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China's healthcare system faces significant challenges, notably the underutilization of primary healthcare resources and the inefficient distribution of healthcare services. In response, this article explores the effectiveness of the New Rural Cooperative Medical System (NRCMS) in improving healthcare accessibility and primary care utilization. Employing a multi-period difference-in-differences model and using data from the China Family Panel Studies spanning 2012-20, it aims to empirically examine how health insurance policy incentivizing primary care influences rural residents' health-seeking behaviour and enhances the efficiency of resource utilization. Results indicate that NRCMS significantly improves the probability of rural residents seeking healthcare services at primary healthcare centres (PHCs), especially for outpatient services. This effect can be attributed to the substantially higher outpatient reimbursement rates at PHCs compared to higher-level medical institutions. Conversely, the Urban Resident Basic Medical Insurance fails to increase urban residents' engagement with primary care, reinforcing the role of price sensitivity in healthcare choices among insured lower-income rural population. Furthermore, the study reveals a stronger preference for PHCs among younger, less-educated insured residents and highlights a synergistic effect between the availability of primary healthcare resources and insurance coverage on primary care utilization. These findings offer crucial implications for refining health insurance policies to improve healthcare service accessibility and efficiency.

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BACKGROUND: Medicaid, unlike any other insurance mechanism, imposes a consent requirement on female patients desiring sterilization that must be completed at least 30 days, but no more than 180 days, before sterilization. Desired sterilization cannot be completed in the Medicaid population without this consent. Large-scale national evidence is lacking on the effect of this requirement. OBJECTIVE: This study aimed to explore the influence of insurance status on the achievement of postpartum sterilization after a self-reported unwanted birth in a nationally representative sample. STUDY DESIGN: This was a retrospective cohort analysis using data from the 2013-2015 National Survey of Family Growth. The National Survey of Family Growth uses a stratified, multistage clustered sample to make nationally representative estimates for men and women aged 15 to 44 years in the household population of the United States. The analysis was limited to a cohort of birthing people who reported their last birth as unwanted and who were insured by either Medicaid or private insurance. The survey was analyzed with the application of inverse probability of treatment weights to balance those with Medicaid and those with private insurance in addition to the survey weight. The association between completion of postpartum sterilization and insurance type was evaluated using weighted logistic regression, adjusting for demographic and clinical characteristics. RESULTS: In an adjusted and inverse probability of treatment weight balanced analysis of a weighted national sample representing 4,164,304 people (416 respondents), Medicaid-insured birthing people with history of unwanted births were found to have 56% lower odds of obtaining postpartum sterilization (odds ratio, 0.44; 95% confidence interval, 0.22-0.87; P=.019) than those with private insurance. CONCLUSION: This study adds to mounting evidence that insurance type plays a significant role in the achievement of desired postpartum sterilization, with individuals with Medicaid less likely to undergo the procedure. The findings call for policy reforms around sterilization policy in the United States, emphasizing the need for uniform consent procedures that do not discriminate based on insurance status.

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A public health student enrolls in Medicaid, only to be unable to access the insurance for months.

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In the Affordable Care Act (ACA) Marketplaces, enrollees must periodically demonstrate their eligibility to receive income-linked health insurance premium subsidies. Marketplaces can verify eligibility using existing records, but only with consumers' consent, which must be renewed at specified times. In a randomized experiment in September 2020, we tested the effect of email nudges reminding consumers to provide consent for verification of their continued eligibility for premium subsidies in California's ACA Marketplace. More than 20,000 households that had applied for subsidies but whose consent for eligibility verification would soon expire were sent one, two, or three emails reminding them to renew consent. Sending three emails increased consent updates by 1.9 percentage points (3.2 percent) and increased receipt of subsidies by 2.0 percentage points (4.0 percent). However, nearly 40 percent of households receiving three emails did not update their consent by the end of the open enrollment period, thus preventing their continued receipt of subsidies. To improve the affordability of Marketplace coverage, new policies and structural changes may be needed to reduce administrative barriers that can inhibit access to subsidies.

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The present cross-sectional study was conducted to evaluate various caries risk factors in children from low socio-economic groups and to assess if children with broad contacts between one or more primary molars (type I and S) should be categorized as at high caries risk. Clinical examinations were performed on 107, 3- to 10-year-old children from low socio-economic settings. Contact types along with other caries risk factors (insurance, diet, plaque, and fluoride use, and diet habits) were analyzed for effect on presence of caries lesions (prevalence) and caries experience (decayed, missing, filled teeth). 78% of the study population had dental caries lesions, with an average dmft of 5.6. Of the 277 evaluated contacts, 88% were categorized as broad contacts. Multivariate analyses failed to validate that broad contacts were a predictor of dental caries lesions. However, the analysis showed an association of insurance status, plaque index with dmft. In conclusion, the present study could not implicate broad contacts as a factor that increased caries risk in the studied population; however, it validates the importance of insurance status, plaque index, as well as diet frequency as predictors of dental caries lesions.

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Cancer is the top leading cause of death among Latino people. Lack of health insurance is a significant contributor to inadequate cancer detection and treatment. Despite healthcare policy expansions such as the Affordable Care Act, Latino people persistently maintain the highest uninsured rate among any ethnic and racial group in the US, especially among Latino individuals who are immigrants or part of a mixed immigration status household. Recognizing that immigration status is a critical factor in the ability of Latino community members to seek health insurance and access healthcare services, a few US states and the District of Columbia have implemented policies that have expanded coverage to children and adults regardless of immigration status. Expansion of Medicaid eligibility regardless of immigration status may significantly benefit Latino communities, however the facilitators and barriers to enrolling in these programs need to be evaluated to ensure reach and achieve health equity across the cancer control continuum for all Latinos.

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Importance: Many US children and adolescents with mental and behavioral health (MBH) conditions do not access MBH services. One contributing factor is limited insurance coverage, which is influenced by state MBH insurance parity legislation. Objective: To investigate the association of patient-level factors and the comprehensiveness of state MBH insurance legislation with perceived poor access to MBH care and perceived inadequate MBH insurance coverage for US children and adolescents. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using responses by caregivers of children and adolescents aged 6 to 17 years with MBH conditions in the National Survey of Children's Health and State Mental Health Insurance Laws Dataset from 2016 to 2019. Data analyses were conducted from May 2022 to January 2024. Exposure: MBH insurance legislation comprehensiveness defined by State Mental Health Insurance Laws Dataset (SMHILD) scores (range, 0-7). Main Outcomes and Measures: Perceived poor access to MBH care and perceived inadequacy of MBH insurance were assessed. Multivariable regression models adjusted for individual-level characteristics. Results: There were 29 876 caregivers of children and adolescents with MBH conditions during the study period representing 14 292 300 youths nationally (7 816 727 aged 12-17 years [54.7%]; 8 455 171 male [59.2%]; 292 543 Asian [2.0%], 2 076 442 Black [14.5%], and 9 942 088 White [69.6%%]; 3 202 525 Hispanic [22.4%]). A total of 3193 caregivers representing 1 770 492 children and adolescents (12.4%) perceived poor access to MBH care, and 3517 caregivers representing 1 643 260 of 13 175 295 children and adolescents (12.5%) perceived inadequate MBH insurance coverage. In multivariable models, there were higher odds of perceived poor access to MBH care among caregivers of Black (adjusted odds ratio [aOR], 1.35; 95% CI, 1.04-1.75) and Asian (aOR, 1.69; 95% CI, 1.01-2.84) compared with White children and adolescents. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to MBH care increased (aORs ranged from 1.68; 95%, CI 1.32-2.13 for 1 ACE to 4.28; 95% CI, 3.17-5.77 for ≥4 ACEs compared with no ACEs). Compared with living in states with the least comprehensive MBH insurance legislation (SMHILD score, 0-2), living in states with the most comprehensive legislation (SMHILD score, 5-7) was associated with lower odds of perceived poor access to MBH care (aOR, 0.79; 95% CI, 0.63-0.99), while living in states with moderately comprehensive legislation (score, 4) was associated with higher odds of perceived inadequate MBH insurance coverage (aOR, 1.23; 95% CI, 1.01-1.49). Conclusions and Relevance: In this study, living in states with the most comprehensive MBH insurance legislation was associated with lower odds of perceived poor access to MBH care among caregivers for children and adolescents with MBH conditions. This finding suggests that advocacy for comprehensive mental health parity legislation may promote improved child and adolescent access to MBH services.

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The introduction of highly effective anti-obesity drugs, such as Wegovy, has prompted debate over Medicare's prohibition on coverage of such products. In this study, we estimated the costs of allowing Medicare coverage of anti-obesity medications. Our analysis incorporated data on drug costs, real-world adherence rates, and potential changes to other health care spending. Using Medicare claims, we also documented beneficiaries' eligibility for nearly identical products approved for different indications. Assuming that anti-obesity drugs were covered in 2025 and that 5 percent or 10 percent of newly eligible patients were prescribed one, annual Part D costs were estimated to increase by $3.1 billion or $6.1 billion, respectively. The marginal costs of this policy could fall by as much as 62.5 percent from baseline estimates if products were approved for additional indications in coming years because these additional conditions are common among people with obesity. This would increase Medicare spending but would occur regardless of a policy change. Longer-term estimates come with significant uncertainty about utilization and price changes, but these results are consistent with this policy change likely increasing Medicare costs by the low to middle tens of billions of dollars over ten years.

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Insurance coverage for prenatal care, labor and delivery care, and postpartum care for undocumented immigrants consists of a patchwork of state and federal policies, which varies widely by state. According to federal law, states must provide coverage for labor and delivery through Emergency Medicaid. Various states have additional prenatal and postpartum coverage for undocumented immigrants through policy mechanisms such as the Children's Health Insurance Program's "unborn child" option, expansion of Medicaid, and independent state-level mechanisms. Using a search of state Medicaid and federal government websites, we found that 27 states and the District of Columbia provide additional coverage for prenatal care, postpartum care, or both, while 23 states do not. Twelve states include any postpartum coverage; 7 provide coverage for 12 months postpartum. Although information regarding coverage is available publicly online, there exist many barriers to access, such as lack of transparency, lack of availability of information in multiple languages, and incorrect information. More inclusive and easily accessible policies are needed as the first step toward improving maternal health among undocumented immigrants, a population trapped in a complicated web of immigration policy and a maternal health crisis. (Am J Public Health. 2024;114(10):1051-1060. https://doi.org/10.2105/AJPH.2024.307750).

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Nearly all patients with type 1 diabetes and 20-30 percent of patients with type 2 diabetes use insulin to manage glycemic control. Approximately one-quarter of patients who use insulin report underuse because of cost. In response, more than twenty states have implemented monthly caps on insulin out-of-pocket spending, ranging from $25 to $100. Using a difference-in-differences approach, this study evaluated whether state-level caps on insulin out-of-pocket spending change insulin usage among commercially insured enrollees. The study included 33,134 people ages 18-64 who had type 1 diabetes or who used insulin to manage type 2 diabetes with commercial insurance coverage that was subject to state-level oversight and was included in the 25 percent sample of the IQVIA PharMetrics database during 2018-21. Insulin out-of-pocket caps did not significantly increase quarterly insulin claims for enrollees who had type 1 diabetes or who used insulin to manage type 2 diabetes. State-level caps on insulin out-of-pocket spending for commercial enrollees did not significantly increase insulin use; that may be in part because of out-of-pocket expenses being lower than cap amounts.

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PURPOSE: Inconsistent access to healthcare for people with epilepsy results in reduced adherence to antiseizure medications, increased seizure frequency, and fewer appropriate referrals for epilepsy surgery. Identifying and addressing factors that impede access to care should consequently improve patient outcomes. We hypothesized that health insurance and transportation affect access to outpatient neurology care for adults living with epilepsy in the United States (US). METHODS: We conducted a retrospective cross-sectional study of US adults with active epilepsy surveyed via the National Health Interview Survey (NHIS) in 2015 and 2017. We established whether patients reported seeing a neurologist in the past year and used multiple logistic regression to determine whether health insurance status and transportation access were associated with this outcome. RESULTS: We identified 735 respondents from 2015 and 2017, representing an estimated 2.98 million US adults with active epilepsy. After adjusting for socioeconomic and seizure-related co-variates, we found that a lack of health insurance coverage was associated with no epilepsy care in the past year (adjusted odds ratio [aOR] 0.22; 95 % confidence interval [CI]: 0.09 - 0.54). Delayed care due to inadequate transportation (aOR 0.42; 95 % CI: 0.19 - 0.93) also resulted in reduced patient access to a neurologist. CONCLUSION: Due to the inherent nature of their condition, people with epilepsy are less likely to have employer-sponsored health insurance or consistent driving privileges. Yet, these factors also impact patient access to neurological care. We must address transportation and insurance barriers through long-term investment and partnership between community, healthcare, and government stakeholders.

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BACKGROUND: The rapid growth of digital health tools, including digital applications, wearables, sensors, diagnostics, digital therapeutics (DTx), and prescription DTx, offers new ways to treat patients and close gaps in care. Payers need transparent, credible, and efficient processes to differentiate products for potential reimbursement from the larger universe of digital health products. OBJECTIVE: To identify areas of agreement, disagreement, and rationale for payers to determine which digital health products should be evaluated for formulary consideration and to develop generalizable criteria for health care decision-makers developing policies and approaches for digital health products. METHODS: Experts from the Academy of Managed Care Pharmacy DTx Advisory Group Payer Evaluation subcommittee rated whether a pharmacy and therapeutics committee, health technology assessment group, or an innovation center within a health plan or pharmacy benefit manager should consider 14 hypothetical products for potential formulary coverage. Using a 4-step modified Delphi approach, experts rated whether it was appropriate for a payer to evaluate each product on a scale of 1 (strongly disagree) to 9 (strongly agree). Quantitative agreement was assessed using terciles of responses, medians, and the distribution of appropriateness scores. The corresponding discussions are summarized to identify generalizable criteria for payers to consider as they develop approaches to determine which digital health products to evaluate. RESULTS: Among the 14 hypothetical products, 4 achieved quantitative agreement that payers should evaluate the product. 5 products had quantitative disagreement, and the remaining were indeterminant. Payers were most likely to review a product if it (1) was reviewed by the US Food and Drug Administration, (2) required a prescription, (3) was intended to be paid for using premium dollars, (4) treated rather than diagnosed or monitored a clinical condition, (5) had a low clinical opportunity cost, and (6) could address population health metrics. CONCLUSIONS: The rapid availability of digital health and DTx options can be daunting for health care decision-makers when determining which products to evaluate. These generalizable criteria can help payers develop a more efficient process.

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More than twelve million US adults ages forty and older are affected by vision impairment, and projections suggest that this number will double by 2050. Although most vision impairment can be eliminated with corrective lenses, many adults lack access to routine eye care. In this study, we analyzed detailed state-by-state Medicaid policies for 2022 and documented variability in coverage for adult vision services. Most fee-for-service Medicaid programs covered routine eye exams, although many did not cover glasses (twenty states) or low vision aids (thirty-five states), and about two-thirds of states with routine coverage required enrollee cost sharing. Managed care plans generally provided consistent or enhanced coverage relative to fee-for-service programs, although coverage sometimes varied between plans within a state. We estimated that about 6.5 million and 14.6 million adult enrollees resided in states without comprehensive coverage for routine eye exams and glasses, respectively. These findings reveal important gaps and opportunities for states to increase access to routine vision care.

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We study the effects of health insurance coverage on agricultural production decisions, examining the causal relationships by exploiting a health care reform and providing a theoretical framework to elucidate underlying mechanisms. We find that the reform led to long-run increases in total cultivation investments and output, accompanied by a shift in households' cultivation portfolio towards riskier crops. We explain these findings using a model of agricultural investment, highlighting the important roles of health insurance in mitigating background medical expenditure risks and enhancing health. We also find that the reform improved households' financial well-being through reduced debts and defaults on loans.

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Importance: By expanding health insurance to millions of people in the US, the Patient Protection and Affordable Care Act (ACA) may have important health, economic, and social welfare implications for people with criminal legal involvement-a population with disproportionately high morbidity and mortality rates. Objective: To scope the literature for studies assessing the association of any provision of the ACA with 5 types of outcomes, including insurance coverage rates, access to care, health outcomes, costs of care, and social welfare outcomes among people with criminal legal involvement. Evidence Review: The literature search included results from PubMed, CINAHL Complete, APA Psycinfo, Embase, Social Science Database, and Web of Science and was conducted to include articles from January 1, 2014, through December 31, 2023. Only original empirical studies were included, but there were no restrictions on study design. Findings: Of the 3538 studies initially identified for potential inclusion, the final sample included 19 studies. These 19 studies differed substantially in their definition of criminal legal involvement and units of analysis. The studies also varied with respect to study design, but difference-in-differences methods were used in 10 of the included studies. With respect to outcomes, 100 unique outcomes were identified across the 19 studies, with at least 1 in all 5 outcome categories determined prior to the literature search. Health insurance coverage and access to care were the most frequently studied outcomes. Results for the other 3 outcome categories were mixed, potentially due to heterogeneous definitions of populations, interventions, and outcomes and to limitations in the availability of individual-level datasets that link incarceration data with health-related data. Conclusions and Relevance: In this scoping review, the ACA was associated with an increase in insurance coverage and a decrease in recidivism rates among people with criminal legal involvement. Future research and data collection are needed to understand more fully health and nonhealth outcomes among people with criminal legal involvement related to the ACA and other health insurance policies-as well as the mechanisms underlying these relationships.

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Importance: Department of Veterans Affairs (VA) health care spending has increased in the past decade, in part due to legislative changes that expanded access to VA-purchased care. Objective: To understand how insurance coverage and enrollment in VA has changed between 2010 and 2021. Design, Setting, and Participants: This cross-sectional study used data from surveys conducted from 2010 to 2021. Participants were respondents across 4 national surveys who reported being a US veteran and reported on health insurance enrollment. Data were analyzed from October 2023 to June 2024. Main Outcomes and Measures: Self-reported health insurance coverage, reliance on VA insurance, and self-reported health. Results: Among a total of 3 644 614 survey respondents (mean [SE] age, 60 [0.04] years; 91.3% [95% CI, 91.2%-91.5%] male) included, 52.2% (95% CI, 52.0%-52.4%) were out of the labor market and 63.1% (95% CI, 62.9%-63.3%) were married. In 2010, 94% of all veterans and 94% of veterans younger than age 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment increased over time, and by 2020, 97% of all veterans and 95% of veterans younger than 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment estimates were similar across the surveys. Approximately one-third of veterans reported being enrolled in VA health coverage. Of those who enrolled in VA insurance, more than 75% had more than 1 form of coverage, with Medicare and private insurance being the most common second insurance sources. VA insurance enrollment was negatively associated with income and health status. Veterans without insurance tended to be unemployed and younger. Conclusions and Relevance: This study of veterans who responded to 4 national surveys found that veterans enrolled in VA health coverage had high rates of dual coverage. Further legislative efforts to increase access without recognizing the high rates of dual coverage may yield unintended consequences, such payer shifting.

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BACKGROUND: Migrant workers are recognized as a vulnerable group of population in the context of accessibility to healthcare services as they are likely to experience multiple challenges and barriers. This study aimed to assess the awareness and perceived knowledge on health insurance coverage among documented migrant workers in Brunei Darussalam. METHODS: This cross-sectional, interviewer-administered study used a pre-designed questionnaire on migrant workers attending the Foreign Worker Health Screening Centre from June until September 2019. Data were analyzed for association between perceived insurance status on health-seeking behavior. RESULTS: The study obtained responses from 469 documented migrant workers (93.8%). 75.1% reported being aware of and having health insurance coverage; and of these, 57.1% were aware of the type of health insurance cover they had. 45.5% and 50.6% had poor knowledge whether their health insurance covered for hospitalization or outpatient expenses, respectively. No significant association was found between the migrant workers' perceived status of insurance and not seeking medical care due to financial barriers (p > 0.05). CONCLUSIONS: A high proportion of documented migrant workers in Brunei Darussalam reported knowledge of having health insurance; however, there was lack of awareness on its actual coverage. By including migrants' health in a nation's healthcare governance, the health rights of migrant workers can be addressed thus aiming to achieve universal health coverage for all individuals.

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