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Background Low-value healthcare is costly and inefficient and may adversely affect patient outcomes. Despite increases in low-value service use, little is known about how the receipt of low-value care differs across payers. Objective To evaluate differences in the use of low-value care between patients with commercial versus Medicaid coverage. Design Retrospective observational analysis of the 2017 Rhode Island All-payer Claims Database, estimating the probability of receiving each of 14 low-value services between commercial and Medicaid enrollees, adjusting for patient sociodemographic and clinical characteristics. Ensemble machine learning minimized the possibility of model misspecification. Participants Medicaid and commercial enrollees aged 18–64 with continuous coverage and an encounter at which they were at risk of receiving a low-value service. Intervention Enrollment in Medicaid or Commercial insurance. Main Measures Use of one of 14 validated measures of low-value care. Key Results Among 110,609 patients, Medicaid enrollees were younger, had more comorbidities, and were more likely to be female than commercial enrollees. Medicaid enrollees had higher rates of use for 7 low-value care measures, and those with commercial coverage had higher rates for 5 measures. Across all measures of low-value care, commercial enrollees received more (risk difference [RD] 6.8 percentage points; CI: 6.6 to 7.0) low-value services than their counterparts with Medicaid. Commercial enrollees were also more likely to receive low-value services typically performed in the emergency room (RD 11.4 percentage points; CI: 10.7 to 12.2) and services that were less expensive (RD 15.3 percentage points; CI 14.6 to 16.0). Conclusion Differences in the provision of low-value care varied across measures, though average use was slightly higher among commercial than Medicaid enrollees. This difference was more pronounced for less expensive services indicating that financial incentives may not be the sole driver of low-value care.

This cross-sectional study uses data from the 2013-2018 National Health Interview Survey to examine the association between enrollment in a high-deductible health plan and access to care among cancer survivors differentiated by race/ethnicity.

Sexual and reproductive health services are a primary reason for care seeking by female young adults, but the association of the 2010 Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE) with insurance use for these services has not been studied to our knowledge. Insurer billing practices may compromise dependent confidentiality, potentially discouraging dependents from using insurance or obtaining care. To evaluate the association between implementation of ACA-DCE and insurance use for confidential sexual and reproductive health services by female young adults newly eligible for parental coverage. For this cross-sectional study, a difference-in-differences analysis of a US national sample of commercial claims from January 1, 2007, to December 31, 2009, and January 1, 2011, to December 31, 2016, captured insurance use before and after policy implementation among female young adults aged 23 to 25 years (treatment group) who were eligible for dependent coverage compared with those aged 27 to 29 years (comparison group) who were ineligible for dependent coverage. Data were analyzed from January 2019 to February 2020. Eligibility for parental coverage under the ACA-DCE as of 2010. Probability of insurance use for contraception and Papanicolaou testing. Emergency department and well visits were included as control outcomes not sensitive to confidentiality concerns. Linear probability models adjusted for age, plan type, annual deductible, comorbidities, and state and year fixed effects, with SEs clustered at the state level. The study sample included 4 690 699 individuals (7 268 372 person-years), with 2 898 275 in the treatment group (mean [SD] age, 23.7 [0.8] years) and 1 792 424 in the comparison group (mean [SD] age; 27.9 [0.8] years). Enrollees in the treatment group were less likely to have a comorbidity (77.3% vs 72.9%) and more likely to have a high deductible plan (14.6% vs 10.1%) than enrollees in the comparison group. Implementation of the ACA-DCE was associated with a -2.9 (95% CI, -3.4 to -2.4) percentage point relative reduction in insurance use for contraception and a -3.4 (95% CI, -3.9 to -3.0) percentage point relative reduction in Papanicolaou testing in the treatment vs comparison groups. Emergency department and well visits increased 0.4 (95% CI, 0.2-0.7) and 1.7 (95% CI, 1.3-2.1) percentage points, respectively. The findings suggest that implementation of the ACA-DCE was associated with a reduction in insurance use for sexual and reproductive health services and an increase in emergency department and well health visits by female young adults newly eligible for parental coverage. Some young people who gained coverage under the expansion may not be using essential, confidential services.

With the rise in the share of privately insured patients covered by high-deductible health plans (HDHPs), understanding sociodemographic trends in the uptake of health savings accounts (HsAs) is increasingly important, as HsAs may help offset the higher up-front costs of care in HDHPs. We used nationally representative data from the National Health Interview Survey from the period 2007-18 to examine trends in HDHP enrollment and HsA participation among privately insured adults by income level and race/ethnicity. Our findings show a substantial increase in HDHP enrollment across all racial/ethnic and income groups from 2007 to 2018. However, Black, Hispanic, and low-income HDHP enrollees were significantly less likely than their White and higher-income counterparts to participate in HSAs, and these gaps increased over time. This means that the HDHP enrollees most likely to benefit from the potential financial protection of HSAs were the least likely to have them. If these trends persist, racial/ethnic and income-based disparities in cost-related barriers to care may widen.

The Hyde Amendment prohibits US federal spending on abortion, including federal Medicaid dollars. Seventeen states cover abortion care in their Medicaid programs, using state funds, but causal evidence on how Medicaid coverage for abortion affects pregnancy outcomes is limited. Using a difference-in-differences design and 2014-21 birth and abortion data from the Centers for Disease Control and Prevention that predate the US Supreme Court's decision in 2022, we evaluated a 2018 policy introducing Medicaid coverage for abortion in Illinois. This change increased the number of abortions in the state by 2.43 per 1,000 reproductive-age females, an 18.2 percent increase, and reduced births by 1.66 per 1,000 reproductive-age females, a 2.8 percent decrease, relative to twenty-nine comparison states that did not cover abortion during the study period. Subgroup analyses of birth rates suggested that decreases in birth rates were more pronounced among Black and Hispanic residents, residents in counties with higher poverty rates, and residents closer to an abortion facility. Our finding suggests that Medicaid can play an important role in abortion access.

Data on the health of transgender and gender diverse (TGD) people are scarce. Researchers are increasingly turning to insurance claims data to investigate disease burden among TGD people. Since claims do not include gender self-identification or modality (i.e., TGD or not), researchers have developed algorithms to attempt to identify TGD individuals using diagnosis, procedure, and prescription codes, sometimes also inferring sex assigned at birth and gender. Claims-based algorithms introduce epistemological and ethical complexities that have yet to be addressed in data informatics, epidemiology, or health services research. We discuss the implications of claims-based algorithms to identify and categorize TGD populations, including perpetuating cisnormative biases and dismissing TGD individuals’ self-identification. Using the framework of epistemic injustice, we outline ethical considerations when undertaking claims-based TGD health research and provide suggestions to minimize harms and maximize benefits to TGD individuals and communities.

Introduction The use of cannabis as a sleep aid has increased despite inadequate evidence of its efficacy or associated risks. Delta-9-tetrahydrocannabinol (THC) is the primary psychoactive constituent of cannabis. Acute THC administration can induce CB1R mediated reductions in total peripheral resistance resulting in dose-dependent increases in heart rate and reductions in heart rate variability (HRV) in awake subjects. However, the influence of THC on vagal-cardiac modulation during sleep is unclear. Methods 7 individuals who use cannabis (>3x/week for 3 months; CUDIT-R = 8±1) and 8 cannabis-naïve participants (combined: age range 21-32 years; 9 female) were recruited to participate in this repeated measure, single blinded, placebo-controlled study. One hour before habitual sleep, participants received either a placebo pill or 10mg of THC. Polysomnography (PSG) and ECG were recorded over these 2 nights. HRV was assessed in both time and frequency domains in 2-min epochs of stable N2, N3 and REM sleep. Repeated measures ANOVA comparisons were made for PSG and HRV variables. [(*)=p< 0.05] Results There were no significant changes in total sleep duration or sleep architecture (N2%, N3%, & REM%) between the placebo and dosing night in either group. Compared to the placebo night, both individuals who use cannabis and cannabis naïve participants exhibited significant decreases in HRV variables throughout the night when dosed with THC. R-R interval decreased by 25±10* ms [mean±SE] (2%) in the naïve group and 62±11* ms (6%) in the cannabis group. RMSSD decreased by 15±3* ms (22%) in the naïve group and 11±3* ms (23%) in the cannabis group. PNN50 decreased by 9±3* % in the naïve group and 11±3* % in the cannabis group. In naïve participants high frequency spectral power decreased by 398±76* ms^2 (32%). Conclusion Our results suggest that THC ingestion before bedtime did not systematically affect sleep depth or duration, but did significantly reduce vagal-cardiac modulation in individuals who use cannabis as well as in cannabis naïve participants. Acute reductions in parasympathetic control of the heart may indicate increased cardiovascular stress during sleep when THC is ingested. Support (if any) AASM; K01HL151745; T32HL083808; OHSU OFDIR; R35 HL155681; Oregon Institute of Occupational Health Sciences