Do non-citizens migrate for welfare benefits? Evidence from the Affordable Care Act Medicaid expansion.
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ABSTRACT:
SUBMITTER: Guo H
PROVIDER: S-EPMC9562776 | biostudies-literature | 2022
REPOSITORIES: biostudies-literature
Publications
Do non-citizens migrate for welfare benefits? Evidence from the Affordable Care Act Medicaid expansion.
Frontiers in public health 20220930
We explore if low-educated noncitizens, who have a considerably high uninsured rate, internally migrate to states with more generous public insurance benefits. We utilize the state-level variation in accessing Medicaid benefits and employ a difference-in-differences methodology that compares in-migration and out-migration rates of non-citizens in states that adopted Medicaid expansion, both before and after the policy implementation, to the outcomes of non-citizens in states that did not adopt t ...[more]
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Project description:IntroductionCommunity health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states.MethodsUsing electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ≥6 visits within the post-expansion period among patients in expansion versus non-expansion states.ResultsPatients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28-1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44-1.62), and having ≥6 follow-up visits (aOR = 1.34, 95% CI: 1.28-1.41) compared to patients from non-expansion states.ConclusionsIncreased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population.ImplicationsCHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs.
| S-EPMC7249916 | biostudies-literature
Project description:BackgroundColorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening.Design, setting, and participantsThis cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods.Main outcomes and measuresThe primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64.ResultsMedicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries.ConclusionsMedicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.
| S-EPMC11002632 | biostudies-literature
Project description:ImportanceDental coverage for adults is a state option in Medicaid, and despite significant gains in coverage after the Medicaid expansion under the Affordable Care Act (ACA), dental outcomes among adults in expansion states remain unexplored.ObjectiveTo explore the association of state coverage of dental benefits through Medicaid expansion with clinical dental outcomes.Design, setting, and participantsThis cross-sectional study analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2018. Included participants were low-income adults aged 19 to 64 years with income up to 138% of the federal poverty level. The study used a difference-in-differences analysis to compare changes from before to after ACA expansion in expansion states vs in control states. Changes were examined in the full sample and separately in states that did and did not provide Medicaid adult dental benefits. We defined a state as providing Medicaid adult dental benefits if it covered services beyond emergency dental benefits in 2014. Data were analyzed from November 2020 to March 2021.ExposuresMedicaid expansion under the ACA.Main outcomes and measuresRates of health coverage, having a dental visit, affordability of dental care in the past year, poor oral health, and teeth flossing were obtained from self-reported data. Mean number of missing teeth and prevalence of untreated decayed teeth, filled teeth, and functional dentition were obtained from clinical examination data.ResultsAmong 7637 low-income adults, the mean (SD) age was 37.8 (13.4) years and 4153 (weighted percentage, 54.5 %) were women. At baseline, 1732 low-income adults in nonexpansion states compared with 2520 low-income adults in expansion states were more likely, as shown by weighted percentage, to be Black (473 individuals [21.0%] vs 508 individuals [15.1%]) and US born (1281 individuals [76.7%] vs 1613 individuals [69.6%]). In the full sample, Medicaid expansion, compared with nonexpansion, was associated with an increased rate of seeing a dentist in the prior year (12.4 percentage points; 95% CI 4.6 to 20.2 percentage points; P = .003). In expansion states that provided dental benefits, compared with nonexpansion states that provided dental benefits, the expansion was associated with increases in rates of Medicaid coverage (8.2 percentage points; 95%CI 0.5 to 15.8 percentage points; P = .04) and having seen a dentist in the previous year (11.4 percentage points, 95% CI, 3.7 to 19.1 percentage points; P = .006) and decreases in the uninsured rate (-12.6 percentage points, 95% CI -18.9 to -6.4 percentage points; P < .001) and prevalence of untreated decayed teeth (-16.8 percentage points; 95% CI, -25.5 to -8.0 percentage points; P = .001). In states without Medicaid dental benefits, the expansion was associated with an increase in the mean number of missing teeth (1.3 teeth; 95% CI 0.1 to 2.5 percentage points; P = .04) and a decrease in the prevalence of functional dentition (-8.7 percentage points; 95% CI, -14.1 to -3.3 percentage points; P = .003) compared with nonexpansion states.Conclusions and relevanceThis study found that the combination of Medicaid expansion and coverage of Medicaid dental benefits was associated with improved oral health among low-income adults.
| S-EPMC8485174 | biostudies-literature
Project description:BackgroundThe Affordable Care Act's Medicaid expansions (ME) increased insurance coverage for low-income Americans, among whom unmet need for mental health care is high. Empirical evidence regarding the impact of expanding insurance coverage on use of mental health services among low income and minority populations is lacking.MethodsData on mental health service use collected between 2007 and 2015 by the Medical Expenditures Panel Survey from nationally representative cross-sectional samples of low income (income<138% of the federal poverty line) adults were analyzed. Use trends among people in states that expanded Medicaid (ME states; n=29,827) were compared with concurrent trends among people in states that did not (non-ME states; n=22,873), with statistical adjustment for demographic characteristics and psychological distress.ResultsAnnual outpatient visits for mental health conditions increased by 0.513 (0.053-0.974) visits per person, from a baseline rate in ME states of 0.894 visits per person. However, no significant changes were observed in number of mental health related hospital stays, emergency department visits or prescription fills. The increase outpatient visits was limited to Hispanics and non-Hispanic Whites, with no increase in service use observed among non-Hispanic Blacks. There was no apparent increase in the number of users of outpatient mental health care (AOR=0.992, P=0.942) and a marginally significant (P=0.096) increase of 3.144 visits per user.DiscussionME had a limited but positive impact on use of mental health services by low income Americans, although it may also have increased racial/ethnic disparities.
| S-EPMC7483910 | biostudies-literature
Project description:The Affordable Care Act (ACA) established a minimum standard of insurance benefits for addiction treatment and expanded federal parity regulations to selected Medicaid benefit plans, which required state Medicaid programs to make changes to their addiction treatment benefits. We surveyed Medicaid programs in all fifty states and the District of Columbia regarding their addiction treatment benefits and utilization controls in standard and alternative benefit plans in 2014 and 2017, when plans were subject to ACA parity requirements. The number of state plans that provided benefits for residential treatment and opioid use disorder medications increased substantially. States imposing annual service limits on outpatient addiction treatment decreased by over 50 percent. Fewer states required preauthorization for services, with the largest reductions for medications treating opioid use disorder. The ACA may have prompted state Medicaid programs to expand addiction treatment benefits and reduce utilization controls in alternative benefit plans. This trend was also observed among standard Medicaid plans not subject to ACA parity laws, which suggests a potential spillover effect.
| S-EPMC6501794 | biostudies-literature
Project description:Background & methodsNational protests in the summer of 2020 drew attention to the significant presence of police in marginalized communities. Recent social movements have called for substantial police reforms, including "defunding the police," a phrase originating from a larger, historical abolition movement advocating that public investments be redirected away from the criminal justice system and into social services and health care. Although research has demonstrated the expansive role of police to respond a broad range of social problems and health emergencies, existing research has yet to fully explore the capacity for health insurance policy to influence rates of arrest in the population. To fill this gap, we examine the potential effect of Medicaid expansion under the Affordable Care Act (ACA) on arrests in 3,035 U.S. counties. We compare county-level arrests using FBI Uniform Crime Reporting (UCR) Program Data before and after Medicaid expansion in 2014-2016, relative to counties in non-expansion states. We use difference-in-differences (DID) models to estimate the change in arrests following Medicaid expansion for overall arrests, and violent, drug, and low-level arrests.ResultsPolice arrests significantly declined following the expansion of Medicaid under the ACA. Medicaid expansion produced a 20-32% negative difference in overall arrests rates in the first three years. We observe the largest negative differences for drug arrests: we find a 25-41% negative difference in drug arrests in the three years following Medicaid expansion, compared to non-expansion counties. We observe a 19-29% negative difference in arrests for violence in the three years after Medicaid expansion, and a decrease in low-level arrests between 24-28% in expansion counties compared to non-expansion counties. Our main results for drug arrests are robust to multiple sensitivity analyses, including a state-level model.ConclusionsEvidence in this paper suggests that expanded Medicaid insurance reduced police arrests, particularly drug-related arrests. Combined with research showing the harmful health consequences of chronic policing in disadvantaged communities, greater insurance coverage creates new avenues for individuals to seek care, receive treatment, and avoid criminalization. As police reform is high on the agenda at the local, state, and federal level, our paper supports the perspective that broad health policy reforms can meaningfully reduce contact with the criminal justice system under historic conditions of mass criminalization.
| S-EPMC8754343 | biostudies-literature
Project description:IntroductionThis study sought to empirically evaluate whether the Medicaid expansion under the Affordable Care Act increased smoking cessation among low-income childless adult smokers.MethodsThe effects of the Medicaid expansion on smoking quit attempts and the probability of 30- and 90-day smoking cessation were evaluated using logistic regression and data from the 2010-2011 and 2014-2015 waves of the Tobacco Use Supplement to the Current Population Survey. Using boosted logistic regression, the Tobacco Use Supplement was restricted to an analytic sample composed of childless adults with high probability of being <138% of the federal poverty level. Propensity score weighting was used to compare changes in smoking cessation among a sample of current and past smokers in states that expanded Medicaid with a control sample of current and past smokers in states that did not expand Medicaid with similar sociodemographic characteristics and smoking histories. This study additionally controlled for state socioeconomic trends, welfare policies, and tobacco control policies. Analysis was conducted between January 2018 and June 2019.ResultsAfter weighting by propensity score and adjusting for state socioeconomic trends, welfare policies, and tobacco control policies, the Medicaid expansion was not associated with increases in smoking quit attempts or smoking cessation.ConclusionsThe Medicaid expansion did not appear to improve smoking cessation, despite extending health insurance eligibility to 2.3 million low-income smokers. Greater commitments to reducing barriers to cessation benefits and increasing smoking cessation in state Medicaid programs are needed to reduce smoking in low-income populations.
| S-EPMC6924922 | biostudies-literature
Project description:Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.
| S-EPMC6578572 | biostudies-literature
Project description:BackgroundThe utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) increased after Medicaid expansion under the U.S. Affordable Care Act (ACA), suggesting a potential unmet need for THA and TKA. We examined the timing of THA and TKA in patients after obtaining Medicaid expansion insurance coverage. We hypothesized that patients with Medicaid expansion insurance would undergo a surgical procedure sooner than patients in traditional Medicaid populations.MethodsWe used administrative data from a Medicaid managed care company to determine the timing of primary THA and TKA in patients who were 18 to 64 years of age in 4 states with Medicaid expansion (Illinois, Ohio, Oregon, and Washington) and 4 states without Medicaid expansion (Louisiana, Mississippi, Texas, and Wisconsin) from 2008 to 2015. The insurance types were Medicaid expansion, Medicaid plans for Supplemental Security Income (SSI), or Temporary Assistance for Needy Families (TANF). Roughly, these 3 groups correspond to relatively healthy childless adults, relatively unhealthy disabled adults, and parents of children with Medicaid insurance. The main outcome measure was time from enrollment to the surgical procedure. The primary exposure of interest was insurance type. We used a generalized linear regression model to adjust for patient age, sex, social deprivation, surgeon supply and reimbursement, and state-level Medicaid enrollment.ResultsIn the unadjusted analysis of 4,117 patients, there was a significantly shorter time from enrollment to THA and TKA for the expansion group (median, 7.5 months) relative to the SSI group (median, 16.1 months; p < 0.0001) and the TANF group (median, 12.2 months; p < 0.0001). In the adjusted analysis, the time from enrollment to THA and TKA was significantly shorter in the expansion group (β, -1.21 [95% confidence interval (CI), -1.35 to -1.07]; p < 0.001) compared with the TANF group (β, -0.27 [95% CI, -0.38 to -0.17]; p < 0.001) and the SSI group (reference). Compared with the SSI group, these coefficients are equivalent to a 70% shorter time to the surgical procedure in the expansion group and a 24% shorter time to the surgical procedure in the TANF group.ConclusionsOur findings suggest an unmet need for THA and TKA among newly enrolled Medicaid expansion beneficiaries. This need should be considered by surgeons, hospitals, and policymakers in ensuring access to care. Furthermore, consideration should be given to existing insurance-based disparities in access to orthopaedic care, as these may be exacerbated by an increased demand for THA and TKA from Medicaid expansion beneficiaries.
| S-EPMC8313181 | biostudies-literature
Project description:ImportanceMedicaid expansion under the Patient Protection and Affordable Care Act is associated with gains in health insurance coverage, earlier stage diagnosis, and improved survival among patients with cancer.ObjectiveTo examine the association of Medicaid expansion with changes in early mortality among adults undergoing surgical resection of non-small cell lung cancer (NSCLC), a setting in which access to care is a major determinant of survival.Design, setting, and participantsThis cohort study used the National Cancer Database to identify 14 984 adults 45 to 64 years of age who underwent surgical resection of NSCLC between 2008 and 2019. Analysis was conducted between March 28, 2021, and September 1, 2023.ExposureState of residence Medicaid expansion status.Main outcomes and measuresDescriptive statistics were used to compare study population characteristics by Medicaid expansion status of patients' state of residence. Difference-in-differences analyses were used to evaluate the association between Medicaid expansion and postoperative mortality before implementation of the ACA (2008-2013) vs after (2014-2019).ResultsAmong 14 984 adults included, the mean (SD) age was 56.3 (5.1) years, 54.6% were women, and 62.1% lived in Medicaid expansion states. Both 30-day (from 0.97% to 0.26%) and 90-day (from 2.63% to 1.32%) postoperative mortality decreased from before the ACA to after among patients residing in Medicaid expansion states (both P < .001) but not in nonexpansion states (30-day mortality before the ACA, 0.75% vs after the ACA, 0.68%; P = .74; and 90-day mortality before the ACA, 2.43% vs after the ACA, 2.20%; P = .57), leading to a difference-in-differences of -0.64 percentage points (95% CI, -1.19 to -0.08; P = .03) for 30-day mortality and -1.08 percentage points (95% CI, -2.08 to -0.08; P = .03) for 90-day mortality. The difference-in-differences for in-hospital mortality was not significant (P = .34) between expansion states (1.41% before the ACA to 0.77% after the ACA; 0.63 percentage point decrease; P = .004) and nonexpansion states (1.49% before the ACA to 1.20% after the ACA; 0.30 percentage point decrease; P = .29).Conclusions and relevanceIn this cohort study of patients with NSCLC, Medicaid expansion was associated with declines in 30- and 90-day postoperative mortality following hospital discharge. These findings suggest that Medicaid expansion may be an effective strategy for improving access to care and cancer outcomes in this population.
| S-EPMC10787311 | biostudies-literature