To evaluate the effects of the Family First Coronavirus Response Act (FFCRA) on work outcomes of women for whom the FFCRA effectively expanded income eligibility for Medicaid beyond 60 days postpartum by prohibiting states from redetermining Medicaid eligibility between March 2020 and March 2023.
Study Setting and Design
We use a difference-in-differences design that leverages the differences in income eligibility between pregnancy and non-pregnancy across states, and compares outcome changes pre–post FFCRA over these differences.
Data Sources and Analytic Sample
Data come from the 2016–2022 American Community Survey. The sample includes 205,104 women aged 19–49 years who reported giving birth within the past 12 months in 41 states and Washington D.C.
Principal Findings
On average, the FFCRA increased postpartum Medicaid coverage by 2.8 percentage points (95% CI: 0.7–4.8) or by 9.3% relative to the 2019 Medicaid coverage rate. In contrast, the FFCRA effects on work outcomes were small and not significant: the average effect was 0.10 percentage points for labor force participation (95% CI: −1.0 to 1.2), 0.7 percentage points for employment (95% CI: −0.02 to 1.4), 0.04 h for weekly work hours (95% CI: −0.4 to 0.5), and 0.2 percentage points for full-time employment (95% CI: −1.1 to 1.5). These confidence intervals rule out an employment decline above 0.02 percentage points and full-time employment decline above 1.1 percentage points. The increase in Medicaid coverage is concentrated among states with a larger difference between pregnancy and non-pregnancy eligibility (+5.9 percentage points; 95% CI: 0.9 to 10.9) and estimates in this group also rule out relatively small declines in work outcomes.
Conclusion
There is no evidence of declines in work outcomes following the increase in Medicaid coverage beyond 60 days postpartum that resulted from the FFCRA. The findings suggest that subsequent postpartum Medicaid coverage extensions for 12 months under the American Rescue Plan are unlikely to disincentivize work among beneficiaries.
{"title":"Effects of Medicaid Coverage on Work: Evidence From Extending Postpartum Medicaid Coverage","authors":"Ufuoma Ejughemre, Wei Lyu, George L. Wehby","doi":"10.1111/1475-6773.70055","DOIUrl":"10.1111/1475-6773.70055","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To evaluate the effects of the Family First Coronavirus Response Act (FFCRA) on work outcomes of women for whom the FFCRA effectively expanded income eligibility for Medicaid beyond 60 days postpartum by prohibiting states from redetermining Medicaid eligibility between March 2020 and March 2023.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We use a difference-in-differences design that leverages the differences in income eligibility between pregnancy and non-pregnancy across states, and compares outcome changes pre–post FFCRA over these differences.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>Data come from the 2016–2022 American Community Survey. The sample includes 205,104 women aged 19–49 years who reported giving birth within the past 12 months in 41 states and Washington D.C.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>On average, the FFCRA increased postpartum Medicaid coverage by 2.8 percentage points (95% CI: 0.7–4.8) or by 9.3% relative to the 2019 Medicaid coverage rate. In contrast, the FFCRA effects on work outcomes were small and not significant: the average effect was 0.10 percentage points for labor force participation (95% CI: −1.0 to 1.2), 0.7 percentage points for employment (95% CI: −0.02 to 1.4), 0.04 h for weekly work hours (95% CI: −0.4 to 0.5), and 0.2 percentage points for full-time employment (95% CI: −1.1 to 1.5). These confidence intervals rule out an employment decline above 0.02 percentage points and full-time employment decline above 1.1 percentage points. The increase in Medicaid coverage is concentrated among states with a larger difference between pregnancy and non-pregnancy eligibility (+5.9 percentage points; 95% CI: 0.9 to 10.9) and estimates in this group also rule out relatively small declines in work outcomes.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusion</h3>\u0000 <p>There is no evidence of declines in work outcomes following the increase in Medicaid coverage beyond 60 days postpartum that resulted from the FFCRA. The findings suggest that subsequent postpartum Medicaid coverage extensions for 12 months under the American Rescue Plan are unlikely to disincentivize work among beneficiaries.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857479/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145253830","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Haley Lescinsky, Maitreyi Sahu, Meera Beauchamp, Sawyer Crosby, Emily Johnson, Theresa A. McHugh, John W. Scott, Kevin Schulman, Azalea Thomson, Maxwell Weil, Joseph L. Dieleman, Arnold Milstein
Objective
To examine trends in state-level health care value over three decades, defined using statewide health care spending and cause-specific mortality, and to explore its associations with potentially modifiable state attributes.
Study Setting and Design
We use stochastic frontier analysis to identify the “inefficiency” of each state's delivery system in converting health care spending into lower mortality–incidence or mortality–prevalence rates, adjusting for underlying population risk (age, smoking, obesity, etc.). We combine these inefficiency scores to score and compare delivery system value for each state and track change over three decades. Then, we use linear regression to look across states and identify state-level attributes significantly associated with greater health care value.
Data Sources and Analytic Sample
For each US state and year from 1991 to 2020, we extracted mortality–incidence or mortality–prevalence rates for 67 high-mortality health conditions from the Global Burden of Disease 2021 Study and state health care spending from the State Health Expenditure Accounts.
Principal Findings
Across US states, value on average increased from 1991 to 2000, remained relatively constant from 2001 to 2010, and then declined from 2011 to 2020 by 16.7% (95% uncertainty interval [UI]: 14.7–20.1) or 13.6 (95% UI: 11.3–15.9) value points. The percentage of state populations with insurance was positively associated with health delivery system value. In contrast, market consolidation among hospitals and among health insurers of small and large groups, and increased for-profit hospital ownership were each associated with a lower health care value. The net effect of these associations was a reduction in the national value score for the decade ending in 2020.
Conclusions
In contrast to the prior two decades, health care delivery system value scores declined over the last decade. This decline was associated with reduced competition among hospitals and health insurers, increased for-profit hospital ownership, and was partly mitigated by wider insurance coverage.
{"title":"Exploring State-Level Change in Health Care Value Over Three Decades in the United States, 1991–2020","authors":"Haley Lescinsky, Maitreyi Sahu, Meera Beauchamp, Sawyer Crosby, Emily Johnson, Theresa A. McHugh, John W. Scott, Kevin Schulman, Azalea Thomson, Maxwell Weil, Joseph L. Dieleman, Arnold Milstein","doi":"10.1111/1475-6773.70054","DOIUrl":"10.1111/1475-6773.70054","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To examine trends in state-level health care value over three decades, defined using statewide health care spending and cause-specific mortality, and to explore its associations with potentially modifiable state attributes.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We use stochastic frontier analysis to identify the “inefficiency” of each state's delivery system in converting health care spending into lower mortality–incidence or mortality–prevalence rates, adjusting for underlying population risk (age, smoking, obesity, etc.). We combine these inefficiency scores to score and compare delivery system value for each state and track change over three decades. Then, we use linear regression to look across states and identify state-level attributes significantly associated with greater health care value.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>For each US state and year from 1991 to 2020, we extracted mortality–incidence or mortality–prevalence rates for 67 high-mortality health conditions from the Global Burden of Disease 2021 Study and state health care spending from the State Health Expenditure Accounts.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>Across US states, value on average increased from 1991 to 2000, remained relatively constant from 2001 to 2010, and then declined from 2011 to 2020 by 16.7% (95% uncertainty interval [UI]: 14.7–20.1) or 13.6 (95% UI: 11.3–15.9) value points. The percentage of state populations with insurance was positively associated with health delivery system value. In contrast, market consolidation among hospitals and among health insurers of small and large groups, and increased for-profit hospital ownership were each associated with a lower health care value. The net effect of these associations was a reduction in the national value score for the decade ending in 2020.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>In contrast to the prior two decades, health care delivery system value scores declined over the last decade. This decline was associated with reduced competition among hospitals and health insurers, increased for-profit hospital ownership, and was partly mitigated by wider insurance coverage.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857514/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145260219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hannah Olson, Ayana Douglas-Hall, Madeleine Haas, Megan L. Kavanaugh
<div> <section> <h3> Objective</h3> <p>To document differential risk of insurance instability by race/ethnicity and nativity and investigate the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access.</p> </section> <section> <h3> Study Setting and Design</h3> <p>We draw on data from the Surveys of Women (SoW), longitudinal household surveys conducted by NORC at the University of Chicago in Arizona, Iowa, New Jersey, and Wisconsin, weighted to reflect the population of women aged 18–44 in each state. SoW respondents included in this analysis were interviewed 2–4 times between 2018 and 2022 about their sexual and reproductive health-related experiences. We use race-stratified population averaged logistic regressions to model the risk of insurance churn and insurance loss for US-born vs. foreign-born people with the capacity for pregnancy, by race/ethnicity. Then, we use within-between (hybrid) logistic regressions to model the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access outcomes, including receipt of any sexual and reproductive health care, receipt of contraceptive care, experiencing barriers to obtaining contraception, and contraceptive use.</p> </section> <section> <h3> Data Sources and Analytic Sample</h3> <p>Our analytic sample includes 12,208 observations from 4558 respondents between the ages of 18 and 44 who were assumed to have the capacity for pregnancy. Respondents were maintained in the sample if they were neither pregnant nor infertile and had non-missing information on key variables.</p> </section> <section> <h3> Principal Findings</h3> <p>Insurance loss was much more common among foreign-born compared to US-born people, particularly those who were racially or ethnically minoritized, with foreign-born BIPOC and foreign-born Hispanic respondents experiencing insurance loss 2.5 and 3 times as often as their US-born counterparts, respectively. Meanwhile, findings from our hybrid models suggest that losing insurance was associated with a five percentage point reduction in the probability of subsequent utilization of sexual and reproductive health care (∆<i>p</i> = −0.046, <i>p</i> < 0.05, SE = −0.02) and a five percentage point increase in the probability of experiencing subsequent barriers to obtaining preferred contraception (∆<i>p</i> = 0.053, <i>p</i> < 0.001, SE = 0.01).</p> </section> <section> <h3> Conclusion</h3> <p>The disproportionate burden of insurance instability among immigrant people of color may exacerbate barriers to sexual and reproductive health care and contraceptive access for a population that already experiences high bar
{"title":"How Health Insurance Instability Differentially Impedes Access to Sexual and Reproductive Healthcare, by Race/Ethnicity and Nativity","authors":"Hannah Olson, Ayana Douglas-Hall, Madeleine Haas, Megan L. Kavanaugh","doi":"10.1111/1475-6773.70049","DOIUrl":"10.1111/1475-6773.70049","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To document differential risk of insurance instability by race/ethnicity and nativity and investigate the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We draw on data from the Surveys of Women (SoW), longitudinal household surveys conducted by NORC at the University of Chicago in Arizona, Iowa, New Jersey, and Wisconsin, weighted to reflect the population of women aged 18–44 in each state. SoW respondents included in this analysis were interviewed 2–4 times between 2018 and 2022 about their sexual and reproductive health-related experiences. We use race-stratified population averaged logistic regressions to model the risk of insurance churn and insurance loss for US-born vs. foreign-born people with the capacity for pregnancy, by race/ethnicity. Then, we use within-between (hybrid) logistic regressions to model the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access outcomes, including receipt of any sexual and reproductive health care, receipt of contraceptive care, experiencing barriers to obtaining contraception, and contraceptive use.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>Our analytic sample includes 12,208 observations from 4558 respondents between the ages of 18 and 44 who were assumed to have the capacity for pregnancy. Respondents were maintained in the sample if they were neither pregnant nor infertile and had non-missing information on key variables.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>Insurance loss was much more common among foreign-born compared to US-born people, particularly those who were racially or ethnically minoritized, with foreign-born BIPOC and foreign-born Hispanic respondents experiencing insurance loss 2.5 and 3 times as often as their US-born counterparts, respectively. Meanwhile, findings from our hybrid models suggest that losing insurance was associated with a five percentage point reduction in the probability of subsequent utilization of sexual and reproductive health care (∆<i>p</i> = −0.046, <i>p</i> < 0.05, SE = −0.02) and a five percentage point increase in the probability of experiencing subsequent barriers to obtaining preferred contraception (∆<i>p</i> = 0.053, <i>p</i> < 0.001, SE = 0.01).</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusion</h3>\u0000 <p>The disproportionate burden of insurance instability among immigrant people of color may exacerbate barriers to sexual and reproductive health care and contraceptive access for a population that already experiences high bar","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857480/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145240499","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
To examine the impact of private equity (PE) hospital acquisitions on maternal health for Medicaid patients.
Study Setting and Design
This quasi-experimental study focuses on 66 PE acquisitions of hospitals between 2014 and 2018, analyzing national Medicaid claims data from 2011 to 2020. Using a difference-in-differences (DiD) framework, the study compares labor and delivery (L&D) outcomes at PE-acquired hospitals with matched control hospitals to evaluate the effects on patient volume, process of care, and quality outcomes for Medicaid patients.
Data Sources and Analytic Sample
The analysis uses data from the Transformed Medicaid Statistical Information System (T-MSIS) and Medicaid Analytic eXtract (MAX), including over 1 million L&D hospitalizations. The analytic sample comprises 66 PE hospitals and 290 matched control hospitals.
Principal Findings
PE acquisition was associated with a significant 12% decrease in Medicaid L&D market share (p < 0.05). The reduction was more pronounced in states with larger Medicaid-to-commercial payment gaps (−15.8% vs. −7.2%). However, no significant changes were observed in low-risk cesarean rates, number of procedures, length of stay, or severe maternal morbidity.
Conclusions
PE acquisitions of hospitals are associated with reduced Medicaid market share, particularly in states with lower Medicaid reimbursement relative to commercial insurance. Policymakers should consider addressing these issues by adjusting Medicaid payment rates to support vulnerable populations in PE-acquired hospitals.
{"title":"The Impact of Private Equity Hospital Acquisitions on Maternal Health for Medicaid Patients","authors":"Yang Amy Jiao","doi":"10.1111/1475-6773.70048","DOIUrl":"10.1111/1475-6773.70048","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To examine the impact of private equity (PE) hospital acquisitions on maternal health for Medicaid patients.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>This quasi-experimental study focuses on 66 PE acquisitions of hospitals between 2014 and 2018, analyzing national Medicaid claims data from 2011 to 2020. Using a difference-in-differences (DiD) framework, the study compares labor and delivery (L&D) outcomes at PE-acquired hospitals with matched control hospitals to evaluate the effects on patient volume, process of care, and quality outcomes for Medicaid patients.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>The analysis uses data from the Transformed Medicaid Statistical Information System (T-MSIS) and Medicaid Analytic eXtract (MAX), including over 1 million L&D hospitalizations. The analytic sample comprises 66 PE hospitals and 290 matched control hospitals.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>PE acquisition was associated with a significant 12% decrease in Medicaid L&D market share (<i>p</i> < 0.05). The reduction was more pronounced in states with larger Medicaid-to-commercial payment gaps (−15.8% vs. −7.2%). However, no significant changes were observed in low-risk cesarean rates, number of procedures, length of stay, or severe maternal morbidity.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>PE acquisitions of hospitals are associated with reduced Medicaid market share, particularly in states with lower Medicaid reimbursement relative to commercial insurance. Policymakers should consider addressing these issues by adjusting Medicaid payment rates to support vulnerable populations in PE-acquired hospitals.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857500/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145226251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I. Papanicolas, J. Cylus, and L. Lorenzoni, “Cross-Country Comparisons in Health Price Growth Over Time,” Health Services Research 59, no. 6 (2024): e14295, https://doi.org/10.1111/1475-6773.14295.
We apologize for this error.
I. Papanicolas， J. Cylus和L. Lorenzoni，“医疗价格随时间增长的跨国比较”，《卫生服务研究》，第59期。6 (2024): e14295, https://doi.org/10.1111/1475-6773.14295.We为这个错误道歉。
{"title":"Correction to “Cross Country Comparisons in Price Growth Over Time”","authors":"","doi":"10.1111/1475-6773.70047","DOIUrl":"10.1111/1475-6773.70047","url":null,"abstract":"<p>I. Papanicolas, J. Cylus, and L. Lorenzoni, “Cross-Country Comparisons in Health Price Growth Over Time,” <i>Health Services Research</i> 59, no. 6 (2024): e14295, https://doi.org/10.1111/1475-6773.14295.</p><p>We apologize for this error.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857473/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kenneth J. Nieser, Daniel J. Tancredi, Alex H. S. Harris
Objective
To estimate the reliability of two outcome quality measures in Veterans Health Administration (VHA) data using three different methods.
Study Setting and Design
We created two cohorts of VHA patients meeting criteria for two measures: (1) risk-standardized complication rates following elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA), and (2) risk-standardized mortality rates following acute myocardial infarction hospitalization (AMI). We fit hierarchical logistic regression models and calculated facility-level risk-standardized rates. We estimated entity-level reliability using three commonly applied methods: (1) delta method approximation; (2) latent scale model; (3) split-sample method.
Data Sources and Analytic Sample
For each measure, we extracted risk adjustment and outcome data from the VHA Corporate Data Warehouse for patients meeting eligibility criteria in fiscal years 2021 and 2022.
Principal Findings
Most facilities had complication rates following total hip and/or knee arthroplasty and mortality rates following hospitalization for acute myocardial infarction that, statistically, were no different from the national average. Reliability estimates based on delta method approximation (0.14 for THA/TKA; 0.12 for AMI) and the split-sample method (0.12 for THA/TKA; 0.19 for AMI) were very low for both measures. As we varied the sample sizes, we found that much higher sample sizes would be needed to reliably differentiate quality of care across facilities. On the other hand, reliability estimates based on the latent scale model were substantially higher than the other two methods (0.64 for THA/TKA; 0.41 for AMI), suggesting that there is substantially more between-facility variation in latent quality than manifests in observed outcomes.
Conclusions
Reliability estimates based on the latent scale approach are not numerically or conceptually interchangeable with estimates based on the other two approaches. Given that health outcomes are generally reported using observed outcomes, reliability estimation based on the latent scale approach should not be used without a strong rationale.
{"title":"The Unreliability of Two Publicly Reported Outcome Quality Measures for Characterizing Health Care Quality Within the Veterans Health Administration","authors":"Kenneth J. Nieser, Daniel J. Tancredi, Alex H. S. Harris","doi":"10.1111/1475-6773.70050","DOIUrl":"10.1111/1475-6773.70050","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To estimate the reliability of two outcome quality measures in Veterans Health Administration (VHA) data using three different methods.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We created two cohorts of VHA patients meeting criteria for two measures: (1) risk-standardized complication rates following elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA), and (2) risk-standardized mortality rates following acute myocardial infarction hospitalization (AMI). We fit hierarchical logistic regression models and calculated facility-level risk-standardized rates. We estimated entity-level reliability using three commonly applied methods: (1) delta method approximation; (2) latent scale model; (3) split-sample method.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>For each measure, we extracted risk adjustment and outcome data from the VHA Corporate Data Warehouse for patients meeting eligibility criteria in fiscal years 2021 and 2022.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>Most facilities had complication rates following total hip and/or knee arthroplasty and mortality rates following hospitalization for acute myocardial infarction that, statistically, were no different from the national average. Reliability estimates based on delta method approximation (0.14 for THA/TKA; 0.12 for AMI) and the split-sample method (0.12 for THA/TKA; 0.19 for AMI) were very low for both measures. As we varied the sample sizes, we found that much higher sample sizes would be needed to reliably differentiate quality of care across facilities. On the other hand, reliability estimates based on the latent scale model were substantially higher than the other two methods (0.64 for THA/TKA; 0.41 for AMI), suggesting that there is substantially more between-facility variation in latent quality than manifests in observed outcomes.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>Reliability estimates based on the latent scale approach are not numerically or conceptually interchangeable with estimates based on the other two approaches. Given that health outcomes are generally reported using observed outcomes, reliability estimation based on the latent scale approach should not be used without a strong rationale.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. John McConnell, Jane M. Zhu, Thomas H. A. Meath, Stephan Lindner
Objective
To assess whether the adoption of Section 1115 Serious Mental Illness and Serious Emotional Disturbance (SMI/SED) Medicaid waivers was associated with increased bed capacity among freestanding psychiatric hospitals.
Study Setting and Design
We used a difference-in-differences design to study changes in bed capacity in freestanding psychiatric hospitals across all 50 states and the District of Columbia, comparing states that adopted waivers to those that did not.
Data Sources and Analytic Sample
We used data from the National Mental Health Services Survey, Centers for Medicare and Medicaid Services Provider of Service files, and other state-level datasets from 2014 to 2023.
Principal Findings
Freestanding hospitals were responsible for most of the growth of psychiatric inpatient bed capacity over the last 10 years. We found no correlation between the option to pursue an SMI/SED waiver and bed capacity or other measures of mental health needs, including state-based estimates of SMI prevalence or suicide rates. In our difference-in-differences analyses, we found no association between the adoption of SMI/SED waivers and bed capacity in freestanding psychiatric hospitals. For example, our estimate of the association of SMI/SED waivers with changes in beds in psychiatric hospitals that accepted Medicaid was −24 beds per 100,000 Medicaid-enrolled adults (95% CI: −115, 67). Other specifications and outcome variables yielded similar results.
Conclusion
While SMI/SED waivers offer the potential to address psychiatric bed shortages, these waivers alone may not suffice to increase inpatient capacity. Given the low uptake and absence of significant change in bed capacity, SMI/SED waivers may need to be redesigned to meet the growing mental health needs of the Medicaid population.
{"title":"Addressing Psychiatric Bed Capacity: Evidence From Medicaid's Institutions for Mental Disease Waivers for Serious Mental Illness","authors":"K. John McConnell, Jane M. Zhu, Thomas H. A. Meath, Stephan Lindner","doi":"10.1111/1475-6773.70051","DOIUrl":"10.1111/1475-6773.70051","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To assess whether the adoption of Section 1115 Serious Mental Illness and Serious Emotional Disturbance (SMI/SED) Medicaid waivers was associated with increased bed capacity among freestanding psychiatric hospitals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We used a difference-in-differences design to study changes in bed capacity in freestanding psychiatric hospitals across all 50 states and the District of Columbia, comparing states that adopted waivers to those that did not.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We used data from the National Mental Health Services Survey, Centers for Medicare and Medicaid Services Provider of Service files, and other state-level datasets from 2014 to 2023.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Freestanding hospitals were responsible for most of the growth of psychiatric inpatient bed capacity over the last 10 years. We found no correlation between the option to pursue an SMI/SED waiver and bed capacity or other measures of mental health needs, including state-based estimates of SMI prevalence or suicide rates. In our difference-in-differences analyses, we found no association between the adoption of SMI/SED waivers and bed capacity in freestanding psychiatric hospitals. For example, our estimate of the association of SMI/SED waivers with changes in beds in psychiatric hospitals that accepted Medicaid was −24 beds per 100,000 Medicaid-enrolled adults (95% CI: −115, 67). Other specifications and outcome variables yielded similar results.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>While SMI/SED waivers offer the potential to address psychiatric bed shortages, these waivers alone may not suffice to increase inpatient capacity. Given the low uptake and absence of significant change in bed capacity, SMI/SED waivers may need to be redesigned to meet the growing mental health needs of the Medicaid population.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208228","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Diana J. Govier, Meike Niederhausen, Alex Hickok, Mazhgan Rowneki, Holly McCready, Abby Moss, Kristina M. Cordasco, Kathryn M. McDonald, Matthew L. Maciejewski, Kathleen C. Thomas, Denise M. Hynes
Objective
To examine associations between receipt of post-hospitalization care coordination and VA-delivered, VA-purchased, and Medicare fee-for-service hospital readmissions among Veterans at high risk for hospitalization and/or mortality.
Study Setting and Design
In this observational retrospective cohort study, we compared high-risk Veterans who received care coordination within one day after hospital discharge (“treated”) with up to five matched high-risk Veterans who did not receive care coordination during this time (“comparators”). Competing risk models estimated adjusted sub-hazard ratios (aSHR) for 30-day all-cause and ambulatory care sensitive condition (ACSC) readmissions between treated and comparators, with death as a competing risk. In sensitivity analyses, we implemented inverse probability of censoring weights to account for censoring due to cross-over to treatment among comparators during follow-up.
Data Sources and Analytic Sample
Data sources included the VA Vital Status File, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services administrative files. Participants included 31,614 treated and 99,634 comparator high-risk Veterans initially hospitalized in fiscal year 2021.
Principal Findings
Participants were primarily male sex, ≥ 65 years of age, and had initial hospitalizations in VA facilities; 15.9% and 2.3% of treated Veterans had 30-day all-cause and ACSC readmissions, respectively, compared with 13.5% and 2.1% of comparators. After accounting for the competing risk of death and covariates that remained imbalanced across groups after matching, post-hospitalization care coordination was associated with no difference in the risk of 30-day all-cause (aSHR 1.03, 95% CI 1.00, 1.07) and ACSC (aSHR 0.97, 95% CI 0.89, 1.05) readmission among high-risk Veterans. The risk of ACSC readmission was similar after including censoring weights (aSHR 1.00, 95% CI 0.92, 1.09); the increased risk of all-cause readmission was small in magnitude but statistically significant (aSHR 1.09, 95% CI 1.05, 1.13).
Conclusions
Receipt of post-hospitalization care coordination was largely associated with no difference in 30-day readmission risk, suggesting that alternative or additional services may be needed to address readmissions among high-risk Veterans.
目的：探讨住院和/或死亡风险高的退伍军人住院后护理协调与va交付、va购买和Medicare按服务收费再入院之间的关系。研究背景和设计：在这项观察性回顾性队列研究中，我们比较了出院后一天内接受护理协调的高风险退伍军人（“治疗”）和多达5名在此期间未接受护理协调的匹配高风险退伍军人（“比较者”）。竞争风险模型估计了治疗组和比较组之间30天全因和门诊敏感状况（ACSC）再入院的调整亚危险比（aSHR），其中死亡为竞争风险。在敏感性分析中，我们实施了审查权值的逆概率，以解释由于随访期间比较者之间的交叉治疗而导致的审查。数据源和分析样本：数据源包括VA重要状态文件、VA公司数据仓库以及医疗保险和医疗补助服务中心的管理文件。参与者包括31,614名接受治疗的退伍军人和99,634名比较高风险退伍军人，最初在2021财政年度住院。主要发现：参与者主要为男性，年龄≥65岁，在退伍军人管理局设施初次住院；15.9%和2.3%接受治疗的退伍军人分别有30天的全因和ACSC再入院，而对照组的这一比例分别为13.5%和2.1%。在考虑了匹配后各组间仍然不平衡的死亡竞争风险和协变量后，住院后护理协调与高风险退伍军人30天全因再入院风险（aSHR 1.03, 95% CI 1.00, 1.07）和ACSC （aSHR 0.97, 95% CI 0.89, 1.05）无差异相关。纳入审查权后，ACSC再入院的风险相似（aSHR 1.00, 95% CI 0.92, 1.09）；全因再入院的风险增加幅度不大，但具有统计学意义（aSHR 1.09, 95% CI 1.05, 1.13）。结论：接受住院后护理协调在很大程度上与30天再入院风险无差异相关，这表明可能需要替代或额外的服务来解决高风险退伍军人的再入院问题。
{"title":"Risk of Hospital Readmissions and Association With Receipt of Post-Hospitalization Care Coordination Services Among High-Risk Veterans","authors":"Diana J. Govier, Meike Niederhausen, Alex Hickok, Mazhgan Rowneki, Holly McCready, Abby Moss, Kristina M. Cordasco, Kathryn M. McDonald, Matthew L. Maciejewski, Kathleen C. Thomas, Denise M. Hynes","doi":"10.1111/1475-6773.70044","DOIUrl":"10.1111/1475-6773.70044","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To examine associations between receipt of post-hospitalization care coordination and VA-delivered, VA-purchased, and Medicare fee-for-service hospital readmissions among Veterans at high risk for hospitalization and/or mortality.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>In this observational retrospective cohort study, we compared high-risk Veterans who received care coordination within one day after hospital discharge (“treated”) with up to five matched high-risk Veterans who did not receive care coordination during this time (“comparators”). Competing risk models estimated adjusted sub-hazard ratios (aSHR) for 30-day all-cause and ambulatory care sensitive condition (ACSC) readmissions between treated and comparators, with death as a competing risk. In sensitivity analyses, we implemented inverse probability of censoring weights to account for censoring due to cross-over to treatment among comparators during follow-up.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>Data sources included the VA Vital Status File, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services administrative files. Participants included 31,614 treated and 99,634 comparator high-risk Veterans initially hospitalized in fiscal year 2021.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>Participants were primarily male sex, ≥ 65 years of age, and had initial hospitalizations in VA facilities; 15.9% and 2.3% of treated Veterans had 30-day all-cause and ACSC readmissions, respectively, compared with 13.5% and 2.1% of comparators. After accounting for the competing risk of death and covariates that remained imbalanced across groups after matching, post-hospitalization care coordination was associated with no difference in the risk of 30-day all-cause (aSHR 1.03, 95% CI 1.00, 1.07) and ACSC (aSHR 0.97, 95% CI 0.89, 1.05) readmission among high-risk Veterans. The risk of ACSC readmission was similar after including censoring weights (aSHR 1.00, 95% CI 0.92, 1.09); the increased risk of all-cause readmission was small in magnitude but statistically significant (aSHR 1.09, 95% CI 1.05, 1.13).</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>Receipt of post-hospitalization care coordination was largely associated with no difference in 30-day readmission risk, suggesting that alternative or additional services may be needed to address readmissions among high-risk Veterans.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857460/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145180458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jacob Duncan, Andrew V. Tran, Ryan Witt, Annes Elfar, Matthew Rashid, Matt Vassar
Objective
To assess potential Medicare cost savings if Mark Cuban Cost Plus Drug Company (MCCPDC) pricing were applied to antihypertensive medications.
Study Setting and Design
We conducted a cross-sectional analysis comparing Medicare Part D spending with MCCPDC pricing for selected antihypertensive drugs.
Data Sources and Analytic Sample
Eighty-seven antihypertensive medications were compared between Medicare Part D and MCCPDC. Volume-adjusted expenditure estimates were calculated under three scenarios: (1) applying MCCPDC prices to all medications, (2) applying MCCPDC prices only to drugs priced lower than Medicare, and (3) applying MCCPDC prices to guideline-recommended first-line therapies.
Principal Findings
In 2022, Medicare spent $4.9 billion on the included medications. Of these, 39 of the 30-count and 58 of the 90-count medications showed cost savings under MCCPDC pricing. Estimated savings totaled $670.1 million (30-count) and $1.4 billion (90-count). Among 47 first-line agents, MCCPDC pricing produced estimated savings of $222.6 million (30-count) and $584.1 million (90-count). The average 90-count price reduction was 23.2% overall and 21.1% among first-line therapies, with several agents showing substantial price advantages.
Conclusion
Adopting MCCPDC pricing could reduce Medicare costs for antihypertensive drugs, especially through 90-count supplies and first-line therapies. Targeted implementation—focusing on medications with clear cost and clinical advantages—may yield meaningful savings. These results support broader policy efforts to incorporate transparent, value-based drug pricing models into Medicare.
{"title":"Disrupting Drug Costs: The Role of Cost-Plus Pricing in Reducing Medicare Spending on Hypertension Treatments","authors":"Jacob Duncan, Andrew V. Tran, Ryan Witt, Annes Elfar, Matthew Rashid, Matt Vassar","doi":"10.1111/1475-6773.70045","DOIUrl":"10.1111/1475-6773.70045","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To assess potential Medicare cost savings if Mark Cuban Cost Plus Drug Company (MCCPDC) pricing were applied to antihypertensive medications.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We conducted a cross-sectional analysis comparing Medicare Part D spending with MCCPDC pricing for selected antihypertensive drugs.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>Eighty-seven antihypertensive medications were compared between Medicare Part D and MCCPDC. Volume-adjusted expenditure estimates were calculated under three scenarios: (1) applying MCCPDC prices to all medications, (2) applying MCCPDC prices only to drugs priced lower than Medicare, and (3) applying MCCPDC prices to guideline-recommended first-line therapies.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>In 2022, Medicare spent $4.9 billion on the included medications. Of these, 39 of the 30-count and 58 of the 90-count medications showed cost savings under MCCPDC pricing. Estimated savings totaled $670.1 million (30-count) and $1.4 billion (90-count). Among 47 first-line agents, MCCPDC pricing produced estimated savings of $222.6 million (30-count) and $584.1 million (90-count). The average 90-count price reduction was 23.2% overall and 21.1% among first-line therapies, with several agents showing substantial price advantages.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusion</h3>\u0000 <p>Adopting MCCPDC pricing could reduce Medicare costs for antihypertensive drugs, especially through 90-count supplies and first-line therapies. Targeted implementation—focusing on medications with clear cost and clinical advantages—may yield meaningful savings. These results support broader policy efforts to incorporate transparent, value-based drug pricing models into Medicare.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145088234","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nicolas P. Goldstein Novick, Peter J. Veazie, Elaine L. Hill, Eva K. Pressman, Peter G. Szilagyi, Timothy D. Nelin, Scott A. Lorch
Objective
To assess the impact of increased Medicaid income eligibility during pregnancy on payment source for prenatal care and birth and on gestational age at birth (GAb).
Study Setting and Design
We performed a quasi-experimental, difference-in-differences study comparing two increases in Medicaid income eligibility during pregnancy to two control states with data from 2007 to 2010: (Dyad 1) Ohio (expanded from 150% to 200% of the Federal Poverty level [FPL]) versus Pennsylvania and (Dyad 2) Wisconsin (185% to 250% FPL) versus Michigan. We performed multinomial logistic regression to assess the impact of increased Medicaid eligibility on the following key outcome variables: payment source for prenatal care and birth and GAb.
Data Sources and Analytic Sample
We utilized CDC Pregnancy Risk Assessment Monitoring System (PRAMS) data (2007–2010) and limited analysis to singleton, in-state live births. After re-weighting for PRAMS survey design, our analytical sample represented about 540,000 births.
Principal Findings
In the higher-income Wisconsin-Michigan dyad, increased Medicaid eligibility during pregnancy significantly increased exclusive Medicaid coverage for prenatal care (7.0%, 95% CI 2.9% to 11.1%) and birth (8.3%, 4.3% to 12.4%). Simultaneously, private insurance coverage dropped for prenatal care (−4.0%, −7.7% to −0.3%) and birth (−3.7%, −7.2% to −0.2%) while self-payment decreased only for birth (−1.8%, −3.5% to −0.2%). In the lower-income Ohio-Pennsylvania dyad, the only statistically significant effects on payment source were decreases in the likelihood of a payment source of other for prenatal care (−3.3%, −6.2% to −0.3%) and birth (−4.7%, −7.9% to −1.6%). There were no statistically significant effects on GAb across both dyads.
Conclusions
Increased Medicaid eligibility during pregnancy for individuals of higher income seems to improve utilization of exclusive Medicaid with diminished uninsurance but also less private insurance after accounting for indicators of socioeconomic advantage but has no clear impact on GAb. Medicaid policy should balance reducing uninsurance with directing scarce resources to high-risk individuals.
目的：评估孕期医疗补助收入资格增加对产前护理和分娩支付来源以及出生胎龄（GAb）的影响。研究设置和设计：我们进行了一项准实验，差异中差异研究，比较了两个对照州在怀孕期间医疗补助收入资格的两次增加，数据来自2007年至2010年：（Dyad 1）俄亥俄州（从联邦贫困水平[FPL]的150%扩大到200%）与宾夕法尼亚州和（Dyad 2）威斯康星州（从185%扩大到250% FPL）与密歇根州。我们使用多项逻辑回归来评估增加医疗补助资格对以下关键结果变量的影响：产前护理和分娩的支付来源和GAb。数据来源和分析样本：我们使用疾病预防控制中心妊娠风险评估监测系统（PRAMS）数据（2007-2010年），并对单胎和州内活产婴儿进行有限分析。在对PRAMS调查设计重新加权后，我们的分析样本代表了大约54万名新生儿。主要发现：在高收入的威斯康辛-密歇根双组中，怀孕期间医疗补助资格的增加显著增加了产前护理（7.0%,95% CI 2.9%至11.1%）和分娩（8.3%，4.3%至12.4%）的独家医疗补助覆盖率。与此同时，私人保险的产前护理（-4.0%,-7.7%,-0.3%）和生育（-3.7%,-7.2%,-0.2%）的保险覆盖率有所下降，而自付保险的保险覆盖率只有生育（-1.8%,-3.5%,-0.2%）有所下降。在收入较低的俄亥俄州和宾夕法尼亚州，对支付来源的唯一统计显著影响是产前护理（-3.3%,-6.2%至-0.3%）和分娩（-4.7%,-7.9%至-1.6%）的其他支付来源的可能性降低。在两对夫妇中，GAb没有统计学上的显著影响。结论：考虑到社会经济优势指标后，高收入个体怀孕期间医疗补助资格的增加似乎提高了独家医疗补助的利用率，减少了不保险，但也减少了私人保险，但对GAb没有明显影响。医疗补助政策应该在减少无保险和将稀缺资源导向高风险人群之间取得平衡。
{"title":"The Impact of Increased Medicaid Eligibility During Pregnancy on Medicaid Utilization and Gestational Age","authors":"Nicolas P. Goldstein Novick, Peter J. Veazie, Elaine L. Hill, Eva K. Pressman, Peter G. Szilagyi, Timothy D. Nelin, Scott A. Lorch","doi":"10.1111/1475-6773.70037","DOIUrl":"10.1111/1475-6773.70037","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To assess the impact of increased Medicaid income eligibility during pregnancy on payment source for prenatal care and birth and on gestational age at birth (GAb).</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We performed a quasi-experimental, difference-in-differences study comparing two increases in Medicaid income eligibility during pregnancy to two control states with data from 2007 to 2010: (Dyad 1) Ohio (expanded from 150% to 200% of the Federal Poverty level [FPL]) versus Pennsylvania and (Dyad 2) Wisconsin (185% to 250% FPL) versus Michigan. We performed multinomial logistic regression to assess the impact of increased Medicaid eligibility on the following key outcome variables: payment source for prenatal care and birth and GAb.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>We utilized CDC Pregnancy Risk Assessment Monitoring System (PRAMS) data (2007–2010) and limited analysis to singleton, in-state live births. After re-weighting for PRAMS survey design, our analytical sample represented about 540,000 births.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>In the higher-income Wisconsin-Michigan dyad, increased Medicaid eligibility during pregnancy significantly increased exclusive Medicaid coverage for prenatal care (7.0%, 95% CI 2.9% to 11.1%) and birth (8.3%, 4.3% to 12.4%). Simultaneously, private insurance coverage dropped for prenatal care (−4.0%, −7.7% to −0.3%) and birth (−3.7%, −7.2% to −0.2%) while self-payment decreased only for birth (−1.8%, −3.5% to −0.2%). In the lower-income Ohio-Pennsylvania dyad, the only statistically significant effects on payment source were decreases in the likelihood of a payment source of other for prenatal care (−3.3%, −6.2% to −0.3%) and birth (−4.7%, −7.9% to −1.6%). There were no statistically significant effects on GAb across both dyads.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>Increased Medicaid eligibility during pregnancy for individuals of higher income seems to improve utilization of exclusive Medicaid with diminished uninsurance but also less private insurance after accounting for indicators of socioeconomic advantage but has no clear impact on GAb. Medicaid policy should balance reducing uninsurance with directing scarce resources to high-risk individuals.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-09-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145066230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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