Brendan Saloner

Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010

IMPORTANCE Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them. OBJECTIVE To determine the association between the presence of state medical cannabis laws and opioid analgesic overdose mortality. DESIGN, SETTING, AND PARTICIPANTS A time-series analysis was conducted of medical cannabis laws and state-level death certificate data in the United States from 1999 to 2010; all 50 states were included. EXPOSURES Presence of a law establishing a medical cannabis program in the state. MAIN OUTCOMES AND MEASURES Age-adjusted opioid analgesic overdose death rate per 100 000 population in each state. Regression models were developed including state and year fixed effects, the presence of 3 different policies regarding opioid analgesics, and the state-specific unemployment rate. RESULTS Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate (95% CI, -37.5% to -9.5%; P = .003) compared with states without medical cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time: year 1 (-19.9%; 95% CI, -30.6% to -7.7%; P = .002), year 2 (-25.2%; 95% CI, -40.6% to -5.9%; P = .01), year 3 (-23.6%; 95% CI, -41.1% to -1.0%; P = .04), year 4 (-20.2%; 95% CI, -33.6% to -4.0%; P = .02), year 5 (-33.7%; 95% CI, -50.9% to -10.4%; P = .008), and year 6 (-33.3%; 95% CI, -44.7% to -19.6%; P < .001). In secondary analyses, the findings remained similar. CONCLUSIONS AND RELEVANCE Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws may interact with policies aimed at preventing opioid analgesic overdose.

Primary Care Access for New Patients on the Eve of Health Care Reform

IMPORTANCE Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients. OBJECTIVE To assess primary care appointment availability by state and insurance status. DESIGN, SETTING, AND PARTICIPANTS We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state. MAIN OUTCOMES AND MEASURES The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured. RESULTS Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to

Pinching the Poor? Medicaid Cost Sharing under the ACA

75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern. CONCLUSIONS AND RELEVANCE Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plans network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

The emerging public discourse on state legalization of marijuana for recreational use in the US: Analysis of news media coverage, 2010–2014

Some U.S. states have begun experimenting with increased cost sharing for Medicaid enrollees, but policymakers will need to monitor such programs carefully to understand their impact on costs, quality, access, and health.

Episodes of mental health treatment among a nationally representative sample of children and adolescents

OBJECTIVES US states have begun to legalize marijuana for recreational use. In the absence of clear scientific evidence regarding the likely public health consequences of legalization, it is important to understand how the risks and benefits of this policy are being discussed in the national dialogue. To assess the public discourse on recreational marijuana policy, we assessed the volume and content of US news media coverage of the topic. METHOD We analyzed the content of a 20% random sample of news stories published/aired in high circulation/viewership print, television, and Internet news sources from 2010 to 2014 (N=610). RESULTS News media coverage of recreational marijuana policy was heavily concentrated in news outlets from the four states (AK, CO, OR, WA) and DC that legalized marijuana for recreational use during the study period. Overall, 53% of news stories mentioned pro-legalization arguments and 47% mentioned anti-legalization arguments. The most frequent pro-legalization arguments posited that legalization would reduce criminal justice involvement/costs (20% of news stories) and increase tax revenue (19%). Anti-legalization arguments centered on adverse public health consequences, such as detriments to youth health and well-being (22%) and marijuana-impaired driving (6%). Some evidence-informed public health regulatory options, like marketing and packaging restrictions, were mentioned in 5% of news stories or fewer. CONCLUSION As additional states continue to debate legalization of marijuana for recreational use, it is critical for the public health community to develop communication strategies that accurately convey the rapidly evolving research evidence regarding recreational marijuana policy.

Access points for the underserved: primary care appointment availability at federally qualified health centers in 10 States.

Despite renewed national interest in mental health care reform, little is known about treatment patterns among youth in the general population. Using longitudinal data from the Medical Expenditure Panel Survey, we examined both initiation and continuity of mental health treatment among 2,576 youth aged 5 to 17 with possible mental health treatment need (defined as a high score on a parent-assessed psychological impairment scale, fair/poor mental health status, or perceived need for counseling). Over a 2-year period, fewer than half of sampled youth initiated new mental health treatment. Minority, female, uninsured, and lower-income youth were significantly less likely to initiate care. Only one third of treatment episodes met criteria for minimal adequacy (≥4 provider visits with psychotropic medication treatment or ≥8 visits without medication). Episodes were significantly shorter for Latino youth. Efforts to strengthen mental health treatment for youth should be broadly focused, emphasizing not only screening and access but also treatment continuity.

Insurance Coverage and Treatment Use Under the Affordable Care Act Among Adults With Mental and Substance Use Disorders

Background:Federally Qualified Health Centers (FQHCs) are a vital source of primary care for underserved populations, such as Medicaid enrollees and the uninsured. Their role in delivering care may increase through new funding allocations in the Affordable Care Act and expanded Medicaid programs across many states. Objective:Examine differences in appointment availability and wait-times for new patient visits between FQHCs and other providers. Research Design:We use experimental data from a simulated patient study to compare new patient appointment rates across FQHC and non-FQHC practices for 3 insurance types (private, Medicaid, and self-pay). Trained auditors, posing as patients requesting the first available new patient appointment, were randomized to call primary care providers in 10 states in late 2012 and early 2013. Multivariate regression models adjust for caller-level, clinic-level, and area-level variables. Study Setting:The sample comprises 10,904 calls, including 544 calls to FQHCs. Results:FQHCs grant new patient appointments at high rates, irrespective of patient insurance status. Adjusting for caller, clinic, and area variables, the Medicaid appointment rate at FQHCs is 22 percentage points higher than other primary care practices. Although the appointment rate difference between FQHCs and non-FQHCs is somewhat smaller for the self-pay group, FQHCs are much more likely to provide a lower-cost visit to these patients. Conditional on receiving an appointment, wait-times at FQHCs are comparable with other providers. Conclusion:FQHCs’ greater willingness to accept new underserved patients before 2014 underscores their potential key roles as health reform proceeds.

Explaining Racial/Ethnic Differences in Adolescent Substance Abuse Treatment Completion in the United States: A Decomposition Analysis

OBJECTIVE Many adults who have mental or substance use disorders or both experience insurance-related barriers to care, contributing to low treatment utilization. Expanded insurance under the Affordable Care Act (ACA) could improve coverage and access. The study identified changes in coverage and treatment use following 2014 ACA insurance expansions. METHODS Data from the National Survey on Drug Use and Health were used to identify individuals ages 18-64 screening positive for any mental disorder (N=29,962) or substance use disorder (N=19,243) for two periods: 2011-2013 and 2014. Regression-adjusted means were calculated for insurance rates and treatment used in each period overall and among individuals with household incomes ≤200% of the federal poverty level (FPL). RESULTS Compared with 2011-2013, in 2014 significant reductions were seen in the uninsured rate for individuals with mental disorders (-5.4 percentage points, p<.01) and substance use disorders (-5.1 percentage points, p<.01). Increases in insurance coverage occurred mostly through Medicaid. Insurance gains were larger for adults with incomes ≤200% of FPL compared with the overall sample. Use of mental health treatment increased by 2.1 percentage points (p=.04), but use of substance use disorder treatment did not change. No significant changes were noted in treatment settings for mental and substance use disorder treatments. Payment by Medicaid for substance use disorder treatment increased by 7.4 percentage points (p=.05). CONCLUSIONS Sizable increases in coverage for adults with mental disorders and adults with substance use disorders were identified in the year following the 2014 ACA expansions; however, low treatment rates among this population remain a concern. Initiatives to engage the newly insured in treatment are needed.

Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families

PURPOSE To identify contributors to racial/ethnic differences in completion of alcohol and marijuana treatment among adolescents at publicly funded providers. METHODS The 2007 Treatment Episode Data Set provided substance use history, treatment setting, and treatment outcomes for youth aged 12-17 years from five racial/ethnic groups (N = 67,060). Individual-level records were linked to variables measuring the social context and service system characteristics of the metropolitan area. We implemented nonlinear regression decomposition to identify variables that explained minority-white differences. RESULTS Black and Hispanic youth were significantly less likely than whites to complete treatment for both alcohol and marijuana. Completion rates were similar for whites, Native Americans, and Asian-Americans, however. Differences in predictor variables explained 12.7% of the black-white alcohol treatment gap and 7.6% of the marijuana treatment gap. In contrast, predictors explained 57.4% of the Hispanic-white alcohol treatment gap and 19.8% of the marijuana treatment gap. While differences in the distribution of individual-level variables explained little of the completion gaps, metropolitan-level variables substantially contributed to Hispanic-white gaps. For example, racial/ethnic composition of the metropolitan area explained 41.0% of the Hispanic-white alcohol completion gap and 23.2% of the marijuana completion gap. Regional differences in addiction treatment financing (particularly use of Medicaid funding) explained 13.7% of the Hispanic-white alcohol completion gap and 9.8% of the Hispanic-white marijuana treatment completion gap. CONCLUSIONS Factors related to social context are likely to be important contributors to white-minority differences in addiction treatment completion, particularly for Hispanic youth. Increased Medicaid funding, coupled with culturally tailored services, could be particularly beneficial.

No Place to Call Home — Policies to Reduce ED Use in Medicaid

IMPORTANCE An increasing diversity of childrens health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Childrens Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. OBJECTIVE To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. DESIGN, SETTING, AND PARTICIPANTS A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Childrens Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. EXPOSURES Insurance type was ascertained using a caregiver-reported measure of insurance status and each households poverty status (percentage of the federal poverty level). MAIN OUTCOMES AND MEASURES Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. RESULTS Among the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the childs needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01). CONCLUSIONS AND RELEVANCE This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.