal image of an increasingly minimalist government should be modified as corporate players and state actors seek an enlargement of the healthcare domain. It focuses on the rules of reproduction for social actors, which affect the political party's historical disposition to bipartisanship, social inclusion, and social policy.

As the United States' largest public health insurance program, Medicaid has since 1965 played a crucial role in the struggle for equitable health care access. It has the potential to be a powerful instrument of reproductive justice, yet discriminatory policies that deny coverage for vital sexual, reproductive, or other health services, or exclude entire populations of people with low incomes from coverage altogether, constrain peoples' health and reproductive futures. Resulting discrimination in Medicaid law and policy thwart the program's ability to promote intergenerational health equity and reproductive justice for underserved communities. This Article provides an account of why reproductive justice is a necessary framework for examining, reimagining, and reforming Medicaid coverage law and policy. Part I gives a brief history and overview of reproductive justice, which serves as "an open source code that people have used to pursue fresh critical thinking regarding power and powerlessness." Part II argues that we should utilize that open source code in Medicaid coverage reform. Using some of the reproductive justice movement's critiques as a starting point, it explores how reproductive oppression has shaped Medicaid coverage law, policy, and mainstream reproductive and health care reform movements' proposals, and to what effect. It argues that examining Medicaid law, policy, and proposed reforms through this lens and in collaboration with the reproductive justice movement can enable health advocates and policymakers to more fully understand, disrupt, and dismantle reproductive injustices that drive health inequities. Ultimately, it can empower reformers to build a more equitable public health insurance safety net that brings us closer to reproductive justice for all. [ABSTRACT FROM AUTHOR]

Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY. Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 – Dec 31, 2019) and post-policy changes (Apr 1, 2020 – Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation. The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55–0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period. LAI-bup access, utilization, and retention increased after several policy changes. [Display omitted] • Policies around the treatment of opioid use disorder (OUD) changed in 2020. • Long-acting injectable buprenorphine (LAI-bup) for OUD is underutilized. • Kentucky removed prior authorization (PA) requirements for LAI-bup in April 2020. • Utilization of LAI-bup doubled in the period after policy changes took effect. • For people initiating LAI-bup, discontinuation rates improved after April 2020. [ABSTRACT FROM AUTHOR]

Using the 2008–2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58–0.66]) and IDD waivers (0.65; [0.64–0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD. [ABSTRACT FROM AUTHOR]

A growing majority of Americans support the implementation of a national single-payer healthcare program, also known as Medicare for All, which would shift payments for healthcare services to a single public payer and provide care based on need rather than ability to pay. However, legislators, scholars, and advocates have suggested state governments rather than the federal government should take the lead by implementing state-based single-payer programs. Dozens of single-payer proposals have been introduced in state legislatures across the country, and proposed legislation in Congress would remove the federal roadblocks to state-based single-payer's implementation. Proponents of state-based single-payer rely on the conventional wisdom that states--as the storied "laboratories of democracy"--can prove the concept of single-payer to other states, who will adopt it in time. But, in taking the "laboratories of democracy" theory at face value, advocates of state-based single-payer ignore a number of realities fatal to the assumption that universal healthcare will come from the states. This Article argues state-based single-payer is not a stepping stone to health justice or the implementation of national single-payer and that it is, rather, a stumbling block that will worsen health inequities in the United States and ultimately make the implementation of a national single-payer system even less likely than it is now. In order to demonstrate this, I analyze the history of state government experimentation in healthcare to conclude the laboratories of democracy theory has been tested in the healthcare domain and failed, harming the nation's most vulnerable and historically oppressed people. Using the example of the Affordable Care Act Medicaid expansion, I discuss the historic and present antidemocratic state government resistance to programs that promote health justice, particularly when those programs would increase healthcare access for poor people and people of color. Furthermore, I employ a political theory analysis to conclude state-based single-payer is not an acceptable policy for the federal government to promote under a health justice framework. This is because the implementation of state-specific single-payer programs will worsen health disparities by weakening the bargaining power of existing federal programs such as Medicare and Medicaid and by fracturing a growing constituency in favor of single-payer, chilling popular momentum toward a national single-payer program. [ABSTRACT FROM AUTHOR]

Context: Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems. Methods: We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana. which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation. Findings: Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid. Conclusions: Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges. [ABSTRACT FROM AUTHOR]

Since its inception in 2010, the Concurrent Care for Children Provision of the Affordable Care Act has enabled seriously ill pediatric patients and their families to access comprehensive, supportive hospice services while simultaneously receiving ongoing treatment-directed therapies. Although this groundbreaking federal legislation has resulted in improvements in care for vulnerable pediatric patients, the implementation of the law has varied from state to state through Medicaid programming. The pediatric professional community is called to consider how Medicaid services can more effectively be delivered by leveraging legislative mandates and collaborative relationships between clinicians, Medicaid administrators, and policy makers. In this article, we examine ways concurrent care has been executed in 3 different states and how key stakeholders in care for children with serious illness advocated to ensure effective implementation of the legislation. The lessons learned in working with state Medicaid programs are applicable to any advocacy issue impacting children and families [ABSTRACT FROM AUTHOR]

An estimated 580 000 people experienced homelessness on any single night in the United States in 2020. This article argues that, to address these persons' unmet needs, Medicaid should collaborate with clinicians and state programs to provide permanent supportive housing and housing support services to individuals experiencing homelessness. Access to shelter can improve health outcomes for individuals experiencing homelessness and reduce overall health care costs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate Medicaid insurance access disparities for urologic care at urgent care centers (UCCs) in the United States.Materials and Methods: We conducted a cross-sectional study using a "secret shopper" methodology. We sampled 240 UCCs across 8 states. Using a standardized script, researchers posed as a patient with either Medicaid or commercial insurance in the clinical setting of obstructing nephrolithiasis. The primary study endpoint was whether a patient's insurance (Medicaid vs commercial) was accepted. We assessed factors associated with Medicaid acceptance using logistic regression models adjusted for state-level and facility-level characteristics. Additionally, we calculated triage rates, emergency department referral rates, and the ability of a UCC to refer the patient to a specialist.Results: Of 240 UCCs contacted, 239 (99.6%) accepted commercial insurance and 159 (66.2%) accepted Medicaid. UCCs in Medicaid expansion states more frequently accepted patients with Medicaid insurance (74.2% vs 58.3%, respectively, P < .01). On multivariable logistic regression analysis, state Medicaid expansion (OR 1.84, 95% CI 1.04-3.26, P = .04) and affiliation with an institution (OR 2.97, 95% CI 1.59-5.57, P < .01) were independently associated with greater odds of accepting Medicaid. Medicaid-insured patients were significantly less likely to be triaged or referred to the emergency department compared to commercial patients.Conclusion: We identified significant disparities in access to UCCs for Medicaid patients presenting with a urologic condition. Given the expanding national role of UCCs, these findings highlight potential sources of insurance disparity in the context of a urologic emergency. [ABSTRACT FROM AUTHOR]

The article presents a cross sectional study which examined the knowledge differences on postpartum care by Medicaid type recipients amidst the state legislation coverage expansion in Oregon as of October 2021. Also cited are the state law that provides emergency Medicaid (EM) enrollees 60-day coverage for postpartum care, and the vulnerabilities faced by low-income U.S. immigrants in accessing medical care.

The COVID-19 pandemic has laid bare the severe public health danger that institutional and congregate care settings pose to people with disabilities, older adults, and the care professionals who work in those settings. While the populations residing in congregate care settings are naturally more susceptible to the virus, the COVID-19 crisis in these settings could have been far more limited if there had been broader access to home and community-based services (HCBS), which allow people to live with the supports they need in their own homes and communities and avoid many of the health risks of congregate care settings. A major barrier to broadening access to HCBS is existing judicial interpretations of the reasonable modifcations regulation under the Americans with Disabilities Act (ADA). This regulation requires states and other public entities to "make reasonable modifications" to avoid disability- based discrimination (which includes unjustified institutionalization) but does not require measures that would "fundamentally alter" the nature of the entity's programs. Unfortunately, the Supreme Court's 1999 Olmstead v. L.C. decision and subsequent lower court decisions interpreting Olmstead have created a standard for this fundamental alteration defense that fails to fully protect individuals' ADA right to services in an integrated setting and does not account for the public health risks of institutionalization. This Note argues that in light of the new and undeniable evidence from the COVID-19 pandemic of the public health risks of institutionalization, the Department of Justice should use its broad regulatory authority under the ADA to promulgate additional regulations that clarify and strengthen the fundamental alteration framework. [ABSTRACT FROM AUTHOR]

Medicaid presents both legislative and regulatory challenges and opportunities. As it moves a legislative agenda forward, the Biden administration also will confront a series of immediate regulatory matters, some of which have been made urgent because of pending judicial action. Chief among these pressing matters are ending Medicaid work requirements and block grant experiments, rescinding the public charge rule, ensuring optimal use of Medicaid's enrollment and renewal simplification tools, rescinding the Title X family planning rule (which has enormous implications for Medicaid beneficiaries), and, when the time comes, preparing states to wind down the "Families First" Medicaid maintenance of effort protection while avoiding erroneous beneficiary disenrollment. The administration could consider encouraging remaining nonexpansion states to pursue §1115 Medicaid expansion experiments; additionally, the administration could pursue Medicaid pandemic recovery demonstrations to support health system recovery during the long period that lies ahead. Thus, while certain advances must await legislation, the administration can move Medicaid forward through executive action. [ABSTRACT FROM AUTHOR]

Incarcerated people are excluded from Medicaid coverage due to a provision in the Social Security Act Amendments of 1965 known as the Medicaid Inmate Exclusion Policy ("MIEP"). This Article argues for the elimination of the MIEP as an anachronistic remnant of an earlier era prior to the massive growth of the U.S. incarcerated population and the expansion of Medicaid eligibility under the Patient Protection and Affordable Care Act of 2010. It explores three reasons for eliminating the MIEP. First, the inclusion of incarcerated populations in Medicaid coverage would signify the final erasure from the Medicaid regime of the distinction between the "deserving" and "undeserving" poor and is consistent with and in furtherance of the ACA's ultimate goal of universal health insurance coverage. Second, elimination of the MIEP furthers the bipartisan criminal legal system reform focus on reducing recidivism through effective reentry. Current efforts to use Medicaid to facilitate reentry require careful workarounds of the MIEP. Elimination of the policy would reduce logistical hurdles to ensuring continuity of care and enhance rehabilitation services provided during incarceration. Third, eliminating the MIEP coalesces with the goals of the emerging discourse around health justice, and specifically, its focus on how social determinants of health drive inequities. In including a health justice framework, this Article seeks to enrich the discussion in two directions. In the first instance, health justice illuminates structural factors such as discrimination and poverty that are root causes of health inequities and must be addressed alongside immediate health needs. At the same time, this Article aims to deepen the health justice discussion with a sharper focus on the role of incarceration in perpetuating health inequities, and the ways in which extending Medicaid access to incarcerated populations can improve treatment of immediate needs while also addressing structural inequities that cause and are caused by justice system involvement. [ABSTRACT FROM AUTHOR]

The Trump administration's Healthy Adult Opportunity waiver follows a long history of Republican attempts to retrench the Medicaid program through block grants and to markedly reduce federal spending while providing states with substantially greater flexibility over program structure. Previous block grant proposals were promulgated during the presidential administrations of Ronald Reagan and George W. Bush and majorities in Congress led by House Speaker Newt Gingrich and House Budget Committee Chair and then Speaker Paul Ryan. Most recently, Medicaid block grants featured prominently in Republican efforts to repeal and replace the Affordable Care Act. This essay traces the history of Republican Medicaid block grant proposals, culminating in the Trump administration's Healthy Adult Opportunity initiative. It concludes that the Trump administration's attempt to convert Medicaid into a block grant program through the waiver process is illegal and, if implemented, would leave thousands of people without necessary medical care. This fact, combined with failed legislative efforts to block grant Medicaid during the last forty years, highlights the substantial roadblocks to radically restructuring a popular program that helps millions of Americans. [ABSTRACT FROM AUTHOR]

Union resistance to Medicare for All is fading as the employment-based healthcare system collapses but some unionists still believe that their unions will be stronger and more secure if they continue to negotiate basic healthcare benefits for their members. Keywords: health care; labor; neoliberalism; working class; trade unions EN health care labor neoliberalism working class trade unions 70 79 10 06/05/21 20210401 NES 210401 The industrialized world's most unequal and inefficient healthcare system underwent a stress test this past pandemic year and failed miserably. If unions no longer had to bargain for basic health care for their members, monies would be freed up to negotiate real "union advantage" benefits like paid family leave, child and elder care that could help launch a revitalized labor movement. B I A central element of the U.S. healthcare system's catastrophic failure in the face of the pandemic is its linkage to employment. i b As unions in much of the rest of the industrialized world were leading the fight to construct robust publicly funded universal healthcare systems that treated health care as a right available to all, the U.S. labor movement helped to craft a "second best solution" that turned health care into a benefit linked to employment. [Extracted from the article]

John would also surely want to be remembered as a prolific writer of economic songs, including a musical tribute to Alan Manning's book I Monopsony in Motion i (Manning [33]).[2] Getting back to conventions, John is likely best known for his research on the sources of growing inequality in the United States. His early work on implicit contracts with Paul Beaudry (Beaudry and DiNardo [3], [4]) illustrates how workers' wages are often insulated from market shocks, a theme John later pursued in his work on unions. We are pleased to introduce this volume of papers, all of which were presented at a conference in honor of John DiNardo held in Ann Arbor, Michigan, in September 2018.[1] After battling leukemia for close to a decade, John left us on August 26, 2017, at the age of 56. Outside of labor economics, John also wrote some notable papers in political science (Brunell and DiNardo [5]; Walsh, Dolfin, and DiNardo [35]). [Extracted from the article]

This paper evaluates the effect of Medicaid expansions for individuals with disabilities on crime rates and mental health status. Using the FBI's Uniform Crime Reports and the CDC's Behavioral Risk Factor Surveillance System Surveys, I estimate the impact of Medicaid using an event study approach. Results indicate a reduction in crime incidence that was strongest in the years immediately following the expansion and dissipated over time. Estimates also suggest a smaller likelihood of one day of poor mental health within the past month, but this impact was short-lived. Analysis suggests that improved alcohol abuse was not a main explanation for mental health improvements. The analysis cannot eliminate whether improvements to non-alcohol substance abuse treatment, financial strain, or access to treatment for other mental illnesses explain the impact to crime and mental health status. Expanding Medicaid shows a degree of impact on both crime and mental health suggesting several policy considerations. [ABSTRACT FROM AUTHOR]

The article presents the Strengthening the Medicaid Reentry Act that had Supporting the Health of People Who Are Incarcerated.

Approximately 3.4% of Americans have a mental health condition and suicide is the 10th leading cause of death. While the rate of mental health conditions has slightly increased for adult populations, America's youth has experienced a significant rise in depression. From 2008 to 2017, occurrence of depression in the adolescent population increased from 8.3% to 13.3%. As adolescents mature into adults; it is likely the rate of mental health conditions for the adult population will rise as well as it is the common thread that binds the diseases of despair : drug abuse, alcoholism, and suicide. Arising out of the deinstitutionalization movement of the 1960s, the Medicaid Institutions for Mental Disease (IMD) Exclusion Rule (§1905(a)(B) of the Social Security Act) prohibits reimbursement for Medicaid recipients ages 21 to 64 years receiving inpatient care at a psychiatric hospital with 16 or more beds. Consequently, the rule limits payment for psychiatric treatment to general hospitals and smaller, nonspecialized centers, which blocks patients from receiving inpatient care and transfers the financial burden of care onto psychiatric hospitals. The IMD Rule is approaching its 55th anniversary. It requires reevaluation. Although a state waiver process is available, use of this option has the potential to increase the incidence of racial and ethnic disparities across states. Full repeal of the IMD Exclusion Rule could help provide immediate access to inpatient care that is consistent nationwide and be a vital step toward creating financial, treatment and ethical parity for mental health services. [ABSTRACT FROM AUTHOR]

Timely access to Medicaid coverage offers many potential benefits to justice-involved adults reentering the community. In 2015 Indiana's Section 1115 Medicaid waiver (the Healthy Indiana Plan [HIP]) expanded eligibility for low-income adults. To expedite coverage for justice-involved adults, Indiana subsequently improved interagency coordination in two ways. First, the Indiana Department of Correction began initiating Medicaid applications for those in custody. Second, Medicaid began temporarily suspending coverage for people while they were incarcerated instead of discontinuing it. Prison release data from the Indiana Department of Correction linked to Medicaid enrollment data indicate that before HIP was implemented, approximately 9 percent of justice-involved adults received Medicaid coverage within 120 days of release. After HIP implementation, coverage rates increased by 9 percentage points. After both interagency coordination policies were implemented, an additional 29-percentage-point increase in coverage occurred. Furthermore, coverage effective within seven days of release increased by 14 percentage points after the interagency coordination policies went into effect. These findings support the notion that policies and procedures encouraging interagency coordination are beneficial in increasing timely access to Medicaid coverage for justice-involved people. [ABSTRACT FROM AUTHOR]

Many argue that the frustrated implementation of the 2010 Affordable Care Act (ACA) stems from the unprecedented level of political polarization that has surrounded the legislation. This article draws attention to the law's "institutionalDNA" as a source of political struggle in the 50 states. As designed, in the context ofUSfederalism, the lawfractured authority in ways that has opened up the possibility of contestation and confusion. The successful implementation of the ACAvaries not only across state lines but also across the various components of the law. In particular, opponents of the ACA have experienced their greatest successes when they could take advantage of weak preexisting policy legacies, high levels of institutional fragmentation, and negative public sentiments. As argued in this article, the fragmented patterns of health care politics in the 50 states identified in previous research have largely persisted during the Trump administration. Moreover, while Republicans were unsuccessful at repealing the legislation, the administration has taken advantage of its structural deficiencies to further weaken the legislation's capacity to expand access to affordable, quality health insurance. [ABSTRACT FROM AUTHOR]

Background: Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum.Methods: A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria.Results: A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities.Conclusions: Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion. [ABSTRACT FROM AUTHOR]

Objective: To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern U.S. states in which residents have high rates of diabetes.Research Design and Methods: Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50-64 years, the percentage of women, Distressed Communities Index value, and rurality.Results: In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states.Conclusions: ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt. [ABSTRACT FROM AUTHOR]

Objective: This study examines insurance coverage rates among working-age adults with low income and with or without obesity before and after Medicaid expansion under the Affordable Care Act.Methods: Individual-level data on noninstitutionalized and nonpregnant adult participants aged 18 to 64 years with household income below $15,000 from the Centers for Disease Control and Prevention 2006-2017 Behavioral Risk Factor Surveillance System were used. A difference-in-differences design with logistic regression was used to examine the likelihood of insurance coverage before and after Medicaid expansion.Results: Working-age adults (analytic sample N = 316,151) who were white, female, less educated, unemployed, and living in a Medicaid-expansion state were more likely to have insurance coverage. The insurance coverage rate in Medicaid-expanded states in years after expansion increased for both subgroups with and without obesity. However, the increase was slightly lower for the subpopulation with obesity (5.59%, 95% CI: 2.35%-8.83%) compared with the subpopulation without obesity (7.35%, 95% CI: 5.35%-9.34%).Conclusions: Increased attention should be paid to reduce insurance coverage barriers for working-age adults with low income and obesity to address potential health disparities caused by lack of access to care. This is important, as access to care provides opportunities to increase prevention and treatment-oriented services to address obesity and associated health care costs. [ABSTRACT FROM AUTHOR]

Objective: To quantify the effects of the Affordable Care Act Medicaid expansion on prescriptions for effective breast cancer hormonal therapies (tamoxifen and aromatase inhibitors) among Medicaid enrollees.Data Source/study Setting: Medicaid State Drug Utilization Database (SDUD) 2011-2018, comprising the universe of outpatient prescription medications covered under the Medicaid program.Study Design: Differences-in-differences and event-study linear models compare population rates of tamoxifen and aromatase inhibitor (anastrozole, exemestane, and letrozole) use in expansion and nonexpansion states, controlling for population characteristics, state, and time.Principal Findings: Relative to nonexpansion states, Medicaid-financed hormonal therapy prescriptions increased by 27.2 per 100 000 nonelderly women in a state. This implies a 28.8 percent increase from the pre-expansion mean of 94.2 per 100 000 nonelderly women in expansion states. The event-study model reveals no evidence of differential pretrends in expansion and nonexpansion states and suggests use grew to 40 or more prescriptions per 100 000 nonelderly women 3-5 years postexpansion.Conclusions: Medicaid expansion may have had a meaningful impact on the ability of lower-income women to access effective hormonal therapies used to treat breast cancer. [ABSTRACT FROM AUTHOR]

Objective: To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.Data Sources: State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.Study Design: The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.Principal Findings: Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).Conclusions: Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates.Data Sources: Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid.Study Design: This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates.Principal Findings: The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance.Conclusions: Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access. [ABSTRACT FROM AUTHOR]

Objective: To examine the associations between Medicaid expansion and nurse staffing ratios and hospital-wide readmission rates.Data Sources: Secondary data from the 2011-2016 Healthcare Cost Report Information System, the American Hospital Association Annual Survey, and the Hospital Compare data.Study Design: Difference-in-difference models are used to compare outcomes in hospitals located in states that expanded Medicaid with those located in nonexpansion states. The changes in nurse staffing ratios and hospital-wide readmission rates are calculated in each one of the postexpansion years (2014, 2015, and 2016), compared to pre-expansion.Principal Findings: Results indicate that nurse staffing ratios increased, whereas hospital-wide readmission rates declined in expansion states relative to nonexpansion states. Nurse staffing ratios increased by 0.33, 0.42, and 0.46 registered nurses hours per adjusted patient days in 2014, 2015, and 2016 in hospitals located in expansion states, compared with hospitals in nonexpansion states after expansion. This increase was statistically significant (P < .001) in 2015 and 2016, but marginally significant (P = .016) in 2014. Hospital-wide readmission rates statistically significantly decreased by 9, 16, and 18 per 10 000 patients (P < .001) in 2014, 2015, and 2016, respectively, in expansion vs nonexpansion states hospitals after expansion.Conclusions: Medicaid expansion was associated with gradually improved hospitals' nurse staffing ratios and hospital-wide readmission rates from 2014 through 2016. The continued monitoring of quality measures of hospitals can help assess the impact of Medicaid expansion over a longer period of time. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the effect of Medicaid expansion under the Affordable Care Act (ACA) on the frequency and payment source for Emergency Department (ED) visits for dental care.Study Design: Retrospective, quasi-experimental study.Data Sources/study Setting: We used the State Emergency Department Database to compare changes in ED visit rates and payment source for dental conditions among patients from 33 states. These states represent four distinct policy environments, based on whether they expanded Medicaid and whether their Medicaid programs provide dental benefits. We first assessed the number of ED dental visits before (2012) and after (2014) the ACA. Then, we used differences-in-differences regression to estimate changes in insurance for dental visits by nonelderly adults.Principal Findings: Our sample contained 375 944 dental ED visits. In states that expanded Medicaid and offered dental coverage, dental ED visits decreased by 14.1 percent (from 19 443 to 16 709, for a net difference of 2734). By contrast, in the remaining three state groups, dental ED visits rose. Meanwhile, the expansion significantly increased Medicaid coverage and decreased the rate of self-pay for ED dental visits.Conclusions: Medicaid expansion, combined with adult dental coverage in Medicaid, was associated with a reduction in ED utilization for dental visits. [ABSTRACT FROM AUTHOR]

Purpose: We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion.Methods: We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county.Results: Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees.Conclusions: In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees. [ABSTRACT FROM AUTHOR]

Objective: To test whether Medicaid expansion is associated with (a) a greater number of naloxone prescriptions dispensed and (b) a higher proportion of naloxone prescriptions paid by Medicaid.Data Sources/study Setting: We used the IQVIA National Prescription Audit to obtain data on per state per quarter naloxone prescription dispensing for the period 2011-16.Study Design: In this quasi-experimental design study, the impact of Medicaid expansion on naloxone prescription dispensing was examined using difference-in-difference estimation models. State-level covariates including pharmacy-based naloxone laws (standing/protocol orders and direct authority to dispense naloxone), third-party prescribing laws, opioid analgesic prescribing rates, opioid-involved overdose death rates, and population size were controlled for in the analysis.Principal Findings: Medicaid expansion was associated with 38 additional naloxone prescriptions dispensed per state per quarter compared to nonexpansion controls, on average (P = .030). Also, Medicaid expansion resulted in an average increase of 9.86 percent in the share of naloxone prescriptions paid by Medicaid per state per quarter (P < .001).Conclusions: Our study found that Medicaid expansion increased naloxone availability. This finding suggests that it will be important to consider naloxone access when making federal- and state-level decisions affecting Medicaid coverage. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of Section 1115 waivers on Medicaid coverage and opioid agonist therapy (OAT) utilization among substance use treatment admissions.Data Source: Treatment Episode Data Set-Admissions (TEDS-A) (2001-2012).Study Design: We examined effects of 1115 waiver implementation on proportions of substance use treatment admissions with Medicaid and receiving OAT, using random intercept linear regression.Principal Findings: 1115 waiver implementation was associated with an average of a 6 percentage point increase in proportion of all admissions with Medicaid, and 4 percentage point increase among opioid outpatient admissions. Implementation was not associated with change in proportion of opioid outpatient admissions receiving OAT.Conclusions: 1115 waivers influence Medicaid coverage among substance use treatment admissions. The findings improve our understanding of how state policies impact substance use treatment utilization. [ABSTRACT FROM AUTHOR]

Context: In contrast to the Affordable Care Act, some have suggested the opioid epidemic represents an area of bipartisanship. This raises an important question: to what extent are Democrat-led and Republican-led states different or similar in their policy responses to the opioid epidemic? Methods: Three main methodological approaches were used to assess state-level policy responses to the opioid epidemic: a legislative analysis across all 50 states, an online survey of 50 state Medicaid agencies, and in-depth case studies with policy stakeholders in five states. Findings: Conservative states pursue hidden and targeted Medicaid expansions, and a number of legislative initiatives, to address the opioid crisis. However, the total fiscal commitment among these Republican-led states pales in comparison to states that adopt the ACA Medicaid expansion. Because the state legislative initiatives do not provide treatment, these states spend substantially less than states with Democratic control. Conclusions: Rather than persistently working to retrench all programs, conservatives have relied on policy designs that emphasize devolution, fragmentation, and inequality to both expand and retrench benefits. This strategy, which allocates benefits differentially to different social groups and obfuscates responsibility, allows conservatives to avoid political blame typically associated with retrenchment. [ABSTRACT FROM AUTHOR]

The article presents a health care report on The Affordable Care Act (ACA) at 10 years and its coverage and access provisions. Topics include core provisions and their implememntation of the law; increasing the number of insured Americans through federal subsides; and effects of coverage expansions and reforms.

The article analyzes the various developments in estate recovery programs in U.S. states. Also cited are the use of these programs to fund Medicaid, the provisions of the Omnibus Budget Reconciliation Act of 1993 about Medicaid programs, and the expanded estate recovery laws enacted by states like California.