BACKGROUND AND OBJECTIVE:Children with intellectual disabilities and related conditions (IDRC) and autism often require dental treatment in surgical settings. Studies of older adults suggest that ambulatory surgery centers (ASCs) can reduce costs without reducing quality, but it is unknown whether this is true for children with autism and IDRC and dental surgeries. This study compared outcomes among children with IDRC and autism receiving dental caries-related surgeries at ASCs and hospital outpatient departments (HOPDs). METHODS:This cross-sectional analysis used Medicaid data from 29 states (2016-2020) to examine 17 552 outpatient dental surgeries in ASCs and HOPDs for children with IDRC or autism. Regression models were used to examine whether outcomes varied by setting of care (ASC vs HOPD). The following outcomes were included: days from diagnosis to surgery, Medicaid payment, emergency department (ED) visits, and hospitalization after surgery. RESULTS:Multivariate regression results indicate time from diagnosis to surgery was, on average, 8.7 days sooner for a child with autism and 13.2 days sooner for a child with IDRC if furnished in an ASC compared with a HOPD (P < .001 for both). Average Medicaid payment was $419 and $363 less in an ASC than HOPD for a child with autism (P = .003) or IDRC (P = .02), respectively. The likelihood of an ED visit or hospitalization was lower in an ASC than HOPD for a child with IDRC (P < .001), but not autism (P > .05). CONCLUSIONS:Increasing use of ASCs for dental care may increase timely receipt of care and lower Medicaid costs without increasing adverse outcomes for children with autism and IDRC.

BACKGROUND:Use of ambulatory surgery centers (ASCs) relative to hospital outpatient departments (HOPDs) for outpatient surgeries for caries in children with intellectual disabilities and related conditions (IDRC) and autism has not been characterized. METHODS:In this cross-sectional analysis of Medicaid data (2016-2020) from 40 states, the authors examined 601,286 outpatient dental surgeries performed in ASCs and HOPDs in children (1-18 years) with IDRC, with autism, and without IDRC or autism (IDRC/A), overall and according to race and ethnicity. Multivariable regression models estimated regression-adjusted probabilities of receiving care in ASCs. Models included year and state fixed effects and child-level clustered SEs. RESULTS:Among surgeries in ASCs and HOPDs, the regression-adjusted predicted probability of ASC use was 14.0 percentage points lower for children with IDRC (15.9%; P < .001) and 3.8 percentage points lower for children with autism (26.1%: P < .001) than for children without IDRC/A (29.9%). Racial and ethnic differences within disability groups were small. Among surgeries in ASCs and HOPDs, the probability of ASC use was 1.8 percentage points lower for Hispanic autistic children (P = .009) than White autistic children. Among children without IDRC/A who were treated in an ASC or HOPD, ASC use was 0.6 percentage points higher for Black children (P < .001) and 1.1 percentage points higher for Hispanic children (P = .001) than for White children. CONCLUSIONS:Children with IDRC and autism were less likely to receive care in ASCs than HOPDs than children without IDRC/A. PRACTICAL IMPLICATIONS:Because ASCs are less costly than HOPDs, providing more care at ASCs for children with IDRC and autism may help reduce costs for this population.

BACKGROUND:School-based health centers (SBHCs) and other school-based clinics (OSBCs) reduce health care access barriers and support positive outcomes in disadvantaged children by providing primary medical care and other services, respectively. This study describes California SBHCs and OSBCs and identifies school characteristics associated with access. METHODS:Databases on California SBHCs, OSBCs, and schools were compiled. Descriptive statistics characterize the number of clinics and services offered from 2011 to 2023. Multivariable logistic regression models estimate associations between school characteristics and SBHC/OSBC access in 2023. RESULTS:Between 2011and 2023, the SBHCs increased from 124 to 186, and services became more comprehensive. OSBCs increased from 18 to 104, with most offering mental health services. SBHC access was more likely in schools with a larger share of students who were English Learners and "other" as their race and ethnicity; high schools; and in large cities. OSBC access was more likely in schools with a larger share of English Learner students and in cities. CONCLUSIONS:SBHCs and OSBCs expanded and largely served disadvantaged schools, which may promote health and academic equity.

OBJECTIVE:Examine the association between perceived racial discrimination and children's oral health outcomes by race-ethnicity and socioeconomic status (SES). METHODS:Using the National Survey of Children's Health (2016-2022), we examined the relationship between perceived racial discrimination (caregiver-reported child exposure) and two outcomes: a child's receipt of a dental visit and the presence of any oral health problem in the past year. Logistic regression models were estimated, stratified by race-ethnicity (Black, Hispanic, White), and adjusted for SES using the federal poverty level (FPL). We also interacted perceived racial discrimination and FPL to observe how associations differ by SES. RESULTS:Perceived racial discrimination was associated with lower rates of dental visits for White and Hispanic children, with no significant association for Black children. Perceived racial discrimination was associated with a higher likelihood of having an oral health problem for all three racial-ethnic groups. In interaction models, associations with dental visits were inconsistent. The association between perceived racial discrimination and having an oral health problem in the past year was primarily isolated to the lowest SES strata (< 200% FPL), with higher likelihoods of having an oral health problem for all three racial-ethnic groups among those who perceived racial discrimination. CONCLUSIONS:Perceived racial discrimination is associated with worse oral health and inconsistently with having a dental visit. The stronger association with oral health problems among children in the lowest SES strata highlights the need for targeted interventions addressing both racial discrimination and SES disparities to improve child oral health outcomes.

BACKGROUND AND OBJECTIVES Biannual preventive dental visits are recommended to promote good oral health and identify problems, yet children in many families do not receive this care due to time-related barriers. Paid sick leave mandates have the potential to relieve parental time constraints and facilitate scheduling and attending pediatric dental visits; thus, we sought to evaluate the effects of state paid sick leave mandates on children’s receipt of preventive dental care. METHODS Using 2016 to 2023 National Survey of Children’s Health data and a difference-in-differences approach, we compared trends in children’s receipt of preventive dental care in states that did and did not implement paid sick leave mandates. RESULTS Pre-implementation of paid sick leave mandates, children residing in states that later implemented these policies were more likely to have received preventive dental care, to be non-Hispanic white, to have private health insurance, and to have parents with more than a high school education, relative to children residing in states that never implemented paid sick leave mandates. State paid sick leave mandates were associated with a 3.2% relative increase (95% CI: 0.2%, 6.2%) in rates of children receiving preventive dental care, controlling for time-varying demographic and policy characteristics, with state and year fixed effects. CONCLUSIONS State-paid sick leave mandates may alleviate competing parental work and caregiving responsibilities and provide parents with additional time and flexibility to obtain dental care for their children.

OBJECTIVE:To examine how site of care and insurance network contribute to price differences for common adult outpatient surgeries paid by commercial insurers. STUDY DESIGN:Observational study using a 50-state sample of commercial medical claims data. METHODS:We compared insurer-paid amounts, patient out-of-pocket payments, and balance billing amounts for 4 common adult outpatient surgeries (arthroscopy, cataract, colonoscopy, and upper gastrointestinal procedures) by site of care (ambulatory surgery center [ASC] vs hospital outpatient department [HOPD]) and insurance network status (in network vs out of network). RESULTS:Compared with a surgery occurring at an in-network ASC, insurers paid $306 (32%) more to an out-of-network ASC, $1042 (110%) more to an in-network HOPD, and $1041 (110%) more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, which both had cost-sharing rates lower than out-of-network facilities. CONCLUSIONS:Patients saved money by choosing in-network facilities regardless of the site of care, whereas insurers saved by increasing the usage of ASCs for common adult outpatient surgeries paid by commercial insurers. Insurance models that better align patient and insurer incentives could increase utilization of ASCs and lower overall spending on outpatient surgeries.

Importance:Despite need, children face access barriers to dental surgical procedures. Surgical procedures for older adults delivered in ambulatory surgical centers (ASCs) are less costly than and of comparable quality to care delivered in hospital outpatient departments (HOPDs), but it remains unknown whether this association extends to pediatric dental surgical procedures. Objective:To determine whether payment, time from diagnosis to care, and adverse events for pediatric surgical procedures for dental caries vary between ASCs and HOPDs paid by Medicaid. Design, Setting, and Participants:This cross-sectional study of Medicaid data (July 1, 2016, through January 31, 2020) used an instrumental variables regression approach and exploited a source of exogeneous variation influencing ASC supply. Analysis was conducted October 2024 to April 2025, using records from 29 states with high-quality Medicaid data. Participants were children aged 18 years or younger enrolled in Medicaid who underwent surgical procedures for dental caries in an ASC or HOPD. Exposure:Receipt of dental surgical care in an ASC or HOPD. Main Outcomes and Measures:The primary outcomes were Medicaid payment, days from diagnosis to surgery, and any emergency department visits and hospitalizations within 7 days after surgery. Results:Across 391 628 pediatric dental surgical procedures, patients had a mean (SD) age of 5.00 (3.05) years, and 211 819 (54.09%) were male. Medicaid payment was $604 (95% CI, $149-$1058; P < .009) less for a surgery occurring in an ASC vs an HOPD, corresponding to a 27% reduction in spending, and time from diagnosis to surgery was 8.9 days (95% CI, 5.5-12.3 days; P < .001) less for a surgery occurring in an ASC than HOPD. A surgery occurring in an ASC (vs HOPD) was statistically significantly less likely to be followed by an emergency department visit or hospitalization within 7 days after surgery (0.27 percentage points; 95% CI, 0.18-0.36 percentage points) and a hospitalization within 30 days after surgery (0.28 percentage points, 95% CI, 0.11-0.45 percentage points). Conclusions and Relevance:In this cross-sectional study of pediatric surgical procedures for dental caries paid by Medicaid, procedures performed in ASCs were less costly and had lower rates of adverse events compared with those performed in HOPDs. The time from diagnosis to surgery was shorter for surgical procedures in ASCs compared with HOPDs, suggesting that ASCs may improve access to care for children from low-income families needing for dental treatment. Increased use of ASCs for pediatric dental surgical procedures may reduce costs for Medicaid and improve patient experiences.

This cross-sectional study examines rates of insurance claim denials for fluoride varnish treatment and well-child medical visits among US children.

OBJECTIVE:Primary care medical providers are recommended to apply fluoride varnish to the teeth of young children to prevent tooth decay. The COVID-19 pandemic interrupted care delivery in health care settings and may have differentially impacted patients with different types of insurance. The objective of this study was to examine changes in children's receipt of fluoride varnish in the medical office during 2014-2022. METHODS:Using all-payer claims data from Massachusetts (2014-2022), we examined children's receipt of fluoride varnish during medical visits over time overall and by insurance-type. Because rates were highest in 2019, this was used as the reference year. We examined if results were driven by receipt (or non-receipt) of medical visits. RESULTS:Following growth from 2014 to 2019, the probability of a child receiving fluoride varnish in 2022 compared to 2019 was 2.4 (95% confidence interval [CI] = -3.5 to -1.3) percentage points (pp) lower for a child with private insurance and 6.0 (95% CI = -8.0 to -4.0) pp lower for a child with Medicaid, representing declines of 15% and 37%, respectively. We did not observe a similar decline in children's receipt of medical visits during this time and our findings on fluoride varnish receipt were similar when we controlled for receipt of medical visits. CONCLUSIONS:Fluoride varnish receipt among young children declined precipitously during the COVID-19 pandemic and was not explained by declines in well-child medical visits. Declines were greater for children with Medicaid, erasing nearly a decade of progress in promotion of this evidence-based preventive service.

OBJECTIVES:This qualitative study aimed to understand dental professionals' perspectives and practices regarding preventive dental care for very young children and preventive oral health services (POHS) provided outside of dental practices. METHODS:Semi-structured interviews were conducted on Zoom with a purposive sample of dental professionals in Massachusetts between December 12, 2022, and June 15, 2023, until theoretical saturation was reached. The Consolidated Framework for Implementation Research was the study's conceptual framework. Applying Charmaz's approach to grounded theory, transcripts were coded line-by-line in an iterative process, using memos and axial coding to identify themes. RESULTS:Twenty-eight interviews were conducted with general dentists (n = 18), pediatric dentists (n = 5), registered dental hygienists (n = 3), a dental assistant (n = 1), and a dental administrator (n = 1). Major themes included: (1) facilitators and barriers to providing preventive dental care for children under 3 years old; (2) perceptions of POHS delivery outside of dental practices and care coordination; (3) public policies potentially impacting the provision of preventive dental care for young children; and (4) potential levers for change to improve receipt of recommended preventive dental services. Sub-themes included training, concerns about the quality of care in non-dental sites, public insurance barriers, and increasing joint dental-medical curriculum programs. CONCLUSIONS:Potentially modifiable barriers were identified at provider, practice, and policy levels. Further research is needed regarding the financial impacts of public insurance reimbursement rates, the potential role of bias in access to preventive dental services, and the effects of systematic accountability for performance on quality and equity measures related to preventive dental care.

ImportanceMillions of economically disadvantaged children depend on Medicaid for dental care, with states differing in whether they deliver these benefits using fee-for-service or capitated managed care payment models. However, there is limited research examining the association between managed care and the accessibility of dental services.ObjectiveTo estimate the association between the adoption of managed care for dental services in Florida’s Medicaid program and nontraumatic dental emergency department visits and associated charges.Design, Setting, and ParticipantsThis cohort study used an event-study difference-in-differences design, leveraging Florida Medicaid’s staggered adoption of managed care to examine its association with pediatric nontraumatic dental emergency department visits and associated charges. This study included all Florida emergency department visits from 2010 to 2014 in which the patient was 17 years or younger, the patient was a Florida resident, Medicaid paid for the visit, and a primary or secondary International Classification of Diseases, Ninth Revision, code was used to classify a nontraumatic dental condition. Analyses were conducted between May 2023 and April 2024.ExposureThe county of residence transitioning Medicaid dental services from fee-for-service to a fully capitated managed care program managed by a dental plan.Main Outcomes and MeasuresThe rate of nontraumatic dental emergency department visits per 100 000 pediatric Medicaid enrollees and the associated mean charges per visit. Nontraumatic dental emergency department visits are a well-documented proxy for access to dental care. Data on emergency department visit counts came from the Florida Agency for Health Care Administration. Medicaid population denominators were derived from the American Community Survey’s 5-year estimates.ResultsAmong the 34 414 pediatric nontraumatic dental emergency department visits that met inclusion criteria across Florida’s 67 counties, the mean (SD) age of patients was 8.11 (5.28) years, and 50.8% of patients were male. Of these, 10 087 visits occurred in control counties and 24 327 in treatment counties. Control counties generally had lower rates of NTDC ED visits per 100 000 enrollees compared with treatment counties (123.5 vs 132.7). Over the first 2.5 years of implementation, the adoption of managed care was associated with an 11.3% (95% CI, 4.0%-18.4%; P = .002) increase in nontraumatic dental emergency department visits compared with pre-implementation levels. There was no evidence that the average charge per visit changed.Conclusions and RelevanceIn this cohort study, Florida Medicaid’s adoption of managed care for pediatric dental services was associated with increased emergency department visits for children, which could be associated with decreased access to dental care.

Introduction: Black children in the United States have lower rates of dental visits and higher rates of poor oral health. However, few studies have examined the role of structural racism as a contributor to racial gaps in children's oral health. This study assessed associations between state-level structural racism and oral health outcomes of children and the related Black-White disparities.Methods: This repeated cross-sectional observational study examined children aged 1 to 17 y in the 2016 to 2021 National Survey of Children's Health (NSCH). Three outcomes were examined: utilization (dentist visit in past 12 mo), any oral health problem (difficulty in past 12 mo with bleeding gums, cavities, or toothaches), and oral health (teeth in excellent or very good condition). A state-level index was constructed to measure Black-White structural racism composed of 5 dimensions (judicial, educational, economic, political, and neighborhood segregation) and linked to the NSCH. Estimated population-weighted logit regression models were used to assess associations between the outcomes and race and structural racism, adjusting for demographics and socioeconomic status.Results: The dataset consisted of 98,423 Black (11%) or White (88%) children. Black children had relatively worse outcomes than White children did, with the largest difference observed for the children having teeth in excellent or very good condition (73% vs. 83%). State-level structural racism was not statistically significantly associated with a child receiving dental care, having any oral health problem, or having teeth in excellent or very good condition. US Black-White disparities in these outcomes were unchanged after adjustment for state-level structural racism.Conclusions: Expanded efforts are needed to address US Black-White disparities in child oral health outcomes. State-level structural racism was not associated with these outcomes. Future research should explore whether findings change when examining these associations at a different geographic level and whether indices of structural racism should explicitly include items specific to health care access and child-specific institutional domains.Knowledge Transfer Statement: Black children in this US study had relatively worse oral health and were less likely to have a dental visit than White children were. Structural racism did not explain these disparities, which suggests the need for further research to study mechanisms driving these disparities and how to address them. Policy makers should consider policies that expand where care is delivered, who delivers care, and increase dentists' Medicaid participation, strategies identified previously for reducing disparities.

OBJECTIVES: To identify factors associated with clinicians' likelihood and intensity of applying fluoride varnish (FV) overall and for visits paid by Medicaid and private insurers. STUDY DESIGN: Observational study using claims data. METHODS: Using the Massachusetts All-Payer Claims Database (2016-2018), we conducted a repeated crosssectional study of 2911 clinicians (7277 clinician-year observations) providing well-child visits to children aged 1 to 5 years. Zero-inflated negative binomial models estimated the probability of a clinician applying FV and the number of visits with FV applications, overall and separately for visits paid by Medicaid and private insurers. RESULTS: A total of 30.9% of clinician-years applied FV at least once, and overall, an average of 8.4% of a clinician's well-child visits included FV annually. Controlling for all covariates, having a higher percentage of patients insured by Medicaid was associated with applying FV (OR, 1.35; 95% CI, 1.23-1.45) and a higher expected number of applications (OR, 1.05; 95% CI, 1.02-1.09). Additionally, having a higher percentage of patients aged 1 to 5 years was associated with applying FV (OR, 1.20; 95% CI, 1.01-1.43), but not the number of applications. Similar associations were observed among visits paid by private insurers. CONCLUSIONS: Despite clinical recommendations and mandated insurance reimbursements, the likelihood and intensity of FV applications was low for most pediatric primary care clinicians. Clinician behavior was associated with patient-panel characteristics, suggesting the need for interventions that account for these differences.

Objective National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application. Methods We conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study's theoretical framework and data were analyzed using a modified grounded theory approach. Results Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists. Conclusions This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.

BACKGROUND AND OBJECTIVES: The Affordable Care Act required private insurers to cover a set of recommended preventive services without cost-sharing. This included coverage of fluoride varnish (FV) applications without cost-sharing for children aged 1 through 5 during medical visits, an evidence-based treatment that prevents tooth decay. We examined if this coverage mandate was associated with more young children receiving FV. METHODS: Using the Massachusetts All-Payer Claims Database (2014-2018), we examined the likelihood that a privately insured child received FV during a medical visit in a month. We used a difference-in-differences approach, comparing those included in the coverage mandate (aged 1-5) to those excluded from the mandate (aged 6-9), before and after the mandate was enacted (January 2015). We repeated analyses in children with Medicaid because this mandate may have had spillover effects for this population. RESULTS: Among children aged 1 through 5 years with private insurance, 1-year postmandate the probability of FV receipt in a month increased 0.16 percentage points more relative to December 2014 (premandate) compared with the change among children aged 6 to 9 years (P < .001; 95% confidence interval = 0.1-0.22). When examining spillover to children with Medicaid, the mandate was not associated with a significant increase in the probability of monthly FV receipt 1-year postmandate. CONCLUSIONS: This Affordable Care Act mandate requiring coverage of FV without cost-sharing was associated with higher rates of young children receiving FV in medical settings, with the largest result observed among children with private insurance.

Background The COVID-19 pandemic created new barriers to oral health care, which may worsen oral health and exacerbate disparities. The authors quantified changes in children's dental care receipt and oral health outcomes during the pandemic and examined differences among racial and ethnic groups. Methods Using the National Survey of Children's Health (163,948 child observations from 2017-2021), the authors used weighted modified Poisson models to examine caregiver-reported receipt of a dental visit (for any reason and for preventive care) and adverse oral health outcomes (teeth in fair or poor condition; difficulty with toothaches, cavities, or bleeding gums) from 2017 through 2019 (prepandemic) compared with 2020 and 2021. The authors examined outcomes within and across racial and ethnic groups. Results Children from all racial and ethnic groups experienced declines in receipt of dental visits, but there were limited changes in adverse oral health outcomes during 2020 and 2021. Prepandemic disparities in receipt of dental visits persisted for Black children and Asian children compared with White children. Hispanic children experienced larger increases in risk of experiencing both adverse oral health outcomes compared with White children in 2020 and in having teeth in fair or poor condition in 2021. Conclusions The pandemic did not create new disparities in receipt of dental visits or oral health outcomes, but disparities in care persisted, and the oral health of Hispanic children was affected differentially. Practical Implications Continued monitoring of dental visits and adverse oral health outcomes by race and ethnicity is critical to ensuring all children have access to oral health care. This information can help develop targeted interventions to improve children's oral health, including for minoritized racial and ethnic groups.

Objective To examine perceived barriers and strategies adopted to continue the delivery of school-based health services when schools reopened in Fall of 2021 during the COVID-19 pandemic and to assess whether these barriers and strategies varied by locality. Methods We developed and subsequently conducted an online survey of school nurses who worked at the 1178 public elementary schools in Virginia in May 2021 to describe the impact of the COVID-19 pandemic on the delivery of school-based health services. We compared perceived barriers, strategies adopted and the effectiveness of strategies to continue the delivery of school-based health services by geographic locality (city vs. rural; suburban vs. rural and city vs. suburban). Results More than half of schools located in cities expected nine of ten potential barriers to affect the delivery of school-based health services during Fall 2021. More than 50% of responding schools located in urban, suburban and rural area indicated that external barriers outside of their control, including insufficient funding and families not able to bring students to school, were likely to be barriers to delivering care. Strategies identified as “very effective” did not vary by locality. Across all localities, more schools reported virtual strategies were less effective than in-person strategies. Conclusions for Practice Lessons from the early stages of the COVID-19 pandemic provide critical information for natural disaster and public health emergency preparedness. School locality should be considered in the development of plans to continue the delivery of school-based health services after natural disasters or during public health emergencies.

OBJECTIVES In 2008, Florida's Medicaid program began reimbursing medical providers for preventive oral health services (POHS) delivered to children aged 6 months to 42 months. We examine whether Medicaid comprehensive managed care (CMC) and fee for service (FFS) had different rates of POHS during pediatric medical visits. STUDY DESIGN Observational study using claims data (2009-2012). METHODS Using repeated cross-sections of 2009-2012 Florida Medicaid data for children 3.5 years or younger, we examined pediatric medical visits. We estimated a weighted logistic regression model to compare POHS rates among visits reimbursed by CMC and FFS Medicaid. The model controlled for FFS (vs CMC), years Florida had a policy allowing POHS in medical settings, an interaction between these 2 variables, and additional child- and county-level characteristics. Results are presented as regression-adjusted predictions. RESULTS Among 1,765,365 weighted well-child medical visits in Florida, POHS were included in 8.33% of CMC-reimbursed visits and 9.67% of FFS-reimbursed visits. Compared with FFS, CMC-reimbursed visits had a nonsignificant 1.29-percentage-point lower adjusted probability of including POHS (P = .25). When examining differences over time, although the POHS rate was 2.72 percentage points lower for CMC-reimbursed visits after 3 years of policy enactment (P = .03), rates were similar overall and increased over time. CONCLUSIONS POHS rates among pediatric medical visits in Florida were similar for visits paid via FFS and CMC, with low rates that increased modestly over time. Our findings are important because more children continue to be enrolled in Medicaid CMC.

The one-year U.S. Equity-First Vaccination Initiative (EVI), launched in April 2021, aimed to reduce racial inequities in coronavirus disease 2019 (COVID-19) vaccination across five demonstration cities (Baltimore, Chicago, Houston, Newark, and Oakland) and over the longer term strengthen the United States' public health system to achieve more-equitable outcomes. This initiative comprised nearly 100 community-based organizations (CBOs), who led hyper-local work to increase vaccination access and confidence in communities of individuals who identify as Black, Indigenous, and People of Color. In this study, the second of two on the initiative, the authors examine the results of the EVI. They look at the initiative's activities, effects, and challenges, and provide recommendations for how to support and sustain this hyper-local community-led approach and strengthen the public health system in the United States.

Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.