Medicaid expansion and infant mortality, revisited: A difference-in-differences analysis.
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ABSTRACT: Objective
To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.Data sources
State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.Study design
The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.Principal findings
Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).Conclusions
Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.
SUBMITTER: Wiggins A
PROVIDER: S-EPMC7240769 | biostudies-literature |
REPOSITORIES: biostudies-literature
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| S-EPMC8128375 | biostudies-literature
Project description:ImportanceMedicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for nonelderly adults in the United States. However, its association with cardiovascular mortality is unclear.ObjectiveTo investigate the association of Medicaid expansion with cardiovascular mortality rates in middle-aged adults.Design, setting, and participantsThis study used a longitudinal, observational design, using a difference-in-differences approach with county-level data from counties in 48 states (excluding Massachusetts and Wisconsin) and Washington, DC, from 2010 to 2016. Adults aged 45 to 64 years were included. Data were analyzed from November 2018 to January 2019.ExposuresResidence in a Medicaid expansion state.Main outcomes and measuresDifference-in-differences of annual, age-adjusted cardiovascular mortality rates from before Medicaid expansion to after expansion.ResultsAs of 2016, 29 states and Washington, DC, had expanded Medicaid eligibility, while 19 states had not. Compared with counties in Medicaid nonexpansion states, counties in expansion states had a greater decrease in the percentage of uninsured residents at all income levels (mean [SD], 7.3% [3.2%] vs 5.6% [2.7%]; P < .001) and in low income strata (19.8% [5.5%] vs 13.5% [3.9%]; P < .001) between 2010 and 2016. Counties in expansion states had a smaller change in cardiovascular mortality rates after expansion (146.5 [95% CI, 132.4-160.7] to 146.4 [95% CI, 131.9-161.0] deaths per 100 000 residents per year) than counties in nonexpansion states did (176.3 [95% CI, 154.2-198.5] to 180.9 [95% CI, 158.0-203.8] deaths per 100 000 residents per year). After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 (95% CI, 1.8-6.9) fewer deaths per 100 000 residents per year from cardiovascular causes after Medicaid expansion than if they had followed the same trends as counties in nonexpansion states.Conclusions and relevanceCounties in states that expanded Medicaid had a significantly smaller increase in cardiovascular mortality rates among middle-aged adults after expansion compared with counties in states that did not expand Medicaid. These findings suggest that recent Medicaid expansion was associated with lower cardiovascular mortality in middle-aged adults and may be of consideration as further expansion of Medicaid is debated.
| S-EPMC6552110 | biostudies-literature
Project description:To examine whether rates of 30-day readmission after acute ischemic stroke changed differentially between Medicaid expansion and non-expansion states, and whether race/ethnicity moderated this change, we conducted a difference-in-differences analysis using 6 state inpatient databases (AR, FL, GA, MD, NM, and WA) from the Healthcare Cost and Utilization Project. Analysis included all patients aged 19-64 hospitalized in 2012-2015 with a principal diagnosis of ischemic stroke and a primary payer of Medicaid, self-pay, or no charge, who resided in the state where admitted and were discharged alive (N=28 330). No association was detected between Medicaid expansion and readmission overall, but there was evidence of moderation by race/ethnicity. The predicted probability of all-cause readmission among non-Hispanic White patients rose an estimated 2.6 percentage points (or 39%) in expansion states but not in non-expansion states, whereas it increased by 1.5 percentage points (or 23%) for non-White and Hispanic patients in non-expansion states. Therefore, Medicaid expansion was associated with a rise in readmission probability that was 4.0 percentage points higher for non-Hispanic Whites compared to other racial/ethnic groups, after adjustment for covariates. Similar trends were observed when unplanned and potentially preventable readmissions were isolated. Among low-income stroke survivors, we found evidence that 2 years of Medicaid expansion promoted rehospitalization, but only for White patients. Future studies should verify these findings over a longer follow-up period.
| S-EPMC8695744 | biostudies-literature
Project description:Importance:The Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined. Objective:To examine whether Medicaid expansion is associated with county?×?year counts of opioid overdose deaths overall and by class of opioid. Design, Setting, and Participants:This serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N?=?3109 counties ×?17 years?=?52?853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019. Exposures:The primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility. Main Outcomes and Measures:The outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs. Results:There were 383?091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08). Conclusions and Relevance:Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.
| S-EPMC6991255 | biostudies-literature
Project description:ImportanceMedicaid expansion under the Patient Protection and Affordable Care Act may be associated with increased screening and may improve access to earlier treatment for cancer, but its association with mortality for patients with cancer is uncertain.ObjectiveTo determine whether Medicaid expansion is associated with improved mortality among patients with cancer.Design, setting, and participantsThis is a quasi-experimental, difference-in-difference (DID), cross-sectional, population-based study. Patients in the National Cancer Database with breast, lung, or colorectal cancer newly diagnosed from January 1, 2012, to December 31, 2015, were included. Data analysis was performed from January to May 2020.ExposureLiving in a state where Medicaid was expanded vs a nonexpansion state.Main outcomes and measuresThe main outcome was mortality rate according to whether the patient lived in a state where Medicaid was expanded.ResultsA total of 523 802 patients (385 739 women [73.6%]; mean [SD] age, 54.8 [6.5] years) had a new diagnosis of invasive breast (273 272 patients [52.2%]), colorectal (111 720 patients [21.3%]), or lung (138 810 patients [26.5%]) cancer; 289 330 patients (55.2%) lived in Medicaid expansion states, and 234 472 patients (44.8%) lived in nonexpansion states. After Medicaid expansion, mortality significantly decreased in expansion states (hazard ratio [HR], 0.98; 95% CI, 0.97-0.99; P = .008) but not in nonexpansion states (HR, 1.01; 95% CI, 0.99-1.02; P = .43), resulting in a significant DID (HR, 1.03; 95% CI, 1.01-1.05; P = .01). This difference was seen primarily in patients with nonmetastatic cancer (stages I-III). After adjusting for cancer stage, the mortality improvement in expansion states from the periods before and after expansion was no longer evident (HR, 1.00; 95% CI, 0.98-1.02; P = .94), nor was the difference between expansion vs nonexpansion states (DID HR, 1.00; 95% CI, 0.98-1.02; P = .84).Conclusions and relevanceAmong patients with newly diagnosed breast, colorectal, and lung cancer, Medicaid expansion was associated with a decreased hazard of mortality in the postexpansion period, which was mediated by earlier stage of diagnosis.
| S-EPMC7645694 | biostudies-literature
Project description:Background and objectiveDue to conflicting results in multiple studies, uncertainty remains regarding sex differences in severity and mortality after intracerebral hemorrhage (ICH). We investigated the impact of sex on ICH severity, expansion, and mortality.MethodsWe analyzed prospectively collected ICH patients and assessed clinical variables and mortality rate. Mediation analyses were used to examine associations between sex and mortality and sex and hematoma expansion.Results2212 patients were investigated, 53.5% male. Men with ICH were younger (72 vs. 77years), had greater smoking and alcohol use, and were more likely to have hypertension, diabetes, hypercholesterolemia and coronary artery disease (all p<0.05). Lobar hemorrhages were more frequent in women (47.6% vs 38.4%, p<0.001). Male sex was a risk factor for hematoma expansion (Odd Ratio (OR) 1.7, 95% confidence interval (CI) 1.15-2.50, p=0.007). Multivariable analysis found that male sex was independently associated with 90-day mortality (OR 2.15 (95% CI 1.46-3.19), p<0.001), and one-year mortality (Hazard Ratio 1.28 (95% CI: 1.09-1.50), p=0.003). Early hematoma expansion mediated a portion of the association between sex and mortality (mediation p=0.02).ConclusionsMen with ICH experience a higher risk of both expansion and early and late mortality, even after controlling for known risk factors. Further research is needed to explore the biological mechanisms underlying these observed differences.
| S-EPMC5538146 | biostudies-literature
Project description:OBJECTIVE:To assess the effect of the 2014 Medicaid expansion on Medicaid managed care plan quality. DATA SOURCES:Three composite measures of plan-level quality constructed from the Health Care Effectiveness Data and Information Set. STUDY SETTING:One hundred and sixty-three plans in 27 Medicaid expansion states and 100 plans in 14 nonexpansion states. STUDY DESIGN:Quasi-experimental difference-in-differences (DID) analysis, comparing quality before (2011-13) and after (2014-15) Medicaid expansion in states that elected to expand Medicaid eligibility and those that did not. PRINCIPAL FINDINGS:Mean plan enrollment increased from 130,533 to 274,259 in expansion states and from 105,449 to 148,194 in nonexpansion states. The proportion of enrollees receiving recommended preventive care increased from 62.6 to 65.2 percent in expansion states and from 59.3 to 62.5 percent in nonexpansion states (adjusted DID: -0.7 percentage points [95% CI -2.2, 0.7]). The proportion of enrollees receiving recommended chronic disease care management increased from 65.4 to 66.0 percent in expansion states and from 62.5 to 63.1 percent in nonexpansion states (adjusted DID: 1.1 percentage points [95% CI -0.5, 2.6]). We observed similar patterns for the receipt of recommended maternity care. CONCLUSIONS:Medicaid expansion increased enrollment in managed care plans, but it did not result in erosion of quality.
| S-EPMC6056574 | biostudies-other
Project description:BACKGROUND:There is interest in assessing health care utilization and expenditures among new Medicaid enrollees after the 2014 Medicaid expansion. Recent studies have not differentiated between newly enrolled individuals and those returning after coverage gaps. OBJECTIVES:To assess health care expenditures among Medicaid enrollees in the 24 months after Oregon's 2014 Medicaid expansions and examine whether expenditure patterns were different among the newly, returning, and continuously insured (CI). RESEARCH DESIGN:Retrospective cohort study using inverse-propensity weights to adjust for differences between groups. SUBJECTS:Oregon adult Medicaid beneficiaries insured continuously from 2014 to 2015 who were either newly, returning, or CI. MEASURES:Monthly expenditures for inpatient care, prescription drugs, total outpatient care, and subdivisions of outpatient care: emergency department, dental, mental and behavioral health, primary care, and specialist care. RESULTS:After initial increases, newly and returning insured (RI) outpatient expenditures dropped below CI. Expenditures for emergency department and dental services among the RI remained higher than among the newly insured. Newly insured mental and behavioral health, primary care, and specialist expenditures plateaued higher than RI. Prescription drug expenditures increased over time for all groups, with CI highest and RI lowest. All groups had similar inpatient expenditures over 24 months post-Medicaid expansion. CONCLUSIONS:Our findings reveal that outpatient expenditures for new nonpregnant, non-dual-eligible Oregon Medicaid recipients stabilized over time after meeting pent-up demand, and prior insurance history affected the mix of services that individuals received. Policy evaluations should consider expenditures over at least 24 months and should account for enrollees' prior insurance histories.
| S-EPMC5893375 | biostudies-literature
Project description:Objectives: To investigate the association of state-level Medicaid expansion and non-elderly mortality rates from 1999 to 2018 in Northeastern urban settings. Methods: This quasi-experimental study utilized a synthetic control method to assess the association of Medicaid expansion on non-elderly urban mortality rates [1999-2018]. Counties encompassing the largest cities in the Northeastern Megalopolis (Washington D.C., Baltimore, Philadelphia, New York City, and Boston) were selected as treatment units (n = 5 cities, 3,543,302 individuals in 2018). Cities in states without Medicaid expansion were utilized as control units (n = 17 cities, 12,713,768 individuals in 2018). Results: Across all cities, there was a significant reduction in the neoplasm (Population-Adjusted Average Treatment Effect = -1.37 [95% CI -2.73, -0.42]) and all-cause (Population-Adjusted Average Treatment Effect = -2.57 [95%CI -8.46, -0.58]) mortality rate. Washington D.C. encountered the largest reductions in mortality (Average Treatment Effect on All-Cause Medical Mortality = -5.40 monthly deaths per 100,000 individuals [95% CI -12.50, -3.34], -18.84% [95% CI -43.64%, -11.67%] reduction, p = < 0.001; Average Treatment Effect on Neoplasm Mortality = -1.95 monthly deaths per 100,000 individuals [95% CI -3.04, -0.98], -21.88% [95% CI -34.10%, -10.99%] reduction, p = 0.002). Reductions in all-cause medical mortality and neoplasm mortality rates were similarly observed in other cities. Conclusion: Significant reductions in urban mortality rates were associated with Medicaid expansion. Our study suggests that Medicaid expansion saved lives in the observed urban settings.
| S-EPMC8637894 | biostudies-literature
Project description:Importance:The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. Objective:To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. Design, Setting, and Participants:Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. Exposure:Living in a Medicaid expansion state. Main Outcomes and Measures:The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. Results:A total of 142?724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93?522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. Conclusions and Relevance:Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.
| S-EPMC6417808 | biostudies-literature