Health affairs scholar最新文献

Introduction: In 2014, multiple states expanded Medicaid coverage to low-income adults under the Affordable Care Act. We evaluated the association of Medicaid expansion (ME) with children's insurance coverage and health service utilization.

Methods: We compared changes in children's insurance coverage and health service utilization between 2010-2013 and 2014-2016 in expansion and non-expansion states. Repeated cross-sectional analysis with linear difference-in-differences (DID) models was conducted using the Medical Expenditure Panel Survey.

Results: Medicaid expansion was not associated with changes in the proportion of children with ≥1 month of insurance coverage (DID: -1.9% point [pp], 95% CI -4.1 to 0.3) or the proportion of children with continuous coverage for 12 months (DID: -1.8 pp, 95% CI -5.6 to 2.0). Expansion was not associated with changes in any utilization outcome, including having ≥1 annual well-child visit (DID: -1.9 pp, 95% CI -6.6 to 2.8) or ≥1 annual dental visit (DID: 1.9 pp, 95% CI -2.8 to 6.5).

Conclusion: Medicaid expansion was not associated with changes in children's coverage and utilization. While policymakers in states that have not yet expanded Medicaid might still consider doing so for other reasons, findings suggest that alternative interventions will be needed to improve coverage and utilization patterns in children.

Objective: To examine the association between post-pandemic era Medicaid eligibility redeterminations ("unwinding") and emergency department (ED) payer mix in California.

Methods: We conducted a retrospective secondary analysis of California's quarterly ED visit data (2021-2024) across 281 general acute-care hospitals, using interrupted time-series analysis.

Results: During unwinding, Medicaid ED visits declined by 0.37 percentage points (pp) and uninsured ED visits increased by 0.16 pp per quarter (P < .001) relative to the pre-unwinding period. The largest Medicaid declines occurred in investor-owned (0.87 pp, 11.9%) and medium-sized (0.47 pp, 7.4%) hospitals (P < .001). In contrast, the largest increases in uninsured visits occurred among hospitals in rural (0.29 pp, 46.7%) and high-poverty (0.24 pp, 7.7%) areas, in addition to small hospitals (0.22 pp, 25.8%) (P < .001). Private visits saw an immediate decrease of 0.49 pp (P < .001), followed by a continued reduction of 0.15 pp per quarter (P < .05), showing flattening of the previously increasing trend. Medicare visits increased by 0.18 pp per quarter (P < .001) relative to the pre-unwinding period.

Conclusion: Medicaid unwinding was associated with a decline in Medicaid ED visits and a corresponding increase in uninsured ED visits, with varying impacts across hospital types in California.

Introduction: Medicare and commercial payers pay more for services delivered in hospital outpatient departments than in physicians' offices or ambulatory surgery centers. These "site-of-care" payment differentials contribute to rising health care spending and drive hospital acquisition of physician practices. Because many non-hospital settings can provide equivalent or higher-quality care at lower costs, site-neutral payment has gained traction in Medicare, with the potential to save patients and taxpayers billions. A growing number of states are exploring similar policies in the commercial market by capping payments for routine services at a percentage of the Medicare payment in non-hospital settings. The impact of such policies for commercial purchasers and patients has not yet been modeled.

Methods: This study uses 2022 commercial claims data from the Health Care Cost Institute and estimates potential savings by capping prices for 2561 routine services (Current Procedural Terminology codes) at 150% of the Medicare payment in hospital, office, and ambulatory surgery center settings.

Results: Site-neutral payment for commercial purchasers and patients could save $10.8 billion across 48 states and Washington, D.C. State level aggregate hospital operating margins would decline modestly.

Conclusion: Site-neutral policies could yield substantial savings but require ongoing monitoring for unintended effects.

Introduction: Access to contraception services is an essential component of reproductive autonomy; however, low-income individuals frequently face barriers to care, including a shortage of providers who both accept Medicaid and offer contraception services.

Methods: We used 2021 Transformed Medicaid Statistical Information System Prescription and Other Service files to identify clinicians who provided contraception (prescription, implant, and/or intrauterine device (IUD)) to Medicaid beneficiaries.

Results: We identified 523 077 primary care and women's health specialty clinicians (obstetrician-gynecologists, family medicine, internal medicine, pediatrics, nurse practitioners, physician assistants, and midwives) who provided care to reproductive aged (15-44 years) female Medicaid beneficiaries for any service; of these, only 181 019 (34.6%) provided at least one contraception method to Medicaid beneficiaries and even fewer 20 160 (3.9%) provided prescriptions (pill, patch, and/or ring), IUDs, and implants. Over half (54%) of US counties had greater or equal numbers of advanced practice clinicians-nurse practitioners, physician assistants, and midwives-prescribing contraception compared with physicians.

Conclusion: Few clinicians provided a wide range of contraception to Medicaid beneficiaries. Advanced practice clinicians are important providers in counties with limited access to physicians. Documenting workforce variation for contraception care has important implications for access, especially as recent policy changes may make contraception less accessible for Medicaid beneficiaries.

The Hatch-Waxman Act of 1984 was designed to accelerate generic drug entry by establishing a framework for resolving patent disputes between brand-name and generic manufacturers. While the Act has facilitated competition and expanded the availability of affordable medicines, brand-name firms have increasingly exploited its procedural structure to delay or deter generic competition through "serial litigation." This strategy involves filing successive, questionable lawsuits, often based on non-innovative continuation patents. Even if the brand ultimately loses, the delays and litigation costs can discourage generic firms from entering the market or compel them to settle on terms that undermine patients' timely access to affordable generics. In the case of Astellas's overactive bladder drug mirabegron (Myrbetriq), after an initial Hatch-Waxman case settled in 2020 with generic entry expected in 2024, Astellas pursued 4 additional lawsuits, each built on new but substantively indistinguishable patents. These tactics have delayed broad competition, leaving only 2 firms to launch in 2024 under the threat of massive damages. Similar patterns are observed with other drugs, including bimatoprost (Latisse), aflibercept (Eylea), and tasimelteon (Hetlioz).

Introduction: In 2017, Connecticut prohibited hospitals from billing "facility fees" for certain services delivered off their main campuses.

Methods: Using Hospital Medicare Cost Reports and the National Academy for State Health Policy Hospital Cost Data (2011-2022), we applied a difference-in-differences model within an event study framework to compare hospital financial outcomes between Connecticut hospitals and matched control hospitals nationwide.

Results: Unadjusted trends suggest small declines in operating margins and outpatient-to-total charges after the ban, alongside an increase in inpatient-to-total charges. In adjusted analyses, operating margins and inpatient-to-total charges did not change significantly, while outpatient-to-total charges declined significantly by 6.91%.

Conclusion: Given the small sample and limited precision, a policy effect cannot be ruled out for several outcomes. Future research evaluating the long-term sustainability and impacts on hospital financials, access, and care quality are warranted.

Introduction: Routine screening for health-related social needs (HRSNs) is inconsistent, creating disparities in who gets identified and supported. Transgender patients, already facing structural stigma, may be especially affected.

Methods: We analyzed electronic health records from a large urban safety-net system (2018-2023). We identified 2639 transgender patients with at least one outpatient visit and created a ∼11:1 comparison cohort of 23 944 cisgender patients. Overall, 7.5% (n = 1997) completed a Social Needs Questionnaire (SNQ), including 1840 cisgender and 157 transgender patients. We compared screening rates using chi-square tests and assessed adjusted odds for HRSN with logistic regression.

Results: Transgender patients were screened less often than cisgender patients (5.9% vs 7.7%, P = 0.001). Among those screened, they had more than twice the odds of housing instability, poor-quality housing, and healthcare costs. Odds for interpersonal violence were th3ree times higher. Findings were consistent in sensitivity analyses adjusting for age, insurance, and neighborhood.

Conclusion: Transgender patients were underscreened yet faced greater HRSNs. Standardized screening and expanded supports are critical to support transgender communities.