Termination from Medi-Cal--does it affect health?

The effect of the exit of an insurer, due to government liquidation, on access to health care: evidence from Colombia

Our study evaluates the liquidation effect of a health insurer from a subsidized scheme, with the largest number of members in Colombia, on restrictions to future access to user care. Based on the information regarding complaints and judicial claims about healthcare, the effect of this government decision is estimated using a dynamic econometric model of differences in differences. Our results suggest that the liquidation of the Health-Promoting Entity (EPS, its acronym in Spanish) CAPRECOM has a negative effect, specifically, it led to an increase of 0.32 and 0.21 in complaints rates per 1,000 members in the receiving EPSs during the first and second quarters after the intervention, respectively. However, this effect does not persist over time and becomes diluted in the following quarters. There is no evidence of a relationship between the magnitude of the effect and the EPSs performance ranking. Additionally, we do not find significant effects on judicial claims. Our results are important concerning the design and implementation of public policies for EPSs liquidation. We demonstrate the necessity of implementing actions to incorporate guidelines and strategic plans during the transition period. Such actions would enable safeguarding the right to health for the affected population in a liquidation insurer case.

Women Veterans' Attrition from the VA Health Care System

PURPOSE

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care.

METHODS

A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.

RESULTS

Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.

CONCLUSIONS

Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.

Higher Rates of Preventive Health Care With Commercial Insurance Compared With Medicaid: Findings From the Arkansas Health Care Independence "Private Option" Program

BACKGROUND

A requirement of the Arkansas Medicaid Section 1115 demonstration waiver was to evaluate the level of care received for Medicaid expansion eligible beneficiaries enrolled in commercial Qualified Health Plans (QHPs) in the Health Care Independence "Private Option" Program. This allowed for a direct comparison of Medicaid and commercial system performance serving similar newly covered adults.

RESEARCH DESIGN

In 2014, assignment to either Medicaid or a QHP was made based upon a psychometrically derived continuous composite score to exceptional health care needs assessment screener using a sharp a priori threshold cutpoint. Using a regression discontinuity design we compared preventive care (flu vaccination and screening rates) services in the 2 programs over 3 years.

RESULTS

Compared with Medicaid enrollees, a higher percentage of QHP enrollees consistently received eligible preventive care screenings with 15.3, and 6.9% more receiving at least 1 or all eligible screenings, respectively. For individual preventive care outcomes and compared with Medicaid enrollees over the 3 years under study, a higher percentage of eligible QHP enrollees received a flu shot, cholesterol screenings, glycated hemoglobin assessment, and cervical and breast cancer periodic assessments. No differences were found for colorectal periodic assessments.

CONCLUSIONS

These findings suggest that at least for preventive services, the Medicaid federal equal access requirement is not being met for those within Medicaid fee-for-service coverage. This persisted across all 3 years of the program. Differential payment rates for services between Medicaid and QHPs are likely a major contributing factor.

Lifetime Consequences of Early-Life and Midlife Access to Health Insurance: A Review

Over the past decade, the number of studies examining the effects of health insurance has grown rapidly, along with the breadth of outcomes considered. In light of growing research in this area and the intense policy focus on coverage expansions in the United States, there is need for an up-to-date and comprehensive literature review and synthesis of lessons learned. We reviewed 112 experimental or quasi-experimental studies on the effects of health insurance prior to people becoming eligible for Medicare on a broad set of outcomes. Over the past decade, evidence related to the effect of increased access to health insurance has strengthened, illuminating that children and vulnerable adults are most likely to see health and economic benefits. We identified promising areas for future study in this active and burgeoning research area, noting benefit design of health insurance and outcomes such as government program participation and self-reported health status as targets.

What Makes Vietnamese (Not) Attend Periodic General Health Examinations? A 2016 Cross-sectional Study

Objectives

General health examinations (GHE) have become an increasingly common measure for preventive medicine in Vietnam. However, little is known about the factors among Viet-namese people who attend or miss GHE. Budget or time constraints remain to be evaluated for better-informed policy making. This study investigates factors affecting behaviors in attending periodic GHE. The main objectives are as follows: (1) to explore empirical relationships between influencing factors and periodic GHE frequencies, and (2) to predict the probabilities of attending GHE under associated conditions.

Methods

The study used a 2,068-observational dataset, obtained from a Vietnamese survey in 2016. The analysis was then performed using the methods of baseline-category logits for establishing relationships between predictor and response variables.

Results

Significant relationships were found among the expenditure and time consumption, health priority and sensitivity to health data, insurance status, and frequency of GHE, with most p-values = 0.01.

Conclusion

Generally, people attended the GHE when they had the resources and health priorities (72.7% probability). Expenditure and time remain key obstacles to the periodic GHE. Health priority and health data are important in improving rates for GHEs. Health insurance should play a positive role in promoting the GHE.

Did Medicare Part D reduce mortality?

We investigate the implementation of Medicare Part D and estimate that this prescription drug benefit program reduced elderly mortality by 2.2% annually. This was driven primarily by a reduction in cardiovascular mortality, the leading cause of death for the elderly. There was no effect on deaths due to cancer, a condition whose drug treatments are covered under Medicare Part B. We validate these results by demonstrating that the changes in drug utilization following the implementation of Medicare Part D match the mortality patterns we observe. We calculate that the value of the mortality reduction is equal to $5 billion per year.

Self-reported health-related quality of life (HRQoL) and factors affecting HRQoL among individuals with health insurance in Iran

OBJECTIVES

The aim of this study was to measure the health-related quality of life (HRQoL) and to evaluate the factors affecting HRQoL in individuals with health insurance in Tehran, Iran.

METHODS

A cross-sectional analytical study was conducted using the 3-level EuroQol 5-dimensions (EQ-5D) questionnaire. In order to estimate the determinants of HRQoL, information about participants’ demographic, socioeconomic, and health status was gathered. The cluster sampling technique was used to collect data from May to June, 2016. The chi-square test and weighted least squares method were employed for data analysis. Data were analyzed using Stata version 11.0.

RESULTS

A total of 600 Iranians with insurance completed the study, of whom 327 (54.5%) were male and 273 (45.5%) were female. The mean age of the participants was 41.48 years (standard deviation [SD], 14.60 years). Meanwhile, the mean duration of education was 12.36 years (SD, 4.68 years). The mean EQ-5D score was 0.74 (SD, 0.16). The most common health problems in the participants were anxiety/depression (42.3%), followed by pain/discomfort (39.2%). Sex, age, years of schooling, income, chronic disease, and body mass index had a significant effect on HRQoL (p<0.05). Healthy insured individuals, on average, had a HRQoL score 0.119 higher than that of people with a chronic disease, all else being equal (p<0.001).

CONCLUSIONS

Among all determinants of HRQoL, chronic disease was found to be the highest priority for interventions to improve the health status of Iranians with insurance. This finding can help policymakers and health insurance organizations improve their planning to promote the HRQoL of individuals with insurance and society as a whole in Iran.

The Voyage of a Navigator An aspiring scholar's inside observations on the Affordable Care Act's rocky roll-out in North Carolina

North Carolina, a federally facilitated marketplace under the Affordable Care Act (ACA), stumbled in 2013 when opening its health-insurance exchange. Trouble was easy to foresee, as North Carolina had instituted a law barring any state agency from assisting enrollment in health-insurance plans made available through the ACA. Trained workers were needed to help citizens and legal immigrants "navigate" to these plans. Some of these "navigators" could be paid with federal funds, but many others had to work as volunteers. I was one of these volunteer navigators. Much went wrong in training, staffing, and operations, but much still was accomplished. Here I report observations, share assessments, and offer suggestions for similarly complex situations.

What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage

BACKGROUND

The Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on cancer screening rates within the framework of a randomized controlled trial. Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence, which cannot be used to make causal inferences.

METHODS

The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups.

RESULTS

Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk.

CONCLUSIONS

Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.

Medicaid primary care physician fees and the use of preventive services among Medicaid enrollees

OBJECTIVE

The Patient Protection and Affordable Care Act (ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force (USPSTF)-recommended preventive care use among Medicaid enrollees.

DATA SOURCES/STUDY SESSION

We used data from the 2003 and 2008 Medical Expenditure Panel Survey (MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008.

STUDY DESIGN

Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors.

DATA COLLECTION/EXTRACTION METHODS

Data were linked using state identifiers.

PRINCIPAL FINDINGS

Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant.

CONCLUSIONS

Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees.

Balancing investments in Federally Qualified Health Centers and Medicaid for improved access and coverage in Pennsylvania

Two common health disparities in the US include a lack of access to care and a lack of insurance coverage. To help address these disparities, healthcare reform will provide $11B to expand Federally Qualified Health Centers (FQHCs) over the next 5 years. In 2014, Medicaid rules will be modified so that more people will become eligible. There are, however, important tradeoffs in the investment in these two programs. We find a balanced investment between FQHC expansion and relaxing Medicaid eligibility to improve both access (by increasing the number of FQHCs) and coverage (by FQHC and Medicaid expansion) for the state of Pennsylvania. The comparison is achieved by integrating multi-objective mathematical models with several public data sets that allow for specific estimations of healthcare need. Demand is estimated based on current access and coverage status in order to target groups to be considered preferentially. Results show that for Pennsylvania, FQHCs are more cost effective than Medicaid if we invest all of the resources in just one policy. However, we find a better investment point balancing those two policies. This point is approximately where the additional expenses incurred from relaxing Medicaid eligibility equals the investment in FQHC expansion.

The Oregon experiment--effects of Medicaid on clinical outcomes

BACKGROUND

Despite the imminent expansion of Medicaid coverage for low-income adults, the effects of expanding coverage are unclear. The 2008 Medicaid expansion in Oregon based on lottery drawings from a waiting list provided an opportunity to evaluate these effects.

METHODS

Approximately 2 years after the lottery, we obtained data from 6387 adults who were randomly selected to be able to apply for Medicaid coverage and 5842 adults who were not selected. Measures included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services. We used the random assignment in the lottery to calculate the effect of Medicaid coverage.

RESULTS

We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (-9.15 percentage points; 95% confidence interval, -16.70 to -1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.

CONCLUSIONS

This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.

Health care utilization and health outcomes: a population study of Taiwan

Facing escalating health care expenditures, the governments of countries with national health insurance programs are trying to control or even to reduce health care utilization. Little research has examined the effects of decreased health care utilization on health outcomes. Applying a natural experiment design to the Taiwan population between 2000 and 2004, which includes the 2003 SARS epidemic when an average 20% decline in health care utilization occurred, this study examines the association between a decline in health care utilization and health outcomes measured by cause-specific mortality rates. We analyse the monthly mortality rates caused by infectious diseases, cancer, diabetes mellitus, nervous system diseases, cerebrovascular diseases, heart and other vascular diseases, respiratory system diseases, digestive system diseases, genitourinary system diseases and accidents. Models control for age, sex, month and year effects. Results show the heterogeneous effect of reduced health care utilization on health outcomes. Patients with diabetes mellitus or cerebrovascular diseases are vulnerable to short-term reductions in health care; compared with the non-SARS period, mortality caused by diabetes mellitus and cerebrovascular diseases significantly increased during the SARS epidemic by 8.4% and 6.2%, respectively. No significant change in mortality rates caused by the other diseases or accidents is found. This study suggests that governments of countries where health care utilization and spending are similar to or inferior to those in Taiwan should carefully evaluate the impact of policies that attempt to reduce health care utilization. Furthermore, when an area encounters an epidemic, governments should be aware of the negative consequences of voluntary restraints on access to health care that accompany decreases in utilization.

Health insurance and cardiovascular disease risk factors

BACKGROUND

Compared with those with health insurance, the uninsured receive less care for chronic conditions, such as hypertension and diabetes, and experience higher mortality.

METHODS

We investigated the relations of health insurance status to the prevalence, treatment, and control of major cardiovascular disease risk factors-hypertension and elevated low-density lipoprotein (LDL) cholesterol-among Framingham Heart Study (FHS) participants in gender-specific, age-adjusted analyses. Participants who attended the seventh Offspring cohort examination cycle (1998-2001) or the first Third Generation cohort examination cycle (2002-2005) were studied.

RESULTS

Among 6098 participants, 3.8% were uninsured at the time of the FHS clinic examination and ages ranged from 19 to 64 years. The prevalence of hypertension and elevated LDL cholesterol was similar for the insured and uninsured; however, the proportion of those who obtained treatment and achieved control of these risk factors was lower among the uninsured. Uninsured men and women were less likely to be treated for hypertension with odds ratios for treatment of 0.19 (95% confidence interval [CI], 0.07-0.56) for men and 0.31 (95% CI, 0.12-0.79) for women. Among men, the uninsured were less likely to receive treatment or achieve control of elevated LDL cholesterol than the insured, with odds ratios of 0.12 (95% CI, 0.04-0.38) for treatment and 0.17 (95% CI, 0.05-0.56) for control.

CONCLUSION

The treatment and control of hypertension and hypercholesterolemia are lower among uninsured adults. Increasing the proportion of insured individuals may be a means to improve the treatment and control of cardiovascular disease risk factors and to reduce health disparities.

What the Oregon health study can tell us about expanding Medicaid

The recently enacted Patient Protection and Affordable Care Act includes a major expansion of Medicaid to low-income adults in 2014. This paper describes the Oregon Health Study, a randomized controlled trial that will be able to shed some light on the likely effects of such expansions. In 2008, Oregon randomly drew names from a waiting list for its previously closed public insurance program. Our analysis of enrollment into this program found that people who signed up for the waiting list and enrolled in the Oregon Medicaid program were likely to have worse health than those who did not. However, actual enrollment was fairly low, partly because many applicants did not meet eligibility standards.

Impact of discontinuity in health insurance on resource utilization

Background

This study sought to describe the incidence of transitions into and out of Medicaid, characterize the populations that transition and determine if health insurance instability is associated with changes in healthcare utilization.

Methods

2000-2004 Medical Expenditure Panel Survey (MEPS) was used to identify adults enrolled in Medicaid at any time during the survey period (n = 6,247). We estimate both static and dynamic panel data models to examine the effect of health insurance instability on health care resource utilization.

Results

We find that, after controlling for observed factors like employment and health status, and after specifying a dynamic model that attempts to capture time-dependent unobserved effects, individuals who have multiple transitions into and out of Medicaid have higher emergency room utilization, more office visits, more hospitalizations, and refill their prescriptions less often.

Conclusions

Individuals with more than one transition in health insurance status over the study period were likely to have higher health care utilization than individuals with one or fewer transitions. If these effects are causal, in addition to individual benefits, there are potentially large benefits for Medicaid programs from reducing avoidable insurance instability. These results suggest the importance of including provisions to facilitate continuous enrollment in public programs as the United States pursues health reform.

Health insurance and mortality in US adults

OBJECTIVES

A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data.

METHODS

We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death.

RESULTS

Among all participants, 3.1% (95% confidence interval [CI]=2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI=1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance.

CONCLUSIONS

Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.

Health consequences of uninsurance among adults in the United States: recent evidence and implications

CONTEXT

Uninsured adults have less access to recommended care, receive poorer quality of care, and experience worse health outcomes than insured adults do. The potential health benefits of expanding insurance coverage for these adults may provide a strong rationale for reform. However, evidence of the adverse health effects of uninsurance has been largely based on observational studies with designs that do not support causal conclusions. Although recent research using more rigorous methods may offer a better understanding of this important subject, it has not been comprehensively reviewed.

METHODS

The clinical and economic literature since 2002 was systematically searched. New research contributions were reviewed and evaluated based on their methodological strength. Because the effectiveness of medical care varies considerably by clinical risk and across conditions, the consistency of study findings with clinical expectations was considered in their interpretation. Updated conclusions were formulated from the current body of research.

FINDINGS

The quality of research has improved significantly, as investigators have employed quasi-experimental designs with increasing frequency to address limitations of earlier research. Recent studies have found consistently positive and often significant effects of health insurance coverage on health across a range of outcomes. In particular, significant benefits of coverage have now been robustly demonstrated for adults with acute or chronic conditions for which there are effective treatments.

CONCLUSIONS

Based on the evidence to date, the health consequences of uninsurance are real, vary in magnitude in a clinically consistent manner, strengthen the argument for universal coverage in the United States, and underscore the importance of evidence-based determinations in providing health care to a diverse population of adults.

Lapses in Medicaid coverage: impact on cost and utilization among individuals with diabetes enrolled in Medicaid

BACKGROUND

Gaps in Medicaid coverage can result in inadequate access to care. This can be particularly detrimental to those with a chronic disease such as diabetes.

OBJECTIVE

To assess whether a lapse in Medicaid coverage is associated with an increase in expenditures, and acute care utilization upon reenrollment among beneficiaries with diabetes.

RESEARCH DESIGN

Using multivariate regression analyses, we compared pre- versus post-expenditures and utilization among 2102 individuals with diabetes who had experienced at least one 1-month lapse in their Medicaid coverage.

MEASURES

Dependent variables were the number of inpatient episodes, total length of stay, total number of emergency room visits, total expenditure, and pharmaceutical expenditures. These were aggregated over 3-month spans that either immediately preceded or immediately followed a lapse in coverage. Key predictor variables included a variable that identified the span as occurring pre-lapse or post-lapse in coverage, and a continuous variable identifying the length of the lapse. Predicted expenditure and utilization were calculated.

RESULTS

Overall total program expenditures were higher for post-lapse periods compared with pre-lapse periods. Total expenditures were estimated to increase by $239 per member per month for the 3-month period. The likelihood of having any expenditure was actually lower in the post-lapse period. However inpatient and emergency room use was higher.

CONCLUSIONS

The results from this study suggest that interruptions in Medicaid coverage are associated with overall greater program expenditures in the post-lapse periods. However, this increase in expenditures seems to be driven by a subset of individuals whose greater use of inpatient and emergency room services increased overall program costs.

The health effects of Medicare for the near-elderly uninsured

OBJECTIVE

To determine whether Medicare enrollment at age 65 has an effect on the health trajectory of the near-elderly uninsured.

DATA SOURCES

Eight biennial waves (1992-2006) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51-61 year olds and their spouses.

STUDY DESIGN

We use a quasi-experimental approach to compare the health effects of insurance for the near-elderly uninsured with previously insured contemporaneous controls. The primary outcome measure is overall self-reported health status combined with mortality (i.e., excellent to very good, good, fair to poor, dead).

RESULTS

The change in the trajectory of overall health status for the previously uninsured that can be attributed to Medicare is small and not statistically significant. For every 100 persons in the previously uninsured group, joining Medicare is associated with 0.6 fewer in excellent or very good health (95 percent CI: -4.8, 3.3), 0.3 more in good health (95 percent CI: -3.8, 4.1), 2.5 fewer in fair or poor health (95 percent CI: -7.4, 2.3), and 2.8 more dead (-4.0, 10.0) by age 73. The health trajectory patterns from physician objective health measures are similarly small and not statistically significant.

CONCLUSIONS

Medicare coverage at age 65 for the previously uninsured is not linked to improvements in overall health status.

Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services

To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a 'usual VA care' group before the demonstration clinic opened (N = 130) and the 'integrated care' group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.

Racial/ethnic variations in women's health: the social embeddedness of health

This article provides an overview of the magnitude of and trends in racial/ethnic disparities in health for women in the United States. It emphasizes the importance of attending to diversity in the health profiles and populations of minority women. Socioeconomic status is a central determinant of racial/ethnic disparities in health, but several other factors, including medical care, geographic location, migration and acculturation, racism, and exposure to stress and resources also play a role. There is a need for renewed attention to monitoring, understanding, and actively seeking to eliminate racial/ethnic disparities in health.

Insurance status and the severity of breast cancer at the time of diagnosis

RATIONALE AND OBJECTIVES

To evaluate how the insurance status of women diagnosed with breast cancer correlates with size and stage at the time of diagnosis.

METHODS AND MATERIALS

The age-adjusted incidence of early- and late-stage breast cancer as determined by the tumor node metastasis classification system of stages in situ, local, regional, or distant was calculated for insured and uninsured women from our institution's database between 2002 and 2004. Late-stage breast cancer was defined as present when patients had either regional or distant disease. Statistical analysis was conducted using generalized linear models and chi(2) tests.

RESULTS

There were a total of 617 patients in our retrospective study. Of these, 564 (91.4%) had insurance and 53 (8.6%) were uninsured. Four hundred forty-seven (72.4%) patients were Caucasian and 170 (27.6%) patients were non-Caucasian. Of the 463 patients with early-stage breast cancer (0, I, or II), 433 (93.5%) had insurance and 30 (6.5%) were uninsured. Of the 154 patients with late-stage breast cancer (III or IV), 131 (85.1%) had insurance and 23 (14.9%) patients were uninsured. Analysis demonstrated that there was a significant effect in the insurance status on cancer stage (P = .006) and tumor size (P = .010). Compared to insured patients, uninsured patients had a 66% higher likelihood of presenting with a late-stage cancer and larger tumor. The analysis from the chi(2) test also supports the above with a significant association between patients' cancer stage and insurance status (P = .001) and also between tumor size and insurance status (P = .001). Patients' ages and geographic locations were not significant correlated with size and stage, but non-Caucasians had a significantly higher risk of larger tumors and more advanced stage than Caucasians (P < .005).

CONCLUSIONS

Uninsured, non-Caucasian patients have a higher probability of presenting with a more advanced stage of breast cancer and larger tumor size than patients with insurance in a large university multidisciplinary breast cancer population.

The impact of health insurance on health

How does health insurance affect health? After reviewing the evidence on this question, we reach three conclusions. First, many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors. Second, convincing evidence demonstrates that health insurance can improve health measures of some population subgroups, some of which, although not all, are the same subgroups that would be the likely targets of coverage expansion policies. Third, for policy purposes we need to know whether the results of these studies generalize. Solid answers to the multitude of important questions about how specific health insurance policy options may affect health seem likely to be forthcoming only with investment of substantial resources in social experiments.

Does extending health insurance coverage to the uninsured improve population health outcomes?

BACKGROUND

An ongoing debate exists about whether the US should adopt a universal health insurance programme. Much of the debate has focused on programme implementation and cost, with relatively little attention to benefits for social welfare.

OBJECTIVE

To estimate the effect on US population health outcomes, measured by mortality, of extending private health insurance to the uninsured, and to obtain a rough estimate of the aggregate economic benefits of extending insurance coverage to the uninsured.

METHOD

We use state-level panel data for all 50 states for the period 1990-2000 to estimate a health insurance augmented, aggregate health production function for the US. An instrumental variables fixed-effects estimator is used to account for confounding variables and reverse causation from health status to insurance coverage. Several observed factors, such as income, education, unemployment, cigarette and alcohol consumption and population demographic characteristics are included to control for potential confounding variables that vary across both states and time.

RESULTS

The results indicate a negative relationship between private insurance and mortality, thus suggesting that extending insurance to the uninsured population would result in an improvement in population health outcomes. The estimate of the marginal effect of insurance coverage indicates that a 10% increase in the population-insured rate of a state reduces mortality by 1.69-1.92%. Using data for the year 2003, we calculate that extending private insurance coverage to the entire uninsured population in the US would save over 75 000 lives annually and may yield annual net benefits to the nation in excess of $US400 billion.

CONCLUSION

This analysis suggests that extending health insurance coverage through the private market to the 46 million Americans without health insurance may well produce large social economic benefits for the nation as a whole.

Health insurance and access to health care in the United States

Health insurance, poverty, and health are all interconnected in the United States. This article synthesizes a large and compelling body of health services research, finding a strong association between health insurance coverage and access to primary and preventive care, the treatment of acute and traumatic conditions, and the medical management of chronic illness. Moreover, by improving access to care, health insurance coverage is also fundamentally important to better health care and health outcomes. Research connects being uninsured with adverse health outcomes, including declines in health and function, preventable health problems, severe disease at the time of diagnosis, and premature mortality.

The demise of Oregon's Medically Needy program: effects of losing prescription drug coverage

BACKGROUND

In January 2003, people covered by Oregon's Medically Needy program lost benefits owing to state budget shortfalls. The Medically Needy program is a federally matched optional Medicaid program. In Oregon, this program mainly provided prescription drug benefits.

OBJECTIVE

To describe the Medically Needy population and determine how benefit loss affected this population's health and prescription use.

DESIGN

A 49-question telephone survey instrument created by the research team and administered by a research contractor.

PARTICIPANTS

A random sample of 1,269 eligible enrollees in Oregon's Medically Needy Program. Response rate was 35% with 439 individuals, ages 21-91 and 64% women, completing the survey.

MEASUREMENTS

Demographics, health information, and medication use at the time of the survey obtained from the interview. Medication use during the program obtained from administrative data.

RESULTS

In the 6 months after the Medically Needy program ended, 75% had skipped or stopped medications. Sixty percent of the respondents had cut back on their food budget, 47% had borrowed money, and 49% had skipped paying other bills to pay for medications. By self-report, there was no significant difference in emergency department visits, but a significant decrease in hospitalizations comparing 6 months before and after losing the program. Two-thirds of respondents rated their current health as poor or fair.

CONCLUSIONS

The Medically Needy program provided coverage for a low-income, chronically ill population. Since its termination, enrollees have decreased prescription drug use and increased financial burden. As states make program changes and Medicare Part D evolves, effects on vulnerable populations must be considered.

The effect of new insurance coverage on the health status of low-income children in Santa Clara County

OBJECTIVE

To examine whether providing health insurance coverage to undocumented children affects the health of those children.

DATA SOURCES/STUDY SETTING

The data come from a survey of 1235 parents of enrollees in the new insurance program ("Healthy Kids") in Santa Clara County, California. The survey was conducted from August 2003 to July 2004.

STUDY DESIGN

Cross-sectional study using a group of children insured for one year as the study group (N=626) and a group of newly insured children as the comparison group (N=609). Regression analysis is used to adjust for differences in the groups according to a range of characteristics.

DATA COLLECTION

Parents were interviewed by telephone in either English or Spanish (most responded in Spanish). The response rate was 89 percent.

PRINCIPAL FINDINGS

The study group-who were children continuously insured by Healthy Kids for one year-were significantly less likely to be in fair/poor health and to have functional impairments than the comparison group of newly insured children (15.9 percent versus 28.5 percent and 4.5 percent versus 8.4 percent, respectively). Impacts were largest among children who enrolled for a specific medical reason (such as an illness or injury); indeed, the impact on functional limitations was evident only for this subgroup. The study group also had fewer missed school days than the comparison group, but the difference was significant only among children who did not enroll for a medical reason.

CONCLUSIONS

Health insurance coverage of undocumented children in Santa Clara County was associated with significant improvements in children's health status. The size of this association could be overstated, since the comparison sample included some children who enrolled because of an illness or other temporary health problem that would have improved even without insurance coverage. However, even after limiting the study sample to children who did not enroll for a medical reason, a significant association remained between children's reported health and their health coverage. We thus cautiously conclude that Healthy Kids had a favorable impact on children's health.

The value of antihypertensive drugs: a perspective on medical innovation

Using national survey data and risk equations from the Framingham Heart Study, we quantify the impact of antihypertensive therapy changes on blood pressures and the number and cost of heart attacks, strokes, and deaths. Antihypertensive therapy has had a major impact on health. Without it, 1999-2000 average blood pressures (at age 40+) would have been 10-13 percent higher, and 86,000 excess premature deaths from cardiovascular disease would have occurred in 2001. Treatment has generated a benefit-to-cost ratio of at least 6:1, but much more can be achieved. More effective use of antihypertensive medication would have an impact on mortality akin to eliminating all deaths from medical errors or accidents.

Access to care for U.S. health center patients and patients nationally: how do the most vulnerable populations fare?

This study examined access to care for uninsured and Medicaid-insured community health center patients in comparison to nonhealth center patients nationally. Using nationally representative data from 2 major surveys in 2002, there was a positive association between seeking care in community health centers and self-reported access to care for both uninsured and Medicaid patients. This suggests that health centers may fill a critical gap in access to care for patients who use their services. Given recent budget cuts to the Medicaid program, health centers remain an important policy option to assure access to care for vulnerable populations.

Health care markets, the safety net, and utilization of care among the uninsured

OBJECTIVE

To quantify the relationship between utilization of care among the uninsured and the structure of the local health care market and safety net.

DATA SOURCES/STUDY SETTING

Nationally representative data from the 1996 to 2000 waves of the Medical Expenditure Panel Survey (MEPS) linked to data from multiple secondary sources.

STUDY DESIGN

We separately analyze outpatient care utilization and whether an individual incurred any medical expenditure among uninsured adults living in urban and rural areas. Safety net measures include distances between each individual and the nearest safety net providers as well as a measure of capacity based on local government and hospital health expenditures. Other covariates include the managed care presence in the local health care market, the percentage of individuals who are uninsured in the area, and local primary care physician supply. We simulate utilization using standardized predictions.

PRINCIPAL FINDINGS

Distances between the rural uninsured and safety net providers are significantly associated with utilization. In urban areas, we find that the percentage of individuals in the area who are uninsured, the pervasiveness and competitiveness of managed care, the primary care physician supply, and safety net capacity have a significant relationship with health care utilization.

CONCLUSIONS

Facilitating transport to safety net providers and increasing the number of such providers are likely to increase utilization of care among the rural uninsured. Our findings for urban areas suggest that the uninsured living in areas where managed care presence is substantial, and especially where managed care competition is limited, could be a target for policies to improve the ability of the uninsured to obtain care. Policies oriented toward enhancing funding for the safety net and increasing the capacity of safety net providers are likely to be important to ensuring the urban uninsured are able to obtain health care.

Risk of cardiovascular events and death--does insurance matter?

BACKGROUND

Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes.

OBJECTIVE

To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures.

DESIGN AND PARTICIPANTS

We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987-1989 and returned for follow-up visits every 3 years, for a total of 4 visits.

MAIN OUTCOME MEASURES

We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions.

RESULTS

Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22-2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03-1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08-1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00-1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03-1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08-1.39).

CONCLUSIONS

Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes.

Crisis & commitment: 150 years of service by Los Angeles county public hospitals

The Los Angeles County University of Southern California Medical Center will open soon, replacing the county's current 74-year-old facility with a modern, although smaller, facility. Los Angeles County has provided hospital care to the indigent since 1858, during which time, the operation of public hospitals has shifted from a state-mandated welfare responsibility to a preeminent part of the county's public health mission. As this shift occurred, the financing of Los Angeles County hospitals changed from primarily county support to state and federal government sources, particularly Medicaid. The success of the new hospital will depend on whether government leaders at all levels provide the reforms needed to help the county and its partners stabilize its funding base.

Changes in health for the uninsured after reaching age-eligibility for Medicare

BACKGROUND

Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance.

OBJECTIVE

To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare.

DESIGN

Prospective cohort study.

PARTICIPANTS

Participants (N=3,419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview.

MEASUREMENTS

We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t(-2) to t(0)) and the following 2 years (t(0) to t(2)).

RESULTS

Between the interview before age 65 (t(-2)) and the first interview after reaching age 65 (t(0)), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t(0) to t(2)), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare.

CONCLUSIONS

Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.

Short-term impacts of coverage loss in a Medicaid population: early results from a prospective cohort study of the Oregon Health Plan

PURPOSE

Medicaid programs in all 50 states recently implemented cost-saving strategies, including benefit reductions, cost sharing, and tightened administrative rules. These changes resulted in loss of insurance coverage for thousands of low-income adults nationwide. In this study we assessed the immediate impacts of disrupted and lost Medicaid coverage on adults enrolled in the Oregon Health Plan (OHP) when program changes were implemented.

METHODS

Data come from baseline survey results of a prospective cohort study designed to assess the impacts of OHP changes on adult beneficiaries. We used bivariate and multivariate analyses to examine the effects of disrupted and lost insurance coverage on unmet health care needs, utilization, and medical debt occurring in the first 10 months after OHP changes were implemented.

RESULTS

After OHP changes were implemented, 31% of enrolled adults reported losing coverage, and another 15% reported disrupted coverage. Controlling for demographic characteristics, income, and health status, those with disrupted coverage were less likely to have a primary care visit (odds ratio [OR] = .66; P <.05) and more likely to report unmet health care needs (OR = 1.85; P <.01) and medical debt (OR = 1.99; P <.01) when compared with those continuously insured. Those who lost coverage were less likely to have a primary care visit (OR = 0.18; P <.01) and more likely to report unmet health care needs (OR = 5.55; P <.01), unmet medication needs (OR = 2.05; P <01), and medical debt (OR = 3.06; P <.01) than those continuously insured.

CONCLUSIONS

Medicaid program changes that increase cost sharing and limit enrollment have significant negative impacts on health care access and utilization among Medicaid beneficiaries; these impacts occur rapidly, within the first 10 months after changes.

Unintended consequences of caps on Medicare drug benefits

BACKGROUND

Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries.

METHODS

We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at 1,000 dollars and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements.

RESULTS

After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more.

CONCLUSIONS

A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.

Disparities in primary care for vulnerable children: the influence of multiple risk factors

OBJECTIVES

To analyze vulnerability as a profile of multiple risk factors for poor pediatric care based on race/ethnicity, poverty status, parent education, insurance, and language. Profiles are used to examine disparities in child/adolescent health status and primary care experience.

DATA SOURCES

Cross-sectional data on 19,485 children/adolescents 0-19 years of age from the 2001 California Health Interview Survey.

STUDY DESIGN

Multiple logistic regression models are used to examine risk profiles in relation to health status and three aspects of primary care: access (physician and dental visit; access surety), continuity (regular source of care), and comprehensiveness (i.e., health promotion counseling).

PRINCIPAL FINDINGS

About 43 percent of (or 4.4 million) children in California have two or more risk factors (RF). Controlling for age and gender, more RFs is associated with poorer health status (i.e. percent reporting "excellent/very good" health: no RFs=81 percent, 1=71 percent, 2=57 percent, 3=45 percent, 4=35 percent, 5=28 percent, all p<.001). Controlling for health status, higher risk profiles is associated with poorer primary care access and continuity, but greater comprehensiveness of care. For example, higher risk profile children are less likely to have a regular source of care: one RF (prevalence ratio [PR]=0.92, confidence interval [CI]: 0.86-0.98), two (PR=0.77, CI: 0.69-0.84), three (PR=0.55, CI: 0.46-0.65), and four or more (PR=0.31, CI: 0.22-0.44), all p<.001.

CONCLUSIONS

This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status, access to, and continuity of primary care. Having gained access, however, adolescents with higher risk profiles are more likely to receive health promotion counseling. Higher profiles appear to be associated with greater barriers to accessing primary care for children in "fair or poor" health, suggesting that vulnerable children who have the greatest health care needs also have the greatest difficulty obtaining primary care.

Health insurance coverage and the risk of decline in overall health and death among the near elderly, 1992-2002

BACKGROUND

Although individuals' health insurance coverage changes frequently, previous analyses have not accounted for changes in insurance coverage over time.

OBJECTIVE

We sought to determine the independent association between lack of insurance and the risk of a decline in self-reported overall health and death from 1992 to 2002, accounting for changes in self-reported overall health and insurance coverage.

METHODS

We analyzed data from the Health and Retirement study, a prospective cohort study of a national sample of community-dwelling adults age 51-61 years old at baseline. Major decline in self-reported overall health and mortality was determined at 2-year intervals.

RESULTS

People who were uninsured at baseline had a 35% (95% confidence interval [CI] 12-62%) higher risk-adjusted mortality from 1992 to 2002 compared with those with private insurance. However, when we analyzed outcomes over 2-year intervals, individuals who were uninsured at the start of each interval were more likely to have a major decline in their overall health (pooled adjusted relative risk 1.43, 95% CI 1.28-1.63), but they were equally likely to die (pooled adjusted relative risk 0.96, 95% CI 0.73-1.27). Of the 1512 people who were uninsured at baseline, 220 (14.6%) died; of those who died, only 70 (31.8%) were still uninsured at the HRS interview prior to death.

CONCLUSIONS

Death does not appear to be a short-term consequence of being uninsured. Instead, higher long-term mortality among the uninsured results from erosion in this population's health status over time and the attendant higher mortality associated with this. Most deaths among the uninsured occur after individuals have gained either public or private health insurance.

Medicaid programme changes and the chronically ill: early results from a prospective cohort study of the Oregon Health Plan

OBJECTIVE

To describe the impacts of recent Oregon Health Plan (OHP) policy changes on individuals living with chronic illness in Oregon.

METHODS

A mail survey was conducted of 1374 OHP beneficiaries who were directly affected by the new policies. The analyses reported in this article represent baseline findings from the first of three survey waves in an ongoing prospective cohort study.

RESULTS

A significant association was found between Medicaid policy changes and high rates of disenrolment from the OHP. Compared to the non-chronically ill, the chronically ill were more likely to report inability to pay for medications, higher medical debt, more unmet health needs, and poorer health status. Among the chronically ill, those who lost insurance reported decreased access to and utilization of healthcare, more medical debt, and more restriction of medications.

DISCUSSION

As policy-makers restructure public programmes to accommodate tight budgets and rising healthcare costs, people with chronic illness can easily be overlooked. Chronically ill individuals face disproportionate financial and health burdens. Small cost-saving policy changes can lead to widespread disenrolment that cascades into reduced access to healthcare services, altered utilization patterns, and financial strain.

What do health savings accounts mean for the emergency department?

The insurance market is evolving, with increased emphasis on plans with high deductibles and a large degree of coinsurance. This article serves as an introduction to the defining characteristics of consumer-driven health care plans and their associated health savings accounts. We discuss the most recent evidence on the adoption of these plans and their effects on use and reimbursement. Compared to many specialties, the emergency department (ED) may be insulated from extensive shopping and price negotiation, because visits to the ED are often for urgent and time-sensitive conditions. However, ED utilization patterns may change if cost-conscious health savings account holders forgo other necessary medical care, or if they seek out substitutes to the ED for less urgent problems. In the long run, the ED may feel the impact of changes that stem from 2 areas: the ability of health savings accounts to control the increase in health care costs, and the potential of health savings accounts to replace or undermine more comprehensive health insurance plans. We note areas that emergency physicians should monitor as health savings accounts become more prominent.

The unintended impact of welfare reform on the medicaid enrollment of eligible immigrants

BACKGROUND

During welfare reform, Congress passed legislation barring legal immigrants who entered the United States after August 1996 from Medicaid for five years after immigration. This legislation intended to bar only new immigrants (post-1996 immigrants) from Medicaid. However it may have also deterred the enrollment of legal immigrants who immigrated before 1996 (pre-1996 immigrants) and who should have remained Medicaid eligible.

OBJECTIVES

To compare the Medicaid enrollment of U.S.-born citizens to pre-1996 immigrants, before and after welfare reform, and to determine if variation in state Medicaid policies toward post-1996 immigrants modified the effects of welfare reform on pre-1996 immigrants.

DATA SOURCE/STUDY DESIGN

Secondary database analysis of cross-sectional data from 1994-2001 of the U.S. Census Bureau, Annual Demographic Survey of March Supplement of the Current Population Survey.

SUBJECTS

Low-income, U.S.-born adults (N=116,307) and low-income pre-1996 immigrants (N=24,367) before and after welfare reform.

MEASURES

Self-reported Medicaid enrollment.

RESULTS

Before welfare reform, pre-1996 immigrants were less likely to enroll in Medicaid than the U.S.-born (OR=0.55; 95 percent CI, 0.51-0.59). After welfare reform, pre-1996 immigrants were even less likely to enroll in Medicaid. The proportion of immigrants in Medicaid dropped 3 percentage points after 1996; for the U.S.-born it dropped 1.6 percentage points (p=0.012). Except for California, state variation in Medicaid policy toward post-1996 immigrants did modify the effect of welfare reform on pre-1996 immigrants.

CONCLUSIONS

Federal laws limiting the Medicaid eligibility of specific subgroups of immigrants appear to have had unintended consequences on Medicaid enrollment in the larger, still eligible immigrant community. Inclusive state policies may overcome this effect.