Postpartum long-acting reversible contraceptive adoption after a statewide initiative.

OBJECTIVES: To examine the effects of a comprehensive, multiyear (2015-2020) statewide contraceptive access intervention in Delaware on the contraceptive initiation of postpartum Medicaid patients. The program aimed to increase access to all contraceptives, including long-acting reversible contraceptives (LARC). The program included interventions specifically targeting postpartum patients (Medicaid payment reform and hospital-based immediate postpartum (IPP) LARC training) and interventions in outpatient settings (provider training and operational supports). DATA SOURCES AND STUDY SETTING: We used Medicaid claims data between 2012 and 2019, from Delaware and Maryland (a comparison state), to identify births and postpartum contraceptive methods up to 60 days postpartum among patients aged 15-44 years who were covered in a full-benefit eligibility category. STUDY DESIGN: Using difference-in-differences, we assessed changes in LARC, tubal ligation, and short-acting methods (oral contraceptive, injectable, patch/ring). LARC rates were assessed at 60 days after delivery and on an immediate postpartum basis. Other methods were only assessed at 60 days. Analyses were conducted separately for an early-adopting high-capacity hospital (that delivers approximately half of all Medicaid financed births) and for all other later-adopting hospitals in the state. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from administrative claims. PRINCIPAL FINDINGS: The program increased postpartum LARC insertions by 60 days after delivery by 11.7 percentage points (95% CI: 10.7, 12.8) in the early-adopting hospital and 6.9 percentage points (95% CI: 4.8, 5.9) in later-adopting hospitals. Increases in IPP versus outpatient LARC drove the change, but we did not find evidence that IPP crowded-out outpatient LARC services. We observed decreases in short-acting methods, suggesting substitution between methods, but the share of patients with any method increased at the early-adopting hospital (5.2 percentage points; 95% CI: 3.5, 6.9) and was not statistically significantly different at the later-adopting hospitals. CONCLUSIONS: Direct reimbursement for IPP LARC, in combination with provider training, had a meaningful impact on the share of Medicaid-enrolled postpartum women with LARC claims.

School-Based Health Centers, Access to Care, and Income-Based Disparities.

Importance: School-based health centers (SBHCs) are primary care clinics colocated at schools. SBHCs have the potential to improve health care access and reduce disparities, but there is limited rigorous evidence on their effectiveness at the national level. Objective: To determine whether county-level adoption of SBHCs was associated with access, utilization, and health among children from low-income families and to measure reductions in income-based disparities. Design, Setting, and Participants: This survey study used a difference-in-differences design and data from a nationally representative sample of children in the US merged with SBHC indicators from the National Census of School-Based Health Centers. The main sample included children aged 5 to 17 years with family incomes that were less than 200% of the federal poverty level observed in the National Health Interview Survey, collected between 1997 to 2018. The sample was restricted to children living in a county that adopted a center between 2003 and 2013 or that did not have a center at any time during the study period. Analyses of income-based disparities included children from higher income families (ie, 200% or higher than the federal poverty level). Data were analyzed between January 2020 and July 2023. Exposure: County-by-year SBHC adoption. Main Outcomes and Measures: Outcomes included access (usual source of care, insurance status, barriers), ambulatory care use (general physician, eye doctor, dental, mental health visits), and health (general health status, missed school days due to illness). P values were adjusted for multiple comparisons using the sharpened q value method. Results: This study included 12 624 unweighted children from low-income families and 24 631 unweighted children from higher income families. The weighted percentage of children in low-income families who resided in counties with SBHC adoption included 50.0% aged 5 to 10 years. The weighted percentages of the race and ethnicity of these children included 36.7% Hispanic children, 25.2% non-Hispanic Black children, and 30.6% non-Hispanic White children. The weighted percentages of children in the counties that never adopted SBHCs included 50.1% aged 5 to 10 years. The weighted percentages of the race and ethnicity of these children included 20.7% Hispanic children, 22.4% non-Hispanic Black children, and 52.9% non-Hispanic White children. SBHC adoption was associated with a 6.4 percentage point increase in dental visits (95% CI, 3.2-9.6 percentage points; P < .001), an 8.0 percentage point increase in having a usual source of care (95% CI, 4.5-11.5 percentage points; P < .001), and a 5.2 percentage point increase in insurance (95% CI, 1.2-9.2 percentage points; P = .03). No other statistically significant associations were found with other outcomes. SBHCs were associated with relative reductions in income-based disparities to dental visits by 76% (4.9 percentage points; 95% CI, 2.0-7.7 percentage points), to insured status by 63% (3.5 percentage points; 95% CI, 1.3-5.7 percentage points), and to having a usual source of care by 98% (7.2 percentage points; 95% CI, 5.4-9.1 percentage points). Conclusions and Relevance: In this survey study with difference-in-differences analysis of SBHC adoption, SBHCs were associated with access to care and reduced income-based disparities. These findings support additional SBHC expansion.

Contraceptive access reform and abortion: Evidence from Delaware.

OBJECTIVE: To examine the effects of a comprehensive contraceptive access reform, Delaware Contraceptive Access Now, on abortion-one of the most common outcomes of unintended pregnancy. DATA SOURCE: We used abortion data by state of residence from the Abortion Surveillance System, published by the Centers for Disease Control and Prevention. Our data covers 5 years prior to (2010-2014) and 5 years after the intervention (2015-2019). STUDY DESIGN: We used synthetic control methods to estimate program effects. Our design compares Delaware to a weighted average of 45 control states ("synthetic Delaware"), where the quality of the comparison is assessed by its similarity to Delaware in pre-period outcome levels and trends. DATA COLLECTION/EXTRACTION METHODS: Not applicable. We relied on secondary sources. PRINCIPAL FINDINGS: We did not find statistically significant evidence that the program reduced abortion rates (0.61 fewer abortions per 1000 women, p-value = 0.74) on average, during the intervention period. The treatment effects were slightly larger in 2016 and 2017 (1.97 fewer abortions per 1000 women but not statistically significant) and attenuated in 2018 and 2019. This does not rule out program benefits in easing barriers to contraceptive methods or in reducing unplanned births. However, findings do suggest that increasing contraceptive access might not be an adequate substitute for restricted abortion access resulting from Dobbs v. Jackson Women's Health Organization. CONCLUSIONS: Our results suggest that comprehensive efforts to improve contraceptive access may not reduce the need for accessible and affordable abortion care.

The effect of contraceptive access reform on privately insured patients: Evidence from Delaware Contraceptive Access Now.

BACKGROUND: Many states are implementing comprehensive programs aimed at reducing persistent barriers to contraceptive care. Evidence on the effectiveness of these programs is essential for practice improvement and policy development. OBJECTIVE: To evaluate changes in the probability of initiating a contraceptive method by women with employer sponsored insurance after implementation of Delaware Contraceptive Access Now (DelCAN), a statewide initiative that aimed to increase access to long-acting reversible contraceptives (LARCs). DESIGN, SETTING, AND PARTICIPANTS: We used a difference-in-differences design to examine contraceptive initiation rates. Data came from IBM Marketscan and covered women age 15-44 enrolled in employer sponsored insurance. The primary outcome was insertion of a LARC, both in the overall study population and in the immediate postpartum (IPP) setting. Secondary analysis examined changes to other contraceptive method types. RESULTS: The cohort of 4,550,459 enrollees generated a sample of 11,888,837 person-years and 615,670 childbirth hospitalizations. Difference-in-differences estimates suggested that DelCAN was associated with a 0.3 percentage point (95% CI [0.2, 0.5], p<0.001) increase in the LARC insertion rate in the overall study population and a 0.4 percentage point increase (95% CI [0.2, 0.6], p<0.001) in the percent of births adopting IPP LARC. Associations between DelCAN and LARC insertion appeared stronger for adolescents compared to older women. Results for other method types were less consistent. CONCLUSIONS: A comprehensive statewide program was associated with increased LARC insertion rates among enrollees with employer sponsored insurance. Understanding the effect of these programs is critical for on-going policy development for states engaged in contraceptive access reform.

Same-day long-acting reversible contraceptive utilization after a statewide contraceptive access initiative.

BACKGROUND: Same-day placement of long-acting reversible contraceptives, occurring when the device is requested and placed within a single visit, reduces barriers to the patient and reduces unintended pregnancies. Despite the safety and efficacy of same-day placement, access to same-day services remains low. OBJECTIVE: This study aimed to evaluate the effects of the Delaware Contraceptive Access Now initiative, a statewide initiative in Delaware focused on increasing same-day access to effective contraception on same-day receipt of long-acting reversible contraceptives. STUDY DESIGN: We used Medicaid claims and encounter data to identify instances of same-day and multivisit receipts of long-acting reversible contraceptives among Medicaid-enrolled individuals in Delaware and Maryland aged 15-44 years who were covered in a full-benefits or family planning Medicaid aid category during the month of the placement and the 2 previous months. We used a difference-in-differences design that compared changes in the outcome from before to after implementation of the initiative among placements at agencies that participated in the initiative (n=6676) vs 2 alternative comparison groups: placements at Delaware agencies that did not participate (n=688) and placements in Maryland (n=35,847). RESULTS: We found that the intervention was associated with a 13.3 percentage point increase (95% confidence interval, 1.9%-24.7%) in receipt of same-day long-acting reversible contraceptives using a nonparticipating Delaware comparison group, a 21.1 percentage point increase (95% confidence interval, 13.7%-28.6%) using a Maryland comparison group, and a 21.0 percentage point increase (95% confidence interval, 14.1%-27.9%) using a pooled comparison group. The effects were larger for implants than intrauterine devices. CONCLUSION: The Delaware Contraceptive Access Now initiative substantially increased the number of patients receiving long-acting reversible contraceptives through a single-visit encounter. Our findings suggested that coordinated interventions involving provider and staff training and capital investments that seed device stocking can increase the number of patients receiving same-day long-acting reversible contraceptives.

Effects of the Children's Health Insurance Reauthorization Act on immigrant children's healthcare access.

OBJECTIVE: To estimate the effects of Children's Health Insurance Reauthorization Act (CHIPRA), a policy that provided states the option to extend Medicaid/CHIP eligibility to immigrant children who have not been legal residents for five years or more, on insurance coverage, access, utilization, and health outcomes among immigrant children. DATA SOURCES: Restricted use 2000-2016 National Health Interview Survey (NHIS). STUDY DESIGN: We used a difference-in-differences design that compared changes in CHIPRA expansion states to changes in non-expansion states. DATA COLLECTION: Our sample included immigrant children who were born outside the US, aged 0-18 with family income below 300% of the Federal Poverty Level (FPL). Subgroup analyses were conducted across states that did and did not have a similar state-funded option prior to CHIPRA (state-funded vs. not state-funded), by the length of time in the US (5 years vs. 5-14 years), and global region of birth (Latin American vs. Asian countries). PRINCIPLE FINDINGS: We found that CHIPRA was associated with a significant 6.35 percentage point decrease in uninsured rates (95% CI: -11.25, -1.45) and an 8.1 percentage point increase in public insurance enrollment for immigrant children (95% CI: 1.26, 14.98). However, the effects of CHIPRA became small and statistically not significant 3 years after adoption. Effects on public insurance coverage were significant in states without state-funded programs prior to CHIPRA (15.50 percentage points; 95% CI:8.05, 22.95) and for children born in Asian countries (12.80 percentage points; 95% CI: 1.04, 24.56). We found no significant changes in health care access and utilization, and health outcomes, overall and across subgroups due to CHIPRA. CONCLUSIONS: CHIPRA's eligibility expansion was associated with increases in public insurance coverage for low-income children, especially in states where CHIPRA represented a new source of coverage versus a substitute for state-funded coverage. However, we found evidence of crowd-out in certain subgroups and no effect of CHIPRA on access to care and health. Our results suggest that public coverage may be an important tool for promoting the well-being of immigrant children but other investments are still needed.

Delaware Contraceptive Access Now and Contraceptive Initiation Among Medicaid Enrollees, 2015‒2020.

Delaware Contraceptive Access Now was a statewide contraceptive access program implemented in Delaware between 2015 and 2020. We evaluated the association of the program with contraceptive initiation in Delaware's Medicaid program using a difference-in-differences design that compared changes in Delaware to changes in Maryland. Results suggest that program implementation was associated with increased initiation of long-acting reversible methods, particularly among adolescent patients aged 15 to 18 years. We found less-consistent evidence for changes to any contraceptive method. (Am J Public Health. 2022;112(S5):S537-S540. https://doi.org/10.2105/AJPH.2022.306938).

Association of the Delaware Contraceptive Access Now Initiative with Postpartum LARC Use.

OBJECTIVES: Although multi-component policy interventions can be important tools to increase access to contraception, we know little about how they may change contraceptive use among postpartum women. We estimate the association of the Delaware Contraceptive Access Now (DelCAN) initiative with use of postpartum Long-Acting Reversible Contraception (LARC). DelCAN included Medicaid payment reform for immediate postpartum LARC use, provider training and technical assistance in LARC provision, and a public awareness campaign. METHODS: We used a difference-in-differences design and data from the 2012 to 2017 pregnancy risk assessment monitoring system to compare changes in postpartum LARC use in Delaware versus 15 comparison states, and differences in such changes by women's Medicaid enrollment. RESULTS: Relative to the comparison states, postpartum LARC use in Delaware increased by 5.26 percentage points (95% CI 2.90-7.61, P < 0.001) during the 2015-2017 DelCAN implementation period. This increase was the largest among Medicaid-covered women, and grew over the first three implementation years. By the third year of the DelCAN initiative (2017), the relative increase in postpartum LARC use for Medicaid women exceeded that for non-Medicaid women by 7.24 percentage points (95% CI 0.12-14.37, P = 0.046). CONCLUSIONS FOR PRACTICE: The DelCAN initiative was associated with increased LARC use among postpartum women in Delaware. During the first 3 years of the initiative, LARC use increased progressively and to a greater extent among Medicaid-enrolled women. Comprehensive initiatives that combine Medicaid payment reforms, provider training, free contraceptive services, and public awareness efforts may reduce unmet demand for highly effective contraceptives in the postpartum months.

An evaluation of the Be Your Own Baby public awareness campaign.

OBJECTIVE: Assess the impact of the Be Your Own Baby (BYOB) public awareness campaign including population-level exposure, the effectiveness of ad platforms, and the effect of the campaign on family planning clinic attendance, the campaign's primary goal. DATA SOURCES: The study relied on administrative data on traffic and engagement from the campaign's website, population survey data measuring campaign exposure, and clinic attendance volumes from state-by-year restricted-use versions of the Office of Population Affairs' Family Planning Annual Reports (2006-2018). STUDY DESIGN: Bivariate analyses were used to assess website traffic and engagement and population-level exposure across key subgroups. We then used the synthetic control method to examine the impact of the BYOB campaign on per capita Title X clinic attendance among the target demographic, women 18-29 years of age. DATA COLLECTION/EXTRACTION METHODS: Not applicable. We relied on secondary sources. PRINCIPAL FINDINGS: Primary media platforms used by the campaign included social media, digital display, streaming audio, YouTube, and search. Website traffic was driven primarily by digital display ads, but engagement was highest for search. Our results suggest nearly 12% of Delaware women 18-29 years of age were exposed to the campaign. However, exposure was measured at the end of the campaign and was likely much larger during its peak. Our results indicated that the campaign was associated with between 13 and 23 additional Title X clinic visits per 1000 women compared with 110 users per 1000 at baseline in 2014. CONCLUSIONS: Our findings suggest the BYOB campaign was successful at increasing clinic attendance among the target demographic. These results have important implications for other programs seeking to use public awareness messaging to increase participation in the health care system and are especially important for Title X administrators who have faced declining patient volumes for over 10 years.

Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population.

OBJECTIVE: To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type. STUDY DESIGN: We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status. RESULTS: Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI. CONCLUSIONS: In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth. IMPLICATIONS: Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.

The Benefits of Rental Assistance for Children's Health and School Attendance in the United States.

Programs that provide affordable and stable housing may contribute to better child health and thus to fewer missed days of school. Drawing on a unique linkage of survey and administrative data, we use a quasi-experimental approach to examine the impact of rental assistance programs on missed days of school due to illness. We compare missed school days due to illness among children receiving rental assistance with those who will enter assistance within two years of their interview, the average length of waitlists for federal rental assistance. Overall, we find that children who receive rental assistance miss fewer days of school due to illness relative to those in the pseudo-waitlist group. We demonstrate that rental assistance leads to a reduction in the number of health problems among children and thus to fewer days of school missed due to illness. We find that the effect of rental assistance on missed school days is stronger for adolescents than for younger children. Additionally, race-stratified analyses reveal that rental assistance leads to fewer missed days due to illness among non-Hispanic White and Hispanic/Latino children; this effect, however, is not evident for non-Hispanic Black children, the largest racial/ethnic group receiving assistance. These findings suggest that underinvestment in affordable housing may impede socioeconomic mobility among disadvantaged non-Hispanic White and Hispanic/Latino children. In contrast, increases in rental assistance may widen racial/ethnic disparities in health among disadvantaged children, and future research should examine why this benefit is not evident for Black children.

Maryland's Global Budget Revenue Program: Impact on Neonatal Intensive Care Unit Admissions and Infant Mortality.

BACKGROUND: In 2014, Maryland implemented the Global Budget Revenue (GBR) program to reduce unnecessary hospital utilization and contain spending. Little is known about its impact on pediatric health outcomes and high-cost services that are primarily financed by payers other than Medicare. OBJECTIVE: The aim was to examine the impact of the GBR program on neonatal intensive care unit (NICU) admission and infant mortality. RESEARCH DESIGN: We conducted a difference-in-differences analysis comparing changes of NICU admissions and infant mortality in Maryland with changes in 20 comparison states (including DC), before and after implementation of the GBR program. Effects were estimated for all infants and for risk groups defined by birthweight and gestation. SUBJECTS: A total of 11,965,997 newborns in Maryland and the comparison states was identified using US birth certificate data from 2011 to 2017. MEASURES: NICU admissions, the infant mortality rate, and the neonatal mortality rate. RESULTS: The GBR program was associated with a 1.26 percentage points (-16.8%, P=0.03) decline in NICU admissions over three full years of implementation. Reductions were driven by fewer admissions among moderately low to normal birthweight (1500-3999 g) and moderately preterm to term (32-41 wk) infants. The effects for very-low birthweight and very preterm infants were small and not statistically precise. There was no significant change in infant or neonatal mortality rates. CONCLUSIONS: Maryland's hospitals reacted to the GBR program by reducing NICU services for infants that did not have clear observed clinical need. Our results suggest that GBR constrained high-cost services, without adversely affecting infant mortality.

Contraceptive method type and satisfaction, confidence in use, and switching intentions.

OBJECTIVE: We examined whether contraceptive method type, satisfaction with use, and confidence in correct use were independently associated with switching intentions, a precursor of switching behaviors. STUDY DESIGN: Data were from a probability-based sample survey carried out in Delaware and Maryland in 2016 and 2017 among women ages 18 to 44. Women's current contraceptive methods were classified into 5 categories: coitally-dependent methods (barrier methods, withdrawal, and natural family planning); oral contraceptive pills, patches, and rings; injections; implants; and intrauterine contraception (IUC). Satisfaction, confidence, and switching intentions were dichotomized into being very versus less satisfied, being completely versus less confident, and having very low versus not very low switching intentions. We conducted binomial logistic regression to examine whether method type, satisfaction, and confidence were independently associated with having very low switching intentions, adjusting for a range of covariates including sociodemographics, perceived health, religious attendance frequency, sexual, contraceptive, and reproductive experiences, and state of residence (Maryland or Delaware). RESULTS: Among 1,077 women using reversible contraception, those using IUC relative to implants, pills, patches, or rings, and coitally-dependent methods were more likely to have very low switching intentions. Among all survey respondents, those who were very satisfied and those who were completely confident in correct use were also more likely to report very low switching intentions. CONCLUSIONS: Using IUC, being very satisfied, and being very confident in correct use were independently associated with having very low switching intentions. IMPLICATIONS: These results suggest that those using IUC have very low intentions to switch for reasons in addition to satisfaction-level with their method. Other aspects of using IUC such as ease of use, perceived barriers to switching, or having very low switching intentions before beginning IUC may be such reasons.

Changes to Contraceptive Method Use at Title X Clinics Following Delaware Contraceptive Access Now, 2008-2017.

Objectives. To measure changes in the contraceptive methods used by Title X clients after implementation of Delaware Contraceptive Access Now, a public-private initiative that aims to increase access to contraceptives, particularly long-acting reversible contraceptives (LARCs).Methods. Using administrative data from the 2008-2017 Family Planning Annual Reports and a difference-in-differences design, we compared changes in contraceptive method use among adult female Title X family planning clients in Delaware with changes in a set of comparison states. We considered permanent methods, LARCs, moderately effective methods, less effective methods, and no method use.Results. Results suggest a 3.2-percentage-point increase in LARC use relative to changes in other states (a 40% increase from baseline). We were unable to make definitive conclusions about other contraceptive method types.Conclusions. Delaware Contraceptive Access Now increased LARC use among Title X clients. Our results have implications for states considering comprehensive family planning initiatives.

Psychosocial Factors Associated With Postpartum Contraceptive Method Use After an Unintended Birth.

OBJECTIVE: To examine whether depression, intimate partner violence, and other psychosocial stressors were independently associated with effectiveness level of postpartum contraception among women who recently had an unintended birth. METHODS: We analyzed cross-sectional data from PRAMS (the Pregnancy Risk Assessment Monitoring System) to identify women who had an unintended birth between 2012 and 2015. The effectiveness level of the contraceptive method was coded into one of five categories based on the postpartum contraceptive method that women were using: none, less effective (withdrawal, rhythm, condoms, or other barrier), moderately effective (pill, patch, ring, or shot), long-acting reversible contraception (LARC; intrauterine devices or implants), and sterilization (female or male sterilization). Multinomial logistic regression was used to examine whether prepregnancy depression or elevated postpartum depressive symptoms, intimate partner violence before or during pregnancy, and number of psychosocial stressors before birth were associated with effectiveness level of method (compared with no method), in models adjusted for sociodemographics, pregnancy context, and postpartum context. RESULTS: Complete data were available for 56,445 (88.2%) of the 64,030 eligible women: 24.2% experienced depression; 5.3% experienced intimate partner violence; and 16.8% experienced five or more psychosocial stressors around the time of pregnancy or birth. In adjusted models, experiencing intimate partner violence and more stressors lowered women's relative risk of using sterilization, LARC, moderately effective methods, and less-effective contraceptive methods relative to no method use. Only prepregnancy depression was associated with using sterilization compared with no method use. CONCLUSIONS: Experiencing intimate partner violence and having more psychosocial stressors were each independently associated with not using a postpartum contraceptive method. Standardized screening for psychosocial factors during prenatal and postpartum care should be integrated, and practices that encourage the discussion of patients' psychosocial experiences and postpartum contraception use together are warranted.

Association of Childhood Asthma With Federal Rental Assistance.

Importance: Millions of low-income children in the United States reside in substandard or unaffordable housing. Relieving these burdens may be associated with changes in asthma outcomes. Objectives: To examine whether participation in the US Department of Housing and Urban Development's (HUD) rental assistance programs is associated with childhood asthma outcomes and to examine whether associations varied by program type (public housing, multifamily housing, or housing choice vouchers). Design, Setting, and Participants: This survey study used data from the nationally representative National Health Interview Survey linked to administrative housing assistance records from January 1, 1999, to December 31, 2014. A total of 2992 children aged 0 to 17 years who were currently receiving rental assistance or would enter a rental assistance program within 2 years of survey interview were included. Data analysis was performed from January 15, 2018, to August 31, 2019. Exposures: Participation in rental assistance provided by HUD. Main Outcomes and Measures: Ever been diagnosed with asthma, 12-month history of asthma attack, and 12-month history of visiting an emergency department for the treatment of asthma among program participants vs those waiting to enter a program. Overall participation was examined, and participation in public or multifamily housing was compared with participation in housing choice vouchers. Results: This study included 2992 children who were currently participating in a HUD program or would enter a program within 2 years. Among children with an asthma attack in the past year, participation in a rental assistance program was associated with a reduced use of emergency departments for asthma of 18.2 percentage points (95% CI, -29.7 to -6.6 percentage points). Associations were only found after entrance into a program, suggesting that they were not confounded by time-varying factors. Statistically significant results were found for participation in public or multifamily housing (percentage point change, -36.6; 95% CI, -54.8 to -18.4) but not housing choice vouchers (percentage point change, -7.2; 95% CI, -24.6 to 10.3). No statistically significant evidence of changes in asthma attacks was found (percentage point change, -2.7; 95% CI, -12.3 to 7.0 percentage points). Results for asthma diagnosis were smaller and only significant at the 10% level (-4.3; 95% CI, -8.8 to 0.2 percentage points). Conclusions and Relevance: Among children with a recent asthma attack, rental assistance was associated with less emergency department use. These results may have important implications for the well-being of low-income families and health care system costs.

Life and Death in the American City: Men's Life Expectancy in 25 Major American Cities From 1990 to 2015.

The past several decades have witnessed growing geographic disparities in life expectancy within the United States, yet the mortality experience of U.S. cities has received little attention. We examine changes in men's life expectancy at birth for the 25 largest U.S. cities from 1990 to 2015, using mortality data with city of residence identifiers. We reveal remarkable increases in life expectancy for several U.S. cities. Men's life expectancy increased by 13.7 years in San Francisco and Washington, DC, and by 11.8 years in New York between 1990 and 2015, during which overall U.S. life expectancy increased by just 4.8 years. A significant fraction of gains in the top-performing cities relative to the U.S. average is explained by reductions in HIV/AIDS and homicide during the 1990s and 2000s. Although black men tended to see larger life expectancy gains than white men in most cities, changes in socioeconomic and racial population composition also contributed to these trends.

Medicaid expansion and the Medicaid undercount in the American Community Survey.

OBJECTIVE: To measure discordance between aggregate estimates of means-tested coverage from the American Community Survey (ACS) and administrative counts and examine the association of discordance with ACA Medicaid expansion. DATA SOURCES: 2010-2016 ACS and counts of Medicaid and Children's Health Insurance Program enrollment from the Centers for Medicare & Medicaid Services. STUDY DESIGN: State-by-year counts of means-tested coverage from the ACS were compared to administrative counts using percentage differences. Discordance was compared for states that did and did not adopt expansion using difference-in-differences. We then contrasted the effect of expansion on means-tested coverage estimated from the ACS with results from administrative data. DATA COLLECTION/EXTRACTION: Survey and administrative data. PRINCIPAL FINDINGS: One year before expansion there was a 0.8 and 4 percent overcount in expansion and nonexpansion states, respectively. By 2016, there was a 10.64 percent undercount in expansion states vs a 0.02 percent undercount in nonexpansion states. The ACS suggests that expansion increased means-tested coverage in the full population by three percentage points, relative to five percentage points suggested by administrative records. CONCLUSIONS: Discordance between the ACS and administrative records has increased over time. The ACS underestimates the impact of Medicaid expansion, relative to administrative counts.

Using Data From the Healthcare Cost and Utilization Project for State Health Policy Research.

BACKGROUND: The Healthcare Cost and Utilization Project (HCUP), the nation's most complete source of all-payer hospital care data, supports analyses at the national, regional, state and community levels. However, national HCUP data are often used in inappropriate ways in studies of state-specific issues. OBJECTIVE: To describe the opportunities and challenges of using HCUP data to conduct state health policy research and to provide empirical examples of what can go wrong when using the national HCUP data inappropriately. RESEARCH DESIGN: Comparison of results from state-level analyses using national HCUP data and the state-specific HCUP data recommended by the Agency for Healthcare Research and Quality (AHRQ). Analyses included trends in state-specific rates of cesarean delivery and a difference-in-differences analysis of Connecticut's Medicaid expansion. SUBJECTS: Hospital discharges from the 2004 to 2011 HCUP Nationwide Inpatient Samples (NIS) and State Inpatient Databases (SID). MEASURES: Cesarean delivery rates, discharges per capita, and discharges by the payer. RESULTS: State-level estimates derived from the NIS are volatile and often provide misleading policy conclusions relative to estimates from the SID. CONCLUSIONS: The NIS should not be used for state-level research. AHRQ provides resources to assist analysts with state-specific studies using SID files.

The Role of Health Literacy in Family Planning Use among Senegalese Women.

Health communication has contributed to an increase in family planning use through education and mass media as a means to increase health literacy. In this research, we investigate health literacy as an auxiliary component of health communication. We test the validity of the Health Literacy Skills Framework by examining the correlation of health literacy indicators to family planning use among Senegalese women in the 2014 Demographic Health Survey. We found that increased family planning use was most strongly associated with hearing family planning messages through television and radio. Other health literacy indicators, including access to printed family planning messaging, textual literacy, and knowledge of ovulatory cycles did not strengthen family planning use, even when performing a subgroup analysis of women who could read. The implications are that the Health Literacy Skills framework can measure health literacy's ability (assessed through proxy indicators of health literacy) to predict modern family planning use among Senegalese women and that audio and visual health literacy measures are most strongly associated with increased family planning use.