Women’s Health and the Affordable Care Act: High Hopes Versus Harsh Realities?

Our population-based survey of 1078 randomly sampled US women, aged 18 to 55 years, sought to characterize their understanding of and attitudes toward the Affordable Care Act (ACA). Most women, especially socially disadvantaged groups, had negative or uncertain attitudes toward the ACA and limited understanding of its health benefits, including its relevance for their own health service coverage and utilization. Our findings are important for continued research, policy, and practice, with implications for whether, when, and how improved coverage will translate to improved access and outcomes for US women.Women’s health clinicians, researchers, and policymakers are hopeful that expanding health care coverage under the Patient Protection and Affordable Care Act (ACA)1 will improve the health of US women. By requiring coverage, increasing access to affordable health plans, incentivizing utilization of high-value services, establishing benefit mandates, and reducing cost sharing, the ACA is expected to improve health outcomes and reduce health disparities for women. Since ACA implementation began, however, it has become clear that the public’s participation in its programs and benefits is compromised by widespread confusion.2–6 Recognizing that the ACA can only have an impact on women’s health (individual and population) if women are aware of available benefits and act upon them,7–9 we conducted a study to examine women’s understanding of and attitudes toward the ACA. Specifically, we sought to determine (1) whether women were aware and approved of the ACA and the women’s health benefits attributable to it, (2) whether women expected their coverage of women’s health services and subsequent service utilization to change as a result of the ACA, and (3) whether women’s awareness and attitudes differed across sociodemographic groups.     

Primary care physicians’ perspective on financial issues and adult immunization in the Era of the Affordable Care Act

BackgroundFinancial barriers to adult vaccination are poorly understood. Our objectives were to assess among general internists (GIM) and family physicians (FP) shortly after Affordable Care Act (ACA) implementation: (1) proportion of adult patients deferring or refusing vaccines because of cost and frequency of physicians not recommending vaccines for financial reasons; (2) satisfaction with reimbursement for vaccine purchase and administration by payer type; (3) knowledge of Medicare coverage of vaccines; and (4) awareness of vaccine-specific provisions of the ACA.MethodsWe administered an Internet and mail survey from June to October 2013 to national networks of 438 GIMs and 401 FPs.ResultsResponse rates were 72% (317/438) for GIM and 59% (236/401) for FP. Among physicians who routinely recommended vaccines, up to 24% of GIM and 30% of FP reported adult patients defer or refuse certain vaccines for financial reasons most of the time. Physicians reported not recommending vaccines because they thought the patient’s insurance would not cover it (35%) or the patient could be vaccinated more affordably elsewhere (38%). Among physicians who saw patients with this insurance, dissatisfaction (‘very dissatisfied’) was highest for payments received from Medicaid (16% vaccine purchase, 14% vaccine administration) and Medicare Part B (11% vaccine purchase, 11% vaccine administration). Depending on the vaccine, 36–71% reported not knowing how Medicare covered the vaccine. Thirty-seven percent were ‘not at all aware’ and 19% were ‘a little aware’ of vaccine-specific provisions of the ACA.ConclusionsPatients are refusing and physicians are not recommending adult vaccinations for financial reasons. Increased knowledge of private and public insurance coverage for adult vaccinations might position physicians to be more likely to recommend vaccines and better enable them to refer patients to other vaccine providers when a particular vaccine or vaccines are not offered in the practice.     

Do Maternity Care Coordination Services Encourage Use of Behavioral Health Treatment among Pregnant Women on Medicaid?

ObjectiveMaternity care coordination (MCC) may provide an opportunity to enhance access to behavioral health treatment services. However, this relationship has not been examined extensively in the empirical literature. This study examines the effect of MCC on use of behavioral health services among perinatal women.MethodsMedicaid claims data from October 2008 to September 2010 were analyzed using linear fixed effects models to investigate the effects of receipt of MCC services on mental health and substance use–related service use among Medicaid-eligible pregnant and postpartum women in North Carolina (n = 7,406).ResultsReceipt of MCC is associated with a 20% relative increase in the contemporaneous use of any mental health treatment (within-person change in probability of any mental health visit 0.5% [95% CI, 0.1%–1.0%], or an increase from 8.3% to 8.8%); MCC in the prior month is associated with a 34% relative increase in the number of mental health visits among women who receive MCC (within-person change in the number of visits received 1.7% [95 CI, 0.2%–3.3%], or from 0.44 to 0.46 mental health visits). No relationship was observed between MCC and Medicaid-funded substance use–related treatment services.ConclusionsMCC may be an effective way to quickly address perinatal mental health needs and engage low-income women in mental health care. However, currently there may be a lost opportunity within MCC to increase access to substance use–related treatment. Future studies should examine how MCC improves access to mental health care such that the program's ability can be strengthened to identify women with substance use–related disorders and transition them into available care.     

Spillover Effects of the Affordable Care Act? Exploring the Impact on Young Adult Dental Insurance Coverage

ObjectivesTo assess whether the Affordable Care Act’s (ACA) dependent coverage health insurance mandate had a spillover impact on young adult dental insurance coverage and whether any observed effects varied by household income.DataMedical Expenditure Panel Surveys from 2006 through 2011.ResultsPrivate dental insurance increased by 6.7 percentage points among young adults compared to a control group of 27–30-year olds. Increases were concentrated at middle-income levels (125–400 percent FPL).ConclusionsThe dependent coverage mandate provision of the Affordable Care Act has not only increased health insurance rates among young adults but also dental insurance coverage rates.     

Healthcare Utilization After a Children’s Health Insurance Program Expansion in Oregon

Objective The future of the Children’s Health Insurance Program (CHIP) is uncertain after 2017. Survey-based research shows positive associations between CHIP expansions and children’s healthcare utilization. To build on this prior work, we used electronic health record (EHR) data to assess temporal patterns of healthcare utilization after Oregon’s 2009–2010 CHIP expansion. We hypothesized increased post-expansion utilization among children who gained public insurance. Methods Using EHR data from 154 Oregon community health centers, we conducted a retrospective cohort study of pediatric patients (2–18 years old) who gained public insurance coverage during the Oregon expansion (n = 3054), compared to those who were continuously publicly insured (n = 10,946) or continuously uninsured (n = 10,307) during the 2-year study period. We compared pre-post rates of primary care visits, well-child visits, and dental visits within- and between-groups. We also conducted longitudinal analysis of monthly visit rates, comparing the three insurance groups. Results After Oregon’s 2009–2010 CHIP expansions, newly insured patients’ utilization rates were more than double their pre-expansion rates [adjusted rate ratios (95 % confidence intervals); increases ranged from 2.10 (1.94–2.26) for primary care visits to 2.77 (2.56–2.99) for dental visits]. Utilization among the newly insured spiked shortly after coverage began, then leveled off, but remained higher than the uninsured group. Conclusions This study used EHR data to confirm that CHIP expansions are associated with increased utilization of essential pediatric primary and preventive care. These findings are timely to pending policy decisions that could impact children’s access to public health insurance in the United States.     

Why Uninsured Free Clinic Patients Don’t Apply for Affordable Care Act Health Insurance in a Non-expanding Medicaid State

Even after the introduction of the Patient Protection and Affordable Care Act (ACA), uninsured visits remain high, especially in states that opted out of Medicaid expansion. Since the ACA does not provide universal coverage, free clinics serve as safety nets for the un- or under-insured, and will likely continue serving underserved populations. The purpose of this study is to examine factors influencing intentions to not apply for health insurance via the ACA among uninsured free clinic patients in a state not expanding Medicaid. Uninsured primary care patients utilizing a free clinic (N = 551) completed a self-administered survey in May and June 2015. Difficulty obtaining information, lack of instruction to apply, and cost, are major factors influencing intention not to apply for health insurance through the ACA. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of perceived barriers to applying for health insurance through the ACA. Age is an important factor impacting individuals’ intentions not to apply for health insurance through the ACA, as older patients in particular need assistance to obtain relevant information about the ACA and other resources. A number of unchangeable factors limit the free clinics’ ability to promote enrollment of health insurance through the ACA. Yet free clinics could be able to provide some educational programs or the information of resources to patients. In particular, non-US born English speakers, Spanish speakers, and older adults need specific assistance to better understand health insurance options available to them.     

ONE Nano: NIEHS’s Strategic Initiative on the Health and Safety Effects of Engineered Nanomaterials

Background: The past decade has seen tremendous expansion in the production and application of engineered nanomaterials (ENMs). The unique properties that make ENMs useful in the marketplace also make their interactions with biological systems difficult to anticipate and critically important to explore. Currently, little is known about the health effects of human exposure to these materials.Objectives: As part of its role in supporting the National Nanotechnology Initiative, the National Institute of Environmental Health Sciences (NIEHS) has developed an integrated, strategic research program—“ONE Nano”—to increase our fundamental understanding of how ENMs interact with living systems, to develop predictive models for quantifying ENM exposure and assessing ENM health impacts, and to guide the design of second-generation ENMs to minimize adverse health effects.Discussion: The NIEHS’s research investments in ENM health and safety include extramural grants and grantee consortia, intramural research activities, and toxicological studies being conducted by the National Toxicology Program (NTP). These efforts have enhanced collaboration within the nanotechnology research community and produced toxicological profiles for selected ENMs, as well as improved methods and protocols for conducting in vitro and in vivo studies to assess ENM health effects.Conclusion: By drawing upon the strengths of the NIEHS’s intramural, extramural, and NTP programs and establishing productive partnerships with other institutes and agencies across the federal government, the NIEHS’s strategic ONE Nano program is working toward new advances to improve our understanding of the health impacts of engineered nanomaterials and support the goals of the National Nanotechnology Initiative.     

Medicaid Expansion’s Impact on Emergency Department Use by State and Payer

ObjectivesThe Affordable Care Act’s Medicaid Expansion Program influences healthcare use by increasing insurance coverage. Of particular interest is how this will affect inefficient and expensive emergency department (ED) visits. We estimated the impact of the Medicaid expansion on ED use by states and payer (Medicaid, private insurance, and uninsured) 5 years after the implementation of the Medicaid expansion and illustrated the use of the generalized synthetic control method.MethodsIn this quasi-experiment study, we implemented the generalized synthetic control method to compare states with Medicaid expansion and states without Medicaid expansion. Data were from the Healthcare Cost Utilization Project Fast Stats, which cover >95% of all ED visits. We included states with complete data from 2010 to 2018.ResultsOverall, the Medicaid expansion increased Medicaid share of ED visits (average treatment effect on the treated [ATT] 11.39%; 95% confidence interval [CI] 8.76-14.02) and decreased private share of ED visits (ATT ?5.80%; 95% CI ?7.40 to ?4.12) and uninsured share of ED visits (ATT ?6.66%; 95% CI ?9.78 to ?3.55).ConclusionsMedicaid Expansion Program shifted ED payer mix to Medicaid ED visits from private insurance and uninsured ED visits for adults at age of 19 to 64 years, whereas its effect on total ED volume is mixed among states. States that experienced the largest increase in Medicaid enrollment seem to experience an increase in ED visits although such results did not reach statistical significance.     

Health Promotion and Psychosocial Services and Women’s Assessments of Interpersonal Prenatal Care in Medicaid Managed Care

Objectives: If prenatal health promotion and psychosocial support services are to remain accessible to Medicaid eligible women, evidence is needed as to whether the services improve care and benefit women in ways that matter to health plans. The aims of this study are to determine whether prenatal health promotion and psychosocial services are associated with better interpersonal care and greater satisfaction with care; and whether the effects on interpersonal care help explain satisfaction with care. Research Design: A telephone survey of 363 African American, Latina (US and nonUS-born) and White women receiving prenatal care in four Medicaid public health plans in California in 2001. Multivariate regression analyses were done with adjustments for potentially confounding variables. Measures: Independent variables included dichotomous variables for health promotion advice (five separate areas) and composite scales for psychosocial assessment (six areas combined). Dependent variables included satisfaction with care, and indices for interpersonal care (communication, decision-making, and interpersonal style). Results: Women who report receiving health promotion or psychosocial services also report receiving better interpersonal care and rate their satisfaction with care higher. Receiving either type of support service is associated with higher quality communication, decision-making and interpersonal style. The effects of the support services on satisfaction are, in turn, explained by the effects on interpersonal care. Conclusions: Prenatal health promotion and psychosocial services have associated benefits to enrollees that should matter to Medicaid health plans and their providers.     

Exploring the Roles of Family Members in Women’s Decision to Use Postpartum Healthcare Services from the Perspectives of Women and Health Care Providers

Although the postpartum period is a significant time in a family’s life, few studies have addressed the lack of continuity of care and service use during the postpartum period. The aim of this study was to explore the roles of family members in Jordanian women’s decision to use postpartum health care services. An exploratory qualitative design was employed to elicit the perspectives of 24 women and 30 health care providers through six focus groups discussions conducted in April 2006. Interviews were transcribed verbatim, translated to English, and analyzed using an inductive content analysis approach. In our study, three roles of family members influencing Jordanian women’s decision to use postpartum health care services emerged: supporter role, opponent role, and active participant in care role. Findings supported the need for a family-centered approach when providing postpartum care to enhance positive family roles and limit negative ones to promote continuity of healthcare services use during the postpartum period.     

The Combined Effects of the Expansion of Primary Health Care and Conditional Cash Transfers on Infant Mortality in Brazil, 1998–2010

Objectives. I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil.Methods. I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest.Results. The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%.Conclusions. The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.Income inequality in Brazil is among the highest in the world, and major inequalities of health status across socioeconomic levels are pervasive despite improvements associated with an expansion in health and social programs since the late 1990s.1,2 In 1988, a newly drafted federal constitution mandated universal access to health care, leading to the creation of the Unified Health System. The main driver of the early implementation of the Unified Health System was expansion of primary health care, mainly through the Family Health Program (FHP) introduced in 1994. Currently, the FHP has 109.3 million registered users (57.3% of the Brazilian population). The program finances primary care services by teams of health professionals composed of physicians, nurses, technicians, and community health agents serving specific catchment areas. Previous studies have found evidence that, between 1990 and 2004, the FHP reduced levels of infant mortality, ambulatory care–sensitive hospitalization, and adult mortality.3–8In 2001, the federal government introduced conditional cash transfer (CCT) programs, which provide cash to poor families if they comply with regular school attendance and growth monitoring. In 2003 CCT programs were overhauled, and the Bolsa Familia Program (BFP) was created. Unlike its predecessors, the BFP included a specific health services utilization component: the program required younger children and their mothers to use preventive care services. The expansion of BFP coverage was very rapid; it included 11 million families by 2006 and peaked at 13 million in 2010.Currently, families enrolled in the BFP receive a monthly cash transfer, averaging US$75.25, and 92% of registered beneficiaries are women. The requirement for participation is uniform across the country and depends on household income per capita and the number and ages of family members. The maximum family income per capita for eligibility is US$70.25 per month. Studies have associated the expansion of the BFP with reduction in poverty and income inequality, positive nutritional outcomes in children, and improvements in school attendance.9,10 In other countries, similar programs are associated with the increased use of preventive services and improved anthropometric and nutritional outcomes.11–13Previous studies argue that the association between primary health care services on the supply side and CCT programs on the demand side should improve health outcomes.13,14 Low-income families are likely to experience stronger barriers to access to health care services; however, providing cash and requiring families to use preventive care will probably not improve health status if services are unavailable. Despite theoretical expectations, the relationship between the supply- and demand-side aspects of primary health care has not been sufficiently tested in the literature.Important decreases in infant mortality in Brazil and expansions of both the FHP and the BFP occurred between 1998 and 2010 (a figure illustrating this trend is available as a supplement to the online version of this article at http://www.ajph.org), but, to my knowledge, no study has examined whether these events are related. Recent official data state that infant mortality fell from 29.7 deaths per 1000 live births in 2000 to 15.6 deaths per 1000 live births in 2010. Most of this reduction is associated with improvements in postneonatal infant mortality (PNIM) rates (infants dying between ages 28 and 364 days), which is likely associated with primary care services.15Infant mortality is an interesting indicator because of the intrinsic importance of the concept it captures and because it correlates with medical care and socioeconomic development. The experience of Brazil provides a unique set of circumstances to test how enhanced access to medical services and expansion of poverty alleviation measures interact in the reduction of infant mortality.I examined the combined effects of community-based primary health care provided through the FHP and the CCTs the BFP provided for the reduction of the PNIM rate in Brazil from 1998 to 2010. I conducted a longitudinal ecological analysis of publicly available administrative data at the municipal level from 1998 to 2010.     

Mother-Perceived Social Capital and Children’s Oral Health and Use of Dental Care in the United States

Objectives. We examined the association between mother-perceived neighborhood social capital and oral health status and dental care use in US children.Methods. We analyzed data for 67 388 children whose mothers participated in the 2007 National Survey of Children’s Health. We measured mothers’ perceived social capital with a 4-item social capital index (SCI) that captures reciprocal help, support, and trust in the neighborhood. Dependent variables were mother-perceived ratings of their child’s oral health, unmet dental care needs, and lack of a previous-year preventive dental visit. We performed bivariate and multivariable logistic regression analyses for each outcome.Results. After we controlled for potential confounders, children of mothers with high (SCI = 5–7) and lower levels (SCI ≥ 8) of social capital were 15% (P = .05) and about 40% (P ≤ .02), respectively, more likely to forgo preventive dental visits than were children of mothers with the highest social capital (SCI = 4). Mothers with the lowest SCI were 79% more likely to report unmet dental care needs for their children than were mothers with highest SCI (P = .01).Conclusions. A better understanding of social capital’s effects on children’s oral health risks may help address oral health disparities.It is well established that children living in families with low income and low educational attainment have poorer oral health and access to dental care than children with more affluent and educated families.1,2 Previous research has rigorously described oral health disparities by sociodemographic characteristics of individuals over the years, but only more recently have investigations begun to study the influence of larger contextual, environmental, and societal factors on the population’s oral health.3–6As part of this broader interest in the social determinants of health, the social connections that people have within their communities are receiving growing interest in public health research. This interest is rooted, in part, in the potential for people’s social connections to reduce health inequities through the mobilization of resources in society to better facilitate access to horizontally and vertically available social capital. Furthermore, social capital in the neighborhood may be particularly important for children’s well-being because the neighborhood is usually a central context for children’s psychosocial development. Children learn many of their social skills and values from within their neighborhood social networks.7 Especially in the absence of different kinds of support for children within the family,8 adult intervention on behalf of children in the neighborhood could serve as an important buffer against stressors and social risk factors embedded in the context of children’s lives.Although there is no consensus definition or a standardized approach to measuring social capital, it usually is thought of as consisting of some aspect of social structure and actions of individuals embedded in that structure.7 In social cohesion theory, social capital is conceptualized as the collective resources, such as trust, norms, and reciprocity, available to members of social groups, usually defined by geographic locales.9,10 This “social cohesion” school of social capital has been criticized for overlooking some aspects of social capital such as differences in residents’ abilities to access social capital and its potential negative effects on health.9,11 Nevertheless, greater social capital, measured by various features of social organizations in the community, has been linked to lower mortality and morbidity as well as self-reported better health outcomes.12 The hypothesized mechanisms are that social capital can influence health through (1) the diffusion of knowledge about health promotion, (2) maintenance of healthy behavioral norms or prevention of deviant health-related behaviors through informal social control, (3) promotion of access to local services and amenities, and (4) psychosocial processes that provide effective support, build self-esteem, and foster mutual respect.13It has been reported in the dental literature that a greater number of churches in neighborhood clusters was associated with the reduced severity of dental caries among low-income African American preschool children residing in Detroit, Michigan.3 Bramlett et al. previously examined various child-, family-, and neighborhood-level factors available in the 2003 National Survey of Children’s Health (NSCH) along with state-level factors from a variety of surveillance and census databases to test a multilevel conceptual model of determinants of young children’s oral health.5 Factors related to neighborhood cohesiveness and physical safety were correlated with parent-rated oral health status in children aged 1 through 5 years.5 Lower neighborhood social capital and community empowerment opportunities were also linked to higher rates of dental injuries14 and more dental caries among Brazilian adolescents.15Hypothesized sociobehavioral mechanisms linking social capital to health, empirical evidence on the association of social capital and general health, and initial evidence on the association of social capital–related variables and oral health strongly support further study of its potential impact on children’s oral health. It is evident from the literature that maternal oral health status, knowledge, and self-efficacy have a significant influence on children’s oral health behaviors and outcomes.16–19 In addition, gender may affect one’s perception of neighborhood social capital, patterns, and levels of social engagement and community participation.20,21 Little is known, however, about how social capital is perceived by female caregivers of children and how it might influence their behaviors and their children’s oral health. The purposes of this study were, therefore, to (1) describe the distribution of perceived social capital, using population-based data of self-reported neighborhood social cohesion among US mothers of children younger than 18 years, and (2) determine the association between neighborhood social capital and children’s oral health status and use of dental care.     

Women’s Use of Health Care in the First 2 Years Postpartum: Occurrence and Correlates

Objectives We sought to determine rates and correlates of accessing health care in the 2 years following delivery among women at an urban academic medical center. Methods We used electronic medical records, discharge, and billing data to determine the occurrence of primary care, other non-primary outpatient care, emergency department visits, and inpatient admissions among women delivering at a single medical center who had a known primary care affiliation to that medical center over a 5 year period. We explored sociodemographic, clinical, and health care-related factors as correlates of care, using bivariate and multivariable modeling. Results Of 6216 women studied, most (91 %) had had at least one health care visit in the window between 2 months and 2 years postpartum (the “late postpartum period”). The majority (81 %) had had a primary care visit. Factors associated with use of health care in this period included a chronic medical condition diagnosed prior to pregnancy (adjusted odds ratio (AOR) 1.42, 95 % CI [1.19, 1.71]), prenatal care received in an urban community health center (AOR 1.35 [1.06, 1.73]), having received obstetric (AOR 1.90 [1.51, 2.37]), primary (AOR 2.30 [1.68, 3.23]), or other non-primary outpatient care (AOR 2.35 [1.72, 3.39]) in the first 2 months postpartum, and living closer to the hospital [AOR for residence >17.8 miles from the medical center (AOR 0.74 [0.61, 0.90])]. Having had an obstetrical complication did not increase the likelihood of receipt of care during this window. Conclusions for Practice Among women already enrolled in a primary care practice at our medical center, health care utilization in the late postpartum period is high, but not universal. Understanding the characteristics of women who return for health care during this window, and where they are seen, can improve transitions of care across the life course and can provide opportunities for important and consistent interconception and well-woman messaging.     

Language and Immigrant Status Effects on Disparities in Hispanic Children’s Health Status and Access to Health Care

The objective of this study is to estimate Hispanic/non-Hispanic (nH)-white health disparities and assess the extent to which disparities can be explained by immigrant status and household primary language. The 2007 National Survey of Children’s Health was funded by the Maternal and Child Health Bureau, and conducted by Centers for Disease Control and Prevention’s National Center for Health Statistics as a module of the State and Local Area Integrated Telephone Survey. We calculated disparities for various health indicators between Hispanic and nH-white children, and used logistic regression to adjust them for socio-economic and demographic characteristics, primary language spoken in the household, and the child’s immigrant status. Controlling for language and immigrant status greatly reduces health disparities, although it does not completely eliminate all disparities showing poorer outcomes for Hispanic children. English-speaking and nonimmigrant Hispanic children are more similar to nH-white children than are Hispanic children in non-English speaking households or immigrant children. Hispanic/nH-white health disparities among children are largely driven by that portion of the Hispanic population that is either newly-arrived to this country or does not speak primarily English in the household.