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Before the implementation of the Affordable Care Act (ACA), most children in low-income families were already eligible for public insurance through Medicaid or the Children's Health Insurance Program. Increased coverage observed for these children since the ACA's implementation suggest that the legislation potentially had important spillover or \"welcome mat\" effects on the number of eligible children enrolled. This study used data from the 2013-15 American Community survey to provide the first national-level (analytical) estimates of welcome-mat effects on children's coverage post ACA. We estimated that 710,000 low-income children gained coverage through these effects. The study was also the first to show a link between parents' eligibility for Medicaid and welcome-mat effects for their children under the ACA. Welcome-mat effects were largest among children whose parents gained Medicaid eligibility under the ACA expansion to adults. Public coverage for these children increased by 5.7 percentage points-more than double the 2.7-percentage-point increase observed among children whose parents were ineligible for Medicaid both pre and post ACA. Finally, we estimated that if all states had adopted the Medicaid expansion, an additional 200,000 low-income children would have gained coverage.

ABSTRACT BACKGROUND Because pregnancy complications, including gestational diabetes mellitus (GDM) and hypertensive disorders in pregnancy, are risk factors for diabetes and cardiovascular disease, post-delivery follow-up is recommended. OBJECTIVE To determine predictors of post-delivery primary and obstetric care utilization in women with and without medical complications. RESEARCH DESIGN Five-year retrospective cohort study using commercial and Medicaid insurance claims in Maryland. SUBJECTS 7,741 women with a complicated pregnancy (GDM, hypertensive disorders and pregestational diabetes mellitus [DM]) and 23,599 women with a comparison pregnancy. MEASURES We compared primary and postpartum obstetric care utilization rates in the 12 months after delivery between the complicated and comparison pregnancy groups. We conducted multivariate logistic regression to assess the association between pregnancy complications, sociodemographic predictor variables and utilization of care, stratified by insurance type. RESULTS Women with a complicated pregnancy were older at delivery ( p  < 0.001), with higher rates of cesarean delivery ( p  < 0.0001) and preterm labor or delivery ( p  < 0.0001). Among women with Medicaid, 56.6 % in the complicated group and 51.7 % in the comparison group attended a primary care visit. Statistically significant predictors of receiving a primary care visit included non-Black race, older age, preeclampsia or DM, and depression. Among women with commercial health insurance, 60.0 % in the complicated group and 49.5 % in the comparison group attended a primary care visit. Pregnancy complication did not predict a primary care visit among women with commercial insurance. CONCLUSIONS Women with pregnancy complications were more likely to attend primary care visits post-delivery compared to the comparison group, but overall visit rates were low. Although Medicaid expansion has potential to increase coverage, innovative models for preventive health services after delivery are needed to target women at higher risk for chronic disease development.

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users. Adapted from the source document.

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.

In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1 percent, decreased uninsured visits by 31.4 percent, and decreased privately insured visits by 6.7 percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3 percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume.

Background: The rapid increase in the prevalence of chronic pain and disability, and the explosion of interventional pain management associated health care costs are a major concern for our community. Further, the increasing utilization of numerous modalities of treatments in managing chronic pain, continue to escalate at a pace which may not be sustainable. There are multiple regulations in place to control the growth of health care expenditures which seem to have been largely ineffective. Among the various modalities utilized in managing chronic pain, interventional techniques have shown a significant increase in their utilization in the face of continued debate with respect to the accuracy of diagnostic interventions and the efficacy of therapeutic interventions. Objective: To update and assess the utilization of interventional techniques in chronic pain management in fee-for-service Medicare population. Study Design: An updated analysis of the growth of interventional techniques in managing chronic pain in fee-for-service Medicare beneficiaries from 2000 through 2013. Methods: The data were derived and analyzed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master Data from 2000 through 2013. Results: From 2000 through 2013, in fee-for-service Medicare beneficiaries, the overall utilization of interventional techniques services increased 236% at an annual average growth of 9.8%, whereas the per 100,000 Medicare population utilization increased 156% with an annual average growth of 7.5%. During this period, the US population increased 12% with an annual average increase of 0.9%, whereas those above 65 years of age increased 27% with an annual average increase of 1.9%. Total Medicare beneficiaries increased 31% with an annual average increase of 2.1%, with an overall increase of 64% for those above 65 years of age, an increase of 26%, constituting 17% of the US population in 2013. The overall increases in epidural and adhesiolysis procedures were 165% compared to 102% per 100,000 fee-for-service population with annual average increases of 7.8% and 5.6%. Facet joint and sacroiliac joint injections increased 417% for services with an annual average increase of 13.5%, whereas the rate per 100,000 fee-for-service Medicare beneficiaries increased 295% with an annual average increase of 11.1%. Limitations: Limitations of this assessment include the lack of inclusion of participants from Medicare Advantage plans, lack of appropriate available data for state-wide utilization, and potential errors in documentation, coding, and billing. Conclusion: This update once again shows a significant increase in interventional techniques in feefor-service Medicare beneficiaries from 2000 through 2013 with an increase of 156% per 100,000 Medicare population with an annual average increase of 7.5%. During this period the Medicare population increased 31% with an annual average increase of 2.1%. Key words: Chronic pain, chronic spinal pain, interventional pain management, interventional techniques, epidural injections, facet joint interventions, sacroiliac joint injections

Context: The Affordable Care Act provides new Medicaid coverage to an estimated 12 million low-income adults. Barriers to access or quality could hamper the program's success. One of these barriers might be the stigma associated with Medicaid or poverty. Methods: Our mixed-methods study involved 574 low-income adults and included data from an in-person survey and follow-up interviews. Our analysis of the interviews showed that many participants who were on Medicaid or uninsured described a perception or fear of being treated poorly in the health care setting. We defined this experience as stigma and merged our qualitative interviews coded for stigma with our quantitative survey data to see whether stigma was related to other sociodemographic characteristics. We also examined whether stigma was associated with access to care, quality of care, and self-reported health. Findings: We were unable to identify other sociodemographic characteristics associated with stigma in this low-income sample. The qualitative interviews suggested that stigma was most often the result of a provider-patient interaction that felt demeaning, rather than an internalized sense of shame related to receiving public insurance or charity care. An experience of stigma was associated with unmet health needs, poorer perceptions of quality of care, and worse health across several self-reported measures. Conclusions: Because a stigmatizing experience in the health system might interfere with the delivery of high-quality care to new Medicaid enrollees, further research and policy interventions that target stigma are warranted.

Recurrent hospitalizations represent a substantial and often preventable human and financial burden in the United States. In 2008 North Carolina initiated a statewide population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. In a study of patients hospitalized during 2010-11, we found that those who received transitional care were 20 percent less likely to experience a readmission during the subsequent year, compared to clinically similar patients who received usual care. Benefits of the intervention were greatest among patients with the highest readmission risk. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. This study suggests that locally embedded, targeted care coordination interventions can effectively reduce hospitalizations for high-risk populations. [PUBLICATION ABSTRACT]

The Affordable Care Act expands health insurance coverage to millions of Americans, but the availability of health care services for the newly insured population remains uncertain. The authors conducted a simulated patient (or \"secret shopper\") study to assess primary care appointment availability and wait times for new patients with Medicaid or private insurance before and after implementation of Michigan's Medicaid expansion in 2014. The expansion, which was made possible through a section 1115 waiver, has a unique requirement that new beneficiaries must be seen by a primary care provider within 60-90 days of enrollment. During a period of rapid coverage expansion in Michigan, they found that appointment availability increased 6 percentage points for new Medicaid patients and decreased 2 percentage points for new privately insured patients, compared to availability before the expansion. Wait times remained stable, at 1-2 weeks for both groups. Further research is needed to determine whether access to primary care for newly insured patients will endure over time.

This study examined differences by age in service use and associated expenditures during 2005 for Medicaid-enrolled children with autism spectrum disorders. Aging was associated with significantly higher use and costs for restrictive, institution-based care and lower use and costs for community-based therapeutic services. Total expenditures increased by 5 % with each year of age; by 23 % between 3–5 and 6–11 year olds, 23 % between 6–11 and 12–16, and 14 % between 12–16 and 17–20 year olds. Use of and expenditures for long-term care, psychiatric medications, case management, medication management, day treatment/partial hospitalization, and respite services increased with age; use of and expenditures for occupational/physical therapy, speech therapy, mental health services, diagnostic/assessment services, and family therapy declined.