Immigrant Health, Value-Based Care, and Emergency Medicaid Reform

Association of uninsured status and rurality with risk of financial toxicity after pediatric trauma

BACKGROUND

Pediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity.

METHODS

Pediatric patients (<18 years) experiencing traumatic injury were identified in the 2016-2019 National Inpatient Sample. Patients were considered to be at risk of financial toxicity if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with risk of financial toxicity.

RESULTS

Of an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience risk of financial toxicity (29.1 vs 22.2%, P < .001) compared to Urban patients. After adjustment, rurality (reference: urban status; adjusted odds ratio 1.45, 95% confidence interval 1.36-1.55) and uninsured status (reference: private; adjusted odds ratio 1.85, 95% confidence interval 1.67-2.05) remained linked to increased odds of risk of financial toxicity. Specifically among those with private insurance, Rural patients experienced markedly higher predicted risk of financial toxicity, relative to Urban.

CONCLUSION

Our findings suggest a complex interplay between rural status and insurance type in the prediction of risk of financial toxicity after pediatric trauma. To target policy interventions, future studies should characterize the patients and communities at greatest risk of financial devastation among rural pediatric trauma patients.

Moving Toward Inclusion: Access to Care Models for Uninsured Immigrant Children

Policy Points Models for access to care for uninsured immigrant children that mitigate structural and sociopolitical barriers to inclusive health care include funding structures (e.g., state-sponsored coverage) and care delivery systems (e.g., federally qualified health centers,). Although the quintessential model of access to care necessitates health coverage for all children regardless of immigration status or date of United States entry, incremental policy change may more realistically and efficiently advance equitable access to high-quality health care. Intentional advocacy efforts should prioritize achievable goals that are grounded in data, are attentive to the sociopolitical milieu, are inclusive of diverse perspectives, and would meaningfully impact health care access and outcomes.

Differences in Self-Reported and Billed Postpartum Visits Among Medicaid-Insured Individuals

Importance

State Medicaid programs have recently implemented several policies to improve access to health care during the postpartum period. Understanding whether these policies are succeeding will require accurate measurement of postpartum visit use over time and across states; however, current estimates of use vary substantially between data sources.

Objectives

To examine disagreement between postpartum visit use reported in the Pregnancy Risk Assessment Monitoring System (PRAMS) and Medicaid claims and assess whether insurance transitions from Medicaid at the time of childbirth to other insurance types after delivery are associated with the degree of disagreement.

Design, Setting, and Participants

This cross-sectional study was conducted among individuals in South Carolina after delivery who had completed a PRAMS survey and for whom Medicaid was the payer of their delivery care. PRAMS responses from 2017 to 2020 were linked to inpatient, outpatient, and physician Medicaid claims; survey-weighted logistic regression models were then used to examine the association between postpartum insurance transitions and data source disagreement. Data were analyzed from February through October 2023.

Exposure

Insurance transition type: continuous Medicaid, Medicaid to private insurance, Medicaid to no insurance, and Emergency Medicaid to no insurance.

Main Outcome and Measure

Data source disagreement due to reporting a postpartum visit in PRAMS without a Medicaid claim for a visit or having a Medicaid claim for a visit without reporting a postpartum visit in PRAMS.

Results

Among 836 PRAMS respondents enrolled in Medicaid at delivery (663 aged 20-34 years [82.9%]), a mean of 85.7% (95% CI, 82.1%-88.7%) reported a postpartum visit in PRAMS and a mean of 61.6% (95% CI, 56.9%-66.0%) had a Medicaid claim for a postpartum visit. Overall, 253 respondents (30.3%; 95% CI, 26.1%-34.7%) had data source disagreement: 230 individuals (27.2%; 95% CI, 23.2%-31.5%) had a visit in PRAMS without a Medicaid claim, and 23 individuals (3.1%; 95% CI, 1.8%-5.2%) had a Medicaid claim without a visit in PRAMS. Compared with individuals continuously enrolled in Medicaid, those who transitioned to private insurance after delivery and those who were uninsured after delivery and had Emergency Medicaid at delivery had an increase in the probability of data source agreement of 15.8 percentage points (95% CI, 2.6-29.1 percentage points) and 37.2 percentage points (95% CI, 19.6-54.8 percentage points), respectively.

Conclusions and Relevance

This study's findings suggest that Medicaid claims may undercount postpartum visits among people who lose Medicaid or switch to private insurance after childbirth. Accounting for these insurance transitions may be associated with better claims-based estimates of postpartum care.

State Flexibility in Emergency Medicaid to Care for Uninsured Noncitizens

This Viewpoint discusses how Emergency Medicaid offers an immediately available pathway for states to improve access to care for uninsured, lower-income noncitizens with serious health conditions.

Successful pathways to liver transplant for undocumented immigrants

Liver transplant (LT) for undocumented immigrants presents numerous challenges. Although the United Network for Organ Sharing has implemented multiple policy changes to lessen the disparities in LT throughout the years, undocumented immigrants remain especially marginalized and disadvantaged when compared with other populations. Since 2013, the Mount Sinai Hospital's Recanati Miller Transplant Institute has transplanted 16 undocumented immigrants with successful outcomes. Here, we will share our experience of evaluating, caring for, and transplanting these patients and also highlight our team's mission to ensure that this population has equitable access to lifesaving medical treatment.

Assessment of Immigrants' Premium and Tax Payments for Health Care and the Costs of Their Care

IMPORTANCE

Some worry that immigrants burden the US economy and particularly the health care system. However, no analyses to date have assessed whether immigrants' payments for premiums and taxes that fund health care programs exceed third-party payers' expenditures on their behalf.

OBJECTIVE

To assess immigrants' net financial contributions to US health care programs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis used 2017 data from the Medical Expenditure Panel Survey (MEPS) and the Current Population Survey (CPS) and 2014 to 2018 data from the American Community Survey. The main analyses used data from the calendar year 2017. Data from the calendar years 2012 to 2016 were also reported. Data were analyzed from June 15, 2020, to August 14, 2022. Participants comprised 210 669 community-dwelling respondents to the MEPS and CPS (main analysis) and nursing home residents who were included in the American Community Survey (additional analysis).

EXPOSURES

Citizenship and immigration status.

MAIN OUTCOMES AND MEASURES

Total and per capita payments for premiums and taxes that fund health care as well as third-party payers' expenditures for health care in 2018 US dollars.

RESULTS

Among 210 669 participants, 51.0% were female, 18.3% were Hispanic, 12.3% were non-Hispanic Black, 60.3% were non-Hispanic White, and 9.2% were of other races and/or ethnicities. A total of 180 084 participants were respondents to the 2018 CPS, and 30 585 were respondents to the 2017 MEPS. Among the 180 084 CPS respondents, immigrants accounted for 14.1% (weighted to be nationally representative), with the subgroup of citizen immigrants accounting for 6.8%, documented noncitizen immigrants accounting for 3.7%, and undocumented immigrants accounting for 3.6%; US-born citizens constituted 85.9% of the population. Relative to US-born citizens, immigrants were more often age 18 to 64 years (79.6% vs 58.3%), of Hispanic ethnicity (45.0% vs 14.0%), and uninsured (16.8% vs 7.4%); similar percentages (51.4% vs 50.9%) were female. US-born citizens vs immigrants paid similar amounts in premiums and taxes ($6269 per capita [95% CI, $6185-$6353 per capita] vs $6345 per capita [95% CI, $6220-$6470 per capita]). However, third-party expenditures for immigrants' health care ($5061 per capita; 95% CI, $4673-$5448 per capita) were lower than their expenditures for the care of US-born citizens ($6511 per capita; 95% CI, $6275-$6747 per capita). Immigrants, in general, paid significantly more per person (net contribution, $1284; 95% CI, $876-$1691) than was paid on their behalf. Most of this surplus was accounted for by undocumented immigrants, whose contributions exceeded their expenditures by $4418 per person (95% CI, $4047-$4789 per person). US-born citizens collectively paid $67.2 billion (95% CI, -$2.3 to $136.3 billion) less in premiums and taxes than third-party payers paid for their care. This deficit was mostly offset by the $58.3 billion (95% CI, $39.8-$76.8 billion) net surplus of payments from immigrants, 89% of which ($51.9 billion; 95% CI, $47.5-$56.3 billion) was attributable to undocumented immigrants.

CONCLUSIONS AND RELEVANCE

In this study, immigrants appeared to subsidize the health care of other US residents, suggesting that concerns that immigrants deplete health care resources may be unfounded.

Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care

IMPORTANCE

Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid.

OBJECTIVE

To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021.

EXPOSURES

Medicaid coverage of postpartum care.

MAIN OUTCOMES AND MEASURES

Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery.

RESULTS

The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Association of Expanded Prenatal Care Coverage for Immigrant Women With Postpartum Contraception and Short Interpregnancy Interval Births

IMPORTANCE

Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid.

OBJECTIVE

To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021.

EXPOSURES

Medicaid coverage of prenatal care.

MAIN OUTCOMES AND MEASURES

Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy.

RESULTS

The study population consisted of 26 586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14 749 (55.5%) were aged 25 to 35 years, 25 894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17 905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points]).

CONCLUSIONS AND RELEVANCE

This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.

"Not a free version of a broken system:" Medical humanitarianism and immigrant health justice in the United States

Medical humanitarian organizations are increasingly the primary healthcare providers for unauthorized migrants in high-income countries. Existing studies of medical humanitarianism in the Global North reveal tensions between principles of traditionally apolitical humanitarianism and human rights. In practice, these tensions translate into organizational debates about prioritizing direct service provision to meet immediate needs or advocacy to effect long-term systemic change. Informed by these debates, this paper asserts the importance of immigration and health policy contexts as central to shaping the relationship between healthcare provision and political advocacy within medical humanitarian NGOs. Drawing from twelve months of fieldwork with medical humanitarian NGOs in Arizona, I analyze data from ethnographic participant observation and interviews with volunteer healthcare providers at a medical humanitarian organization I call Community Clinic of Phoenix (CCP), a free clinic for uninsured, undocumented immigrants. I find that, in the context of Arizona's anti-immigrant rhetoric and policies, CCP employs medical humanitarianism as both a discourse and a model of care to challenge immigrants' exclusion from health coverage and criminalization through immigration enforcement. The clinic's emphasis on immigrant health justice shapes their critiques of the structural failures of U.S. immigration and health systems, their approach to providing equitable access to quality healthcare for uninsured immigrants, and their work to create broad social change for immigrant rights and health justice. Driven by their mission of "not replicating a free version of a broken system," the clinic's healthcare provision amid a climate inhospitable to immigrants demonstrates the importance of both conceptualizing and practicing medical humanitarianism as healthcare advocacy.

Changes in Health Insurance Coverage Over Time by Immigration Status Among US Older Adults, 1992-2016

IMPORTANCE

Disparities in health insurance coverage by immigration status are well documented; however, there are few data comparing long-term changes in insurance coverage between immigrant and nonimmigrant adults as they age into older adulthood.

OBJECTIVE

To compare longitudinal changes in insurance coverage over 24 years of follow-up between recent immigrant, early immigrant, and nonimmigrant adults in the US.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the nationally representative Health and Retirement Study. Data were collected biennially from 1992 to 2016. The population included community-dwelling US adults born between 1931 and 1941 and aged 51 to 61 years at baseline. Statistical analysis was performed from February 3, 2017, to January 10, 2020.

EXPOSURES

Participants were categorized as nonimmigrants (born in the US), early immigrants (immigrated to the US before the age of 18 years), and recent immigrants (immigrated to the US from the age of 18 years onward).

MAIN OUTCOMES AND MEASURES

Self-reported data on public, employer, long-term care, and other private insurance were used to define any insurance coverage. Longitudinal changes in insurance coverage were examined over time by immigration status using generalized estimating equations accounting for inverse probability of attrition weights. The association between immigration status and continuous insurance coverage was also evaluated.

RESULTS

A total of 9691 participants were included (mean [SD] age, 56.0 [3.2] years; 5111 [52.6%] female). Nonimmigrants composed 90% (n = 8649) of the cohort; early immigrants, 2% (n = 201); and recent immigrants, 8% (n = 841). Insurance coverage increased from 68%, 83%, and 86% of recent immigrant, early immigrant, and nonimmigrant older adults, respectively, in 1992 to 97%, 100%, and 99% in 2016. After accounting for selective attrition, recent immigrants were 15% less likely than nonimmigrants to have any insurance at baseline (risk ratio, 0.85; 95% CI, 0.82-0.88), driven by lower rates of private insurance. However, disparities in insurance decreased incrementally over time and were eliminated, such that insurance coverage rates were similar between groups as participants attained Medicare age eligibility. Furthermore, recent immigrants were less likely than nonimmigrants to be continuously insured (risk ratio, 0.89; 95% CI, 0.85-0.94).

CONCLUSIONS AND RELEVANCE

Among community-dwelling adults who were not age eligible for Medicare, recent immigrants had lower rates of health insurance, but this disparity was eliminated over the 24-year follow-up period because of uptake of public insurance among all participants. Future studies should evaluate policies and health care reforms aimed at reducing disparities among vulnerable populations such as recent immigrants who are not age eligible for Medicare.

Challenges for immigrant health in the USA-the road to crisis

The USA is home to more immigrants than any other country-about 46 million, just less than a fifth of the world's immigrants. Immigrant health and access to health care in the USA varies widely by ethnicity, citizenship, and legal status. In recent decades, several policy and regulatory changes have worsened health-care quality and access for immigrant populations. These changes include restrictions on access to public health insurance programmes, rhetoric discouraging the use of social services, aggressive immigration enforcement activities, intimidation within health-care settings, decreased caps on the number of admitted refugees, and rescission of protections from deportation. A receding of ethical norms has created an environment favourable for moral and public health crises, as evident in the separation of children from their parents at the southern US border. Given the polarising immigration rhetoric at the national level, individual states rather than the country as a whole might be better positioned to address the barriers to improved health and health care for immigrants in the USA.