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Abstract Background In the United States, the Affordable Care Act (ACA) pursued equity in healthcare access and treatment, but ACA implementation varied, especially limiting African Americans’ gains. Marketplaces for subsidized purchase of coverage were sometimes implemented with limited outreach and enrollment assistance efforts. Reflecting state’s ACA receptivity or reluctance, state’s implementation may rest on sociopolitical stances and racial sentiments. Some states were unwilling to provide publicly supported healthcare to nonelderly, non-disabled adults— “the undeserving poor” —who evoke anti-black stereotypes. The present study assessed whether some states shunned Affordable Care Act (ACA) marketplaces and implemented them less vigorously than other states, leading to fewer eligible persons selecting insurance plans. It assessed if states’ actions were motivated by racial resentment, because states connote marketplaces to be government assistance for unworthy African Americans. Methods Using marketplace and plan selection data from 2015, we rated states’ marketplace structures along a four-level continuum indicating greater acceptance of marketplaces, ranging from states assuming sole responsibility to minimal responsibility. Using national data from a four-question modern racism scale, state-wide racial resentment estimates were estimated at the state level. Analysis assessed associations between state levels of racial resentment with states’ marketplace structure. Further analysis assessed relationships between both state levels of racial resentment and states’ marketplace structure with states’ consumer plan selection rates—representing the proportion of persons eligible to enroll in insurance plans who selected a plan. Results Racial resentment was greater in states with less responsibility for the administration of the marketplaces than actively participating states. States higher in racial resentment also showed lower rates of plan selection, pointing to less commitment to implementing marketplace provisions and fulfilling the ACA’s coverage-improvement mission. Differences persisted after controlling for differences in conservatism, uninsurance, poor health, and rejection of Medicaid expansion. Conclusions Resentment of African Americans’ purported irresponsibility and entitlement to government assistance may interfere with states structuring and operating marketplaces to maximize health insurance opportunities for everyone available under the ACA. Trial registration N/A.

Policy Points Looking for a way to curtail market power abuses in health care and rein in prices, 20 states have restricted most-favored-nation (MFN) clauses in some health care contracts. Little is known as to whether restrictions on MFN clauses slow health care price growth. Banning MFN clauses between insurers and hospitals in highly concentrated insurer markets seems to improve competition and lead to lower hospital prices.ContextMost-favored-nation (MFN) contract clauses have recently garnered attention from both Congress and state legislatures looking for ways to curtail market power abuses in health care and rein in prices. In health care, a typical MFN contract clause is stipulated by the insurer and requires a health care provider to grant the insurer the lowest (i.e., the most-favored) price among the insurers it contracts with. As of August 2020, 20 states restrict the use of MFN clauses in health care contracts (19 states ban their use in at least some health care contracts), with 8 states prohibiting their use between 2010 and 2016.MethodsUsing event study and difference-in-differences research designs, we compared prices for a standardized hospital admission in states that banned MFN clauses between 2010 and 2016 with standardized hospital admission prices in states without MFN bans.FindingsOur results show that bans on MFN clauses reduced hospital price growth in metropolitan statistical areas (MSAs) with highly concentrated insurer markets. Specifically, we found that mean hospital prices in MSAs with highly concentrated insurer markets would have been $472 (2.8%) lower in 2016 had the MSAs been in states that banned MFN clauses in 2010. In 2016, the population in our sample that resided in MSAs with highly concentrated insurer markets was just under 75 million (23% of the US population). Hence, banning MFN clauses in all MSAs in our sample with highly concentrated insurer markets in 2010 would have generated savings on hospital expenditures in the range of $2.4 billion per year.ConclusionsOur empirical findings suggest banning MFN clauses between insurers and providers in highly concentrated insurer markets would improve competition and lead to lower prices and expenditures.

To evaluate the association of state-level lack of health insurance among women of reproductive age with variation in state low birth weight (LBW) rates. This cross-section study analyzes data from the 2016–2019 Pregnancy Risk Assessment Monitoring Survey for respondents with singleton, live births. Respondents were divided into groups by state-level percent of uninsured women aged 19–44 years. Poisson regression was used to model the association between state percent uninsured and likelihood of LBW, controlling for individual sociodemographic and clinical risk factors. Sensitivity analyses were done for Medicaid and non-Hispanic Black subpopulations and alternative state characteristics, including Gini coefficients, total and public welfare expenditures, and state reproductive rights rankings. In adjusted multiple regression analyses, compared to respondents from states with <7% uninsured, respondents from states with 7% or more uninsured had an increased risk of LBW status (7–8.99% uninsured: adjusted incidence rate ratio [aIRR] 1.11, 95% confidence interval [CI] 1.04–1.18; 9–11.99% uninsured: aIRR 1.09, 95% CI 1.02–1.17; >11.99% uninsured: aIRR 1.15, 95% CI 1.08–1.22). However, there was no evident dose–response gradient. Sensitivity analyses produced virtually identical findings for subpopulations, and no other state characteristics were significant. States with the highest level of insurance coverage had a significantly lower LBW rate than other states. However, there was little evidence for greater odds of LBW with the highest levels of uninsured. Individual risk factors dominated LBW models, while state differences in income inequality, reproductive health policy, and per capita spending explained little of the variance in LBW. [ABSTRACT FROM AUTHOR]

Background: In the United States, the Affordable Care Act (ACA) pursued equity in healthcare access and treatment, but ACA implementation varied, especially limiting African Americans' gains. Marketplaces for subsidized purchase of coverage were sometimes implemented with limited outreach and enrollment assistance efforts. Reflecting state's ACA receptivity or reluctance, state's implementation may rest on sociopolitical stances and racial sentiments. Some states were unwilling to provide publicly supported healthcare to nonelderly, non-disabled adults— "the undeserving poor" —who evoke anti-black stereotypes. The present study assessed whether some states shunned Affordable Care Act (ACA) marketplaces and implemented them less vigorously than other states, leading to fewer eligible persons selecting insurance plans. It assessed if states' actions were motivated by racial resentment, because states connote marketplaces to be government assistance for unworthy African Americans. Methods: Using marketplace and plan selection data from 2015, we rated states' marketplace structures along a four-level continuum indicating greater acceptance of marketplaces, ranging from states assuming sole responsibility to minimal responsibility. Using national data from a four-question modern racism scale, state-wide racial resentment estimates were estimated at the state level. Analysis assessed associations between state levels of racial resentment with states' marketplace structure. Further analysis assessed relationships between both state levels of racial resentment and states' marketplace structure with states' consumer plan selection rates—representing the proportion of persons eligible to enroll in insurance plans who selected a plan. Results: Racial resentment was greater in states with less responsibility for the administration of the marketplaces than actively participating states. States higher in racial resentment also showed lower rates of plan selection, pointing to less commitment to implementing marketplace provisions and fulfilling the ACA's coverage-improvement mission. Differences persisted after controlling for differences in conservatism, uninsurance, poor health, and rejection of Medicaid expansion. Conclusions: Resentment of African Americans' purported irresponsibility and entitlement to government assistance may interfere with states structuring and operating marketplaces to maximize health insurance opportunities for everyone available under the ACA. Trial registration: N/A. [ABSTRACT FROM AUTHOR]

The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.

States are increasingly the focus of health care spending reform efforts given political deadlock at the federal level. Using the Rhode Island All-Payer Claims Database (APCD) from 2016 to 2019, a modified National Uniform Claim Committee (NUCC) provider taxonomy, and the 2021 Restructured BETOS Classification System (RBCS), we evaluate professional spending trends in commercial and Medicaid populations, identify specialties and clinical service categories driving trends, and examine price and volume contributions to spending changes. We found that professional spending from 2016-2019 in Medicaid is increasing faster than professional spending in commercial (5.2% vs. 2.7% annually). We also found that nurse practitioner and physician assistant evaluation and management (E&M), behavioral health services E&M, anesthesia, diagnostic radiology imaging, and orthopedic procedures were among the largest areas of spending increase during the study period in Rhode Island. Threeyear trends showed heterogeneity in whether volume or price was primarily responsible for these spending increases. [ABSTRACT FROM AUTHOR]

This study aimed to establish criteria to identify priority drugs for CalRx, a California-sponsored initiative to support the manufacture and distribution of affordable generic drugs. A web-based ranking exercise was implemented with key stakeholders in August 2020, using pricing, spending, and public health criteria identified through a review of academic literature and public health agency reports. A total of 39 of 40 invited stakeholders in 4 different categories—patient advocates, healthcare providers, health insurers, and health policy and economic experts—participated in this study (98% response rate). Drugs that treat large populations, drugs that represent high cost to payors, and drugs that represent high cost to consumers were ranked a priority, receiving > 10% of ranking weights. Drugs that treat conditions with high morbidity or mortality, drugs without therapeutic alternatives, and drugs treating vulnerable populations represented criteria of further interest (9%-10% of weights). Shortage risk and curative effect (8%-9% of the weights), high price increases, communicable disease treatments, and high unit prices (< 8% of the weights) represented the bottom of the priority distribution. This study suggests that drugs that treat large populations, drugs that represent large costs to payors, and drugs that represent large costs to consumers should be the priority for California's CalRx generic drug initiative. A prioritizing algorithm will assist California in determining top drugs to target from a public health and spending perspective as it plans the rollout of the CalRx initiative and negotiates with drug manufacturers. • In January 2020, Governor Gavin Newsom announced the creation of CalRx, a California-sponsored generic drug label. CalRx aims to lower prices and increase access to pharmaceuticals in California. The question became how to establish criteria to identify priority drugs for CalRx. • This article describes the development of prioritization criteria to CalRx based on a review of the literature and a ranking exercise with key stakeholders. We found that drugs that treat large populations, drugs that represent large costs to payors, and drugs that represent large costs to consumers should be the priority for California's CalRx generic drug initiative. • By detailing the collaborative process involved in developing the CalRx prioritization criteria, this article models inclusive policy design and implementation in public health decision making. The final set of criteria identified can also help inform prioritization efforts for future initiatives targeting prescription drugs at the state level and beyond. [ABSTRACT FROM AUTHOR]

BackgroundThe Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear.MethodsA quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015. Difference-in-differences multivariable logistic regression models that incorporated 4-group propensity score weighting were estimated. Heterogeneity of SIM effects by grantee state and for CMS populations were assessed.ResultsIn adjusted difference-in-difference analyses, SIM was associated with an increase in odds of 30-day hospital readmission among patients in SIM states in the post-SIM versus pre-SIM period relative to the ratio in odds of readmission among patients in the comparison states post-SIM versus pre-SIM (ratio of adjusted odds ratio=1.057, P=0.01). Restricting the analyses to CMS populations (Medicare and Medicaid beneficiaries), resulted in consistent findings (ratio of adjusted odds ratio=1.057, P=0.034). SIM did not have different effects on 30-day readmissions by state.ConclusionsWe found no evidence that SIM reduced 30-day readmission rates among adults with diabetes during the first 2 years of round 1 implementation, even among CMS beneficiaries. It may be difficult to reduce readmissions statewide without greater investment in health information exchange and more intensive use of payment models that promote interorganizational coordination.

Context: The Mental Health Parity and Addiction Equity Act (MHPAEA) requires coverage for mental health and substance use disorder (MH/SUD) benefits to be no more restrictive than for medical/surgical benefits in commercial health plans. State insurance departments oversee enforcement for certain plans. Insufficient enforcement is one potential source of continued MH/SUD treatment gaps among commercial insurance enrollees. This study explored state-level factors that may drive enforcement variation. Methods: The authors conducted a four-state multiple-case study to explore factors influencing state insurance offices' enforcement of MHPAEA. They interviewed 21 individuals who represented state government offices, advocacy organizations, professional organizations, and a national insurer. Their analysis included a within-case content analysis and a cross-case framework analysis. Findings: Common themes included insurance office relationships with other stakeholders, policy complexity, and political priority. Relationships between insurance offices and other stakeholders varied between states. MHPAEA complexity posed challenges for interpretation and application. Policy champions influenced enforcement via priorities of insurance commissioners, governors, and legislatures. Where enforcement of MHPAEA was not prioritized by any actors, there was minimal state enforcement. Conclusions: Within a state, enforcement of MHPAEA is influenced by insurance office relationships, legal interpretation, and political priorities. These unique state factors present significant challenges to uniform enforcement. [ABSTRACT FROM AUTHOR]

Research Objective: To explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID‐19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss. Data Source: Phase 1 of the Census Bureau's Experimental Household Pulse Survey covering April 23, 2020–July 21, 2020. Study Design: We compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID‐19 pandemic in states that expanded Medicaid against states that did not expand Medicaid. Data Collection/Extraction Methods: Our analytical dataset was limited to 733,181 non‐elderly adults aged 20–64. Principal Findings: Twenty‐six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey—16% experienced job losses (e.g., layoff, furlough) due to the COVID‐19 crisis, and 11% had other reasons they were not working. COVID‐linked job losses were associated with a 20 (p < 0.01) percentage‐point (PPT) lower likelihood of having employer‐sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID‐linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously. Conclusions: Our findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed. [ABSTRACT FROM AUTHOR]

Objectives: Substitution of brand-name drugs with less expensive, equally effective interchangeable generics is an important strategy for promoting adherence and controlling prescription drug spending. US state laws govern generic substitution, but there is variability among states in how these laws are designed. We aimed to determine how different features of state laws regulating generic substitution are associated with use of generic drugs.Methods: Using national claims databases, we studied individuals with commercial insurance or Medicare Advantage plans who newly initiated one of 34 prescription drugs during the year after new generic competition (2017-2018) to determine any association between generic use and 3 different features of state laws. We used multivariable logistic regression to adjust for demographic and clinical characteristics.Results: Of 502 763 individuals who initiated one of the drugs, 409 856 (81.6%) received a generic version. Those in states requiring patient consent or notification had lower use of generics (81.1% vs 82.9%; adjusted odds ratio 0.89; 95% confidence interval 0.87-0.91; P < .001). By contrast, mandating versus permitting generic substitution and protecting pharmacists from liability did not appear to have significant effects.Conclusions: In this study of commercially insured and Medicare Advantage patients, patients in states requiring consent or notification for pharmacists to substitute Food and Drug Administration-certified interchangeable generics had lower use of generics. Laws in 39 states plus the District of Columbia could be amended to improve use of inexpensive and equally effective generic drugs. [ABSTRACT FROM AUTHOR]

There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White. [ABSTRACT FROM AUTHOR]

Policy PointsPolicymakers considering introduction of a health insurance "public option" to lower health spending and reduce the number of uninsured can learn from Washington State, which offered the nation's first public option ("Cascade Care") through its state exchange in 2021.This article examines insurer participation, pricing, and enrollment in the Washington public option. The public option was the lowest‐premium standard silver plan in 9 of the 19 counties in which it was offered.Cascade Care is available solely through private insurers. Voluntary participation of these insurers and uncertainty about the willingness of providers to participate may have hindered greater premium reductions and enrollment in the public option's first year. Context: State and federal policymakers considering introduction of a health insurance "public option" can learn from Washington State, which established the nation's first public option, with coverage beginning in January 2021. Public option plans were offered voluntarily by private insurers through the Washington Health Benefit Exchange and were subject to state‐mandated plan design and payment requirements. Methods: We used plan data from the Washington Health Benefit Exchange, linked to data from the US Census Bureau, the American Hospital Association, and InterStudy. We compared geographic availability and premiums of, and enrollment in, public option and non–public option plans, as well as characteristics of counties where the public option was available and counties where the public option was the lowest‐premium plan. Findings: At least one public option plan was available in 19 of 39 counties and was the lowest‐premium option in 9 of the 19 counties where it was available. Five insurers offered public option plans, including one new entrant to the state and one new entrant to the Exchange. While public option availability was more common in counties where the Exchange was bigger and more competitive, public option plans had the lowest premium in smaller, less competitive counties. In the first year, 1% of enrollees selected the public option, in part due to automatic reenrollment of the majority of returning enrollees in their 2020 plan. Conclusions: Public option plans offered a low‐premium choice in counties that otherwise had fewer affordable plans, but voluntary participation of insurers and providers and accompanying uncertainty about participation hindered widespread and substantial premium reductions. States should consider tying public option participation by insurers and providers to other state programs and using decision support tools to promote active enrollment. Federal policymakers can support state efforts while considering establishment of a national public option. [ABSTRACT FROM AUTHOR]

In the past 5 years, Medicaid programs have implemented administrative barriers to enrollment. The impact of these provisions on access to mental health and substance use disorder treatment has been largely unstudied. This column reviews the literature on the previous changes to Medicaid enrollment and treatment use, current policy landscape, and steps that states or localities may take to offset these administrative burdens. Redirecting savings to other safety-net programs may increase access to care, but these programs lack the comprehensive benefits provided by Medicaid. Without another backstop, the implementation of these barriers will likely exacerbate the United States' behavioral health crises. [ABSTRACT FROM AUTHOR]

Objective: We examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession. Data Source: 2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS). Study Design: Flexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines. Data Collection/Extraction Methods: Nonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics' Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state's 2007 Medicaid guidelines using data from the 2007 Current Population Survey's Annual Social and Economic Supplement. Principal Findings: A percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P <.01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P <.01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P <.01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P <.10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines. Conclusions: Increased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income. [ABSTRACT FROM AUTHOR]

Policy PointsAs Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies.Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers' experiences and perspectives into their program design and governance. Context: Consumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient‐centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done. Methods: We conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio‐recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses. Findings: First, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer‐term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers' participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement. Conclusions: Sharing best practices across states could help strengthen programs' engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice. [ABSTRACT FROM AUTHOR]

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state offi- cials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects. [ABSTRACT FROM AUTHOR]

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

Objective: To estimate the impact of implementing prescription drug monitoring program (PDMP) best practices on prescription opioid use.Data Sources: 2007-2012 Medicare claims for noncancer pain patients, and PDMP attributes from the Prescription Drug Abuse Policy System.Study Design: We derived PDMP composite scores using the number of best practices adopted by states (range: 0-14), classifying states as either no PDMP, low strength (0 < score < median), or high strength (score ≥ median). Using generalized linear models, we quantified the association between the PDMP score category and opioid use measures-overall and stratified by disability/age. Sensitivity analyses assessed the general Medicare sample regardless of pain diagnoses, individual PDMP characteristics, and compared GEE model findings to models with state fixed effects.Principal Findings: Compared to non-PDMP states, strong PDMP states had lower opioid cumulative doses (-296 mg; 95% CI: -512, -132), days supplied (-7.84; 95% CI: -10.6, -5.04), prescription fill rates (0.97; 95% CI: 0.95, 0.98), and mean daily doses (-2.31 mg; 95% CI: -3.14, -1.48) but greater prevalence of high opioid doses in disabled adults, whereas there was little or no change in older adults. Findings in states with weak PDMPs were substantively similar to those of strong PDMPs. Results from sensitivity analyses were mostly consistent with main findings except there was a null relationship with mean daily doses and high doses in models with state fixed effects.Conclusions: Comprehensive or minimal adoption of PDMP best practices was associated with mostly comparable effects on Medicare beneficiaries' opioid use; however, these effects were concentrated among nonelderly disabled adults. [ABSTRACT FROM AUTHOR]

ABSTRACT: BACKGROUND: The purpose of this study was to determine the impact of the coverage of state legislation and the expansiveness ratings of state model policies on the state‐level prevalence of bullying in schools. METHODS: The state‐level prevalence of bullying in schools was based on cross‐sectional data from the 2013 High School Youth Risk Behavior Survey. Multiple regression was conducted to determine whether the coverage of state legislation and the expansiveness rating of a state model policy affected the state‐level prevalence of bullying in schools. RESULTS: The purpose and definition category of components in state legislation and the expansiveness rating of a state model policy were statistically significant predictors of the state‐level prevalence of bullying in schools. The other 3 categories of components in state legislation—District Policy Development and Review, District Policy Components, and Additional Components—were not statistically significant predictors in the model. CONCLUSIONS: Extensive coverage in the purpose and definition category of components in state legislation and a high expansiveness rating of a state model policy may be important in efforts to reduce bullying in schools. Improving these areas may reduce the state‐level prevalence of bullying in schools. [ABSTRACT FROM AUTHOR]

Objectives: Identifying the best and worst states for coverage of cancer-preventing vaccines (hepatitis B [HepB] and human papillomavirus [HPV]) may guide public health officials in developing programs, such as promotion campaigns. However, acknowledging the imprecision of coverage and ranks is important for avoiding over interpretation. The objective of this study was to examine states' vaccination coverage and ranks, as well as the imprecision of these estimates, to inform public health decision making. Methods: We used data on coverage of HepB and HPV vaccines among adolescents aged 13-17 from the 2011-2015 National Immunization Survey-Teen (n ¼ 103 729 from 50 US states and Washington, DC). We calculated coverage, 95% confidence intervals (CIs), and ranks for vaccination coverage in each state, and we generated simultaneous 95% CIs for ranks using a Monte Carlo method with 100 000 simulations. Results: Across years, HepB vaccination coverage was 92.2% (95% CI, 91.8%-92.5%; states' range, 84.3% in West Virginia to 97.0% in Connecticut). HPV vaccination coverage was 57.4% (95% CI, 56.6%-58.2%; range, 41.8% in Kansas to 78.0% in Rhode Island) for girls and 31.0% (95% CI, 30.3%-31.8%; range, 19.0% in Utah to 59.3% in Rhode Island) for boys. States with the highest and lowest ranks generally had narrow 95% CIs; for example, Rhode Island was ranked first (95% CI, 1-1) and Kansas was ranked 51st (95% CI, 49-51) for girls' HPV vaccination. However, states with intermediate ranks had wider and more imprecise 95% CIs; for example, New York was 26th for girls' HPV vaccination coverage, but its 95% CI included ranks 18-35. Conclusions: States' ranks of coverage of cancer-preventing vaccines were imprecise, especially for states in the middle of the range; thus, performance rankings presented without measures of imprecision could be overinterpreted. However, ranks can highlight high-performing and low-performing states to target for further research and vaccination promotion programming. [ABSTRACT FROM AUTHOR]

Addressing racial/ethnic group disparities in health insurance benefits through legislative mandates requires attention to the different proportions of racial/ethnic groups among insurance markets. This necessary baseline data, however, has proven difficult to measure. We applied racial/ethnic data from the 2009 California Health Interview Survey to the 2012 California Health Benefits Review Program Cost and Coverage Model to determine the racial/ethnic composition of ten health insurance market segments. We found disproportional representation of racial/ethnic groups by segment, thus affecting the health insurance impacts of benefit mandates. California's Medicaid program is disproportionately Latino (60 % in Medi-Cal, compared to 39 % for the entire population), and the individual insurance market is disproportionately non-Latino white. Gender differences also exist. Mandates could unintentionally increase insurance coverage racial/ethnic disparities. Policymakers should consider the distribution of existing racial/ethnic disparities as criteria for legislative action on benefit mandates across health insurance markets. [ABSTRACT FROM AUTHOR]

Before 1996, most lawfully present noncitizens were eligible for the same prenatal Medicaid benefits as U.S. citizens. However, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)-welfare reform-restricted benefits for certain lawful noncitizens for the first time. Welfare reform also gave states unprecedented authority to determine Medicaid eligibility. More recent federal policy changes have allowed states to cover some noncitizen pregnant women initially excluded under welfare reform. However, there are few comprehensive studies examining state implementation of these policy options. This study documents state-level trends in prenatal Medicaid and state-funded coverage options for low-income noncitizens just prior to and since welfare reform. While some states have substantially expanded prenatal coverage since PRWORA, wide variation remains. These findings have important implications for understanding the potential effects of the Affordable Care Act and Medicaid expansion on health care utilization and birth outcomes among pregnant noncitizens. [ABSTRACT FROM AUTHOR]

The article discusses a study focusing on the views of state legislators on the Medicaid program in the U.S. Topics discussed include the legislators' priorities for Medicaid reform and policy changes; the difference in views of Democrats and Republicans regarding healthcare spending; and the preference of Republicans for cost-sharing for Medicaid recipients.

Also in Slovak health care day surgery is considered to be highly effective, since the treatment is focused to cure the patient in the shortest period of time without excessive pain and stress, providing highest quality with as little expenditure as possible. In 2009 new regulations came into effect in Slovakia concerning day surgery, which also promoted the development of day child surgery. Rigorous regulations apply for day child surgery to ensure higher responsibility within surgeons and all the medical staff. Suggested partial analyses of day surgery of the juniors obtained during the period of 2009 - 2012 in Slovakia indicate the importance to analyze data accessible at the National Health Information Center, as well as the importance of connection with demographics. These analyses enable us to adequately provide day surgery in individual regions of Slovakia, as well as to interconnect this treatment with optimal funding via health insurance companies, which will lead to increased efficiency of health care. [ABSTRACT FROM AUTHOR]

State health policy making is rarely based on evidence derived from empirical analysis. An exception is an innovative policy established in 2005 in Washington State (Senate Bill [SB] 5763) to provide funding (approximately $30 million) to expand access to substance abuse (SA) treatment for Medicaid beneficiaries. The authors analyzed Medicaid claims data and other administrative data over a 7-year period, July 2001 through June 2008, for three cohorts of welfare clients (n ≈ 44,000) to assess the effect of SA treatment on health care expenditures. Regression analysis showed SA treatment to be associated (p < .001) with per member per month expenditure savings of approximately $160 to $385 depending on the welfare cohort. The aggregate annualized estimated saving ($16.8 million) equaled the cost-saving goal of SB 5763. While it may be tempting for policy makers to cut funding for SA treatment, this may be counterproductive and in the long-run increase Medicaid costs. [ABSTRACT FROM PUBLISHER]

The article offers information on state health rankings which present oversimplified and potentially damaging accounts of health status. It presents several factors that are associated with health status indicators, including demographic data, poverty and educational attainment. It further informs that publicly available data sources were combined across the range of socio-ecological influences on health to identify discrepancies in state health status indices by county.

This quasi-experimental study examines the impact of Idaho’s wellness incentive program, which rewards children with CHIP (Children’s Health Insurance Programs) who are up-to-date with well-child visits with $30 in credits per quarter for use toward their CHIP premiums. Between baseline and the second year of implementation, the percentage of CHIP children who were up-to-date with well-child visits increased by 116% (from 23% to 49%), compared with a 13% increase (from 29% to 32%) among children with Medicaid, who were not eligible for the incentive. The incentive program had a greater impact on children who were recommended to have one annual well-child visit compared with those recommended to have two to four annual visits. The program was not, however, more effective for those whose premiums were fully covered by the reward compared with those whose premiums were partially covered. This study provides encouraging evidence to states about using consumer financial incentives for increasing preventive care use. [ABSTRACT FROM PUBLISHER]

To identify factors associated with small group employer participation in New Mexico's State Coverage Insurance (SCI) program. Telephone surveys of employers participating in SCI ( N=269) and small employers who inquired about SCI ( N=148) were fielded September 2008-January 2009. Descriptive and multivariate analyses investigated differences between employer samples, including employer characteristics, concerns that applied to the business when deciding whether to participate in SCI, prior offerings of insurance to workers, and perceived affordability of the program. Unweighted employer samples yielded 88 and 75 percent response rates for the participating and inquiring employers, respectively. The administrative issue most commonly selected by inquiring employers as applying to their business was difficulty understanding how eligibility requirements applied to their business and its employees (53.5 percent). Inquiring businesses were significantly more likely to report concern about affording to pay the premiums in the first month (35.6 versus 18.7 percent) and the cost to the business over the long run (46.5 versus 26.6 percent) relative to participating employers. From the model results, businesses with the fewest full-time employees (zero to two) were 19 percentage points less likely to participate relative to businesses with six or more full-time employees. Administrative and cost barriers to participation in SCI reported by employers suggest that the tax credit offered to small businesses under new federal provisions, which merely offsets the employer portion of premium, could be more effective if accompanied by additional supports to businesses. [ABSTRACT FROM AUTHOR]

To compare health insurance coverage estimates from the American Community Survey (ACS) to the Current Population Survey (CPS-ASEC). The 2008 ACS and CPS-ASEC, 2009. We compare age-specific national rates for all coverage types and state-level rates of uninsurance and means-tested coverage. We assess differences using t-tests and p-values, which are reported at <.05, <.01, and <.001. An F-test determines whether differences significantly varied by state. Despite substantial design differences, we find only modest differences in coverage estimates between the surveys. National direct purchase and state-level means-tested coverage levels for children show the largest differences. We suggest that the ACS is well poised to become a useful tool to health services researchers and policy analysts, but that further study is needed to identify sources of error and to quantify its bias. [ABSTRACT FROM AUTHOR]

Objective. To introduce the American Community Survey (ACS) and its measure of health insurance coverage to researchers and policy makers. Data Sources/Study Setting. We compare the survey designs for the ACS and Current Population Survey (CPS) that measure insurance coverage. Study Design. We describe the ACS and how it will be useful to health policy researchers. Principal Findings. Relative to the CPS, the ACS will provide more precise state and substate estimates of health insurance coverage at a point-in-time. Yet the ACS lacks the historical data and detailed state-specific coverage categories seen in the CPS. Conclusions. The ACS will be a critical new resource for researchers. To use the new data to the best advantage, careful research will be needed to understand its strengths and weaknesses. [ABSTRACT FROM AUTHOR]

Objective. To inform state policy discussions about the insurance coverage of the near elderly in West Virginia (WV) and the impact of the uninsured near elderly on hospitals in the state. Data Sources. 2003 West Virginia Uniform Bill (UB) hospital discharge data. The data represent all adult inpatient discharges in the state during the year. Study Design. We compare the near elderly with other adults and examine differences by insurance status. Key variables include volume of discharges, health insurance coverage, patient characteristics, and charges incurred. Findings. The near elderly constitute the largest group of nonelderly adult inpatient hospital discharges. They are more likely than younger adults to be admitted for emergency conditions; have comorbidities and complications; have longer hospital stays; and incur higher charges on average. Although the near elderly are least likely to be uninsured, they represent the second largest group of uninsured discharges and incur the most in uninsured charges. Conclusions. The specific needs of the near elderly warrant consideration in WV's (and other states') ongoing development and evaluation of policies aimed at reducing uncompensated care costs, including programs to expand access to health insurance and primary and mental health care among the uninsured. [ABSTRACT FROM AUTHOR]

This article examines the role of the California Health Benefits Review Program (CHBRP) as a source of information in state health policy making. It explains why the California benefits review process relies heavily on university-based researchers and employs a broad set of criteria for review, which set it apart from similar programs in other states. It then analyzes the politics of health insurance mandates and how independent research and analysis might alter the perceived benefits and costs of health insurance mandates and thus political outcomes. It considers how research and analysis is typically used by policy makers, and illustrates how participants inside and outside of state government have used the reports prepared by CHBRP as both guidance in policy design and as political ammunition. Although there is consensus that the review process has reduced the number of mandate bills that are passed out of the legislature, both supporters and opponents favor the new process and generally believe the reports strengthen their case in legislative debates over health insurance mandates. The role of the CHBRP is narrowly defined by statute at the present time, but the program may well face pressure to evolve from its current academic orientation into a more interactive, advisory role for legislators in the future. [ABSTRACT FROM AUTHOR]

Objective. Critically review estimates of health insurance coverage available from different sources, including the federal government, state survey initiatives, and foundation-sponsored surveys for use in state policy research. Study Setting and Design. We review the surveys in an attempt to flesh out the current weaknesses of survey data for state policy uses. The main data sources assessed in this analysis are federal government surveys (such as the Current Population Survey's Annual Social and Economic Supplement, and the National Health Interview Survey), foundation-supported surveys (National Survey of America's Families, and the Community Tracking Survey), and state-sponsored surveys. Principal Findings. Despite information on estimates of health insurance coverage from six federal surveys, states find the data lacking for state policy purposes. We document the need for state representative data on the uninsured and the recent history of state data collection efforts spurred in part by the Health Resources Services Administration State Planning Grant program. We assess the state estimates of uninsurance from the Current Population Survey and make recommendations for a new consolidated federal survey with better state representative data. Conclusions. We think there are several options to consider for coordinating a federal and state data collection strategy to inform state and national policy on coverage and access. [ABSTRACT FROM AUTHOR]

In the midst of ongoing concern about succession planning to develop the next generation of nursing leaders, the profession cannot afford to overlook succession planning in regard to the next generation of nurse leaders in health policy. This article describes a project of the North Carolina Center for Nursing that provides a fellowship in state-level health policy for North Carolina nurses who have completed a graduate level health policy course. Policy fellows are exposed to health policy analysis through the public policy arena, regulatory and administrative arenas, and organizational and institutional arenas. As part of this journey, all major state stakeholders in health policy are involved in the mentoring process. The North Carolina Center for Nursing Health Policy Fellowship is described here as a potential model related to policy initiatives in other states. [ABSTRACT FROM AUTHOR]

Hospital provision of uncompensated care is partly a function of insurance coverage of state populations. As states expand insurance coverage options and reduce the number of uninsured, hospital provision of uncompensated care should also decrease. Controlling for hospital characteristics and market factors, the authors estimate that increases in MinnesotaCare (a state-subsidized health insurance program for the working poor) enrollment resulted in a 5-year cumulative savings of $58.6 million in hospital uncompensated care costs. Efforts to evaluate access expansions should take into account the costs of the program and the savings associated with reductions in hospital uncompensated care. [ABSTRACT FROM AUTHOR]

Early newborn discharge legislation began a movement in health policy towards incremental changes in how medical consumers receive services. While well intentioned, these initiatives may undermine national efforts to address problems through more comprehensive reform, while stifling smaller efforts to address the problems locally. This paper discusses early newborn discharge legislation in Kansas: its origins, apparent impact, and implications. Findings from a hospital survey and two-year follow-up suggest a minimal effect of the legislation on health services in the state. Though acute hospital care appeared to replace home-based programs in many hospitals we spoke with, the more longstanding impact of the legislation seems to have been its precedent in how health policy is now made. [ABSTRACT FROM AUTHOR]

Background : To determine the relative impact of each of the 3 state-level tobacco control policies (cigarette taxation, tobacco control spending, and smoke-free air [SFA] laws) on adult smoking rate overall and separately for adult subgroups in the United States. Methods : A difference-in-differences analysis was conducted with generalized propensity scores. State-level policies were merged with the individual-level Behavioral Risk Factor Surveillance System in 1995-2009. Results : State cigarette taxation was the only policy that significantly impacted smoking among the general adult population, with a 1-standard deviation increase in taxes (i.e., $0.68 in constant 2014 dollars) lowering the adult smoking rate by about a quarter of a percentage point. The taxation impact was consistent, regardless of the presence of, or interactions with, other policies. Taxation was also the only policy that significantly reduced smoking for some adult subgroups, including females, non-Hispanic whites, adults aged 51 or older, and adults with more than a high school education. However, other adult subgroups responded to the other 2 types of policies, either by mediating the taxation effect or by reducing smoking independently. Specifically, tobacco control spending reduced smoking among young adults (ages 18-25 years) and Hispanics. SFA laws affected smoking among men, young adults, non-Hispanic blacks, and Hispanics. Conclusions : State cigarette taxation is the single most important policy for reducing smoking among the general adult population. However, adult subgroups' reactions to taxes are diverse and mediated by tobacco control spending and SFA laws.