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Background This study described the dental caries experience of Palestinian pregnant women and examined its relationships to their oral health knowledge, beliefs, behavior, and access to dental care. Methods Pregnant women receiving prenatal care at the Ministry of Health (MOH) centers in the Jerusalem Governorate were invited to participate in this study. Structured interviews were conducted to assess pregnant mothers’ beliefs about oral health care and their oral hygiene practices. Screening for mothers’ dental caries experience was carried out using the Decayed, Missing and Filled Teeth/Surfaces (DMFT/S) index. Univariate, bi-variate and multi-variable analysis were conducted to explain the high level of disease in this population. Results A total of 152 pregnant women participated in this study. Mean DMFT in this sample was 15.5 ± 4.5 and an average DMFS of 31.8 ± 21. According the World Health Organization (WHO) criteria, 89% of our sample were categorized in the “Extremely High” dental caries experience. Fifty-eight percent of the DMFT scores among this sample were due to untreated dental decay, while 22% of the same DMFT scores demonstrated restorative care received by this sample. Bivariate analysis showed that mothers who completed a degree after high school had lower DMFT scores than mothers who did not (F = 4, n  = 152, p  = .024). In addition, mothers who believed they could lose a tooth just because they are pregnant had higher DMFT scores ( t  = − 4, n = 152, p  = .037). The final model found that age, level of education, providers’ advice on utilizing dental care during pregnancy, and the belief that a woman can lose a tooth just because she is pregnant explained 22% of the variation in DMFT scores. Conclusions Women in this study had a high prevalence of dental diseases and knew little about dental care during pregnancy. Faulty beliefs about dental care during pregnancy among women and health care providers were major factors in the high levels of disease.

An unwelcoming policy climate can create barriers to health care access and produce a ‘Chilling Effect’ among immigrant communities. For undocumented immigrants, barriers may be unique and have a greater impact. We used administrative emergency department (ED) data from 2015 to 2019 for a Midwestern state provided under a data use agreement with the state hospital association. General linear modelling was used to estimate the impact of anti-immigrant rhetoric on ED visit intensity among non-elderly adults who were likely Hispanic/Latino with undocumented status. Compared to 2015, the average ED visit intensity among adults who were likely Hispanic/Latino with undocumented status was significantly higher during 2016–2019 when anti-immigrant rhetoric was heightened. The magnitude of this change increased over time (0.013, 0.014, 0.021, and 0.020, respectively). Additionally, this change over time was not observed in the comparison groups. Our findings suggest that anti-immigrant rhetoric may alter health care utilization for adults who are likely Hispanic/Latino with undocumented status. Limitations to our findings include the use of only those likely to be Hispanic/Latino, data from only one Midwestern state and the loss of data due to non-classification using the NYU ED algorithm. Further research should focus on validating these findings and investigating these identification methods and anti-immigrant rhetoric effects among other undocumented groups including children and adults of different race or ethnicity such as black, both those that identify as Hispanic/Latino and those that do not. Developing strategies to improve health care access for undocumented Hispanic/Latino adults also warrants future research.

Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.

As part of Iowa's Medicaid expansion, the Healthy Behaviors Program was designed to provide members with incentives to complete specified healthy activities in return for waiving monthly premiums. We used claims data and interviews to document the first year (2014) of the program's implementation. Healthy activities completion rates did not exceed 17 percent. Interviews with members and clinic managers revealed low levels of awareness of the program's existence, deficits in knowledge about how the program works, and a variety of barriers to activity completion. Our findings suggest that the lack of knowledge hindered the state's ability to incentivize activities and that it subjected beneficiaries to premium expenses and potential disenrollment. These results should guide federal and state policy makers in devising more effective ways of educating Medicaid beneficiaries and providers about programs that incentivize responsibility for healthy behaviors. The results suggest that efforts by federal and state governments to reform Medicaid by shifting responsibility onto program members for healthy behaviors are unlikely to succeed, especially without careful thought and design of premiums, penalties, and incentives for participants.

Dental coverage for adults is an elective benefit under Medicaid. As a result of budget constraints, California Medicaid eliminated its comprehensive adult dental coverage in July 2009. We examined the impact of this policy change on emergency department (ED) visits by Medicaid-enrolled adults for dental problems in the period 2006-11. We found that the policy change led to a significant and immediate increase in dental ED use, amounting to more than 1,800 additional dental ED visits per year. Young adults, members of racial/ethnic minority groups, and urban residents were disproportionately affected by the policy change. Average yearly costs associated with dental ED visits increased by 68 percent. The California experience provides evidence that eliminating Medicaid adult dental benefits shifts dental care to costly EDs that do not provide definitive dental care. The population affected by the Medicaid adult dental coverage policy is increasing as many states expand their Medicaid programs under the ACA. Hence, such evidence is critical to inform decisions regarding adult dental coverage for existing Medicaid enrollees and expansion populations.

Iowa's Medicaid expansion includes the Healthy Behaviors Program (HBP), which incentivizes enrollees to receive a wellness exam and complete a health risk assessment annually to waive a monthly premium. We conducted a telephone survey with enrollees to examine their awareness and understanding of the HBP, and we then merged the survey data with claims data to examine factors associated with the completion of program requirements. As found in previous research, awareness of the HBP remains low, with approximately half of respondents unaware of the program or the premium requirement. Our results suggest that four years after the program was implemented, requirements are not being effectively communicated to enrollees. When designing and implementing such programs, policy makers should note that they are unlikely to succeed without consideration of how the program is structured and promoted. Limited program awareness is likely to result in low participation and consequences related to paying premiums or being disenrolled.

BACKGROUND:The Affordable Care Act allowed an optional Medicaid State Plan benefit for states to establish Health Homes coordinating care for people who have chronic conditions. Differences in medical home program incentives and implementation styles are important to understand in evaluating effects on key outcomes such as cost and acute care. In Iowa, a Medicaid Health Home (MHH) program was developed targeting Medicaid members with multiple chronic conditions. Provider patient management payments were tied to the number of chronic conditions of MHH members. OBJECTIVES:To assess the effects of an Iowa MHH program on total spending, emergency department (ED) utilization, and ED spending. DATA:Claims data from January 2011 through December 2013; per member per month unit of analysis. RESEARCH DESIGN:We use a difference-in-difference regression design comparing pre/post outcomes for MHH members to pre/post outcomes for Medicaid members not participating in the MHH. We include individual fixed effects and matched controls to minimize the potential for confounding. In addition, we include a series of administrative covariates to control for individual demographic and geographic variation. RESULTS:Participation in the MHH program reduced spending by $132 per member per month. There is also evidence that the largest cost savings occur with a lag, as those in the program longer than a year showed the most savings. Members were less likely to visit the ED compared with traditional Medicaid recipients and ED spending was also lower for MHH members. CONCLUSIONS:Participation in a MHH program led to fewer ED visits and lower overall spending among Medicaid recipients in Iowa.

Objectives. We examined the relationship between preventive well baby visits (WBVs) and the timing of first dental examinations for young Medicaid-enrolled children. Methods. The study focused on children born in 2000 and enrolled continuously in the Iowa Medicaid Program from birth to age 41 months (n = 6322). The main predictor variables were number and timing of WBVs. The outcome variable was timing of first dental examination. We used survival analysis to evaluate these relationships. Results. Children with more WBVs between ages 1 and 2 years and ages 2 and 3 years were 2.96 and 1.25 times as likely, respectively, to have earlier first dental examinations as children with fewer WBVs. The number of WBVs before age 1 year and the timing of the WBVs were not significantly related to the outcome. Conclusions. The number of WBVs from ages 1 to 3 years was significantly related to earlier first dental examinations, whereas the number of WBVs before age 1 year and the timing of WBVs were not. Future interventions and policies should actively promote first dental examinations by age 12 months at WBVs that take place during the first year of life.

To describe the impact of disenrollment from Medicaid because of failure to pay premiums as part of Iowa's Medicaid program's personal responsibility component. We conducted a mixed method study consisting of in-depth interviews with disenrolled members in 2016 and 2017 ( =72) and a survey of disenrolled members in 2017 ( =225). Many disenrollees did not know why they were disenrolled, were unaware of the personal responsibility component or premium requirement, and were confused by the disenrollment process. Disenrollment had negative effects including stress, financial burden, and engaging in behaviors such as skipping medication and postponing medical or dental care. Furthermore, disenrollees were often unable to enroll in health insurance, and for those who did, many reported it was a difficult process. Disenrollment had numerous, negative impacts on members who failed to pay their premiums. There was confusion about program requirements, which might indicate challenges communicating about a complicated program. Policymakers need to consider how to design and implement personal responsibility programs to achieve their desired outcome and reduce confusion and negative consequences.

BACKGROUNDRates for human papilloma virus (HPV) vaccination are low across the United States. Evidence-based-practices to increase immunization coverage have been recommended by public health organizations, yet many primary care clinics do not follow these practices. The purpose of this study was to examine if primary care clinics use these best practices to promote completion of the HPV vaccine series for their adolescent patients. Understanding the prevalence of evidence-based immunization strategies is key to increasing vaccination coverage. METHODSWe mailed 914 surveys to clinic managers of clinics that provide primary care in Iowa. The survey content was based on immunization strategies related to clinic practice and policies that have been proven effective to promote the completion of the HPV vaccination series. RESULTSSurvey responses from 127 clinics were used in the final analysis. Most clinics always used the stateʼs immunization information system to record HPV vaccinations (89.4%). Over a quarter of clinics (27.6%) did not use any type of reminder or recall system to alert parents or providers that an HPV vaccine was due, and 35.0% did not give the vaccine at sick visits. CONCLUSIONSClinics need to focus more on the recommended logistics and processes to ensure that patients receive the entire HPV vaccination series. Survey results indicate that clinics are not consistently implementing the recommended best practices to ensure that vaccination series are completed.