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Most US workers have health insurance plans sponsored and subsidized by their employers. The US Affordable Care Act (ACA) improved and expanded the availability of non-employer-based health insurance, with protections for pre-existing conditions, guaranteed issue, and community rating in non-group markets. Using National Health Interview Survey data for 2009 to 2018 and a difference-in-differences modeling approach, this study finds that the ACA increased self-employment in 2015 and 2016 among US adults with higher demand for health insurance. The probability of self-employment increased by 1.4 to 1.8 percentage points among adults ages 30 to 64 with at least one pre-ACA declinable condition and no alternative source of health insurance through a spouse's employer or public programs. However, these effects were short-lived. As uncertainty about the long-term viability of the ACA's health insurance exchanges increased in 2017 and 2018, the probability of self-employment among individuals with high demand for insurance fell to pre-ACA levels. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: The Affordable Care Act required private insurers to cover a set of recommended preventive services without cost-sharing. This included coverage of fluoride varnish (FV) applications without cost-sharing for children aged 1 through 5 during medical visits, an evidence-based treatment that prevents tooth decay. We examined if this coverage mandate was associated with more young children receiving FV. METHODS: Using the Massachusetts All-Payer Claims Database (2014-2018), we examined the likelihood that a privately insured child received FV during a medical visit in a month. We used a difference-in-differences approach, comparing those included in the coverage mandate (aged 1-5) to those excluded from the mandate (aged 6-9), before and after the mandate was enacted (January 2015). We repeated analyses in children with Medicaid because this mandate may have had spillover effects for this population. RESULTS: Among children aged 1 through 5 years with private insurance, 1-year postmandate the probability of FV receipt in a month increased 0.16 percentage points more relative to December 2014 (premandate) compared with the change among children aged 6 to 9 years (P < .001; 95% confidence interval 5 0.1-0.22). When examining spillover to children with Medicaid, the mandate was not associated with a significant increase in the probability of monthly FV receipt 1-year postmandate. CONCLUSIONS: This Affordable Care Act mandate requiring coverage of FV without cost-sharing was associated with higher rates of young children receiving FV in medical settings, with the largest result observed among children with private insurance. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. Methods: The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. Results: There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42–1.81, p < 0.001) compared to California. Conclusion: There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients. [ABSTRACT FROM AUTHOR]

Introduction: The Affordable Care Act (ACA) aimed to expand Medicaid, enhance health care quality and efficiency, and address health disparities. These goals have potentially influenced medical care, notably revascularization rates in patients presenting with chronic limb-threatening ischemia (CLTI). This study examines the effect of the ACA on revascularization vs amputation rates in patients presenting with CTLI in Maryland. Methods: This was a retrospective analysis of the Maryland State Inpatient Database comparing the rate of revascularization to rate of major amputation in patients presenting with CLTI over 2 periods: pre-ACA (2007-2009) and post-ACA (2018-2020). In this study, we included patients presenting with CLTI and underwent a major amputation or revascularization during that same admission. Using regression analysis, we estimated the odds of revascularization vs amputation pre- and post-ACA implementation, adjusting for pertinent variables. Result: During the study period, 12,131 CLTI patients were treated. Post-ACA, revascularization rate increased from 43.9% to 77.4% among patients presenting with CLTI. This was associated with a concomitant decrease in the proportion of CLTI patients undergoing major amputation from 56.1% to 22.6%. In the multivariate analysis, there was a 4-fold odds of revascularization among patients with CLTI compared to amputation (OR = 4.73, 95% CI 4.34-5.16) post-ACA. This pattern was seen across all insurance groups. Conclusion: The post-ACA period in Maryland was associated with an increased revascularization rate for patients presenting with CLTI with overall benefits across all insurance types. [ABSTRACT FROM AUTHOR]

The article discusses the evolution of pharmacists from being seen as mere dispensers to becoming innovative clinical health care providers. It highlights legislative milestones that have empowered pharmacists to expand their roles in patient care, such as the passage of the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act. The text also explores innovative clinical services that pharmacists can provide, including remote patient monitoring, pharmacogenomics, and annual wellness visits. Pharmacists are increasingly recognized as essential health care providers, with opportunities to bill for their services under Medicare Part B Incident to Billing regulations. [Extracted from the article]

Objective Data Sources and Study Setting Study Design Data Collection Principal Findings Conclusions To examine how private Medicare Advantage (MA) plans responded to slower growth in federal payments after the Affordable Care Act (ACA).We used publicly available data from the Centers for Medicare and Medicaid Services on MA plan subsidies (“benchmarks”), asking prices (“bids”), plan premiums, cost‐sharing, and covered benefits. Data covered all counties with MA plans between 2006 through 2019.We examined plan responses to changes in benchmark subsidies by comparing changes in bids, rebates, and other outcomes between counties experiencing larger changes in benchmarks and counties with smaller changes, pre‐ and post‐ACA. We used longitudinal fixed effects regression models to assess heterogeneity in how plans adjusted premiums and benefits across more and less competitive markets.Analyses included all counties with at least one MA plan available to individual beneficiaries. Plans targeting special populations were excluded.Average plan benchmarks fell by $89 per month post‐ACA, adjusted for inflation. Plans responded similarly to benchmark subsidy decreases and increases, increasing bids by 62 cents for every dollar increase in subsidies pre‐ACA (95% confidence interval [CI]: 0.56 to 0.67) and decreasing them by 57 cents for every dollar reduction in subsidies post‐ACA (95% CI: 0.49–0.65). However, post‐ACA, plans altered less salient benefits, such as cost‐sharing, by about twice as much as they had pre‐ACA. Premiums changed by similar amounts before and after the ACA (−$0.07, 95% CI: from −$0.09 to −$0.06). Plans in more competitive markets responded less to payment changes than plans did in less competitive markets, suggesting the former are operating closer to marginal costs. Finally, payments to plans declined far less than projected due in part to other changes in MA policy.Plans used partial pass‐through of benchmark subsidy decreases to shield beneficiaries from cuts and allocated benchmark decreases to benefits that were less salient to the average enrollee. These findings, combined with higher‐than‐projected payments post‐ACA, may explain the continued growth in MA enrollment. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Plain Language Summary The Patient Protection and Affordable Care Act (ACA) allowed Americans aged 19–25 years to remain on their parents' health insurance plans until age 26 years (the Dependent Care Expansion [DCE]). Have those with cancer diagnoses benefited?The ACE DCE 7‐year age range of 19–25 years was compared for changes in cancer survival and mortality before and after enactment of the ACA with groups that were younger and older (in 7‐year age spans: ages 12–18 and 26–32 years, respectively). Cancer death data for the entire United States were obtained from the Centers for Disease Control and Prevention, and relative survival data of patients who were diagnosed with cancer were obtained from the National Cancer Institute Surveillance, Epidemiology, and End Results regions representing 42%–44% of the country.Joinpoint analysis identified the DCE‐eligible cohort as the only age group of the three groups evaluated that have had improvements in both cancer survival and death rate trends after ACA implementation and that 2010, the year the ACA was passed, was the inflection year for both survival and deaths. By 6 years, the relative survival after cancer diagnosis was 2.6 and 3.9 times greater in the DCE‐eligible age group than in the younger and older control groups, respectively (both p < .001), and the cancer death rate in the DCE‐eligible age group improved 2.1 and 1.5 times greater than in the younger and older control age groups, respectively (both p < .01).During the first decade of the ACA, eligible young adults with cancer have had significantly improved survival and mortality. Additional policies expanding insurance coverage and enabling earlier cancer diagnosis among young adults are needed. The Patient Protection and Affordable Care Act (ACA) Dependent Care Expansion (DCE) that began in the United States in 2011 allowed young adults aged 19–25 years to remain on their parents' health insurance plans until age 26 years. The survival rate at 6 years in young adult patients diagnosed with cancer was 2.6 to 3.9 times greater in the DCE‐eligible age group compared with the younger and older age groups, and the rate of deaths from cancer improved 1.5 to 2.1 times more. During the first decade of the ACA, young adults with cancer who were in the eligible group had significantly longer survival and reduced deaths from cancer. Additional policies that expand insurance coverage and allow the diagnosis of cancer sooner are needed in young adults. The Patient Protection and Affordable Care Act (ACA) Dependent Care Expansion (DCE) that began in the United States in 2011 allowed young adults aged 19–25 years to remain on their parents' health insurance plans until age 26 years.The survival rate at 6 years in young adult patients diagnosed with cancer was 2.6 to 3.9 times greater in the DCE‐eligible age group compared with the younger and older age groups, and the rate of deaths from cancer improved 1.5 to 2.1 times more.During the first decade of the ACA, young adults with cancer who were in the eligible group had significantly longer survival and reduced deaths from cancer.Additional policies that expand insurance coverage and allow the diagnosis of cancer sooner are needed in young adults. [ABSTRACT FROM AUTHOR]

In the current United States economy, wellness is predominantly marketed to society’s privileged individuals, catering to a mostly white and high-income clientele. When marginalized communities encounter wellness services, such as in the workplace, they are faced with an implicitly biased industry. These biases include an emphasis on individual behavior change without considering social determinants of health (SDOH), cultural appropriation of wellness activities for capitalistic gain, use of biased health measures like Body-Mass Index (BMI), and constant images of and expectations of achieving a stereotypical healthy body. The legal community must wake up to these biases and advocate for more equitable wellness services. Wellness-Legal Partnerships (WLPs) are one type of tool that lawyers can use to address inequities baked into current workplace wellness programming. Specifically, lawyers can create WLPs through existing Employee Assistance Programs (EAPs) at Certified B Corporations to address SDOH. Part I of this paper explores the current state of the wellness industry and how the biases of emphasizing individual behavior, cultural appropriation of wellness activities, use of BMI and broadcasting the stereotypical healthy body image adversely impact historically marginalized people. Part II examines workplace wellness programs and how those programs not only incorporate the biases prevalent in the wider wellness industry, but how workplace wellness laws under the Affordable Care Act (ACA) and the Americans with Disabilities Act (ADA) arguably encourage them to do so. Part III explores the history and legal framework of EAPs and their current use by employers and employees. Part III introduces the concept of WLPs by describing the WLP role model, Medical-Legal Partnerships (MLPs) and how WLPs can adopt many of the same MLP concepts and apply them to workplace wellness programs. Then, this Part offers a roadmap on how to start implementing WLPs in workplace wellness programs to demonstrate how these partnerships can not only address SDOH faced by employees, but also offer broader advocacy services by lawyers dedicated to addressing the multiple biases that currently exist in wellness services. [ABSTRACT FROM AUTHOR]

Over 10 million uninsured individuals are eligible for subsidized health insurance coverage through the Affordable Care Act (ACA) marketplaces, and millions more were projected to become eligible with the end of the federal COVID-19 Public Health Emergency in 2023. Individual studies on behaviorally informed interventions designed to encourage enrollment suggest that some are more effective than others. This study summarizes evidence on the efficacy of these interventions and suggests which administrative burdens might be most relevant for potential enrollees. Published and unpublished studies were identified through a systematic review of studies assessing the impact of behaviorally informed interventions on ACA marketplace enrollment from 2014 to 2022. Thirty-four studies comprising over 18 million participants were included (32 randomized controlled trials and 2 quasiexperimental studies). At the time of data extraction, 8 were published. Twenty-seven of the studies qualified for inclusion in a meta-analysis, which found that the average rate of enrollment was about 1 percentage point higher for those who received an intervention (0.009, P < 0.001), a 24% increase relative to control households; for every 1000 people who receive an intervention, that would correspond to about 9 additional enrollees. When stratifying by intervention intensity, support-based interventions increased enrollment by 2 percentage points (0.020, P = 0.004), while information-based interventions increased enrollment by 0.6 percentage points (0.006, P < 0.001). The meta-analysis found that behaviorally informed interventions can increase ACA marketplace enrollment. Interventions aimed at alleviating compliance costs by providing enrollment support were about three times as effective as information alone. [ABSTRACT FROM AUTHOR]

For almost five decades, the development and implementation of integrated care—the simultaneous combination of primary care with mental health and substance use care—has been a major challenge for the behavioral health care field. Integrated care is exceptionally important because many people with behavioral health conditions also have chronic physical health conditions. Early research findings in the mid-1980s showed that persons with mental illness are likely to develop chronic physical conditions earlier and more severely than other people. These findings precipitated efforts to understand this problem and to develop further appropriate integrated care solutions. Subsequently, the US Surgeon General made care integration a major focus of his landmark 1999 Report on Mental Health, as did the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Patient Protection and Affordable Care Act. However, it was not until 2014, and later, that integrated care actually began to be implemented more broadly. This article reviews these major developmental milestones, examines current activities, and explores likely developments over the next several years. Major current issues include the response to the COVID-19 pandemic, adjusting to its effects on the behavioral health care workforce, and the growing realization that behavioral health care must address the social determinants of life. Likely developments over the next several years will include devising ways to address our workforce crisis, developing effective community interventions, and implementing population health management strategies; implementing the CMS Innovation in Behavioral Health Model; improving reimbursement practices; and exploring the potential of AI for integrated care. Implications for future service organization and training of behavioral health care providers also are discussed. Granted the severity of the current workforce crisis in behavioral health care, urgent efforts are needed to advance the deployment of integrated care in the short-term future. [ABSTRACT FROM AUTHOR]

To examine Medicaid-insurance acceptance at facilities treating urologic cancers following implementation of the Affordable Care Act (ACA). We conducted a retrospective, longitudinal study with a pre-post design. We accessed 2010-2017 data from the National Cancer Database, calculating the facility-level change in proportion of urologic cancer patients with Medicaid following implementation of the ACA. We used multivariable logistic regression to assess baseline clinical and demographic factors associated with changes in the proportion of patients at a facility insured through Medicaid. We identified 630 facilities, including 287 in Medicaid expansion states and 343 in non-expansion states associated with 436,082 urologic cancer patients. The mean facility-level change in proportion of patients with Medicaid was + 5.8% (95% CI 5.0%-6.5%) in expansion states versus + 0.6% (95% CI 0.2%-0.9%) in non-expansion states. There were 179 facilities that experienced a decrease in the post-ACA period, representing 13.6% of facilities in expansion states and 40.8% in non-expansion states (P <.001). Factors associated with a decrease in proportion of urologic cancer patients insured by Medicaid included non-expansion state status (OR 8.9, 95% CI 5.3-15.6, P <.001), higher baseline proportion of patients with Medicaid (highest quartile vs lowest: OR 4.6, 95% CI 2.3-9.4, P <.001) and high-income zip code (highest vs lowest quartile: OR 3.1, 95% CI 1.5-6.6, P <.001). Urologic cancer care for Medicaid-insured Americans remains unevenly distributed across cancer care centers, even in states that expanded coverage. Our findings suggest that this variation may reflect the effort of some facilities to reduce their financial exposure to increased numbers of Medicaid patients in the wake of ACA-supported state expansions. [ABSTRACT FROM AUTHOR]

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Before 2010, violators of the Anti-Kickback Statute (AKS) could avoid False Claims Act (FCA) liability if claims for items or services borne of their kickback scheme were submitted to federal healthcare programs by a third party. In 2010, as part of the Affordable Care Act (ACA), Congress attempted to close this loophole in the FCA by amending the AKS. Under the amendment's terms, claims submitted to federal healthcare programs for items or services "resulting from" an AKS scheme are false for the purposes of establishing FCA liability, regardless of who submitted the claims. Although the amendment widened the FCA liability net, its language also raised a new question as courts grappled with what "resulting from" requires plaintiffs to prove in AKS-based FCA claims. This Note examines how federal circuit courts have analyzed the amendment's "resulting from" causation standard. The U.S. Court of Appeals for the Third Circuit imposed a relaxed standard that requires plaintiffs to establish a connection that is less stringent than but-for causation, whereas the U.S. Courts of Appeals for the Sixth and Eighth Circuits concluded that a but-for standard is required by the amendment's language. This Note argues that a but-for causation standard, like the one adopted by the Sixth and Eighth Circuits, is the proper standard considering the amendment's plain language. Ultimately, this Note argues a but-for standard is likely to be adopted by the U.S. Supreme Court should the Court grant certiorari on the question of what "resulting from" in the 2010 AKS amendment requires. [ABSTRACT FROM AUTHOR]

The 2010 Affordable Care Act (ACA) included two provisions, the Employer Shared Responsibility Provision (the "employer mandate") and the Small Business Health Options Program ("SHOP"), aimed at increasing the availability of employer‐sponsored health insurance (ESI) among workers at small firms. To examine whether these provisions led to greater ESI availability, I use 2011–2017 Medical Expenditure Panel Survey (MEPS) data in a difference‐in‐difference framework that compares changes in ESI availability among workers at small and large firms before and after the ACA's provisions come into effect. My estimates show that there is a 3.5 percentage point increase in ESI availability among workers at smaller firms after 2013. When focusing on workers most likely to be affected by the employer mandate, I find a larger 5.2 percentage point increase in ESI availability, amounting to a 39% decline in the proportion who do not have ESI available. However, I find no evidence that greater ESI availability led to increases in ESI coverage rates. Instead, descriptive estimates suggest that gains in health insurance coverage after 2013 consist of significant increases in the number of working adults who report having Medicaid coverage, including among workers who are offered ESI. I use MEPS data for my analysis because, along with employment, firm size, and health insurance details, MEPS also provides health status and healthcare access/utilization information. Looking at changes in these health measures, I find only limited evidence to suggest that the ACA's provisions improved access to care or measures of health status for workers. [ABSTRACT FROM AUTHOR]

Purpose: To investigate changes in breast cancer incidence rates associated with Medicaid expansion in California. Methods: We extracted yearly census tract-level population counts and cases of breast cancer diagnosed among women aged between 20 and 64 years in California during years 2010–2017. Census tracts were classified into low, medium and high groups according to their social vulnerability index (SVI). Using a difference-in-difference (DID) approach with Poisson regression models, we estimated the incidence rate, incidence rate ratio (IRR) during the pre- (2010–2013) and post-expansion periods (2014–2017), and the relative IRR (DID estimates) across three groups of neighborhoods. Results: Prior to the Medicaid expansion, the overall incidence rate was 93.61, 122.03, and 151.12 cases per 100,000 persons among tracts with high, medium, and low-SVI, respectively; and was 96.49, 122.07, and 151.66 cases per 100,000 persons during the post-expansion period, respectively. The IRR between high and low vulnerability neighborhoods was 0.62 and 0.64 in the pre- and post-expansion period, respectively, and the relative IRR was 1.03 (95% CI 1.00 to 1.06, p = 0.026). In addition, significant DID estimate was only found for localized breast cancer (relative IRR = 1.05; 95% CI, 1.01 to 1.09, p = 0.049) between high and low-SVI neighborhoods, not for regional and distant cancer stage. Conclusions: The Medicaid expansion had differential impact on breast cancer incidence across neighborhoods in California, with the most pronounced increase found for localized cancer stage in high-SVI neighborhoods. Significant pre-post change was only found for localized breast cancer between high and low-SVI neighborhoods. [ABSTRACT FROM AUTHOR]

This paper examines whether expanding Medicaid eligibility affects the employment patterns and academic progress of college students. To estimate causal relationships, we use variation in eligibility due to the Affordable Care Act Medicaid expansions that occurred in a subset of US states. Using data from the National Postsecondary Student Aid Study, we show that expanding Medicaid resulted in a decrease in employment intensity that is most pronounced for students at community colleges. We also see evidence of students making better progress towards graduation, suggesting that expanding Medicaid may have benefited some students by allowing them to shift their focus from work to school. These findings provide insight into how access to publicly provided health insurance can reduce inequalities in long-term education and socioeconomic outcomes. [ABSTRACT FROM AUTHOR]

In response to political gridlock at the federal level and concerns about market concentration in the private health insurance industry, several U.S. states have proposed their own bills to establish state-based public option programs, including three that recently became law in Washington State, Colorado, and Nevada. I study Washington State's Cascade Care Law, which implemented a state-based public option program in its individual health insurance market starting in 2021. I use plan offering data and administrative enrollment data from the Washington Health Benefit Exchange, Washington's state-based Affordable Care Act exchange, to provide a descriptive analysis of how market structure, insurers' plan offering decisions, individual enrollment, and market concentration evolved during the 2020–2022 plan years. A key descriptive finding of this paper is that county-level insurance market competition has improved since Washington's state-based public option program was implemented; with thirteen and twelve insurers offering plans in 2021 and 2022, respectively, up from nine insurers in 2020. I also document considerable variation in the set of plans insurers decided to offer and the set of counties they served. Enrollment in the public option plans that were offered was low. [ABSTRACT FROM AUTHOR]

Cancer is the top leading cause of death among Latino people. Lack of health insurance is a significant contributor to inadequate cancer detection and treatment. Despite healthcare policy expansions such as the Affordable Care Act, Latino people persistently maintain the highest uninsured rate among any ethnic and racial group in the US, especially among Latino individuals who are immigrants or part of a mixed immigration status household. Recognizing that immigration status is a critical factor in the ability of Latino community members to seek health insurance and access healthcare services, a few US states and the District of Columbia have implemented policies that have expanded coverage to children and adults regardless of immigration status. Expansion of Medicaid eligibility regardless of immigration status may significantly benefit Latino communities, however the facilitators and barriers to enrolling in these programs need to be evaluated to ensure reach and achieve health equity across the cancer control continuum for all Latinos. [ABSTRACT FROM AUTHOR]

Introduction: Medical financial hardship in the United States is a growing public health concern. This study aims to assess the south vs. non-south disparities in medical financial hardship among US adults of different generations – Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1980), and the Millennials (born between 1981 and 1996) across periods pre- and post- Affordable Care Act (ACA). Methods: This observational study utilizes data from multiple waves of the National Health Interview Survey (NHIS) split into three periods: pre–ACA (2011–2013), ii) post ACA (2015–2018), and iii) COVID-19 pandemic (2021–2022). Multivariable logistic regressions were fitted, separately for each generation in each period, to compare the extent of medical financial hardship among those from South to rest of the US, and Karlson-Holm-Breen (KHB) decomposition was applied to analyze whether there was a mediating impact of health insurance coverage. Results: Adults living in the South were more likely to experience medical financial hardship in all three periods. Residing in the South was associated with 1.7 to 2.6% points (pp) higher probability of medical financial hardship among boomers, 1.8 to 4.0 pp among generation Xers, and 1.7 to 2.8 pp among millennials. The relationship was robust after accounting for chronic comorbidities, sociodemographic and socioeconomic attributes and was partially mediated through differences in health insurance coverage. Conclusions: The problem of medical financial hardship has been deeply rooted in the South across generations, which was partly attributable to the regional differences in health insurance coverage. [ABSTRACT FROM AUTHOR]

Background The Affordable Care Act (ACA) increased private nonemployer health insurance options, expanded Medicaid eligibility, and provided preexisting health condition protections. We evaluated insurance coverage among long-term adult survivors of childhood cancer pre- and post-ACA implementation. Methods Using the multicenter Childhood Cancer Survivor Study, we included participants from 2 cross-sectional surveys: pre-ACA (2007-2009; survivors: n = 7505; siblings: n = 2175) and post-ACA (2017-2019; survivors: n = 4030; siblings: n = 987). A subset completed both surveys (1840 survivors; 646 siblings). Multivariable regression models compared post-ACA insurance coverage and type (private, public, uninsured) between survivors and siblings and identified associated demographic and clinical factors. Multinomial models compared gaining and losing insurance vs staying the same among survivors and siblings who participated in both surveys. Results The proportion with insurance was higher post-ACA (survivors pre-ACA 89.1% to post-ACA 92.0% [+2.9%]; siblings pre-ACA 90.9% to post-ACA 95.3% [+4.4%]). Post-ACA insurance increase in coverage was higher among those aged 18-25 years (survivors: +15.8% vs +2.3% or less ages 26 years and older; siblings +17.8% vs +4.2% or less ages 26 years and older). Survivors were more likely to have public insurance than siblings post-ACA (18.4% vs 6.9%; odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1 to 2.6). Survivors with severe chronic conditions (OR = 4.7, 95% CI = 3.0 to 7.3) and those living in Medicaid expansion states (OR = 2.4, 95% CI = 1.7 to 3.4) had increased odds of public insurance coverage post-ACA. Among the subset completing both surveys, low- and mid-income survivors (<$40 000 and <$60 000, respectively) experienced insurance losses and gains in reference to highest household income survivors (≥$100 000), relative to odds of keeping the same insurance status. Conclusions Post-ACA, more childhood cancer survivors and siblings had health insurance, although disparities remain in coverage. [ABSTRACT FROM AUTHOR]

The COVID‐19 public health emergency led to federal legislation that changed the landscape of Medicaid coverage for low‐income people in the United States. Policy responses led to a surge in Medicaid caseloads due to new rules preventing Medicaid disenrollment, and total Medicaid enrollment increased more from 2020 to 2023 than the net increase in insurance coverage from 2013 to 2017 following the Affordable Care Act's implementation. It is crucial for scholars and practitioners to understand the implications of this continuous coverage policy and its 2023–2024 unwinding. This paper provides an overview of Medicaid enrollment, renewal, and funding policies, highlighting how policy changed during and immediately following the acute phase of the pandemic; describes enrollment increases and their composition; reviews relevant literature; and identifies key areas for research. By examining this unprecedented period in Medicaid, we can inform future policy decisions and optimize safety net programs to be effective under a broad set of circumstances. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective Study. Objective: At the North American Spine Society (NASS) conference, participants may influence spine surgery practices and patient care through their contributions. Therefore, their financial conflicts of interest are of notable interest. This study aims to compare the demographics and payments made to participating surgeons. Methods: A list of 151 spine surgeons was created based on those who participated in the 2022 NASS conference. Demographic information was obtained from public physician profiles. General payments, research payments, associated research funding, and ownership interest were collected for each physician. Descriptive statistics and two-tailed t-tests were used. Results: In 2021, 151 spine surgeon participants received industry payments, totaling USD 48 294 115. The top 10% of orthopedic surgeons receiving payments accounted for 58.7% of total orthopedic general value, while the top 10% of neurosurgeons accounted for 70.1%. There was no significant difference between these groups' general payment amounts. Surgeons with 21-30 years of experience received the most general funding. There was no difference in funding between surgeons in academic or private settings. For all surgeons, royalties accounted for the largest percentage of the general value exchanged, while food/beverage accounted for the largest percentage of transactions. Conclusion: Our study found that only years of experience had a positive association with general payments, and most monetary value belonged to a small handful of surgeons. These participants receiving significant money may promote techniques requiring products of companies providing their compensation. Future conferences may require disclosure policy changes so attendees understand the degree of funding participants receive. [ABSTRACT FROM AUTHOR]

In this study, we test for the impact of the Affordable Care Act's dependent coverage expansion on the career choices of young college graduates with majors in the arts in the United States. Since working as an artist often involves employment arrangements like self-employment and project-based work that lack health insurance coverage, policies that expand access to health insurance have the potential to make employment in the arts more attractive for arts graduates. Using American Community Survey data, we use a difference-in-differences regression approach comparing the likelihood of working in the arts for college graduates with majors in the arts who are just under- and just over-26, pre- and post-implementation of the ACA's dependent coverage expansion. We find that the ACA increased the likelihood that arts graduates under 26 years of age were working in the arts by over 2% points, effects that are statistically significant and large as less than 20% of arts graduates in our sample work in the arts. Such changes are not observed for other graduates, suggesting that this response is unique to arts graduates, who are often found to behave differently than other workers. [ABSTRACT FROM AUTHOR]

Latinx persons have lower levels of health insurance coverage than other racial and ethnic groups even after passage of the Patient Protection and Affordable Care Act (ACA). Using 182 interviews from the American Voices Project, this study examines how U.S.-born Latinx adults experience health-care coverage and health-care use. Interview data demonstrate that health-care access is insufficient to ensure full health-care use. Health-care use costs are so high that they are insurmountable for Latinx Americans. Wealth and liquid assets constrain and are constrained by health-care use. Family members become a safety net. This study can inform policies and programs aiming to improve equity in Latinx individuals' health-care access by centering the importance of reducing economic costs of health-care use. [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]

Health insurance expansions can exert wellbeing effects on individuals who provide informal care to their loved ones, reducing their experience of depression. This study exploits evidence from the Patient Protection and Affordable Care Act's Medicaid expansion (ACA Medicaid) to examine the effects on the mental wellbeing of informal caregivers. Drawing on an event study and a Difference-in-Differences (DID) design we investigate the policy impact of ACA Medicaid using longitudinal evidence (from the Health and Retirement Study, HRS) for low-income individuals aged 64 or below. We find that ACA Medicaid reduced the likelihood of depressive symptoms among spousal caregivers. We document that exposure to ACA Medicaid gives rise to 8.2% points (on average, equivalent to 30% decrease) reduction in the feeling of depression and 8.7% points increase in the feeling of happiness (on average, 11% increase). The estimates are robust to various specifications, are driven by reductions in out of -pocket expenses and labor supply and, as expected, increased after Medicaid uptake. The evidence from falsification tests confirms that the estimated effects are likely due to ACA Medicaid. [ABSTRACT FROM AUTHOR]

The article discusses the importance of using geospatial technologies in cancer research to address health disparities and drive prevention efforts among specific populations. It highlights the formation of the Catchment Area Research and Data Science (CARDS) group to foster collaboration among cancer centers. The text provides examples of open-source projects and partnerships that have enhanced data accessibility and visualization for cancer research. It also emphasizes the need for greater data access, the development of new metrics, and measuring the impact of geospatial approaches in cancer research. [Extracted from the article]

Routine alcohol screening of people with chronic health conditions that are exacerbated by alcohol can help to prevent morbidity and mortality. The U.S. Affordable Care Act and other recent health reforms expanded insurance coverage and supported alcohol screening in primary care. This study assessed increases in alcohol screening following health reform and insurance-related and racial and ethnic disparities in screening. Data are from the 2013 to 2019 National Surveys on Drug Use and Health for adults with alcohol-related chronic conditions who received primary care in the past year (N =46,014). The outcome was receipt of alcohol screening (yes/no) in which a healthcare provider inquired whether, how often, or how much the respondent drank, or about having alcohol-related problems. Multivariable logistic regression models assessed temporal changes in screening overall and by insurance type and race/ethnicity, adjusting for demographics, health conditions, and primary care utilization. Statistical analysis was performed in 2023. Alcohol screening prevalence rose from 69% to 77% from 2013 through 2019, with a notable increase in 2014–2015 for both Medicaid-insured and privately-insured patients. Black and Asian American patients were generally less likely to be screened than White patients. Importantly, racial disparities in screening were found among privately-insured patients, patients with hypertension, patients with heart disease, and patients with diabetes who drink alcohol. Alcohol screening of primary care patients with chronic conditions increased following health reform, but persistent disparities among patients with private insurance and specific chronic conditions underscore the need to address drivers of unequal preventive care. [ABSTRACT FROM AUTHOR]

The article discusses the government discrimination against women, LGBTQIA+ individuals, and racial/ethnic minority individuals, which is said to be the return of Jim Crow. Topics include governmental actions that sought to make the promise of equality found in the 14th Amendment of the U.S. Constitution a reality for women and LGBTQIA1 and racial/ethnic minority individuals and Jim Crow era discriminatory policies and actions from 1877 to 2024.

The onset of the COVID-19 pandemic in March 2020 had a sudden and substantial impact on health care utilization for most, if not all, individuals. We study the impact the pandemic had on the population insured in the individual and small group markets under the Patient Protection and Affordable Care Act (ACA) of 2010, using administrative claims data from January 2019 through December 2021. Our results demonstrated how health care utilization differed between the acute phase (i.e., 2020) and the post-acute phase (i.e., 2021) compared with the pre-pandemic phase. We found that in the ACA markets, most spending and utilization categories decreased drastically during the initial months of the pandemic and recovered by the end of 2021. While the role of telehealth among office visits decreased substantially by the end of 2021, it remained the main mode of delivery for mental health services. [ABSTRACT FROM AUTHOR]

This article provides an overview of trends in self-insured health coverage in the United States, focusing on the period since the passage of the Affordable Care Act (ACA) in 2010. It highlights that the percentage of private-sector establishments offering self-insured plans has been increasing since the 1990s, with larger firms more likely to self-insure. However, since the ACA, self-insurance has increased among small and medium-sized firms while decreasing among larger firms. Enrollment in self-insured plans has also increased, particularly in large firms. The article also examines trends in stop-loss coverage, which protects employers from large claims, and finds significant differences by firm size. The text concludes by acknowledging the impact of the ACA on self-insured health plans, particularly among smaller employers, but notes that the reasons for the decline in self-insurance among larger firms are not clear. [Extracted from the article]

Enacted in 2010 as part of the Affordable Care Act, the Physician Payments Sunshine Act (PPSA) mandates transparency in financial interactions between pharmaceutical companies and healthcare providers. This study investigates the PPSA's effectiveness and its impact on industry payments to physicians. Utilizing ProPublica and Open Payments databases, a difference-in-difference analysis was conducted across ten states. Results reveal a significant reduction in pharmaceutical companies' meal-related payments post-PPSA, impacting both the total payment amount and the number of unique physicians reached. Conversely, travel payments showed no significant impact in the primary analysis. However, subsequent analyses revealed nuanced reductions in the number of unique physicians reached, highlighting a more intricate relationship wherein pharmaceutical companies likely adjusted their financial interaction strategies with physicians differently across states. State-level variations in meals further underscore the complexity of PPSA's influence. This pioneering research contributes valuable empirical evidence, addressing gaps in prior studies and emphasizing the ongoing need for policy assessment to guide industry-physician relationships. [ABSTRACT FROM AUTHOR]

To examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services. We used a previously described algorithm to define a cohort of gender-diverse adults in the MarketScan Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data were also used to evaluate the patient contribution towards services. There were 70,733 gender-diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase in claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1019.20 (8.6%). Commercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender-diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services. [ABSTRACT FROM AUTHOR]

We tested the hypothesis that children in New York City (NYC) with an immigrant parent were more likely to lack health insurance and report poorer parent-rated health compared to those of US-born parents in this serial, cross-sectional study using existing data from 2009 to 2017 among children age < 12 years in two NYC health surveys. Main outcomes were parent-reported responses for (1) child insurance coverage and (2) child general health status. In multivariable logistic regression models, we estimated likelihood of outcomes for children of immigrants compared to those of US-born parents, adjusting for child, parent, and household characteristics. We included 2,637 children in 2009 and 7,042 in 2017 in NYC. In 2017, children of immigrant parents were more likely to experience uninsurance than children of US-born parents [adjusted odds ratio (AOR) 2.36 (95% CI: 1.05–5.31)]. Compared to children of US-born parents, children with an immigrant parent were more likely to have a gap in insurance coverage in both 2009 (AOR 1.88; 95% CI: 1.08–3.27) and 2017 (AOR 1.60; 95% CI: 1.06–2.41). Although more children of immigrants had poor/fair health than those of US-born parents in both years, differences were not statistically significant after adjusting for covariates. Our findings among a sample of children eligible for health insurance suggest policies intended to expand child health care access did not equitably reach children of immigrants despite their eligibility for health insurance. Tailored interventions for children of immigrants are needed to mitigate disparities in health insurance coverage. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of the Affordable Care Act (ACA) health insurance exchanges (Marketplace) on the rate of uninsured discharges in Texas. Data Source and Study Setting: Secondary discharge data from 2011 to 2019 from Texas. Study Design: We conducted a retrospective study estimating the effects of the ACA Marketplace using difference‐in‐difference regressions, with the main outcome being the uninsured discharge rate. We stratified our sample by patient's race, age, gender, urbanicity, major diagnostic categories (MDC), and emergent type of admissions. Data Collection/Extraction Methods: We used Texas hospital discharge records for non‐elderly adults collected by the state of Texas and included acute care hospitals who reported data from 2011 to 2019. Principal Findings: The expansion of insurance through ACA Marketplaces led to reductions in the uninsured discharge rate by 9.9% (95% CI, −17.5%, −2.3%) relative to the baseline mean. The effects of the ACA were felt strongest in counties with any share of Hispanic, in counties with a larger population of Black, and other racial groups, in counties with a significant share of female and older age individuals, in counties considered to be urban, in high‐volume diagnoses, and emergent type of admissions. Conclusions: These findings indicate that the ACA facilitated a shift in hospital payor mix from uninsured to insured. [ABSTRACT FROM AUTHOR]

The article focuses on oncologists' ethical concerns regarding the use of artificial intelligence (AI) in cancer care. Topics discussed include the challenges of explaining AI tools to patients; the debate over patient consent for AI use in treatment versus diagnostics; and the need for clear informed consent addressing AI's ethical and legal implications.

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]

Research Summary: This article examines whether the Affordable Care Act (ACA) health insurance reform reduced the gender gap in science, technology, engineering, and mathematics (STEM) entrepreneurship. I argue that the ACA mitigated mobility constraints imposed by employer‐provided health insurance and encouraged entrepreneurship with important contingencies: effects were limited to women because of gender differences in supply‐side cost reduction and demand‐side health insurance needs and were specific to women in STEM (vs. non‐STEM) entrepreneurship because of the human and financial capital needed to navigate insurance markets. Leveraging the ACA quasi‐experiment, I find consistent evidence of a reduced gender gap in STEM entrepreneurship. Surprisingly, the effects were driven by increased STEM entrepreneurship for married women founding unincorporated businesses. Qualitative interview insights and empirical findings provide explanations for these patterns. Managerial Summary: This study examines whether the science, technology, engineering, and mathematics (STEM) entrepreneurial gender gap can be reduced by institutional factors mitigating labor market mobility constraints imposed by employer‐provided work benefits. Through the lens of the US ACA reform, I find that broadened access to more affordable health insurance in the alternative individual insurance markets disproportionately encouraged female (vs. male) STEM (vs. non‐STEM) entrepreneurship, thus reducing the STEM entrepreneurial gender gap. Contrary to common assumptions, this effect is driven by married (vs. unmarried) women and is in unincorporated (vs. incorporated) self‐employment. The findings help discern which groups benefit from policy efforts to promote diversity in STEM entrepreneurship and imply that the effectiveness of employer‐provided work benefits as retention tools is dependent on various worker characteristics. [ABSTRACT FROM AUTHOR]

The use of revascularization (coronary artery bypass surgery [CABG] and percutaneous coronary intervention [PCI]) in the United States is declining, but they remain important procedures for the treatment of patients with coronary artery disease. There are large and long‐standing disparities in the use of revascularization among patients hospitalized with heart disease. In this article, we investigate whether the implementation of the Patient Protection and Affordable Care Act (ACA) is associated with a reduction in disparities in the use of revascularization. We use data from the Agency for Healthcare Research and Quality (AHRQ)'s National Inpatient Sample (NIP) of the Healthcare Cost and Utilization Project (HCUP) project to compare the use of revascularization among patients 45 years and older in the United States in 2012 and 2018. For both years, we conducted multiple logistic regression analysis to assess the factors associated with coronary revascularization among patients hospitalized with heart disease. Hospitalizations for heart disease and the use of revascularization both fell between 2012 and 2018 at a rate that was greater than the reduction in heart disease deaths in the country. These findings are consistent with the clinical literature on the growth of medical management of heart disease. Disparities in the use of revascularization, by gender, insurance status, neighborhood, and race/ethnicity, were just as large after the implementation of the ACA in 2014. The expansion of insurance by the ACA, alone, was insufficient to reduce disparities in the use of revascularization in patients with diagnosed coronary heart disease in the United States. [ABSTRACT FROM AUTHOR]

Nurse practitioners (NP) complete a formal graduate-level education program focusing on a specific patient population. NPs are then eligible to sit for a board certification examination that aligns with their program of study. As part of the credentialing and privileging process, core privileges are granted based on one's initial board certification; NPs can request supplemental privileges in addition to their core privileges, such as office cystoscopy. Credentialing and privileging are the processes by which health care institutions ensure that their providers are competent and properly qualified to provide care to patients. This paper offers guidance for obtaining additional clinical privileges, with office cystoscopy as the exemplar. [ABSTRACT FROM AUTHOR]

This article explores the relationship between genre and identity in contraceptive health discourses. It examines different types of contraceptive texts, such as patient education materials and promotional materials, and analyzes their inclusivity and accessibility. The study focuses on contraception patient education materials from Planned Parenthood and identifies common genre features. It also discusses the need for inclusive language for marginalized communities and the lack of queer critiques in the fields of Technical and Professional Communication and Rhetoric of Health and Medicine. The article emphasizes the importance of addressing health disparities in marginalized communities and concludes by discussing a study analyzing online patient education materials on contraception from Planned Parenthood's website. The study analyzes the frequency of different codes used in the texts and highlights the importance of consistent and inclusive language when discussing sex acts and gender. The study suggests that including more information about reproductive health considerations beyond the gender binary would promote greater reproductive health literacy for people of all genders. The author also emphasizes the importance of access to accurate information about contraception and reproductive health, particularly in the current political climate. The text includes a list of academic articles and resources related to reproductive justice, contraception, transgender health care, and technical communication, providing diverse perspectives on these topics. Additionally, the text provides a codebook that categorizes information about contraception for research purposes, aiming to provide a comprehensive framework for analysis. [Extracted from the article]