The Impact of Medicaid Expansions on Nonprofit Hospitals

The 2010 Affordable Care Act expanded Medicaid eligibility to states’ residents with incomes below the federal poverty line, creating both opportunities and challenges to hospitals in states that adopted the new Medicaid eligibility. This article explores the effect of Medicaid expansions on nonprofit hospitals. Using data from Internal Revenue Service and a difference-in-differences design, this article examines the impact of the expansions on the number of, contributions to, and profitability of nonprofit hospitals. The results suggest that Medicaid expansions did not affect the number and profitability of nonprofit hospitals; however, the expansions were associated with a reduction in contributions to certain types of hospitals by around 23%. Therefore, the effects of policy changes vary by the type of nonprofit hospitals, which then need to find better strategies to cope with these changes.

Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic

Background Cross-sectional studies have found that the coronavirus disease 2019 (COVID-19) pandemic has negatively affected population-level mental health. Longitudinal studies are necessary to examine trajectories of change in mental health over time and identify sociodemographic groups at risk for persistent distress. Purpose To examine the trajectories of mental distress between March 10 and August 4, 2020, a key period during the COVID-19 pandemic. Methods Participants included 6,901 adults from the nationally representative Understanding America Study, surveyed at baseline between March 10 and 31, 2020, with nine follow-up assessments between April 1 and August 4, 2020. Mixed-effects logistic regression was used to examine the association between date and self-reported mental distress (measured with the four-item Patient Health Questionnaire) among U.S. adults overall and among sociodemographic subgroups defined by sex, age, race/ethnicity, household structure, federal poverty line, and census region. Results Compared to March 11, the odds of mental distress among U.S. adults overall were 1.84 (95% confidence interval [CI] = 1.65–2.07) times higher on April 1 and 1.92 (95% CI = 1.62–2.28) times higher on May 1; by August 1, the odds of mental distress had returned to levels comparable to March 11 (odds ratio [OR] = 0.80, 95% CI = 0.66–0.96). Females experienced a sharper increase in mental distress between March and May compared to males (females: OR = 2.29, 95% CI = 1.85–2.82; males: OR = 1.53, 95% CI = 1.15–2.02). Conclusions These findings highlight the trajectory of mental health symptoms during an unprecedented pandemic, including the identification of populations at risk for sustained mental distress.

Longitudinal Trends and Predictors of Medicaid Utilization Among Middle-Aged and Older Adults

Over fifteen million older adults in the United States rely on the means-tested Medicaid program for healthcare coverage (accounting for approximately 20% of total Medicaid beneficiaries according to the Centers for Medicare and Medicaid Services). With the older adult population growing exponentially, there has been concern that steadily rising Medicaid spending will skyrocket among this group and that there may be a need to reconfigure coverage of the program. However, few studies have longitudinally examined which factors are related to utilization of the program over time among older adults in order to better understand how any future coverage changes might impact this group. This study used the 1998 to 2014 waves of the Health and Retirement Study (N=8,162) to analyze a representative sample of those 50 and older regarding demographic, health, and economic trends associated with Medicaid utilization over a sixteen-year period. Descriptive analyses showed stable longitudinal patterns such that those who utilized Medicaid had significantly poorer health and fewer financial resources compared to those who never accessed Medicaid. Multivariate analyses further revealed those who were older, female, minority race/ethnicity, less educated, in poorer health, below the federal poverty line, and with lower net wealth had a higher proportional risk of utilizing Medicaid during the observed time period than their counterparts. The findings from this study highlight the importance of monitoring changes in the documented risk factors over time in terms of their impact on Medicaid utilization and underscore the need to consider how these factors may be interrelated.

How developmental neuroscience can help address the problem of child poverty

Nearly 1 in 5 children in the United States lives in a household whose income is below the official federal poverty line, and more than 40% of children live in poor or near-poor households. Research on the effects of poverty on children's development has been a focus of study for many decades and is now increasing as we accumulate more evidence about the implications of poverty. The American Academy of Pediatrics recently added “Poverty and Child Health” to its Agenda for Children to recognize what has now been established as broad and enduring effects of poverty on child development. A recent addition to the field has been the application of neuroscience-based methods. Various techniques including neuroimaging, neuroendocrinology, cognitive psychophysiology, and epigenetics are beginning to document ways in which early experiences of living in poverty affect infant brain development. We discuss whether there are truly worthwhile reasons for adding neuroscience and related biological methods to study child poverty, and how might these perspectives help guide developmentally based and targeted interventions and policies for these children and their families.

The Effects of ACA Medicaid Expansions on Health After 5 Years

We examine the Affordable Care Act Medicaid expansion effects on self-rated health status over 5 years. The study uses data from the Behavioral Risk Factor Surveillance System for 2011-2018 and a difference-in-differences design. There is improvement in health status on a 1 to 5 point scale from poor to excellent health among individuals below 100% of the federal poverty line by 0.031, 0.068, 0.031, 0.064, and 0.087 points in 2014, 2015, 2016, 2017, and 2018, respectively. Changes in 2015, 2017, and 2018 are statistically significant ( p < .05), and the 2014 change is marginally significant. The difference between 2014 and 2018 effects is statistically significant ( p < .05). In most years, we cannot distinguish changes in days not in good physical or mental health from no effect. Overall, there is only minimal evidence for effects intensifying over time, suggesting that health gains thus far have mostly occurred early on due to unmet needs among those previously uninsured.

Beyond the supermarket: analyzing household shopping trip patterns that include food at home and away from home retailers

Background Modifying a household’s food environment by targeting a single retailer type, like supermarkets, has a limited impact on dietary outcomes. This may be because the food environment has a limited impact on shopping behaviors, or because households are not as reliant on supermarkets as we assume. However, our understanding of how households shop for food, especially when considering the use of both food at home (FAH) retailers, such as supermarkets, and away from home retailers (FAFH), such as restaurants, is limited. Thus, understanding how households shop for food is a necessary first step when developing programs to modify food purchasing behavior. Methods K-means cluster analysis was used to identify weekly food shopping trip patterns based on the percentage of trips to FAH and FAFH retailers in the 2013 Food Acquisition and Purchase Survey (FoodAPS) dataset (n = 4665 households). Multinomial logistic regression was used to examine the relationship between shopping trip patterns, household and food environment characteristics. Results Three patterns emerged: primarily supermarket, primarily supercenter, or mix (i.e. no dominant retailer type, but high FAFH use). Households with incomes below 185% of the federal poverty line were evenly divided between patterns that rely primarily on FAH retailers, and the mix pattern. While nearly 70% of households with incomes above 185% of the federal poverty line are in the mix cluster. Supermarket and superstore availability significantly influenced the likelihood of belonging to those clusters respectively, while having a child, higher income, and attitudes towards healthy meal preparation time or taste significantly influenced the likelihood of belonging to the mix cluster. Conclusion Although lower-income households are more likely to rely primarily on FAH retailers, household’s, regardless of income, that primarily utilize FAH retailers show a strong preference for either superstores or supermarkets suggesting a need for interventions to reach both retailer types. However, altering the food environment alone may not be sufficient to discourage use of FAFH retailers as households relying on FAFH retailers are significantly influenced by meal preparation time and healthy food taste.

Beyond the 405 and the 5: Geographic variations and factors associated with SARS-CoV-2 positivity rates in Los Angeles County

Objectives To highlight geographic differences and the socio-structural determinants of SARS-CoV-2 test positivity within Los Angeles County (LAC). Methods A geographic information system was used to integrate, map, and analyze SARS-CoV-2 testing data reported by LAC DPH, and data from the American Community Survey. Structural determinants included race/ethnicity, poverty, insurance status, education, population and household density. We examined which factors were associated with positivity rates, using a 5% test positivity threshold, with spatial analysis and spatial regression. Results Between 1 March and 30 June 2020 there were 843,440 SARS-CoV-2 tests and 86,383 diagnoses reported, for an overall positivity rate of 10.2% within the study area. Communities with high proportions of Latino/a residents, those living below the federal poverty line and with high household densities had higher crude positivity rates. Age- adjusted diagnosis rates were significantly associated with the proportion of Latino/as, individuals living below the poverty line, population, and household density. Conclusions There are significant local variations in test positivity within LAC and several socio-structural determinants contribute to ongoing disparities. Public health interventions, beyond shelter in place, are needed to address and target such disparities.

Accessible Elections to Help Poor People

Inequality in who votes matters. People with lower incomes are significantly less likely to participate in elections, creating a class bias in the electorate. Even if overall voter participation improves, can accessible elections shrink turnout inequality between higher and lower socio-economic class citizens? Chapter 5 empirically evaluates whether the voting laws and election administration lead to an increased probability of poor individuals (proxied as those at or below the federal poverty line) voting when comparing 2010 to 2014 midterm election turnout, and 2008 to 2012 presidential election turnout. The results show that no-excuse absentee/mail voting (in midterm elections) and same day registration (in both presidential and midterm elections) increases voter turnout among the economically disadvantaged. Better election administration also leads to improved outcomes for lower socio-economic citizens.

The ACA Medicaid Expansions and Employment of Adults With Disabilities

The Patient Protection and Affordable Care Act (ACA) of 2010 substantially expanded the availability of health insurance coverage, particularly for adults with disabilities. One notable change was the option for states to offer Medicaid coverage to adults with household incomes that were below 138% of the federal poverty line; most but not all states expanded Medicaid to this population. This article investigates whether states that expanded Medicaid coverage through the ACA in 2014—the first year that expansion was possible under the ACA, and the year that most states opted to expand—experienced differential changes in the employment rate of adults with disabilities relative to states that did not expand Medicaid. Using nationally representative data from the American Community Survey, we do not find evidence that the postexpansion employment trend in Medicaid expansion states was significantly different from that trend in states that did not expand Medicaid.

Children With Special Needs: Social Determinants of Health and Care Coordination

Care coordination (CC) facilitates access to resources/services for children/youth with special health care needs (CYSHCN). We conducted a cross-sectional analysis of the 2009-2010 National Survey of CSHCN to examine socioeconomic factors related to report of receiving adequate CC services for CYSHCN. Descriptive statistics were used to describe sociodemographic characteristics of respondents and examine socioeconomic factors. Receiving adequate CC varied by socioeconomic variables including income (100% to 199% federal poverty line [FPL]; aOR [adjusted odds ratio] = 0.848; 95% CI [confidence interval] = 0.722-0.997; P < .05), insurance (uninsured; aOR = 0.446; 95% CI = 0.326-0.609; P < .0001), and marital status (never married; aOR = 0.79; 95% CI = 0.64-0.97; P < .05). More families reporting adequate CC had private insurance, non-Hispanic white ethnicity, income >400% federal poverty level, and 2-parent households. Findings suggest unmet needs in terms of adequate access or knowledge leading to insufficient provision of CC for families with the greatest needs. Further analysis identifying specific deficits and implementing strategies to address these disparities is warranted.