A Foundation for Health Reform: Findings of a 50 State Survey 2009

Surveys state actions on Medicaid and Children's Health Insurance Plans and analyzes advances and setbacks in expanding coverage for low-income children and parents as well as disparities between the two groups. Discusses legislative and economic factors

Shaping Health Policy for Low-Income Populations: An Assessment of Public Comments in a New Medicaid Waiver Process

Since the Supreme Court decided that the Affordable Care Act\u27s (ACA) Medicaid expansion is optional for the states, several have obtained federal approval to use Section 1115 waivers to expand Medicaid while changing its coverage and benefits design. There has long been concern that policy making for Medicaid populations may lack meaningful engagement with low-income constituents, and therefore the ACA established a new process under which the public can submit comments on pending Medicaid waiver applications. We analyzed 291 comment letters submitted to federal regulators pertaining to Medicaid Section 1115 waiver applications in the first five states to seek such waivers: Arkansas, Indiana, Iowa, Michigan, and Pennsylvania. We found that individual citizens, including those who identified as Medicaid-eligible, submitted a sizable majority of the comment letters. Comment letters tended to mention controversial provisions of the waivers and reflected the competing political rhetoric of “personal responsibility” versus “vulnerable populations.” Despite the fact that the federal government seemed likely to approve the waiver applications, we found robust public engagement, reflecting the salience of the issue of Medicaid expansion under the ACA. Our findings are consistent with the argument that Medicaid is a program of growing centrality in US health politics

The role of policy in promoting women's health during pregnancy and postpartum

This dissertation research, presented in three manuscripts, uses a variety of quantitative methods to inform the role that policy can play to promote healthy behaviors to improve women’s health during and after pregnancy. The first manuscript assessed whether states’ adoption of an optional Medicaid enrollment policy known as the “Unborn Child” (UC) option was associated with an increase in prenatal insurance coverage or the receipt of adequate prenatal care. Adoption of the policy was associated with a 12 percentage-point increase in Medicaid enrollment during pregnancy, but was not significantly associated with an increased receipt of adequate prenatal care. The second manuscript took advantage of a natural experiment based on state variation in the timing of adoption of optional Medicaid enrollment policies to study the policies’ effects on prenatal cigarette smoking cessation and adverse birth outcomes. Presumptive eligibility, an optional enrollment policy that permits states to presume a pregnant woman to be eligible while her application is pending, led to a 7.7 percentage-point increase in prenatal smoking cessation. However, optional enrollment policies did not significantly affect adverse birth outcomes. The third manuscript employed propensity score matching methods to estimate the effect of breastfeeding on maternal weight loss in the 12 months postpartum. Exclusive breastfeeding for at least 3 months resulted in an increased weight loss of 3.2 pounds at 12 months postpartum; and led to a 6 percentage-point increase in the probability of returning to pre-pregnancy weight or body mass index category

Addressing health inequalities in the United States: Key data trends and policy action

Health inequalities, which have been well documented for decades, have recently become policy targets in the United States. This report summarizes current patterns and trends in health inequalities, commitments to reduce health inequalities, and progress made to eliminate health inequalities. Time trend data indicate improvements in health status and major risk factors but increases in morbidity, with black and lower-education individuals experiencing a disproportionate burden of disease. A common policy response has been priority setting in the form of national objectives or goals to address health inequalities. More research and better methods are needed to precisely measure relationships between stated policy goals and observed trends in health inequalities. Despite these challenges, the United States has made commitments to advancing research and policy to eliminate health inequalities. There remain considerable opportunities for local public health systems and practioners to develop innovative solutions to address the problem of health inequalities, particularly related to action steps, and for researchers to address knowledge gaps in the scientific literature related to the evaluation and measurement of progress aimed at addressing health inequalities

Employer Health Benefits 2008 Annual Survey

Presents annual survey data on the health plans employers offer, including plan types, providers, premiums, coverage, eligibility, enrollment patterns, employee cost-sharing, prescription drug benefits, retiree benefits, and employer opinions

Effect of tobacco control policies on perinatal and child health:a systematic review and meta-analysis

Background: Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health. Methods: We searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448. Findings: We identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (–3·77% [95% CI −6·37 to −1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (–9·83% [–16·62 to −3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (–3·45% [–4·64 to −2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (–18·48% [–32·79 to −4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias. Interpretation: Smoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world. Funding: Chief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC

Disparities in Access to Primary Care and Emergency Department Utilization in a Large Medicaid Program

Identifying and eliminating disparities are priorities for State Medicaid programs, especially in the context of increased enrollment through Medicaid expansion. We assessed racial, ethnic, regional, and managed care organization (MCO) differences, as well as time trends before and after Medicaid expansion, in primary care and emergency department (ED) utilization in a large Medicaid program. We performed a cross-sectional evaluation of data from Pennsylvania Medicaid from 2011-2015. Three primary care outcomes included: 1) adult access to primary care; 2) adolescent access to primary care; and 3) pediatric access to dental care. Our fourth outcome reflected ED utilization. We observed significant racial and regional disparities in access to primary care and ED utilization. In the context of Medicaid Expansion, adult primary care and ED utilization had wide racial disparities but were stable over time, while adolescent access to primary care worsened and pediatric access to dental care improved. Hispanic enrollees had higher primary care access compared with non-Hispanics. We additionally identified high and low-performing MCOs, and racial disparities within MCOs. In conclusion, disparity-reducing interventions should address region and MCO in addition to race, and should focus on post-Expansion trends. The state Medicaid program should consider these results in MCO recommendations and contracts

Project DREAM (Doula Research for Equitable Advances in Medicaid Pregnancy Health)

The research will assess both the implementation of doula programs in 6 diverse state Medicaid programs and will assess the extent to which doula care programs have a positive impact on Black and Black, Indigenous, and People of Color (BIPOC) birthing populations. This research will address doula care program decisions related to reimbursement levels, integration of doulas with managed care and healthcare systems, and certification processes required for Medicaid to reimburse for doula services. It will also address patient decision-making related to navigating the healthcare system to find the best quality of care and to maximize patient autonomy in healthcare during the postpartum period