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The Supreme Court's Surprising Decision On The Medicaid Expansion: How Will The Federal Government And States Proceed?

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Abstract

In National Federation of Independent Business v. Sebelius, the US Supreme Court upheld the constitutionality of the requirement that all Americans have affordable health insurance coverage. But in an unprecedented move, seven justices first declared the mandatory Medicaid eligibility expansion unconstitutional. Then five justices, led by Chief Justice John Roberts, prevented the outright elimination of the expansion by fashioning a remedy that simply limited the federal government's enforcement powers over its provisions and allowed states not to proceed with expanding Medicaid without losing all of their federal Medicaid funding. The Court's approach raises two fundamental issues: First, does the Court's holding also affect the existing Medicaid program or numerous other Affordable Care Act Medicaid amendments establishing minimum Medicaid program requirements? And second, does the health and human services secretary have the flexibility to modify the pace or scope of the expansion as a negotiating strategy with the states? The answers to these questions are key because of the foundational role played by Medicaid in health reform.

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... A key component of the Affordable Care Act (ACA) was an expansion of Medicaid eligibility to adults earning up to 138% of the federal poverty level (FPL). To support this expanded coverage, effective January 1, 2014, states would receive 100 percent federal funding for the first 3 years phasing to 90 percent federal funding in subsequent years [4][5][6]. Although this provision was originally intended to be enacted in all states, a United States Supreme Court decision gave states the option not to adopt it [7,8]. ...
... These racial and geographic disparities strongly impact access to screening and cancer related outcomes. CRC screening specifically has been shown to be affected by the affordability of health insurance, associated cost-sharing by beneficiaries as well a lack of a recommendation for screening by a primary care provider [5][6][7]. With the passage of the ACA, there has been an increase in the number of individuals with a primary care provider and a decrease in the number of individuals who defer care due to cost [5]. ...
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Background: Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA's Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants. Aim: To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States. Methods: This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status. Results: A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55). Conclusion: Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across all low-income populations, but not all races or levels of education.
... Te primary policy objectives of the ACA were to decrease the number of uninsured individuals and improve the afordability of health care in the US [2]. However, since the Obama Administration signed the ACA in 2010, states have repeatedly challenged the constitutionality of mandatory Medicaid expansion [3]. As a result, it was not until January 2014 that the frst batch of states adopted the Medicaid coverage expansion. ...
... Te passage of the ACA expanded Medicaid eligibility to uninsured adults whose household incomes were below 138% of the federal poverty level (FPL) and adults without dependent children [15]. Since Medicaid is a federal-state partnership program, the federal government's actions relating to mandatory Medicaid expansion have repeatedly been challenged by states [3]. ...
Article
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The United States’ Affordable Care Act (ACA) aims to improve access to and quality of care for low-income patients. To do so, it expands Medicaid eligibility from individuals under 100% of the federal poverty level (FPL) to include those under 138% of the FPL. Based on the 2014 Health Center Patient Survey (a nationally representative survey sponsored by the Health Resources and Services Administration (HRSA) (n = 4,380)), this study examined the effects of the Medicaid eligibility on having a usual source of care and the utilization of preventive services among health center patients. A regression discontinuity approach was used to identify the causative impact of Medicaid enrollment on low-income and nonelderly health center patients. Our findings suggest that Medicaid enrollment led to a substantial increase in the probability of both undergoing a routine checkup and having had a fecal occult blood test within the past year. These results indicate that changes to Medicaid policy have the potential to affect vulnerable populations. The evidence we provide supports the importance of maintaining the ACA due to its expanded Medicaid funding.
... Major coverage provisions went into full effect in January 2014 and had the potential to reach as many as 47 million Americans who did not have health insurance. 1 The goal of the expansion was to improve timely health care access for previously uninsured adults while working to mitigate the prohibitive costs of care. ...
... Despite passage of this bill, several states debated its legality in the context of state sovereignty over health care, leading to the US Supreme Court decision to uphold the states' decision-making capacity over Medicaid expansion. 1 Data from the Kaiser Family Foundation found that as of 2018, 37 states (including the District of Columbia) had adopted Medicaid expansion and 14 states had not. Of the 37 expansion states, 32 have plans that cover parents and other adults with incomes up to 138% of the federal poverty limit ($29 435 per year for a 3-person family and $17 236 per year for an individual, as of 2019). ...
Article
Importance The expansion of Medicaid sought to fill gaps in insurance coverage among low-income Americans. Although coverage has improved, little is known about the relationship between Medicaid expansion and breast cancer stage at diagnosis. Objective To review the association of Medicaid expansion with breast cancer stage at diagnosis and the disparities associated with insurance status, age, and race/ethnicity. Design, Setting, and Participants This cohort study used data from the National Cancer Database to characterize the relationship between breast cancer stage and race/ethnicity, age, and insurance status. Data from 2007 to 2016 were obtained, and breast cancer stage trends were assessed. Additionally, preexpansion years (2012-2013) were compared with postexpansion years (2015-2016) to assess Medicaid expansion in 2014. Data were analyzed from August 12, 2019, to January 19, 2020. The cohort included a total of 1 796 902 patients with primary breast cancer who had private insurance, Medicare, or Medicaid or were uninsured across 45 states. Main Outcomes and Measures Percent change of uninsured patients with breast cancer and stage at diagnosis, stratified by insurance status, race/ethnicity, age, and state. Results This study included a total of 1 796 902 women. Between 2012 and 2016, 71 235 (4.0%) were uninsured or had Medicaid. Among all races/ethnicities, in expansion states, there was a reduction in uninsured patients from 22.6% (4771 of 21 127) to 13.5% (2999 of 22 150) (P < .001), and in nonexpansion states, there was a reduction from 36.5% (5431 of 14 870) to 35.6% (4663 of 13 088) (P = .12). Across all races, there was a reduction in advanced-stage disease from 21.8% (4603 of 21 127) to 19.3% (4280 of 22 150) (P < .001) in expansion states compared with 24.2% (3604 of 14 870) to 23.5% (3072 of 13 088) (P = .14) in nonexpansion states. In African American patients, incidence of advanced disease decreased from 24.6% (1017 of 4136) to 21.6% (920 of 4259) (P < .001) in expansion states and remained at approximately 27% (27.4% [1220 of 4453] to 27.5% [1078 of 3924]; P = .94) in nonexpansion states. Further analysis suggested that the improvement was associated with a reduction in stage 3 diagnoses. Conclusions and Relevance In this cohort study, expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced incidence of advanced-stage breast cancer. African American patients and patients younger than 50 years experienced particular benefit. These data suggest that increasing access to health care resources may alter the distribution of breast cancer stage at diagnosis.
... The stick was the threat of withdrawing federal funds for the state's existing Medicaid program (i.e, prior to any expansion) from states that did not implement the expansion. In response, the state of Florida, joined ultimately by 25 other states, filed a lawsuit against the federal government, arguing that the threat of withdrawing existing federal Medicaid funds was coercive (KFF 2012;Rosenbaum and Westmoreland 2012). ...
... In June 2012 the Supreme Court ruled in favor of these states: the threat to take away federal funds for existing Medicaid programs was, indeed, coercive and therefore unconstitutional (KFF 2012;Rosenbaum and Westmoreland 2012). This decision rendered Medicaid expansion effectively optional for the states. ...
Article
Context: Medicaid expansion has costs and benefits for states. The net impact on a state's budget is a central concern for policy makers debating implementing this provision of the Affordable Care Act. How large is the state-level fiscal impact of expanding Medicaid, and how should it be estimated? Methods: We use Michigan as a case study for evaluating the state-level fiscal impact of Medicaid expansion, with particular attention to the importance of macroeconomic feedback effects relative to the more straightforward fiscal effects typically estimated by state budget agencies. We combine projections from the state of Michigan's House Fiscal Agency with estimates from a proprietary macroeconomic model to project the state fiscal impact of Michigan's Medicaid expansion through 2021. Findings: We find that Medicaid expansion in Michigan yields clear fiscal benefits for the state, in the form of savings on other non-Medicaid health programs and increases in revenue from provider taxes and broad-based sales and income taxes through at least 2021. These benefits exceed the state's costs in every year. Conclusions: While these results are specific to Michigan's budget and economy, our methods could in principle be applied in any state where policy makers seek rigorous evidence on the fiscal impact of Medicaid expansion.
... Localities do not have the same immunity from state preemption that states have from federal preemption (Blair et al. 2020;Kamal et al. 2018;Rosenbaum and Westmoreland 2012). ...
Article
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During the COVID-19 pandemic, governors preempted local governments at unprecedented levels. A rich literature examines state preemption of local governments, but gubernatorial preemption – and the strategies governors use to do so – remain understudied. This paper examines what institutional and political factors influenced governors’ preemption style during the pandemic by analyzing a dataset of over 1,200 COVID-19 executive orders, classified by their style of preemption: ceiling, floor, or vacuum. Governors in states with high local autonomy rely on ceiling and floor preemptions. Republican governors are likelier to issue ceiling preemptions that bind local governments’ hands. Governors in states with ideologically dissimilar local governments tend to issue vacuum preemptions. When non-preempting previsions are dropped from the analysis, local autonomy does not significantly affect issuing one type of preemption over another. On the other hand, Republican governors are more likely to issue both ceiling and floor preemptions over vacuum preemptions. Governors in states with high ideological asymmetry are less likely to issue ceiling and floor preemptions over vacuum preemptions. These findings provide insight into gubernatorial behavior, interactions between state and local governments, and how theories of federalism can teach us more about how governments respond to crises.
... Under the Patient Protection and Affordable Care Act "ACA" or "Obamacare" passed in 2010, expansion of Medicaid to cover all adults at or below 133% of the poverty line was a cornerstone of the policy framework. In summer of 2012, the Supreme Court upheld the ACA framework as constitutional, but ruled that states could not be compelled to expand their Medicaid programs (Rosenbaum and Westmoreland 2012). In turn, multiple states have refused to expand Medicaid, leaving millions of low-income individuals and families without access to health insurance coverage and healthcare services. ...
... While the original law intended to expand the program eligibility across the U.S., the Supreme court decision of unlawfulness of such a requirement hindered a nationwide implementation of Medicaid expansions. 1 By the end of our study period in 2019, thirty-five states including the District of Columbia expanded the program, while 16 had kept the income eligibility at prior levels. 2 The positive effects of Medicaid expansions on a range of outcomes have been extensively documented in the literature 3 and estimates suggest that up to 60% of insurance coverage gains could be attributed to Medicaid. ...
Article
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The positive effects of Medicaid expansions have been extensively documented in the literature. However, it is not clear whether the reform has had an equally meaningful effect with respect to underinsurance, which is the state of having health insurance yet lacking adequate coverage or facing substantial financial risks upon usage of services. Based on a quasi-experimental difference-in-differences approach, we analyzed the data from a nationally representative sample to estimate the effect of Medicaid expansion on the probability of underinsurance among the non-elderly low-income adult population of the U.S. We found no evidence of significant changes in the likelihood of underinsurance due to Medicaid expansion during the first 4 years after the ACA implementation. However, a supplementary analysis of the longer-term impact (2018-2019) suggests that there might be a time lag between Medicaid expansion and its effect on underinsurance. It is important to realize that expansion of coverage alone may not be sufficient to protect millions of Americans, particularly those with low incomes, from underinsurance. It is, therefore, crucial for policymakers to build legislative frameworks that protect individuals from excessive healthcare expenses and prevent treatment avoidance or delay.
... This legislation included expanding Medicaid insurance to individuals below 138% of the federal poverty level as a core provision. 7 While several studies have investigated the impact of the ACA on health outcomes, its influence on breast cancer health disparities has not been comprehensively defined. ...
... 3 After a Supreme Court case evaluating the constitutionality of the ACA, Medicaid expansion became optional for states. 4 Since the initial expansions in January 2014, thirty-eight states and Washington, D.C., have expanded Medicaid either through the initial ACA mechanism or through waivers. 5 Waivers allow states to modify their programs in ways that are outside of federal Medicaid regulations. ...
Article
With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.
... The socio-economic theory is attractive because with a generous reimbursement from the federal government, conventional economic theory assumed that resource challenged states would be more inclined to expand Medicaid (Rosenbaum andWestmoreland 2012, Ayanian, Ehrlich et al. 2017). This rationale is particularly striking in response to the Great Recession of 2007. ...
Thesis
When the Supreme Court held in June 2012 that states were not required to expand their Medicaid program under the Affordable Care Act (ACA), it reset the politics of health reform at the state level, creating a natural experiment to understand implementation decisions. With a generous reimbursement from the federal government, economic benefits for businesses and health systems, and coverage for the previously uninsured, states had much to gain by expanding Medicaid. Yet, the political divisions which emerged during Congressional debate and passage of the ACA marked the implementation of the Medicaid expansion. With 18 states rejecting implementing the Medicaid expansion, what explains state decision-making and the Medicaid expansion? I find that partisanship matters, but the Medicaid expansion has had a destabilizing effect on the Republican Party; the institutional design, organized interests, waivers, and national events have influenced whether and how a state decides to implement the Medicaid expansion. Implementation decisions are complex social phenomena, influenced by several interacting factors. One common account of ACA implementation decisions has focused on the role of partisanship. While Democrats have embraced the Medicaid expansion, Republicans have a much more complicated connection with the policy. Of all the states that have rejected the expansion, all but one is has a Republican governor and majority control over both chambers of the legislature. Yet, more than forty percent of Republican governors and a third of Republican majority control state legislative chambers have voted to expand Medicaid. To examine the implementation of the Medicaid expansion, I conducted in-depth comparative case studies across three states. To facilitate case selection, I used fuzzy set/Qualitative Comparative Analysis (fsQCA), which identified three “pivot” cases, Arizona, Michigan, and Utah, for analysis. Each of the three Republican controlled states was on the brink of expanding or not their Medicaid programs. I collected two types of data to detect variations in implementation across the cases. First, I conducted semi-structured key informant interviews across each of the case study states. Second, I analyzed thousands of documents, including written and oral legislative testimony, legal material, and government and think-tank reports related to the expansion. Gubernatorial support was necessary, but not sufficient, to explain state decision-making for implementing the Medicaid expansion. Across each of these cases, the Medicaid expansion created divisions between traditional economic interests and ideologically driven factions within the Republican Party. Supportive Republican policymakers attempted to overcome these intra-party divisions by leveraging the idiosyncratic institutional design to pressure or bypass oppositional legislators. Additionally, organized interests influenced whether and how a state implemented the Medicaid expansion. The role of organized interests was moderated by the ability of these groups to stay unified, the timing of their mobilization in response to the Supreme Court decision, and the intensity of their policy preferences. Waivers gave supporters of the Medicaid expansion flexibility to pursue “reforms” to change the calculus of policymaker perception of Medicaid expansion and expand coalition formation within the legislature, while pushing the Medicaid program in more conservative directions. Lastly, the national political environment influenced whether and how a state implemented the Medicaid expansion. By 2017, each of the states had entered a period of stasis with Medicaid, only for the Trump administration and its shifting politics and policy around Medicaid to unsettle the programs, causing states to reevaluate and adapt their expansions to the new environment.
... Though a few states like Massachusetts did expand Medicaid eligibility prior to 2010, the scale of expansion as part of the ACA was much wider, covering millions more. However, the US Supreme Court later ruled that the states opt out of such requirements (Rosenbaum & Westmoreland, 2012). A combination of political and other forces resulted in a haphazard expansion over the years across states, creating a natural experiment. ...
Article
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Expansion of subsidized health insurance may result in both safer and riskier health behavior and outcomes. While having insurance lowers cost barriers to receive both usual and preventive care, the lower potential cost from adverse health events may also promote risky behavior. In this paper, I exploit expansion in the Medicaid program under the Affordable Care Act to estimate the impact of insurance expansion on health outcomes and behaviors for low-income individuals in the US. I find that expansion of coverage has significantly lowered cost and increased access, particularly among minority populations, but has had no significant impact on preventive health behaviors. At the same time, I also find no evidence of moral hazard or increase risky behavior like smoking and drinking among residents of expansion states.
... A staggered difference-in-differences design was used to compare residents in states that expanded Medicaid with residents in states that did not. Because the 2012 Supreme Court ruling allowed states to differentially implement expansion at different times, 34 this created a natural experiment. If assumptions are met, then difference-in-differences designs can control for secular trends and time-invariant differences between states to isolate the effect of the policy exposure. ...
Article
Introduction The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. Methods A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008–2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18–64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. Results In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= −16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. Conclusions Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.
... In 2012 the US Supreme Court's landmark decision in National Federation of Independent Businesses v. Sebelius allowed for the ACA to remain the law, but made it optional for states to extend Medicaid coverage to individuals with incomes up to 138% of the federal poverty level [18]. North Carolina is one of 12 states that has not fully implemented the ACA through expanding Medicaid, thus leaving many people in the Medicaid coverage gap where they continue to experience access and financial barriers to obtaining health insurance. ...
Article
Prior to the passage of the Affordable Care Act, many individuals across the state and country faced numerous barriers to accessing affordable and quality health care. This paper provides a review of health coverage in North Carolina before the ACA, the impact the ACA has had on access to health care, and how North Carolina could continue to benefit from "complete" implementation of the ACA.
... Health care reform has always been politically volatile, and Medicaid expansion was no exception. Originally, the Affordable Care Act mandated that all states expand public insurance coverage or forgo all federal Medicaid funds 6 ; however, the Supreme Court declared this punitive measure unconstitutional in 2012. 7 States were then allowed to freely decide whether to expand. ...
Article
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PURPOSE Medicaid expansion was designed to increase access to health care. Evidence is mixed, but theory and empirical data suggest that lower cost of care through greater access to insurance increases health care utilization and possibly improves the health of poor and sick populations. However, this major health policy has yet to be thoroughly investigated for its effect on health disparities. The current study is motivated by one of today’s most stark inequalities: the disparity in breast cancer mortality rates between Black and White women. METHODS This analysis used a difference-in-difference fixed effects regression model to evaluate the impact of Medicaid expansion on the disparity between Black and White breast cancer mortality rates. State-level breast cancer mortality data were obtained from the Centers for Disease Control and Prevention. Each state’s Medicaid expansion status was provided by a Kaiser Family Foundation white paper. Two tests were conducted, one compared all expanding states with all nonexpanding states, and the second compared all expanding states with nonexpanding states that voted to expand—but did not by 2014. The difference-in-difference regression models considered the year 2014 a washout period and compared 2012 and 2013 (pretreatment) with 2015 and 2016 (posttreatment). RESULTS Medicaid expansion did not lower the disparity in breast cancer mortality. In contrast to expectations, the Black/White mortality ratio increased in states expanding Medicaid for all Medicaid-eligible age groups, with significant effects in younger age groups ( P = .01 to .15). CONCLUSION These results suggest that states cannot solely rely on access to insurance to alleviate disparities in cancer or other chronic conditions. More exploration of the impacts of low-quality health systems is warranted.
... move that shocked almost everyone." (Rosenbaum and Westmoreland, 2012). The decision raised formidable questions: What other health programs or Medicaid provisions might be considered "coercive" toward the states? ...
Article
Despite unprecedented partisanship, the Affordable Care Act (ACA) traced a familiar political arc: a loud debate full of dramatic symbols, a messy legislative process, clashes over implementation, a slow rise in popularity, entrenchment as part of the health care system, and growing support that blocked Congress from repealing. The politics of the ACA looked, from one angle, like a louder version of health politics as usual. But something new was stirring. Opponents pushed the debate outside the elected branches of government and into the courts—a move that reflects past eras of highly racialized conflict. A federal court marked the ACA's tenth anniversary by doing what Congress could not: it struck down the law, although the litigation continues to wend its way through the court system. The ongoing challenge to the ACA rests on a fundamental critique of the entire New Deal dispensation in jurisprudence. The consequence could be a new era in health care politics.
... Medicaid expansion was more extensive in states with more affluent residents, state administrative capacity, generous Medicaid coverage rules already in place before the ACA, and politically influential health care providers; it was less extensive in areas with higher levels of conservative ideology or racial resentment in the population (Hertel-Fernandez, Skocpol, and Lynch 2016;Jacobs and Callaghan 2013;Lanford and Quadagno 2016). When conservative politicians support expansion, they sometimes do so in combination with other program changes using a Medicaid waiver (Rosenbaum and Westmoreland 2012). This strategy enables them to frame the expansion as a "reform" to Medicaid rather than as an expansion of the existing program (Grogan, Singer, and Jones 2017). ...
Article
Context: In November 2017, Maine became the first state in the nation to vote on a key provision of the Affordable Care Act: the expansion of Medicaid. Methods: This study merged official election results from localities across Maine with Census Bureau and American Hospital Association data to identify characteristics of areas that support Medicaid expansion. Findings: Places with more bachelor's degree holders more often vote in favor, whereas those with more associate's degree graduates tend to vote against. Conditional on education rates, areas with more uninsured individuals who would qualify for expanded coverage tend to vote in favor, while those with more high-income individuals tend to vote against. Also conditional on education rates, greater hospital employment is associated with support for expansion, but the presence of other health professionals, whose incomes might decrease from expansion, is associated with less support. Conclusions: Voting patterns are mostly consistent with economic self-interest, except for the sizable association of bachelor's degree holders with support for Medicaid expansion. Direct democracy can shift Medicaid policy: extrapolating to other states, the model predicts that hypothetical referenda would pass in 5 of the 18 states that had not yet expanded Medicaid at the time of Maine's vote.
... However, the US Supreme Court ruled that Medicaid expansion would be voluntary for the states. 32,33 Ultimately, twenty-five states expanded Medicaid eligibility in January 2014, and twenty-nine states and the District of Columbia did so in either 2014 or 2015. ...
Article
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Diabetes is a top contributor to the avoidable burden of disease. Costly diabetes medications, including insulin and drugs from newer medication classes, can be inaccessible to people who lack insurance coverage. In 2014 and 2015 twenty-nine states and the District of Columbia expanded eligibility for Medicaid among low-income adults. To examine the impacts of Medicaid expansion on access to diabetes medications, we analyzed data on over ninety-six million prescription fills using Medicaid insurance in the period January 2008-December 2015. Medicaid eligibility expansions were associated with thirty additional Medicaid diabetes prescriptions filled per 1,000 population in 2014-15, relative to states that did not expand Medicaid eligibility. Age groups with higher prevalence of diabetes exhibited larger increases. The increase in prescription fills grew significantly over time. Overall, fills for insulin and for newer medications increased by 40 percent and 39 percent, respectively. Our findings suggest that Medicaid eligibility expansions may address gaps in access to diabetes medications, with increasing effects over time.
Article
Importance Medicaid expansion broadened access to care; however, limited data about the effect on access to anti-incontinence surgical procedures exist. Objective Since the Affordable Care Act (ACA) Medicaid expansion in 2014, some regions have had more states adopt expansion (NE—Northeast, W—West) than other regions (S—South, MW—Midwest). We aimed to determine if the proportion of Medicaid funded anti-incontinence procedures increased after Medicaid expansion and whether increases were different by U.S. region. Study Design This was a retrospective cohort study. Results The 2012–2018 Healthcare Cost and Utilization Project National Inpatient Sample was reviewed for anti-incontinence surgical procedures. Medicaid supported surgical procedures were compared by region and year, and among marginalized populations. During the study period 66,510 surgical procedures were performed. Medicaid as a primary payer for anti-incontinence procedures increased from 10% to 12% ( P = <0.001) between 2012 and 2018. The percentage of Medicaid supported procedures performed in the NE (13%) and W (17%) were greater than MW (9%) and S (8%). Procedures among Black, Hispanic or lowest income quartile patients were lowest in the S and did not increase after expansion during the study period (2012 vs 2018, all P = NS). When controlling for confounders, the MW (odds ratio [OR] 0.58; 95% CI 0.46–0.74) and S (OR 0.33; 95% CI 0.26–0.42) were less likely to have Medicaid covered surgical procedures compared to the NE and W (OR 1.04; 95% CI 0.84–1.29). Conclusions Nationally, the percentage of Medicaid-supported anti-incontinence procedures increased after expansion. Northeast and W access to procedures increased, and access by marginalized populations broadened, while the S and MW had the most limited proportion of anti-incontinence surgical procedures covered by Medicaid.
Article
The burden of early onset colorectal cancer (EOCRC) falls disproportionately on minorities and individuals in specific geographic regions. While these disparities are likely multi-factorial, access to high-quality health care plays a significant role. We sought to determine if Medicaid expansion is associated with reducing racial disparities in EOCRC detection in Hispanics and non-Hispanic Blacks (NHB), compared to non-Hispanic Whites (NHW). Analysis of data from National Cancer Database was undertaken to compare incidence of EOCRC among those aged 40–49 between Medicaid expansion states (ES) and non-expansion states (NES) by racial/ethnic groups. Data was classified by race (NHW, NHB, or Hispanic), state of residence (ES or NES), and time (pre- or post-expansion). The primary outcome was change in incidence rate of EOCRC among racial/ethnic groups, according to whether patients resided in Medicaid expansion or non-expansion states. Among Hispanics, the ES showed a significant increase in EOCRC incidence post expansion as compared to NES (p = 0.03). The rate of increase in annual incidence of EOCRC among Hispanics was 4.3% per year (pre-expansion) and 9.8% (post-expansion) for ES; and 6.4% (pre-expansion) and 1% (post-expansion) in NES. However, no difference was noted among NHB (p = 0.33) and NHW (p = 0.94). Medicaid expansion has improved detection rates of EOCRC in ES especially in Hispanic population. This is the first study to demonstrate the effect of Medicaid expansion on the incidence of EOCRC. Based on our study findings we suggest that racial and ethnic disparities should be considered in the earlier CRC screening debates.
Article
Background: The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes. Methods: Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes. Results: A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities. Conclusions: Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.
Article
Objectives: We compared the use of sexual and reproductive health (SRH) services for Medicaid-enrolled women of reproductive age (WRA) living in Oregon by urban/rural status and examined the effect of the Affordable Care Act (ACA) Medicaid expansion on the use of SRH services for these women. Methods: We linked Oregon Medicaid enrollment files and claims for the years 2008-2016 to identify 392,111 WRA. Outcome measures included receipt of five key SRH services. The main independent variables were urban/rural status (urban, large rural cities, and small rural towns) and an indicator for the post-Medicaid expansion time period (2014-2016). We performed (conditional) fixed-effects logistic regression and multiple-group interrupted time-series analyses. Results: Women living in small rural towns were less likely than women living in urban areas to receive well-woman visits (odds ratio [OR] = 0.87; 95% confidence interval [95% CI] [0.80-0.94]), sexually transmitted infection (STI) screening (OR = 0.81; 95% CI [0.72-0.90]), and pap tests (OR = 0.91; 95% CI [0.84-0.99]). Women living in large rural cities were less likely than women living in urban areas to receive STI screening (OR = 0.91; 95% CI [0.84-0.98]). Following the implementation of ACA Medicaid expansion, the average number of all five SRH services increased for all women. With the exception of contraceptive services, the average number of SRH services examined increased more for urban women than for women living in small rural towns. Conclusions: Although Medicaid expansion contributed to increased use of SRH services for all WRA, the policy was unsuccessful in reducing disparities in access to SRH services for WRA living in rural areas compared with urban areas.
Article
Importance: It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations. Objective: To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs). Design, setting, and participants: This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021. Exposures: States were categorized into early-adopter states (expansion by January 2014) and nonadopter states. Main outcomes and measures: Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population. Results: Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (P for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, -6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, -10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion. Conclusions and relevance: This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.
Article
Background: The Affordable Care Act has been associated with increased Medicaid coverage for childbirth among low-income US women. We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia. Methods: We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017. Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate. Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion. Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level. Results: The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states. In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76.3%. Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1.7% in expansion states (95% CI, 1.6-1.8) and 0.9% (95% CI, 0.9-1.0) in nonexpansion states. The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0.47% points (95% CI, -0.63 to 1.57; P = .39). Conclusions: Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period. Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.
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Background: The Affordable Care Act sought to improve access to health care for low-income individuals. This study aimed to assess whether expansion of Medicaid coverage increased rates of post-mastectomy reconstruction (PMR) for patients who had Medicaid or no insurance. Methods: A retrospective analysis performed through the National Cancer Database examined women who underwent PMR and were uninsured or had Medicaid, private insurance, or Medicare, and whose race/ethnicity, age, and state expansion status were known. Trends in the use of PMR after passage of Medicaid expansion in 2014 were evaluated. Results: In all states and at all time periods, patients with private insurance were about twice as likely to undergo PMR as patients who had Medicaid or no insurance. In 2016, only 28.7 % of patients with Medicaid or no insurance in nonexpansion states underwent PMR (p < 0.001) compared with 38.5 % of patients in expansion states (p < 0.001). Patients in expansion states also have higher levels of education, higher income, and greater likelihood of living in metropolitan areas. Additionally, patients in all states saw an increase in early-stage disease, with a concomitant reduction in late disease, but this change was greater in expansion states than in non-expansion states. Conclusions: Expansion states have larger proportions of patients undergoing PMR than non-expansion states. This difference stems from significant differences in income, education, comorbidities, race, and location. Large metropolitan areas have the largest number of patients undergoing PMR, whereas rural areas have the least.
Article
Rampant COVID-19 outbreaks in US nursing homes have presented a massive biosecurity problem for the nation, bringing into stark relief the racialized stratification of eldercare administration and long-term care. This paper, by foregrounding the ways racial capitalism drives the chronic devaluation of nursing home residents and staff, provides an overview of how racism and ageism operate geographically through political ecologies of COVID in relation to the organization of the nursing home industry, medical scarcity, long-term care labor, and pandemic response to elderly populations. The inventory tracks some of the ways nursing homes condition race-based futures by arranging eldercare populations, workers, and spaces for extraction, abandonment, and blame for the pandemic. In doing so, it demonstrates the need for more equitable forms of aging and more just institutions of eldercare that put the social welfare of the aged, especially that of BIPOC elders and caregivers, above corporate compliance and financial performance that reproduce racial hierarchy and white supremacy in US healthcare. The article concludes by engaging with Black feminist data analytics and several policy efforts that challenge the structurally racist conditions of caregiving, pandemic response, and securitized segregation of the aged.
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Objective To quantify impacts of early Affordable Care Act (ACA) Medicaid expansions on Medicaid participation for primary care physicians. Data Sources The study uses secondary Medicaid Analytic eXtract (MAX) data from the United States for 2009-2012 as well as secondary National Plan and Provider Enumeration System (NPPES) data from the United States for 2015. Study Design The study uses a quasi-experimental difference-in-differences study design where the policy change is Medicaid expansion in 6 states that adopted early ACA Medicaid expansions during 2010 and 2011: California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington. The key outcome variables are five monthly measures of physician participation: the number of Medicaid visits, the number of Medicaid patients, seeing at least 1 Medicaid patient, seeing at least 25 Medicaid patients, and seeing at least 50 Medicaid patients. Data Collection/Extraction Methods The sample consists of all physicians who were active between 2005 and 2015 according to the NPPES. Principal Findings For primary care physicians, Medicaid expansion led to a 29% increase in Medicaid visits (5.88 per month; 95% CI: 2.49 to 9.27), a 29% increase in Medicaid patients (4.59 per month; 95% CI: 2.16 to 7.02), and did not affect the probability of any Medicaid participation. Medicaid expansion also led to a 22% increase in the probability of seeing at least 25 Medicaid patients per month (4.58 percentage points; 95% CI: 1.27 to 7.89) and a 31% increase in the probability of seeing at least 50 Medicaid patients per month (2.99 percentage points; 95% CI: 0.99 to 4.99). Conclusions Early ACA Medicaid expansions led to increased Medicaid visits for primary care physicians but did not affect the probability of any Medicaid participation. Primary care physicians who had previously served Medicaid patients responded to early ACA Medicaid expansions by serving substantially more Medicaid patients.
Article
Aims To determine whether Medicaid expansion impacted racially more diverse states similarly as racially less diverse states in endocrine therapy (ET) prescriptions. Methods A quasi-experimental, comparative interrupted time series study of Medicaid-financed ET prescriptions from 2011 to 2018 Medicaid State Drug Utilization Database. The exposures were state’s Medicaid expansion and racial diversity status. The outcome was state’s quarterly number ET prescriptions per 100,000 non-elderly adult females (NAFs). Results During the year of expansion, ET prescriptions increased sharply in expansion states but remained flat in nonexpansion states (slope: 11.96 vs. 0.43 prescriptions per 100,000 NAFs per quarter, p < 0.001). After that, the slopes were similar between expansion and nonexpansion states (1.75 vs. 0.24, p = 0.057) but the level of prescriptions in expansion states maintained at a higher level. When stratified by state’s racial diversity status, the slope of increase in the first year was sharper for raciallymore diverse expansion states (16.49, p = 0.008) than racially less diverse expansion states (8.46, p < 0.001), resulting in significant differences in ET prescriptions between racially more diverse expansion and nonexpansion states but largely nonsignificant differences between racially less diverse expansion and nonexpansion states. Conclusions Although Medicaid expansion significantly increased ET prescriptions in expansion vs. nonexpansion states, this difference was only observed among raciallymore diverse states. Racially more diverse nonexpansion states had the lowest rates of ET prescriptions and the gaps from racially more diverse expansion states significantly widened after expansion. Policy summary Our study shows that, before expansion, racially more diverse nonexpansion states had the lowest rates of ET prescriptions. After expansion, the gaps between these states and racially more diverse expansion states significantly widened. These results highlighted the importance of continuing to examine the health impacts of states not expanding Medicaid, including the health equity impacts for low income racial/ethnic minority populations with cancer and other life-threatening diseases.
Article
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.
Article
Introduction: The U.S. Affordable Care Act Medicaid expansion, which allowed states to expand Medicaid coverage to low-income adults beginning in 2014, has reduced the risk factors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental illness. This study examines the associations between Medicaid expansion and the rates of overall, first-time, and repeat reports of child neglect and physical abuse incidents per 100,000 children aged 0-5, 6-12, and 13-17 years. Methods: The 2008-2018 National Child Abuse and Neglect Data System was analyzed using an extension of the difference-in-differences approach that accounts for staggered policy implementation across time. Owing to evidence of nonparallel preperiod trends in the 6 states that expanded Medicaid from 2015 to 2017, the main analyses included 20 states that newly expanded Medicaid in 2014 and 18 states that did not expand Medicaid from 2008 to 2018. Analyses were conducted in 2020-2021. Results: Medicaid expansion states were associated with reductions of 13.4% (95% CI= -24.2, -9.6), 14.8% (95% CI= -26.4, -1.4), and 16.0% (-27.6, -2.6) in the average rate of child neglect reports per 100,000 children aged 0-5, 6-12, and 13-17 years, per state-year, relative to control states. Expansion was associated with a 17.3% (95% CI= -28.9, -3.8) reduction in the rate of first-time neglect reports among children aged 0-5 years and with 16.6% (95% CI= -29.3, -1.6) and 18.7% (95% CI= -32.5, -2.1) reductions in the rates of repeat neglect reports among children aged 6-12 and 13-17 years, respectively. There were no statistically significant associations between Medicaid expansion and the rates of physical abuse among children in any age group. Conclusions: Insurance expansions for low-income adults may reduce child neglect.
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Partisan and ideological polarization have been major barriers to the implementation of the Affordable Care Act’s Medicaid expansion in Republican-controlled states. Scholars have referred to this situation as “fractious federalism,” with Republican state policymakers toeing the national party line in refusing to cooperate with a major policy initiative. In some cases, however, diverse advocacy coalitions have overcome fractious federalism to pass expansion legislation in deeply Republican states. More recently, such coalitions have resorted to ballot initiative campaigns as another means of overcoming such polarization, and won impressive victories in a series of “deep red” states. Drawing on forty-four interviews with people involved in expansion advocacy in eleven states, I report important insights on the formation and activities of these coalitions in both the legislative and ballot initiative eras of Medicaid expansion politics.
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Courts play a significant role in the human life. What is the history of the court? What are the characteristics of early development of the United States court system? What are the milestone cases of the supreme court history? What is the history of the courts in England and Wales? What are the types of the courts? What is the role of the courts? In this research, the Biblical verses concerning the court are described. Therefore, the research deals with various socio-medical aspects of the court. This Research shows that the awareness of the Court has accompanied human during the long years of our existence.
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In clinical trials, smoking-cessation aids (SCAs) have proven to be effective at improving the odds of smoking cessation. Because of the effectiveness of SCAs in these settings, many countries have adopted the coverage of SCAs to reduce tobacco use. However, the effect of such coverage on tobacco use is ambiguous. On one hand, the coverage may have the intended effect and reduce tobacco use. On the other hand, the coverage may cause beneficiaries to participate in tobacco use more as the drug coverage protects beneficiaries from future costs associated with tobacco use. To understand the effect of SCA coverage, we examine it using 2008–2012 Canadian Tobacco Use Monitoring Survey and a difference-in-differences approach. We find that SCA coverage increases cigarette and cigarillo use. Moreover, the effect of SCA coverage on tobacco use is stronger in men and in those with at least a college education. Our results point to the unintended consequences of the coverage of SCAs on tobacco use.
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Background Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014. Methods National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected. Results Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51% (13.2-204%). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77% (9.5-230%) and the average decrease of uninsured rates was 55% (13.4-73%). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities. Conclusion Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed. Policy Summary This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.
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Background States had flexibility in their implementation of the Patient Protection and Affordable Care Act (ACA) Medicaid expansions, which may have led to variation in coverage and changes in access to care for workers with disabilities. Objective /Hypothesis. To examine differential trends in health insurance coverage and access to care among workers with disabilities by states’ decisions about expanding Medicaid under the ACA. Methods We aggregated data from the National Health Interview Survey into groups by time period relative to ACA implementation: pre-ACA (2006–2009), early ACA (2010–2013), and later ACA (2014–2017). We produced health insurance and access statistics for each time period, by state-level Medicaid expansion status. Results Uninsurance rates decreased after 2014 in all states, regardless of the state’s decision whether to expand Medicaid. There was a substantial increase after 2014 in the share of workers with disabilities covered by Medicaid in states that expanded in that year; in other states, workers with disabilities experienced larger increases in privately purchased coverage. At the same time, the share of workers with disabilities reporting cost-related barriers to care declined markedly in 2014 Medicaid expansion states, but it increased slightly in the non-expansion states. Structural barriers to accessing care increased in all states, with the smallest increase in 2014 expansion states. Conclusions Medicaid coverage and cost-related access to care improved significantly among workers with disabilities in 2014 Medicaid expansion states, both overall and relative to workers with disabilities in non-expansion states.
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Objective: The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report "For the Public's Health: Investing in a Healthier Future." Design: Qualitative study involving key informant interviews. Setting and participants: Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report. Main outcome measures: Qualitative feedback about changes to public health finance since the report. Results: Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow. Conclusions: Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level. Implications for policy and practice: Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.
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This article investigates the impact of the 2010 Patient Protection and Affordable Care Act (ACA) on the healthfulness of non‐alcoholic beverage (NAB) choices of low‐income households. A theoretical analysis proposes an income effect that increases unhealthy beverage purchases after Medicaid expansion and a nutrition education effect that decreases them. To empirically test these effects, we utilize household‐level data for NAB purchases in 52 U.S. metropolitan areas. Our identification strategy is based on eligible households following the 2012 Supreme Court ruling that allowed states to opt out of Medicaid expansion. We examine changes in purchases across NAB categories and in purchases at the product‐brand level. Empirical results indicate that Medicaid expansion resulted in eligible households buying more diet carbonated soft drinks (CSDs) and bottled water, with no effect on regular CSDs, fruit juice, fruit drinks, milk, or tea. Moreover, the expansion led to decreases in sugar purchases and increases in purchases of NAB products with lower sugar content, highlighting the benefits of supplementing the medical benefits of Medicaid with diet quality programs, such as nutrition education.
Article
Objective To quantify the effects of the Affordable Care Act Medicaid expansion on prescriptions for effective breast cancer hormonal therapies (tamoxifen and aromatase inhibitors) among Medicaid enrollees. Data Source/Study Setting Medicaid State Drug Utilization Database (SDUD) 2011‐2018, comprising the universe of outpatient prescription medications covered under the Medicaid program. Study Design Differences‐in‐differences and event‐study linear models compare population rates of tamoxifen and aromatase inhibitor (anastrozole, exemestane, and letrozole) use in expansion and nonexpansion states, controlling for population characteristics, state, and time. Principal Findings Relative to nonexpansion states, Medicaid‐financed hormonal therapy prescriptions increased by 27.2 per 100 000 nonelderly women in a state. This implies a 28.8 percent increase from the pre‐expansion mean of 94.2 per 100 000 nonelderly women in expansion states. The event‐study model reveals no evidence of differential pretrends in expansion and nonexpansion states and suggests use grew to 40 or more prescriptions per 100 000 nonelderly women 3‐5 years postexpansion. Conclusions Medicaid expansion may have had a meaningful impact on the ability of lower‐income women to access effective hormonal therapies used to treat breast cancer.
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Academic medical centers (AMC) provide care for most of the underinsured populations of the United States. Their large size and the high acuity of cases make AMCs vulnerable to changes in health care policy. They also are the primary centers for health care research and education and are therefore heavily dependent on federal programs and funding. Since the passage of the Affordable Care Act, AMCs have seen a decrease in the number of patients without insurance. They have also participated in the implementation of alternative payment models, including accountable care organizations, with mixed success.
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The US healthcare systems is struggling to keep pace with increasing demand, as the burden faced by providers and healthcare organizations expands. While care delivery models continue to evolve in the post-reform era, many barriers stemming from capacity constraints, regulation, shortages of manpower and, misallocation of resources persist. In this paper, we provide an analysis of unmet demand in the US system healthcare system. We contribute a deep dive of the literature to elucidate the reasons for which imbalanced and unmet demand, including the heavy use of the emergency department for non-emergent conditions, continues to burden healthcare organizations. We use these findings to motivate recommendations about how to address critical shortcomings in order to better address the needs of patients with both emergent and non-emergent conditions.
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The 2012 Supreme Court decision in National Federation of Independent Business v Sebelius gave states the option to adopt the Medicaid expansion as part of the Affordable Care Act. Many states, especially those under Republican control, have since grappled with their decision to implement the expansion. We conduct a comparative analysis of how Republican governors framed their stance on the Medicaid expansion. We analyze public statements on the Medicaid expansion published in two major in-state newspapers from all Republican governors from June 2012 through June 2018. In total we collected, coded and analyzed 3277 statements from 66 newspapers. Several key themes emerge from our analysis. While every Republican governor used oppositional framing as part of their rhetorical response to the Medicaid expansion, the policy had a destabilizing effect on the previously unified opposition to health reform. We find that Republican framing split after the results of the 2012 election and that overall Republican governors shifted towards more supportive framing prior to the 2016 presidential election. Republican governors transformed how they framed their stance towards Medicaid expansion after Donald Trump was elected in 2016, with both supportive and oppositional moral-based framing of expansion increasing. These findings inform how policymakers use rhetoric to support their stance on controversial policies in a hyper-partisan and polarized political environment.
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The 2010 health reform bill, the Patient Protection and Affordable Care Act, included a provision that would expand eligibility of the public insurance program Medicaid. One concern raised about implementing the Medicaid expansion is that it would lead to reductions in state spending in other policy domains. In this study, we test whether adopting expansion is associated with changes in higher education appropriations. Using a difference-in-difference model, we find no significant changes in higher education appropriations between expansion and non-expansion states. Implications of these findings for universities and state policymakers are discussed.
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Since the 1970s, almost every sector along the agrifood supply chain, such as production, processing, distribution, and retailing, has been characterized by increasing concentration, and this has raised concerns over the welfare of small farms and final consumers. For consumers, the significant external costs associated with unhealthy food consumption have also raised concerns about how to make people, especially those in low-income households, eat healthier. This dissertation explores two key issues in the U.S. agrifood sector: the changing market structure and the impact of public policies on consumers’ healthy eating behavior. The first essay develops a model of firm behavior to generate testable predictions of how concentration in upstream agricultural production affects industrial concentration in the downstream food manufacturing sector. It then uses three independent identification strategies to quantify the causal effect of agricultural production concentration, using commuting zone-level data from the 1982 to 2012 Censuses of Agriculture. The first strategy uses weather-induced variation of agricultural concentration, the second strategy uses the variation of agricultural concentration caused by government payment programs, and the last strategy exploits a policy change that made oilseed eligible for government payments. I find that a more concentrated agricultural production sector leads to a significantly more concentrated food manufacturing sector: at the sample means, a 2.5% increase of the HHI of agricultural production leads to a 0.7% increase of the HHI of food manufacturing. The second essay (coauthored with Zhenshan Chen) investigates the impact of the Supplemental Nutrition Assistance Program (SNAP) on low-income households’ diet quality. Based on data from the National Household Food Acquisition and Purchase Survey (FoodAPS), we find that SNAP does not affect diet quality. The mechanisms through which the Supplemental Nutrition Assistance Program (SNAP) affects diet quality are poorly understood. We develop a theoretical model that generates two effects of SNAP on diet quality: 1) a mental accounting effect, when households use SNAP benefits differently from cash income, and 2) a households healthy eating awareness effect throughout the SNAP benefit cycle. We find no evidence for the mental accounting effect that induces participants to treat SNAP benefits as healthy food money. However, the analysis validates a diet quality cycle in the sense that participants’ healthy eating awareness declines throughout the SNAP benefit month. The third essay (coauthored with Rigoberto Lopez and Rebecca Boehm) investigates the impact of Medicaid expansion under the Affordable Care Act (ACA) on beverage choices by low-income households. We utilize household-level data on beverage purchases from 2013 to 2016 in 52 U.S. metropolitan areas in Medicaid expansion and non-expansion states. Results from a triple-differences model, with nearly one million observations on purchases of seven beverage categories, indicate that Medicaid expansion resulted in eligible households buying more soda and fruit drinks and less bottled water. Results from a mixed-logit model, with nearly 17 million purchase observations at the household-brand level, indicate that Medicaid expansion led to overall increases in eligible households’ purchases of and valuation of sugary beverages and a decrease in their price elasticities of demand. The unintended impacts found in these empirical results highlight the need to complement the benefits of Medicaid expansion with effective diet quality programs or to investigate nudges to improve the healthfulness of low-income household beverage choices.
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Background: As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers. Methods: We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports. Results: Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both). Conclusions: Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.
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he passage of the Patient Protection and Affordable Care Act (ACA) in 2010 drastically transformed the health care system in the United States. This paper examines the factors influencing state decisions relative to Medicaid expansion in a post-ACA environment through the lens of Critical Race Theory. This study incorporates economic, geographic and health variables into a model of post-ACA-Medicaid decision-making by using logistic regression to examine State Medicaid expansion from 2010 to 2014. The size of the minority population in state, tobacco use and southern distinctiveness are significant predictors of decision making relative to Medicaid expansion. Findings support that racialized decision-making, particularly in the South, continue to play a significant role in state-level policymaking.
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The passage of the Patient Protection and Affordable Care Act (ACA) in 2010 drastically transformed the health care system in the United States. This paper examines the factors influencing state decisions relative to Medicaid expansion in a post-ACA environment through the lens of Critical Race Theory. This study incorporates economic, geographic and health variables into a model of post-ACA-Medicaid decision-making by using logistic regression to examine State Medicaid expansion from 2010 to 2014. The size of the minority population in state, tobacco use and southern distinctiveness are significant predictors of decision making relative to Medicaid expansion. Findings support that racialized decision-making, particularly in the South, continue to play a significant role in state-level policymaking.
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Executive summary: The Patient Protection and Affordable Care Act's insurance reforms were expected to have significant and positive implications for hospital finances. In particular, state expansion of Medicaid programs held the promise of reducing hospitals' uncompensated care costs as a result of expanding health insurance to many previously uninsured individuals. Recent research indicates that in the early phases of Medicaid expansion, many hospitals did experience a substantial decline in uncompensated care costs. However, studies to date have not considered whether Medicaid expansion resulted in payment shortfalls that offset some of what hospitals saved from lower uncompensated care costs. We examined filings submitted by hospitals to the Internal Revenue Service (IRS)-one of the few publicly available sources of national data on both uncompensated care costs and Medicaid payment shortfalls. We also compared changes in uncompensated care costs and Medicaid payment shortfalls for hospitals in expansion states with those in nonexpansion states. Our findings indicate that state expansion of Medicaid led to substantial reductions in hospitals' uncompensated care costs, but the savings were offset somewhat by increased Medicaid payment shortfalls. Therefore, studies that focus only on reductions in uncompensated care costs can overstate the benefits of Medicaid expansion on hospitals finances.
Article
Expanding eligibility for Medicaid was a central goal of the Affordable Care Act (ACA), which continues to be debated and discussed at the state and federal levels as further reforms are considered. In an effort to provide a synthesis of the available research, we systematically reviewed the peer-reviewed scientific literature on the effects of Medicaid expansion on the original goals of the ACA. After analyzing seventy-seven published studies, we found that expansion was associated with increases in coverage, service use, quality of care, and Medicaid spending. Furthermore, very few studies reported that Medicaid expansion was associated with negative consequences, such as increased wait times for appointments-and those studies tended to use study designs not suited for determining cause and effect. Thus, there is evidence to document improvements in several areas of health care delivery following the ACA Medicaid expansion. We outline areas for future research that can further reduce current knowledge gaps.
Article
There has been much debate, especially in light of the health insurance expansions in the Affordable Care Act and the current fiscal crisis, about the costs and benefits of Medicaid. Some have argued that Medicaid doesn't deliver much in the way of real benefits, either because it pays providers so little that beneficiaries have trouble gaining access to care, or because the low-income uninsured already have reasonable access to care through clinics, uncompensated care, emergency departments, and out-of-pocket spending. Others have argued that providing Medicaid coverage to the uninsured would reduce total health care spending by improving health and reducing inefficient use of hospitals and emergency rooms. Ultimately, the costs and benefits of Medicaid are empirical questions.
Article
In the thirty-seven years since its creation, Medicaid has grown in terms of whom it covers and what it costs. Current rates of Medicaid enrollment and cost growth are high relative to state budget capacity, but not by historical standards. The current Medicaid fiscal crisis is a result of weak state fiscal conditions and the gradual accretion of populations and services covered by Medicaid. States view Medicaid as an essential part of their current strategies to provide insurance to their low-income populations, cover the chronic care needs of people with disabilities and the elderly, and finance the health care safety net. Medicaid has accomplished much, and it can continue to do so if the underlying fiscal pressures and tensions built into it are addressed.
Bondi v. U.S. Department of Health and Human Services, 780 F. Supp
  • Florida
12 Florida ex rel. Bondi v. U.S. Department of Health and Human Services, 780 F. Supp. 2d 1256 (N.D. Fla. 2011).
Who will enroll in Medicaid in 2014? Lessons from Section 1115 Medicaid waivers Mathematica Policy ResearchMedicaid Policy Brief 1) Available from: https://www.cms.gov/Research- Statistics-Data-and-Systems/ Computer-Data-and-Systems
  • C 16 Natoli
  • V Cheh
  • S Verghese
16 Natoli C, Cheh V, Verghese S. Who will enroll in Medicaid in 2014? Lessons from Section 1115 Medicaid waivers [Internet]. Princeton (NJ): Mathematica Policy Research; 2011 May [cited 2012 July 6]. (Medicaid Policy Brief 1). Available from: https://www.cms.gov/Research- Statistics-Data-and-Systems/ Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/ downloads/MAX_IB_1_080111.pdf ABOUT THE AUTHORS: SARA ROSENBAUM & TIMOTHY M. WESTMORELAND Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy at the George Washington University.
Letter to Secretary Kathleen Sebelius regarding the Affordable Care Act [Internet]. Washington (DC): National Governors Association
  • D Crippen
Crippen D. Letter to Secretary Kathleen Sebelius regarding the Affordable Care Act [Internet]. Washington (DC): National Governors Association; 2012 Jul 2 [cited 2012
10 Printz v. United States, 521 U
10 Printz v. United States, 521 U.S. 898 (1997).
8 States that already had expanded Medicaid receive a highly enhanced payment, but not 100 percent financing
  • The Oregon Experiment
the Oregon experiment. N Engl J Med. 2011;365:683–5. 8 States that already had expanded Medicaid receive a highly enhanced payment, but not 100 percent financing.
Washington (DC); Census Bureau
  • Census Bureau
Census Bureau. Public education finances: 2008 [Internet]. Washington (DC); Census Bureau; 2010 Jun [cited 2012 Jul 17]. p. xi, Figure 1a. Available from: http://www2.census .gov/govs/school/08f33pub.pdf
Income eligibility limits for working adults at application as a percent of poverty level (FPL) by scope of benefit package
  • Statehealthfacts
  • Org
Statehealthfacts.org. Income eligibility limits for working adults at application as a percent of poverty level (FPL) by scope of benefit package [Internet].
Letter from Secretary Kathleen Sebelius to the governors
  • K Sebelius
Sebelius K. Letter from Secretary Kathleen Sebelius to the governors [Internet].