Working Paper
Carrie E. Fry and Laura A. Hatfield. Working Paper. “Do Birds of a Methodological Feather Flock Together?”.
Carrie E. Fry, Richard G. Frank, Brian Case, and Lisa Callahan. Working Paper. “Making Medicaid Expansion Work to Reduce Recidivism: Lessons from Six Cities”.
Carrie E. Fry, Thomas G. McGuire, and Richard G. Frank. Working Paper. “Medicaid Expansion's Spillover to the Criminal Justice System: Evidence from Six Urban Counties”.
Richard G. Frank and Carrie E. Fry. 4/14/2019. “The Impact of Medicaid Expansion on Access to Naloxone.” Addiction 114, Pp. 1567-74. Full paperAbstract

Background and Aims: Deaths from opioid-related overdoses continue to grow, in part due to the increasing lethality of substances being consumed (e.g., fentanyl).  Federal, state, and local governments have sought public policy interventions to reduce the number of deaths due to opioids, including increasing the availability of naloxone. The Affordable Care Act (ACA) expanded Medicaid coverage to low-income, childless adults, potentially giving this group financial access to naloxone.

Methods: We use data from the Medicaid Drug Rebate Program to estimate the impact of Medicaid expansion and Medicaid-covered naloxone. We use difference-in-differences regression analysis to compare states that did not expand to states that did expand before and after Medicaid expansion.

Results: Prior to Medicaid expansion, the number of Medicaid-covered naloxone prescriptions was very similar in expansion and non-expansion states. We find that, on average, states that expanded Medicaid have 78.2 (95%CI: 16.0-140.3;p=0.02) more prescriptions per year for naloxone compared to states that did not expand after expansion, a nearly 10-fold increase over the pre-expansion years. We also find Medicaid expansion contributed to this growth in Medicaid-covered naloxone more than other state-level naloxone policies.

Conclusions: Medicaid expansion has likely put naloxone into the hands of some of the people best positioned to prevent death from an overdose – individuals without opioid use disorder and their friends and members. The difference in difference results imply that the Medicaid expansion accounted for about 8.3% of the growth in take-home naloxone units from 2009 to 2016 holding other factors constant. Additionally, Medicaid is responsible for approximately 13% of the growth in naloxone prescriptions between 2009-2016. However, Medicaid expansion is not a silver bullet for expanding the use of naloxone and curbing the opioid epidemic. Policy makers must consider other ways to improve prevention, harm reduction, and treatment for opioid use disorder.

Carrie E. Fry, Hilary A. Tindle, Caroline Young, Erin I. Rogus, William H. Frist, and Melinda B. Buntin. 2019. “Development of a tobacco control “prescription” in a Southern U.S. city.” Progress in Community Health Partnerships, 13, 3, Pp. 237-246.Abstract
The Problem: Nationwide efforts to reduce smoking in the United States over the past decade have been successful.  Yet, there is unequal geographic progress in reducing rates of smoking and smoking-related illnesses. Located in a tobacco-producing state with weak tobacco laws, Nashville has an adult smoking rate of 20.9%, requiring 45,000 smokers to quit to meet the Healthy People 2020 goal of 12%.
Purpose of the Article: The purpose of this article is to detail the process involved in building a community-academic partnership (CAP), gathering national and grassroots support, and devising an implementation strategy for tobacco control.
Key Points: Nashville’s collective impact approach helped prioritize short- and long-term strategies, identified potential barriers to success, created an energetic CAP, provided early “wins”, and inspired research and implementation collaborations.
Conclusion: Other communities interested in improving tobacco control could engage in a similar process to create, implement, and evaluate tailored recommendations to improve the health of its citizens.
Fry et al PCHP Beyond the Manuscript.pdf Fry, et al 2019 PCHP.pdf
Christine C. Whitmore, Mary N. White, Melinda B. Buntin, Carrie E. Fry, Kevin Calamari, and Stephen W. Patrick. 12/30/2018. “State laws and policies to reduce opioid-related harm: A qualitative assessment of PDMPs and naloxone programs in ten U.S. States.” Preventive Medicine Reports.Abstract

As the magnitude of the opioid epidemic grew in recent years, individual states across the United States of America enacted myriad policies to address its complications. We conducted a qualitative examination of the structure, successes, and challenges of enacted state laws and policies aimed at the opioid epidemic, with an in-depth focus on prescription drug monitoring programs (PDMPs) and naloxone access efforts.

A set of 10 states (Florida, Kentucky, Massachusetts, Michigan, Missouri, New York, North Carolina, Tennessee, Washington, and West Virginia) was chosen a priori to achieve a varied sample of state policies and timing, as well as population opioid complications. Archival research was conducted to identify state-level policies aimed at the opioid epidemic and semi-structured interviews were conducted with 31 key stakeholders between March and September 2016.

The most frequently mentioned key to success was an identifiable champion instrumental in leading the passage of these policies. The lack of a unified legislature and physician pushback were challenges many states faced in implementing policies.

Champion-led task forces, stakeholders' personal stories garnering buy-in, ongoing education and feedback to PDMP users, and inclusive stakeholder engagement are critical aspects of passing and implementing state policies aimed at combating the opioid epidemic. Engaging all interested stakeholders and providing continuing feedback are ongoing challenges in all states. Leveraging stakeholders' personal stories of how opioids affected their lives helped propel state efforts.

Emma Sandoe, Carrie E. Fry, and Richard G. Frank. 10/2/2018. “Policy Levers that States Can Use to Improve Opioid Addiction Treatment and Address the Opioid Epidemic.” Health Affairs Blog. Full blog post
Carrie E. Fry and Benjamin D. Sommers. 8/28/2018. “Effect of Medicaid Expansion on Health Insurance Coverage and Access to Care among Adults with Depression.” Psychiatric Services, 69, 11, Pp. 1146-1152. Full paperAbstract
Objective: Multiple studies have detailed the relationship between Medicaid expansion under the Affordable Care Act and various health and financial outcomes. However, fewer studies have examined Medicaid expansion’s effects on individuals with psychiatric diagnoses. This study sought to determine the relationship between Medicaid expansion and various health and financial outcomes among low-income adults with depression.
Methods: This quasi-experimental study used a random-digit-dial survey of U.S. citizens ages 19–64 with incomes below 138% of the federal poverty level. Surveys were conducted in three southern states (two expansion states, Arkansas and Kentucky, and one nonexpansion state, Texas) between 2013 and 2016. The study sample consisted of those with a positive screen for depression—score of ≥2 on the two-item Patient Health Questionnaire (N=4,853). Survey-weighted difference-in-differences regressions were conducted with insurance status, health care access and utilization, and affordability of care as outcomes of interest. Subgroup analyses stratified the sample on the basis of the respondent’s residence in a health professional shortage area (HPSA) in mental health and severity of depression.
Results: Medicaid expansion was associated with a significant reduction in the proportion of adults with depression who lacked health insurance (−23 percentage points, 95% confidence interval=–32 to –14, p<.001). Medicaid expansion was also associated with significant reductions in delaying care and medications because of cost. These changes were similar regardless of residence in a mental health HPSA and severity of depression.
Conclusions: Medicaid expansion was associated with improved access to care and medication among persons with depression, even in areas with relative shortages of mental health professionals.
Benjamin D. Sommers, Carrie E. Fry, Robert J. Blendon, and Arnold M. Epstein. 6/22/2018. “New Approaches to Medicaid Expansion: Work Requirements, Health Savings Accounts, and Health Care Access.” Health Affairs, 37, 7, Pp. 1099-1108. Full paperAbstract

Alternative approaches in Medicaid are proliferating under the Trump administration. Using a novel telephone survey, we assessed views on health savings accounts, work requirements, and Medicaid expansion. Our sample consisted of 2,739 low-income nonelderly adults in three Midwestern states: Ohio, which expanded eligibility for traditional Medicaid; Indiana, which expanded Medicaid using health savings accounts called POWER accounts; and Kansas, which has not expanded Medicaid. We found that coverage rates in 2017 were significantly higher in the two expansion states than in Kansas. However, cost-related barriers were more common in Indiana than in Ohio. Among Medicaid beneficiaries eligible for Indiana’s waiver program, 39 percent had not heard of POWER accounts, and only 36 percent were making required payments, which means that nearly two-thirds were potentially subject to loss of benefits or coverage. In Kansas, 77 percent of respondents supported expanding Medicaid. With regard to work requirements, 49 percent of potential Medicaid enrollees in Kansas were already employed, 34 percent were disabled, and only 11 percent were not working but would be more likely to look for a job if required by Medicaid. These findings suggest that current Medicaid innovations may lead to unintended consequences for coverage and access.

Carrie E. Fry, Sayeh S. Nikpay, Erika Leslie, and Melinda B. Buntin. 2018. “Evaluating Community-Based Health Improvement Programs.” Health Affairs, 38, 1, Pp. 22-29. Full paperAbstract
Increasingly, public and private resources are being dedicated to community-based health improvement programs. But evaluations of these programs typically rely on data about process and a pre-post study design without a comparison community. To better determine the association between the implementation of community-based health improvement programs and county-level health outcomes, we used publicly available data for the period 2002–06 to create a propensity-weighted set of controls for conducting multiple regression analyses. We found that the implementation of community-based health improvement programs was associated with a decrease of less than 0.15 percent in the rate of obesity, an even smaller decrease in the proportion of people reporting being in poor or fair health, and a smaller increase in the rate of smoking. None of these changes was significant. Additionally, program counties tended to have younger residents and higher rates of poverty and unemployment than nonprogram counties. These differences could be driving forces behind program implementation. To better evaluate health improvement programs, funders should provide guidance and expertise in measurement, data collection, and analytic strategies at the beginning of program implementation.
Carrie E. Fry and Benjamin D. Sommers. 7/6/2017. “Gains in Coverage and Access to Care from Louisiana's Medicaid Expansion Could be Reversed Under Congress' ACA Repeal-and-Replace Bills.” Edited by The Commonwealth Fund. To The Point. Full blog post
Richard G. Frank and Carrie E. Fry. 7/5/2017. “Medicaid Expands Access to Life-Saving Naloxone.” Edited by Commonwealth Fund. To the Point. Full blog post
Melinda B. Buntin, Carrie E. Fry, and Sachin Jain. 1/25/2017. “Medical schools and health policy: Adapting to the changing healthcare landscape.” NEJM Catalyst. Full blog post
Richard G. Frank and Carrie E. Fry. 2017. “Financing Treatment for Opioid Use Disorder: A Reflection on History.” In Confronting Our Nation’s Opioid Crisis: A Report of the Aspen Health Strategy Group, edited by Alan R. Weil and Rachel Dolan, Pp. 71-90. Full-length report
Stephen W. Patrick, Carrie E. Fry, Tim F. Jones, and Melinda B. Buntin. 6/22/2016. “Implementation of Prescription Drug Monitoring Programs Associated with Reductions in Opioid-Related Death Rates.” Health Affairs, 35, 7, Pp. 1324-1332. Full paperAbstract
Over the past two decades the number of opioid pain relievers sold in the United States rose dramatically. This rise in sales was accompanied by an increase in opioid-related overdose deaths. In response, forty-nine states (all but Missouri) created prescription drug monitoring programs to detect high-risk prescribing and patient behaviors. Our objectives were to determine whether the implementation or particular characteristics of the programs were effective in reducing opioid-related overdose deaths. In adjusted analyses we found that a state’s implementation of a program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics—including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly—had greater reductions in deaths, compared to states whose programs did not have these characteristics. We estimate that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day.