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Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States

      Abstract

      Background

      As employment, financial status, and residential location change, people can gain, lose, or switch health insurance coverage, which may affect care access and health. Among Women's Interagency HIV Study participants with HIV and participants at risk for HIV attending semiannual visits at 10 U.S. sites, we examined whether the prevalence of coverage types and rates of coverage changes differed by HIV status and Medicaid expansion in their states of residence.

      Methods

      Geocoded addresses were merged with dates of Medicaid expansion to indicate, at each visit, whether women lived in Medicaid expansion states. Age-adjusted rate ratios (RRs) and rate differences of self-reported insurance changes were estimated by Poisson regression.

      Results

      From 2008 to 2018, 3,341 women (67% Black, 71% with HIV) contributed 43,329 visits at aged less than 65 years (27% under Medicaid expansion). Women with and women without HIV differed in their proportions of visits at which no coverage (14% vs. 19%; p < .001) and Medicaid enrollment (61% vs. 51%; p < .001) were reported. Women in Medicaid expansion states reported no coverage and Medicaid enrollment at 4% and 69% of visits, respectively, compared with 20% and 53% of visits for those in nonexpansion states. Women with HIV had a lower rate of losing coverage than those without HIV (RR, 0.81; 95% confidence interval [CI], 0.70 to 0.95). Compared with nonexpansion, Medicaid expansion was associated with lower coverage loss (RR, 0.62; 95% CI, 0.53 to 0.72) and greater coverage gain (RR, 2.32; 95% CI, 2.02 to 2.67), with no differences by HIV status.

      Conclusions

      Both women with HIV and women at high risk for HIV in Medicaid expansion states had lower coverage loss and greater coverage gain; therefore, Medicaid expansion throughout the United States should be expected to stabilize insurance for women and improve downstream health outcomes.
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      Biography

      Andrew Edmonds, PhD, is an Assistant Professor of Epidemiology at the University of North Carolina at Chapel Hill. His expertise is in analysis of observational cohort data to address priority research questions impacting women and children with or at risk for HIV.

      Biography

      Nadya Belenky, PhD, is a Health Services Researcher at RTI International, working on Medicare and Medicaid reimbursement policy. Her doctorate is in epidemiology, and her research focus is on health insurance coverage and coverage transitions.

      Biography

      Adebola A. Adedimeji, PhD, is a social epidemiologist at the Albert Einstein College of Medicine. His work focuses on social and structural determinants of health, HIV prevention, stigma, and cancer education/prevention among at-risk and marginalized populations, using mixed methods to design context-specific solutions.

      Biography

      Mardge H. Cohen, MD, is an internal medicine physician at John H. Stroger, Jr. Hospital of Cook County. She founded the Women's and Children HIV Program in 1989, and since then has cared for and participated in research related to women with HIV.

      Biography

      Gina Wingood, ScD, is the Sidney and Helaine Lerner Professor of Public Health Promotion at Columbia University, Mailman School of Public Health. She is interested in designing, implementing, and evaluating social and structural HIV prevention interventions for women of color.

      Biography

      Margaret A. Fischl, MD, a Professor of Medicine in the Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine. Her research interests focus on impacts of the epidemiology and behavioral factors of HIV in men and women.

      Biography

      Elizabeth T. Golub, PhD, is a Senior Lecturer at the Johns Hopkins Bloomberg School of Public Health. Her research interests include epidemiology, HIV, women, antiretroviral therapy, injection drug users, and HCV.

      Biography

      Mallory O. Johnson, PhD, is a Professor in the Department of Medicine at the University of California, San Francisco. His research focuses on multi-level factors affecting engagement in treatment and prevention in the context of HIV and other health conditions.

      Biography

      Daniel Merenstein, MD, is a Professor with tenure of Family Medicine at Georgetown University. His secondary appointment is in undergraduate Department of Human Science, School of Nursing and Health Studies. His research interests are probiotics, antibiotic stewardship in outpatient settings, and HIV.

      Biography

      Joel Milam, PhD, is a Professor in the Department of Epidemiology and Biostatistics at the University of California, Irvine. His research focuses on the long-term psychological and behavioral adaptation to cancer and HIV, with a focus on underrepresented and young adult populations.

      Biography

      Deborah Konkle-Parker, PhD, FNP, holds the Harriet G. Williamson Chair of Population Health Nursing at the University of Mississippi Medical Center. Her research focuses on psychosocial/behavioral factors influencing outcomes of HIV disease. She was a site co-PI for WIHS and currently the MWCCS.

      Biography

      Tracey E. Wilson, PhD, is Distinguished Service Professor of the Department of Community Health Sciences and Vice Dean for Faculty Affairs and Research at SUNY Downstate Health Sciences University. She focuses on social, structural, and psychological causes of racial/ethnic and gender-based health disparities.

      Biography

      Adaora A. Adimora, MD, MPH, is the Sarah Graham Kenan Distinguished Professor of Medicine, and a Professor of Epidemiology, at the University of North Carolina at Chapel Hill. Her research focuses on the epidemiology of sexually transmitted diseases and HIV in women and minorities.