JAMA Health Forum最新文献

Importance: Rising out-of-pocket costs of maternal health care for people with commercial insurance may affect use of health care and outcomes. There are stark racial and ethnic disparities in outcomes, but little is known about differences in spending.

Objective: To measure differences in out-of-pocket spending for maternity care by race and ethnicity.

Design, setting, and participants: This retrospective cross-sectional study used administrative data from Blue Cross Blue Shield of Massachusetts from January 1, 2018, through December 31, 2022, for pregnancies, deliveries, and 42-day postpartum care. Participants were continuously enrolled during pregnancy, delivery, and 42 days post partum (collectively termed maternity episode).

Exposures: The primary characteristic of interest was the birthing person's race and ethnicity.

Main outcomes and measures: The primary outcome was total out-of-pocket spending during the maternity episode. Out-of-pocket spending was measured separately for the pregnancy period, prenatal services, and delivery, by type of cost sharing, and as a percentage of the median household income in the patient's census tract (using American Community Survey data). Race and ethnicity were measured via self-report and imputation.

Results: The analytic sample included 87 253 maternity episodes among 76 826 unique birthing persons (mean [SD] age, 32.4 [4.7] years; 99.8% female) between 2018 and 2022; among maternity episodes, 8572 birthing persons (9.8%) were Asian, 3331 (3.8%) were Black, 6872 (7.9%) were Hispanic, and 68 478 (78.5%) were White. Mean out-of-pocket spending for the maternity episode was highest among Black birthing people ($2398 [$426]), followed by Hispanic ($2300 [$572]), Asian ($2202 [$603]), and White ($2036 [$1547]) birthing people (P < .001). These differences remained statistically significant after adjusting for health and demographic characteristics. The differences were largest in the prenatal period and for coinsurance payments. Black (1003 [30.1%]) and Hispanic (2302 [33.5%]) birthing people were more likely than Asian (1569 [18.3%]) and White (12 600 [18.4%]) birthing people to be enrolled in plans with high coinsurance, but not plans with high deductibles (3317 [38.7%] for Asian, 1232 [37.0%] for Black, 2350 [34.2%] for Hispanic, and 24 515 [35.8%] for White birthing people).

Conclusions and relevance: In this study, differences in out-of-pocket maternity spending among the commercially insured were associated with differences in coinsurance rates. These costs could lead people to forgo needed health care or other basic needs that support health (eg, food or housing). Changes to health plan benefit design could improve equity in out-of-pocket maternity spending and its consequences.

Importance: 2021 Advance child tax credit (ACTC) monthly payments were associated with reduced US child poverty rates; however, policymakers have expressed concerns that permanent adoption would increase parental substance use.

Objective: To assess whether 2021 ACTC monthly payments were temporally associated with changes in substance use among parents compared with adults without children.

Design, setting, and participants: The primary sample included adults aged 18 to 64 years who responded to the National Survey on Drug Use and Health in 2021. Difference-in-differences models were used to test whether substance use changed for parents compared with adults without children after ACTC monthly payments went into effect. Additional National Survey on Drug Use and Health data from 2018 to 2020 were used to assess pretrends in substance use for parents and adults without children. Analyses were survey weighted and conducted from September 2023 to November 2024. The treatment group was defined as adults with dependent children in the home who would have been eligible for the tax credit from July to December 2021. Adults without children, who would not have been eligible for the tax credit, comprised the comparison group.

Main outcomes and measures: Outcomes included binary measures of any self-reported use of tobacco, alcohol, cannabis, and illicit substances (eg, cocaine, opioids, or other stimulants or sedatives) during the previous 30 days; counts of the number of days of use of tobacco, alcohol, cannabis, and illicit substances during the previous 30 days among people who used these substances; and counts of the number of cigarettes and alcoholic beverages consumed during the previous 30 days among people who used these substances.

Results: Of 41 853 adults, 17 308 were parents and 24 545 were adults without children. ACTC monthly payment implementation was associated with a -4.3-percentage point (95% CI, -6.6 to -2.0) decline in the probability of using tobacco during the previous 30 days for parents compared with adults without children. Among parents who smoked, payments were associated with a -46.8-percentage point (95% CI, -93.1 to -0.5) decline in the number of cigarettes smoked during the previous 30 days. Estimated changes in the probability, frequency, and quantity of other substance use (alcohol, cannabis, and illicit substances) for parents were null and not significant.

Conclusions: The study results suggest that 2021 ACTC monthly payments were not associated with increased parental substance use.

Importance: The Affordable Care Act (ACA) expanded Medicaid and Marketplace insurance to nonelderly adults in 2014, but whether these policies improved outcomes later in life is unknown.

Objective: To examine whether exposure to ACA expansions during middle age (50-64 years) was associated with changes in health, utilization, and spending after these adults entered Medicare at 65 years of age.

Design, setting, and participants: This serial analysis of the Health and Retirement Study cohort linked to Medicare enrollment and claims data from January 1, 2010, to December 31, 2018. Adults aged 65 to 68 years entering Medicare after the ACA (exposed to ACA expansions during middle age) were compared with adults entering Medicare before the ACA (4452 person-years). Interrupted time series analyses were used to assess overall changes associated with exposure to ACA expansions and difference-in-differences analyses to isolate changes associated with Medicaid expansion among low-income adults (incomes ≤400% of the federal poverty level for any ACA coverage and ≤138% for Medicaid expansion coverage). Data were analyzed from March 1, 2023, to May 1, 2024.

Exposures: ACA coverage expansion overall in 2014 and Medicaid expansion as of 2018.

Main outcomes and measures: Health (self-reported overall, activities of daily living [ADL], instrumental ADL, and depressive symptoms), utilization (outpatient visits, emergency department visits, and hospital admission), and costs (self-reported out-of-pocket and Medicare costs).

Results: Among the analytic sample of 2782 participants (mean age, 66.4 [95% CI, 66.3-66.5] years), a weighted 59.1% (95% CI, 55.3%-62.7%) were female. In interrupted time series analyses, reductions across cohorts were found in use of chronic disease medications (-5.0 [95% CI, -9.8 to -0.3] percentage points), hospitalizations per year (-0.2 [95% CI, -0.4 to -0.03]), and out-of-pocket costs (-$417 [95% CI, -$694 to -$139]) but no significant changes across cohorts in health status, outpatient or emergency visits, or Medicare costs. In difference-in-differences analyses relative to nonexpansion states, greater reductions were found in the number of ADL limitations (-0.4 [95% CI, -0.8 to -0.02]) and lesser reductions in out-of-pocket costs ($900 [95% CI, $275-$1526]) in Medicaid expansion states but otherwise similar changes in other outcomes.

Conclusions and relevance: This study found modest evidence of reductions in out-of-pocket costs and improvements in health among adults entering Medicare after the ACA. Insurance coverage and financial assistance should be preserved and enhanced to improve health and health care access among vulnerable older adults.