Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19.

Importance: Primary care (PC) receipt is associated with better health outcomes. How telehealth expansion and internet speed are associated with PC use is unclear.

Objective: To examine the association of telehealth and internet speed with PC use across sociodemographic determinants of health.

Nonclinical factors associated with the treatment of older women with newly diagnosed low-grade ductal carcinoma in situ.

Background: Ductal carcinoma in situ (DCIS) is the most common form of noninvasive breast cancer and is associated with an excellent prognosis. As a result, there is concern about overdiagnosis and overtreatment of DCIS because most patients with DCIS are treated as though they have invasive breast cancer and undergo either breast-conserving surgery (BCS)-most commonly followed by radiation therapy (RT)-or mastectomy. Little research to date has focused on nonclinical factors influencing treatments for DCIS.

Adherence to hormonal therapy after surgery among older women with ductal carcinoma in situ: Implications for breast cancer-related adverse health events.

Background: Evidence from randomized clinical trials (RCTs) shows that receipt of hormonal therapy after surgery for estrogen receptor-positive ductal carcinoma in situ (DCIS) reduces the risk of DCIS and contralateral invasive breast cancer (IBC) but not death from breast cancer. RCTs examined homogeneous samples, and therefore whether this evidence can be generalized to diverse populations is unclear.

Methods: Population-based data from four state cancer registries (California, New Jersey, New York, and Texas) were analyzed on women aged 65 years and older newly diagnosed with DCIS who underwent surgery with or without radiation during the years 2006-2013.

Health and Healthcare Access for Essential, Nonessential, and Nonworkers During the COVID-19 Pandemic.

Objective: The aim of the study is to describe sociodemographic characteristics, healthcare access, and health status of low-income essential, nonessential, and nonworkers during the COVID-19 pandemic.

Methods: Using survey data (2020-2021) from Wisconsin Medicaid enrollees ( N = 2528), we compared sociodemographics, healthcare access, and health status between essential, nonessential, and nonworkers.

Results: Essential workers had less consistent health insurance coverage and more problems paying medical bills than nonessential and nonworkers.

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost sharing reductions (CSRs) to low-income consumers on the Marketplaces. We link 2013-2015 All-Payer Claims Data to 2004-2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost sharing on medical spending among low-income individuals.

Trends in Medicaid Enrollment and Disenrollment During the Early Phase of the COVID-19 Pandemic in Wisconsin.

Importance: After the federal public health emergency was declared in March 2020, states could qualify for increased federal Medicaid funding if they agreed to maintenance of eligibility (MOE) provisions, including a continuous coverage provision. The implications of MOE provisions for total Medicaid enrollment are unknown.

Objective: To examine observed increases in Medicaid enrollment and identify the underlying roots of that growth during the first 7 months of the COVID-19 public health emergency in Wisconsin.

Vertical Integration Versus Physician Owners: Trends in Practice Structure Among Breast Cancer Surgeons.

Objective: The objective of this study was to document changes in physician practice structure among surgeons who treat women with breast cancer.

Design: We merged cancer registry records from 5 large states with Medicare Part B claims to identify each surgeon who treated women with breast cancer. We added information from SK&A surveys and extensive internet searches.

Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators.

Objective: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time.

Summary Background Data: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown.

Quantifying the competitiveness of the electronic health record market and its implications for interoperability.

Objective: The objective of this study was to quantify both the competitiveness of the EHR vendor market in the United States of America (US) and the degree of fragmentation of individual Medicare beneficiaries' medical records across the differing EHR vendors found in the US healthcare system.

Methods And Materials: We determined the Part A and Part B Medicare-expenditure weighted market shares of EHR vendors and estimated the rate of attestation of meaningful use (MU) for EHRs among Medicare Part A & B providers from 2011 to 2016. Based on these data we calculated the annual Herfindahl-Hirschman Index to quantify the competitiveness of the EHR market as well as the number of vendors individual Medicare beneficiaries' medical records were stored in for the period 2014-2016.

As Insurers Exit Affordable Care Act Marketplaces, So Do Consumers.

Insurer participation in the Marketplaces for individual health insurance has been lower than expected, with large declines among states using the HealthCare.gov platform for policy years 2017 and 2018. Using HealthCare.

Bariatric surgery among vulnerable populations: The effect of the Affordable Care Act's Medicaid expansion.

Background: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated.

Expansion coverage and preferential utilization of cancer surgery among racial and ethnic minorities and low-income groups.

Background: The Affordable Care Act Medicaid expansion demonstrated inconsistent effects on cancer surgery utilization rates among racial and ethnic minorities and low-income Americans. This quasi-experimental study examines whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid programs.

Methods: A cohort of more than 81,000 patients 18 to 64 years of age who underwent cancer surgery were examined in Medicaid expansion versus nonexpansion states.

Zero-Premium Health Insurance Plans Became More Prevalent In Federal Marketplaces In 2018.

The Affordable Care Act established two federally funded subsidies-cost-sharing reductions and premium tax credits-available in the health insurance Marketplaces. In 2018 federal payments to insurers for cost-sharing reductions were terminated. Insurers responded by increasing plan premiums to account for the loss of these payments.

Affordable Care Act's Medicaid Expansion and Use of Regionalized Surgery at High-Volume Hospitals.

Background: The Affordable Care Act (ACA)'s Medicaid expansion has increased access to surgical care overall. Whether it was associated with reduced disparities in use of regionalized surgery at high-volume hospitals (HVH) remains unknown. Quasi-experimental evaluations of this expansion were performed to examine the use of regionalized surgery at HVH among racial/ethnic minorities and low-income populations.

The Affordable Care Act's Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery.

Background: While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures.

Methods: The State Inpatient Database (2012-2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states.

How does expansion of public health insurance affect risk pools and premiums in the market for private health insurance? Evidence from Medicaid and the Affordable Care Act Marketplaces.

Private insurance market risk pools are likely to be directly affected by expansions of public insurance, in turn affecting premiums. We investigate the effects of Medicaid expansion on private health insurance markets using data on the plans offered through the health insurance "Marketplaces" (also known as Exchanges) established by the Affordable Care Act. We employ geographic matching to compare premiums for private plans in neighboring counties that straddle expansion and nonexpansion states and find that premiums of Marketplace plans are 11% lower in Medicaid expansion states, controlling for demographic and health characteristics as well as measures of health care access.

The well-being of long-term cancer survivors.

Objectives: To compare the well-being of long-term cancer survivors with that of US residents of similar age and demographic characteristics, patients recently diagnosed with cancer, and individuals with chronic illness.

Study Design: Retrospective observational study.

Methods: Using the Health and Retirement Study, a survey of US residents older than 50 years, we defined 4 cohorts: long-term cancer survivors (>4 years post diagnosis), individuals recently diagnosed with cancer (≤4 years post diagnosis), individuals with chronic illness, and US residents older than 50 years ("nationally representative cohort").

Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals.

Background: The Affordable Care Act's Medicaid expansion has been heavily debated due to skepticism about Medicaid's ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure.

Do individuals respond to cost-sharing subsidies in their selections of marketplace health insurance plans?

The Affordable Care Act (ACA) provides assistance to low-income consumers through both premium subsidies and cost-sharing reductions (CSRs). Low-income consumers' lack of health insurance literacy or information regarding CSRs may lead them to not take-up CSR benefits for which they are eligible. We use administrative data from 2014 to 2016 on roughly 22 million health insurance plan choices of low-income individuals enrolled in ACA Marketplace coverage to assess whether they behave in a manner consistent with being aware of the availability of CSRs.

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

Background: Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.

The financial burden and health care utilization patterns associated with amnestic mild cognitive impairment.

Introduction: Individuals with amnestic mild cognitive impairment (aMCI) are at elevated risk of developing Alzheimer's disease (AD) dementia.

Methods: With data from the Aging, Demographics, and Memory Study, we used the Clinical Dementia Rating Sum of Boxes classifications to conduct a cross-sectional analysis assessing the relationship between cognitive state and various direct and indirect costs and health care utilization patterns.

Results: Patients with aMCI had less medical expenditures than patients with moderate and severe AD dementia (P < .

Predicting high-need cases among new Medicaid enrollees.

Objectives: To assess the ability of a short, self-reported health needs assessment (HNA) collected at the time of Medicaid enrollment to predict subsequent utilization and costs.

Study Design: Retrospective cohort study.

Methods: We analyzed individual-level data that included self-reported HNAs, medical care encounter records, and administrative eligibility records for 34,087 childless adult Medicaid enrollees in Wisconsin, covering the period 2009-2010.

What fraction of Medicaid enrollees have private insurance coverage at the time of enrollment? Estimates from administrative data.

We use administrative data from Wisconsin to determine the fraction of new Medicaid enrollees who have private health insurance at the time of enrollment in the program. Through the linkage of several administrative data sources not previously used for research, we are able to observe coverage status directly for a large fraction of enrollees and indirectly for the remainder. We provide strict bounds for the percentages in each status and find that the percentage of new enrollees with private insurance coverage at the time of enrollment lies between 16 percent and 29 percent, and the percentage that dropped private coverage in favor of public insurance lies between 4 percent and 18 percent.

The effects of expanding public insurance to rural low-income childless adults.

Objective: This study measures the change in health care use after enrollment into a new public insurance program for low-income childless adults.

Data Sources/study Setting: The data sources include claims from a large integrated health system in rural Wisconsin and Medicaid enrollment files, January 2007-September 2012.

Study Design: We employ a regression discontinuity design to measure the causal effect of public insurance enrollment on counts of outpatient, emergency department, and inpatient events for 2 years following enrollment for a sample of previously uninsured low-income adults in rural Wisconsin.