Milbank Quarterly最新文献

Policy Points Twenty-four states and the District of Columbia offer public insurance to pregnant undocumented immigrants who are income eligible for Medicaid. We found that residing in a state with public coverage of pregnant undocumented immigrants was associated with increased prenatal Medicaid coverage among immigrants and was not associated with corresponding reductions in private or other insurance coverage. Offering state public insurance to pregnant undocumented immigrants could increase immigrants' access to insurance coverage and recommended care during pregnancy.

Context: Health insurance coverage increases access to recommended pregnancy care, but undocumented immigrants are not eligible for pregnancy Medicaid coverage without state uptake of alternative policy options. Twenty-four states and the District of Columbia (DC) offer public insurance to undocumented immigrants who are income eligible for pregnancy Medicaid through the Children's Health Insurance Program From-Conception-to-End-of-Pregnancy option or state funds. Our objective was to examine the association between residing in a state with public insurance coverage for pregnant undocumented immigrants and prenatal insurance coverage among low-income immigrants.

Methods: We used 2016 to 2021 Pregnancy Risk Assessment Monitoring System responses linked to maternal nativity from birth certificate records from 19 states and DC. We compared the prevalence of any insurance, Medicaid insurance, and private or other insurance coverage of prenatal care between Medicaid income-eligible immigrants and nonimmigrants. We then estimated the association between state public coverage policy and prenatal insurance coverage among immigrants using linear regression models.

Findings: The study included 47,370 adults (13,271 immigrants and 34,099 nonimmigrants) who were income eligible for pregnancy Medicaid. In the ten included states with public coverage of pregnant undocumented immigrants, the proportion of immigrants with any insurance for prenatal care was 16.9 percentage points higher (95% CI, 14.9-18.9) compared with the proportion of immigrants in states without such coverage. In policy-adopting states, the proportion of immigrants with Medicaid for prenatal care was also 16.9 percentage points higher (95% CI, 14.1-19.7) compared with immigrants in nonpolicy-adopting states. We did not find differences by state coverage policy in having had private insurance coverage for prenatal care.

Conclusions: Providing state public insurance coverage to undocumented immigrants during pregnancy may increase overall prenatal insurance coverage by expanding access to Medicaid. We did not find evidence that extending public coverage to this population crowds out other insurance options.

Policy Points Since 2004, beneficiaries in government-administered traditional Medicare decreased by about 3 million (8%), whereas enrollment in Medicare Advantage (MA) plans run by private insurance companies increased by approximately 30 million (500%). MA's growth has exceeded the adequate evolution and refinement of the program's regulatory apparatus. MA now annually costs at least 20% (around $84 billion) more than what Medicare would have spent if all MA enrollees were in traditional Medicare (TM). This differential in payments has advantaged MA relative to TM and transformed the Medicare program in part by corporatizing it for tens of millions of beneficiaries. Most MA revenue now flows to large, increasingly vertically integrated, multinational, for-profit companies that are reshaping the US health care landscape for all patients, providers, and payers. Overpayments have strengthened the political position of the largest MA plan providers such that the program is at risk of interest group capture because of their powerful lobbying and political influence. Reforming MA should include the following: (a) ongoing improvements to the program's risk adjustment system and benchmark policy for rate setting, (b) replacing the quality bonus program with a value incentive program that is budget-neutral, and (c) standardizing MA plans into a small number of basic plan categories and having private health companies make competitive bids in each of them to compete on price instead of on benefit offerings. Savings from any MA payment reforms could shore up Medicare's Hospital Trust Fund or improve TM for a "Medicare 2.0" that competes on a more level playing field with MA.

Policy Points States are concerned about rising health care spending, and this study identifies states that have established health care cost commissions and describes the political and economic factors associated with their establishment. As of August 2024, 17 states had established commissions to reduce the growth of health care spending using various methods, including setting spending growth targets. Politically Democratic states and those with higher commercial hospital prices and higher Medicaid spending were more likely to establish such commissions. Because federal health care reform is difficult to enact, states are enacting their own reforms, tailored to their needs and political feasibility.

Context: States are becoming increasingly concerned about rising health care spending because it crowds out budgets for education and other obligations and it burdens consumers, exposing them to medical debt and bankruptcies. This study identifies states that have established health care cost commissions (HCCCs), examines state-level political and economic factors associated with their establishment, and reports which of these states have also enacted health care competition-related laws that further equip these commissions.

Methods: To identify states with HCCCs and competition-related laws, we reviewed prior reports, supplemented by our own research on state websites and from organizations that track state-level legislative and executive activity in health care. We estimated a regression model to understand how political and economic factors are related to these commissions being established.

Findings: As of August 2024, 17 states had established HCCCs that aim to reduce the growth of health care costs using a variety of methods, such as collecting health care use and spending data and setting spending growth targets. States that lean politically Democratic were more likely to establish these commissions, particularly those states with higher commercial hospital prices or higher Medicaid spending as a share of the state budget, or both. States with HCCCs have also enacted competition-related laws but to varying degrees.

Conclusions: Because health care reform is difficult to enact at the federal level, many states are enacting their own reforms, tailored to their needs and political feasibility with many establishing HCCCs to limit health care spending increases. Future research should study the impact of these commissions on health care spending that increases short-term spending yet moderates long-term spending, including the feasibility and impact of increased spending on primary care services as well as the impact of spending on new health care technologies.

Policy Points The 2015 to 2020 Delaware Contraceptive Access Now (DelCAN) initiative followed other long-acting reversible contraception-focused contraceptive initiatives in Colorado and in St. Louis, Missouri. and preceded statewide contraceptive-access initiatives in South Carolina, Massachusetts, and North Carolina with additional initiatives planned. Our principle conclusion is that the DelCAN did not achieve its goal of reducing the fraction of births from unintended pregnancies. However, we find evidence of a substantial magnitude of decrease in unplanned pregnancies that can be attributed to the initiative, and that this decrease occurred entirely among Medicaid-covered women.

Context: The 2015 to 2020 Delaware Contraceptive Access Now (DelCAN) initiative was motivated by Delaware's having among the highest rates of unintended pregnancies in the United States, of which were either wanted later or unwanted. The expectation of the DelCAN initiative was that by providing greater contraceptive access, especially to long-acting reversible contraception, Delaware's unintended-pregnancy rates could be substantially reduced. In this study, we assess the role of the DelCAN in explaining, for live births, changes in women's pregnancy intentions around the time of conception.

Methods: We examine not only pregnancy intentions, but also the planned status of the pregnancies, including whether the woman was trying to get pregnant and whether she or her partner was using contraception when an unplanned pregnancy occurred. We use the Pregnancy Risk Assessment Monitoring System data with difference-in-difference estimators to compare Delaware with six states in 2007 to 2020 with respect to the planned status of pregnancies ending in births and with 14 states in 2012 to 2020 with respect to the intended status of pregnancies ending in births. Because several components of the DelCAN were designed to facilitate contraceptive access for low-income women, we conduct both an overall analysis and separate analyses for Medicaid-covered and non-Medicaid-covered women.

Findings: The DelCAN was not associated with reductions in unintended pregnancies ending in births in Delaware relative to comparison states but was associated with an increase in pregnancies that were wanted sooner. DelCAN was also associated with an increase in planned pregnancies concentrated among Medicaid-insured women and produced through reductions in pregnancies occurring when not using contraception.

Conclusions: Pregnancy intentions and pregnancy planning should be treated as distinct concepts in contraceptive-access program design and evaluation. Programs should attend to both pregnancies wanted later and pregnancies wanted sooner to address public health goals in concert with enhancing women's reproductive autonomy.

Policy Points Antitrust enforcement has been too narrowly focused on predicting postmerger market share and not enough on the likely impact of mergers and acquisitions on production efficiency and quality. Care delivery redesign is a term that captures various innovations and changes in the organization and delivery of health care, which may lead to increased production efficiency and improved quality of care. Regulators and policymakers can use the framework to develop empirical measures to assist in understanding changes in production processes as well as in resultant outcomes. Significant opportunities exist to improve data collection and require reporting to better assist regulators with antitrust enforcement and help policymakers create effective legislation. Examples include improving compliance with required hospital and insurer transaction price data reporting, growing the availability of all-payer claims databases, improving existing Medicare cost reporting, and achieving consensus on quality measures that are best used to measure the impact of consolidation. There is a fundamental need to systematically track health care organizations and their affiliations and component parts (e.g., hospitals, physician practices, skilled nursing facilities, etc.) longitudinally, especially as organizations expand across markets and state boundaries and are owned by various entities, including private equity.

Policy Points Public health communicators in practice discuss health equity issues in a competitive information environment. Through interviews with 36 communicators from diverse professional perspectives (i.e., journalists, advocates, public health leaders) in 2022-2023, we illuminated key challenges they face and strategies and resources that might mitigate these challenges. Findings can inform communication research priorities and investment in resources to help practitioners communicate about health equity amid a challenging political landscape.

Context: Communicating about health equity is increasingly challenging in light of a changing information environment and the emergence of opposition to equity and equity-related concepts since 2020. Public health communicators often discuss health equity-related concepts, but it is not clear what strategies they use or what resources can support them to overcome challenges they face.

Methods: We conducted qualitative interviews (N = 36) with communicators across four professional categories (public health leaders, journalists, thought leaders, and health advocates/organizers) from late 2022 to mid-2023 to discuss the strategies they employ; the challenges or barriers they face related to audiences, their institutions, or the broader communication landscape; and the resources they rely on, including their social networks, toolkits or guides, trainings, and research.

Findings: Communicators use a range of strategies to explain health equity, the causes of disparities, and the imperative of solutions; data and stories were common approaches used, although these strategies were not considered a panacea. They also face consistent challenges, such as concerns about audience resistance, lack of public understanding of terminology, and a fragmented communication landscape-and for journalists in particular, institutional barriers and the challenge of identifying diverse sources. Communicators rely on a range of resources, though mainly colleagues and interpersonal support, with the use of research-based resources being relatively uncommon. Although there were commonalities among public health leaders' and advocates' approaches, journalists' concerns and resources were often different.

Conclusions: Communicators could benefit from more research to confirm or offset some of their concerns (such as the potential for resistance from the use of key phrases, like "systemic racism," or unintended consequences of using disparities data); researchers must also disseminate this work to these practitioners, including journalists. Academic researchers, foundations, and nonprofit organizations all can play roles in building infrastructure for resource sharing, research dissemination, and convening communicators to build stronger connections and support.

Policy Points Evidence suggests Medicaid expansion has improved cardiovascular disease (CVD) outcomes, especially among those of lower socioeconomic status. However, less is known about the cost-effectiveness of Medicaid in achieving these outcomes and reducing CVD disparities. We found that Medicaid expansion resulted in a reduction in CVD incidence, suggesting that it was cost-effective in reducing CVD outcomes and equity enhancing but with a high degree of uncertainty. Policymakers will need to trade-off among a number of different factors in consideration of the value of Medicaid including health (especially in treating the chronically ill), financial protection, reduced uncompensated care, and health disparities.

Context: Evidence suggests Medicaid expansion has improved cardiovascular disease (CVD) outcomes, especially among those of lower socioeconomic status. However, less is known about the cost-effectiveness of Medicaid in achieving these outcomes and reducing CVD disparities. We use distributional cost-effectiveness analysis methods to examine the efficiency and equitability of Medicaid expansion in reducing CVD outcomes.

Methods: A Monte Carlo Markov-chain microsimulation model was developed to examine lifetime changes in CVD outcomes and disparities as a result of expansion and the associated cost and quality-of-life impacts.

Findings: Medicaid expansion was associated with a reduction of 11 myocardial infarctions, eight strokes, and four CVD deaths per 100,000 person-years compared with no expansion. The largest reductions occurred for those with lower income and education, and those of Black and Hispanic race/ethnicity. We found that the benefits of expansion generally balanced out the costs while redistributing health from higher to lower income groups. In probabilistic sensitivity analysis, we found-using a health opportunity cost threshold of $150,000-that Medicaid expansion was cost-effective in reducing CVD outcomes 53% of the time and both cost-effective (efficient) and equity enhancing 26% to 29% of the time.

Conclusions: Medicaid expansion resulted in a reduction in CVD incidence, suggesting that it was both cost-effective and equity enhancing in reducing CVD outcomes but with a high degree of uncertainty.

Policy Points The Affordable Care Act (ACA) dramatically expanded Medicaid eligibility in participating states. However, many eligible individuals remain uninsured because they do not enroll in (or "take up") coverage. The unwinding of the pandemic continuous enrollment provision in 2023-2024 further raised the importance of this issue. After the ACA, we found a significant increase in Medicaid take-up among eligible individuals across all eligibility pathways; these gains persisted into 2023, which coincided with the beginning of the unwinding. However, important vulnerabilities in enrollment are still apparent, including a steep drop-off in take-up when children become young adults and persistent lower take-up among childless adults and residents of nonexpansion states. These findings can guide policies in the postpandemic post-ACA era and suggest that efforts to reduce outreach or scale back the ACA will threaten coverage for many Medicaid beneficiaries.

Context: Many uninsured individuals in the United States are eligible for Medicaid but not enrolled. The Affordable Care Act (ACA) expanded Medicaid eligibility starting in 2014, streamlined enrollment, and boosted outreach. During the 2020 COVID-19 pandemic, states were required to provide continuous coverage to Medicaid enrollees, a policy that ended in April 2023, with resulting coverage losses during the "unwinding" of this policy.

Methods: Using household data from the American Community Survey and state-level eligibility criteria, we assessed Medicaid participation among US citizens younger than 65 years old who either had Medicaid coverage or no insurance. We compared results before the ACA (2008-2010), after the ACA (2017-2019), and during "unwinding" (2023). We utilized logistic regression to identify predictors of take-up in each of these time periods.

Findings: The national take-up rate among Medicaid-eligible individuals rose from 76.5% before the ACA to 85.0% after the ACA. These gains persisted in 2023 as unwinding began, when take-up was slightly higher (86.5%) than before the pandemic. Post-ACA participation was highest among eligible children; Asian American, Pacific Islander, and Native Hawaiian and Black individuals; and residents of expansion states. Participation was lowest among adults ages 19-21 years old, American Indian and Alaska Native (AI/AN) individuals, employed adults, and those facing premiums for Medicaid coverage. Take-up improved post-ACA in both more and less deprived neighborhoods, whereas urban areas saw greater growth in take-up than rural areas.

Conclusions: From the pre- to post-ACA period, Medicaid take-up rates among eligible individuals increased, and these gains persisted during the beginning of the unwinding period, potentially reflecting increased outreach efforts under the Biden administration. However, areas of vulnerability remain among young adult

Policy Points Despite documented inequities in suicide trends and police-perpetrated killing for Black compared with White Americans, government expenditures have not been examined as upstream drivers of these inequities. This longitudinal study found police expenditures predicted increases in suicide and police-perpetrated killings for Black, but not White, residents. Housing and community development expenditures were associated with decreases in suicide for Black residents only, and kindergarten through 12th grade (K-12) education expenditures were associated with decreases in suicide for White residents only. Findings suggest reducing police, and increasing housing, expenditures may reduce Black-White inequities in suicide and police-perpetrated killing.

Context: Despite documented inequities in suicide trends and police-perpetrated killing for Black US Americans, there is little research investigating how structural factors like government expenditures may drive these outcomes. This study examined associations from police and social services expenditures to later suicides and police-perpetrated killings for Black and White residents.

Methods: This longitudinal study analyzed 2010-2020 US Census of Governments-tracked state and local government expenditures and Centers for Disease Control and Prevention (CDC)-tracked years of potential life lost (YPLL) to suicide and police-perpetrated killing. Dynamic structural equation models estimated 1- and 5-year lagged associations. Models adjusted for reverse associations (i.e., violent death to later expenditures) and state-level variables including Medicaid expansion, Black-White population, racial residential segregation, political representation, overall expenditures, state firearm policies, and firearm violence rates.

Findings: For suicide, every $100 increase in per capita police expenditures was associated with 35 more YPLL 1 year later (γ = 0.35, 95% credible interval [CI] 0.02-0.90) and 28 more YPLL 5 years later (γ = 0.28, 95% CI 0.001-0.55) per 100,000 Black residents. For police-perpetrated killings, every $100 increase in per capita police expenditures was associated with 7 more YPLL 1 year later (γ = 0.07, 95% CI 0.02-0.12) per 100,000 Black residents. As such, a $100 per capita increase in annual police expendiutres translated to 14,385 more YPLL to suicide, and 2,877 more YPLL to police-pepetrated killing, 1 year later for the United States' 41.1 million Black residents. There were no associations between police expenditures and outcomes for White residents. Conversely, every $100 increase in per capita housing and community development expenditures was associated with 29 fewer YPLL to suicide 5 years later per 100,000 Black residents (γ = -0.29, 95% CI -0.53 to -0.05). Every $100 increase in per capita kindergarten through 12th grade (K-12) education expenditures was associated with 4 fewer YPLL to suicide 1 ye