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Rennane S, Sobol D, Stein BD, Dick A. Insurance coverage during transitions: Evidence from Medicaid automatic enrollment for children receiving supplemental security income. Health Serv Res 2024; 59:e14261. [PMID: 37985435 PMCID: PMC11063087 DOI: 10.1111/1475-6773.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES To analyze relationships between Medicaid automatic enrollment for child Supplemental Security Income (SSI) recipients and health insurance coverage during transitions. DATA SOURCES AND STUDY SETTING Medical Expenditure Panel Study, 2000-2020 and National Survey for Children with Special Health Care Needs, 2001-2010. STUDY DESIGN Leveraging variation in SSI-Medicaid automatic enrollment status across regions and over time, we estimate a regression model to quantify associations between automatic enrollment and insurance coverage. We validate our findings in the NS-CSHCN. DATA COLLECTION Our sample includes children receiving SSI for a disability. We also analyze a subsample of children newly enrolled in SSI. PRINCIPAL FINDINGS Automatic enrollment is associated with a statistically significant increase in insurance coverage. Expanding automatic enrollment to all states is associated with increases in Medicaid enrollment of 3% (CI 0.9%-6.7%) among all SSI children and 7% (CI 1.1%-13.9%) among children newly enrolled in SSI. We find similar decreases in uninsurance. Analysis in the NS-CSHCN replicates these findings. CONCLUSIONS Medicaid automatic enrollment policies are associated with increased insurance coverage for SSI children, particularly those transitioning into the program. Medicaid policy defaults could play an important role in reducing administrative burdens to improve children's coverage and access to care.
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Nelson DB, Singer PM, Fung V. Implementing automated Medicaid eligibility renewals was not associated with higher levels of program participation. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae071. [PMID: 38841719 PMCID: PMC11152203 DOI: 10.1093/haschl/qxae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
Increasing participation in Medicaid among eligible individuals is critical for improving access to care among low-income populations. The administrative burdens of enrolling and renewing eligibility are a major barrier to participation. To reduce these burdens, the Affordable Care Act required states to adopt automated renewal processes that use available databases to verify ongoing eligibility. By 2019, nearly all states adopted automated renewals, but little is known about how this policy affected Medicaid participation rates. Using the 2015-2019 American Community Survey, we found that participation rates among nondisabled, nonelderly adults and children varied widely by state, with an average of 70.8% and 90.7%, respectively. Among Medicaid-eligible adults, participation was lower among younger adults, males, unmarried individuals, childless households, and those living in non-expansion states compared with their counterparts. State adoption of automated renewals varied over time, but participation rates were not associated with adoption. This finding could reflect limitations to current automated renewal processes or barriers to participation outside of the eligibility renewal process, which will be important to address as additional states expand Medicaid and pandemic-era protections on enrollment expire.
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Affiliation(s)
- Daniel B Nelson
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
| | - Phillip M Singer
- Department of Political Science, University of Utah, Salt Lake City, UT 84112, United States
| | - Vicki Fung
- Department of Medicine, Mongan Institute, Massachusetts General Hospital, Boston, MA 02114, United States
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Johnson KJ, Brown DS, O'Connell CP, Thompson T, Barnes JM, King AA. Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients. Pediatr Blood Cancer 2024; 71:e30861. [PMID: 38235939 DOI: 10.1002/pbc.30861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/12/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment. METHODS SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates. RESULTS Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively. CONCLUSIONS Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.
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Affiliation(s)
- Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Tess Thompson
- School of Social Work, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Allison A King
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics Hematology/Oncology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
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Ilea P, Ilea I. Administrative burden for patients in U.S. health care settings Post-Affordable Care Act: A scoping review. Soc Sci Med 2024; 345:116686. [PMID: 38368662 DOI: 10.1016/j.socscimed.2024.116686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/20/2024] [Accepted: 02/08/2024] [Indexed: 02/20/2024]
Abstract
Administrative burdens are the costs associated with receiving a service or accessing a program. Based on the Herd & Moynihan framework, they occur in three subcategories: learning costs, compliance costs, and psychological costs. Administrative burdens manifest inequitably, more significantly impacting vulnerable populations. Administrative burdens may impact the health of those trying to access services, and in some cases block access to health-promoting services entirely. This scoping review examined studies focused on the impact on patients of administrative burden administrative burden in health care settings in the U.S. following the passage of the Affordable Care Act. We queried databases for empirical literature capturing patient administrative burden, retrieving 1578 records, with 31 articles ultimately eligible for inclusion. Of the 31 included studies, 18 used quantitative methods, nine used qualitative methods, three used mixed methods, and one was a case study. In terms of administrative burden subcategories, most patient outcomes reported were learning (22 studies) and compliance costs (26 studies). Psychological costs were the most rarely reported; all four studies describing psychological costs were qualitative in nature. Only twelve studies connected patient demographic data with administrative burden data, despite previous research suggesting an inequitable burden impact. Additionally, twenty-eight studies assessed administrative burden and only three attempted to reduce it via an intervention, resulting in a lack of data on intervention design and efficacy.
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Affiliation(s)
- Passion Ilea
- Portland State University, School of Social Work, 1800 SW 6th Avenue, Portland, OR, 97201, 503.725.4040, USA.
| | - Ian Ilea
- The Center to Improve Veteran Involvement in Care, Portland VA Research Foundation, USA
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Fung V, Price M, Cheng D, Patel TA, Yang Z, Hsu J, Alegria M, Newhouse JP. Associations Between Annual Medicare Part D Low-Income Subsidy Loss and Prescription Drug Spending and Use. JAMA HEALTH FORUM 2024; 5:e235152. [PMID: 38306091 PMCID: PMC10837747 DOI: 10.1001/jamahealthforum.2023.5152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Importance The Medicare Part D Low Income Subsidy (LIS) program provides millions of beneficiaries with drug plan premium and cost-sharing assistance. The extent to which LIS recipients experience subsidy losses with annual redetermination cycles and the resulting associations with prescription drug affordability and use are unknown. Objective To examine how frequently annual LIS benefits are lost among Medicare Part D beneficiaries and how this is associated with prescription drug use and out-of-pocket costs. Design, Setting, and Participants In this cohort study of Medicare Part D beneficiaries from 2007 to 2018, annual changes in LIS recipients among those automatically deemed eligible (eg, due to dual eligibility for Medicare and Medicaid) and nondeemed beneficiaries who must apply for LIS benefits were analyzed using Medicare enrollment and Part D event data. Subsidy losses were classified in 4 groups: temporary losses (<1 year); extended losses (≥1 year); subsidy reductions (change to partial LIS); and disenrollment from Medicare Part D after subsidy loss. Temporary losses could more likely represent subsidy losses among eligible beneficiaries. Multinomial logit models were used to examine associations between beneficiary characteristics and subsidy loss; linear regression models were used to compare changes in prescription drug cost and use in the months after subsidy losses vs before. Analyses were conducted between November 2022 and November 2023. Exposure Subsidy loss at the beginning of each year among subsidy recipients in December of the prior year. Main Outcomes and Measures The main outcomes were out-of-pocket costs and prescription drug fills overall and for 4 classes: antidiabetes, antilipid, antidepressant, and antipsychotic drugs. Results In 2008, 731 070 full LIS beneficiaries (17%) were not deemed automatically eligible (39% were aged <65 years; 59% were female). Nearly all beneficiaries deemed automatically eligible (≥99%) retained the subsidy annually from 2007 to 2018, compared with 78% to 84% of nondeemed beneficiaries. Among nondeemed beneficiaries, disabled individuals younger than 65 years and racial and ethnic minority groups were more likely to have temporary subsidy losses vs none. Temporary losses were associated with an average 700% increase in out-of-pocket drug costs (+$52.72/mo [95% CI, 52.52-52.92]) and 15% reductions in prescription fills (-0.58 fills/mo [95% CI, -0.59 to -0.57]) overall. Similar changes were found for antidiabetes, antilipid, antidepressant, and antipsychotic prescription drug classes. Beneficiaries who retained their subsidy had few changes. Conclusions and Relevance The conclusions of this cohort study suggest that efforts to help eligible beneficiaries retain Medicare Part D subsidies could improve drug affordability, treatment adherence, and reduce disparities in medication access.
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Affiliation(s)
- Vicki Fung
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - David Cheng
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Tej A Patel
- Massachusetts General Hospital, Boston
- University of Pennsylvania, Philadelphia
| | | | - John Hsu
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Margarita Alegria
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Joseph P Newhouse
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Chatillon A, Vizcarra E, Kumar B, Dickman SL, Beasley AD, White K. Access to care following Planned Parenthood's termination from Texas' Medicaid network: A qualitative study. Contraception 2023; 128:110141. [PMID: 37597715 DOI: 10.1016/j.contraception.2023.110141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES This study aimed to explore Planned Parenthood Medicaid patients' experiences getting reproductive health care in Texas after the state terminated Planned Parenthood providers from its Medicaid program in 2021. STUDY DESIGN Between January and September 2021, we recruited Medicaid patients who obtained care at Planned Parenthood health centers prior to the state termination using direct mailers, electronic messages, community outreach, and flyers in health centers. We conducted baseline and 2-month follow-up semistructured phone interviews about patients' previous experiences using Medicaid at Planned Parenthood and other providers and how the termination affected their care. We qualitatively analyzed the data using the principles of grounded theory. RESULTS We interviewed 30 patients, 24 of whom completed follow-up interviews. Participants reported that Planned Parenthood reliably accepted different Medicaid plans, worked with patients to ameliorate the structural barriers they face to care, and referred them to other providers as needed. After Planned Parenthood's termination from the Texas Medicaid program, participants faced difficulties accessing care elsewhere, including same-day appointments and on-site medications. Consequences included delayed or forgone reproductive health care, including contraception, and emotional distress. CONCLUSIONS Planned Parenthood Medicaid patients found it difficult to connect with other providers for reproductive health care and to obtain evidence-based care following the organization's termination from Medicaid. Ensuring all Medicaid patients have freedom to choose providers would improve access to quality contraception and other reproductive health care. IMPLICATIONS Medicaid-funded reproductive health care access is restricted for people living on low incomes when providers do not reliably accept all Medicaid plans or cannot participate in Medicaid. This situation can lead to lower quality care, delayed or forgone care, and emotional distress.
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Affiliation(s)
- Anna Chatillon
- Population Research Center, University of Texas at Austin, Austin, TX, United States
| | | | - Bhavik Kumar
- Planned Parenthood Gulf Coast, Houston, TX, United States
| | | | - Anitra D Beasley
- Planned Parenthood Gulf Coast, Houston, TX, United States; Baylor College of Medicine, Houston, TX, United States
| | - Kari White
- Population Research Center, University of Texas at Austin, Austin, TX, United States; Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, United States.
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Nelson DB, Goldman AL, Zhang F, Yu H. Continuous Medicaid coverage during the COVID-19 public health emergency reduced churning, but did not eliminate it. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad055. [PMID: 38223316 PMCID: PMC10786332 DOI: 10.1093/haschl/qxad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Preserving insurance coverage in the wake of pandemic-related job loss was a priority in early 2020. To this end, the Families First Coronavirus Response Act implemented a continuous coverage policy in Medicaid to shore up access to health insurance. Prior to the pandemic, Medicaid enrollees experienced frequent coverage disruptions, known as "churning." The effect of the continuous coverage policy on churning during the COVID-19 public health emergency (PHE) is unknown. We performed a difference-in-differences analysis of nonelderly Medicaid enrollees using longitudinal national survey data to compare a 2019-2020 cohort exposed to the policy with a control cohort in 2018-2019. We found that the policy led to reduced transitions to uninsurance among adults, although not among children. The policy prevented over 300 000 transitions to uninsurance each month. However, disenrollment from Medicaid persisted at a low rate, despite the continuous coverage policy. As the PHE unwinds, policymakers should consider long-term continuous coverage policies to minimize churning in Medicaid.
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Affiliation(s)
- Daniel B. Nelson
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
| | - Anna L. Goldman
- Department of Medicine, Boston University School of Medicine, Boston, MA 02118, United States
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
| | - Hao Yu
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, United States
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Qin X, Huckfeldt P, Abraham J, Yee D, Virnig BA. Was Unstable Medicaid Coverage Among Older Medicare Beneficiaries Associated With Worse Clinical Outcomes? Evidence From the Delivery of Breast Cancer Care. Med Care 2023; 61:611-618. [PMID: 37440716 DOI: 10.1097/mlr.0000000000001885] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes. OBJECTIVES Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries. RESEARCH DESIGN Population-based cohort study. SUBJECTS A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database. MEASURES We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups. RESULTS Duals had poorer outcomes than those who were "never dual." Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support. CONCLUSIONS These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.
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Affiliation(s)
- Xuanzi Qin
- Department of Health Policy and Management, University of Maryland School of Public Health, MD
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Peter Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Jean Abraham
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Douglas Yee
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Beth A Virnig
- Division of Health Policy and Management, University of Minnesota School of Public Health
- University of Florida College of Public Health and Health Professions, Gainesville, FL
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Grembowski D, Leibbrand C. A conceptual model of health insurance stability in the United States health care system. Health Serv Manage Res 2022:9514848221146677. [DOI: 10.1177/09514848221146677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.
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Affiliation(s)
- David Grembowski
- Health Systems and Population Health, University of Washington, Seattle, WA, USA
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10
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Barón-Miras LE, Sisó-Almirall A, Kostov B, Sánchez E, Roura S, Benavent-Àreu J, González-de Paz L. Face-to-Face and Tele-Consults: A Study of the Effects on Diagnostic Activity and Patient Demand in Primary Healthcare. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14119. [PMID: 36360997 PMCID: PMC9656153 DOI: 10.3390/ijerph192114119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
Primary healthcare services have changed from face-to-face to tele-consults during the two COVID-19 years. We examined trends before and during the COVID-19 pandemic years based on groups of professionals, patient ages, and the associations with the diagnostic registry. We analyzed proportions for both periods, and ratios of the type of consults in 2017-2019 and 2020-2021 were calculated. The COVID-19 period was examined using monthly linear time trends. The results showed that consults in 2020-2021 increased by 24%. General practitioners saw significant falls in face-to-face consults compared with 2017-2019 (ratio 0.44; 95% CI: 0.44 to 0.45), but the increase was not proportional across age groups; patients aged 15-44 years had 45.8% more tele-consults, and those aged >74 years had 18.2% more. Trends in linear regression models of face-to-face consults with general practitioners and monthly diagnostic activity were positive, while the tele-consult trend was inverse to the trend of the diagnostic registry and face-to-face consults. Tele-consults did not resolve the increased demand for primary healthcare services caused by COVID-19. General practitioners, nurses and primary healthcare professionals require better-adapted tele-consult tools for an effective diagnostic registry to maintain equity of access and answer older patients' needs and priorities in primary healthcare.
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Affiliation(s)
- Lourdes E. Barón-Miras
- Department of Preventive Medicine and Epidemiology, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Antoni Sisó-Almirall
- Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain
- Primary Healthcare Transversal Research Group, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Belchin Kostov
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya (UPC), 08034 Barcelona, Spain
| | - Encarna Sánchez
- Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain
| | - Silvia Roura
- Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain
| | - Jaume Benavent-Àreu
- Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain
| | - Luis González-de Paz
- Consorci d’Atenció Primària de Salut Barcelona Esquerra (CAPSBE), 08028 Barcelona, Spain
- Primary Healthcare Transversal Research Group, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
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11
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Patterns in Medicaid Coverage and Service Utilization Among People with Serious Mental Illnesses. Community Ment Health J 2022; 58:729-739. [PMID: 34448985 DOI: 10.1007/s10597-021-00878-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
Disruptions in Medicaid adversely affect service use and outcomes among individuals with serious mental illnesses (SMI). A retrospective longitudinal study examined Medicaid coverage and service utilization patterns among individuals with SMI (N = 8358) from 2007 to 2010. Only 36% of participants were continuously enrolled in Medicaid and 20% experienced multiple enrollment disruptions. Mental health diagnosis did not predict continuous coverage; however, individuals with schizophrenia were 19% more likely to have multiple coverage disruptions than those with depression (b = - 0.21; p < 0.01). Single and multiple coverage disruptions were associated with decreased rates of outpatient service days utilized (IRR = 0.77 and 0.65, respectively, p < 0.001) and decreased odds of not using acute care services (OR 0.26 and 0.19, respectively, p < 0.001). Future research should explore mechanisms underlying Medicaid stability and develop interventions that facilitate insurance stability and service utilization.
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12
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Bensken WP, Ciesielski TH, Williams SM, Stange KC, Sajatovic M, Koroukian SM. Inconsistent Medicaid Coverage is Associated with Negative Health Events for People with Epilepsy. J Health Care Poor Underserved 2022; 33:1036-1053. [PMID: 35574892 PMCID: PMC9147776 DOI: 10.1353/hpu.2022.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Examine the association between gaps in Medicaid coverage and negative health events (NHEs) for people with epilepsy (PWE). METHODS Using five years of Medicaid claims for PWE, we identified gaps in Medicaid coverage. We used logistic regression to evaluate the association between a gap in coverage and being in the top quartile of NHEs and factors associated with having a gap. These models adjusted for: demographics, residence, medication adherence, disease severity, and comorbidities. RESULTS Of 186,616 PWE, 21.7% had a gap in coverage. The odds of being in the top quartile of NHEs per year were 66% higher among those with a gap (OR: 1.66; 95% CI: 1.61, 1.70). Being female, younger, and having psychiatric comorbidities increased the odds of having a gap. CONCLUSIONS Gaps in Medicaid coverage are associated with being a high utilizer during covered periods. Specific groups could be targeted with interventions to reduce churning.
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Affiliation(s)
- Wyatt P. Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Timothy H. Ciesielski
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Scott M. Williams
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Kurt C. Stange
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Center for Community Health Integration, Departments of Family Medicine & Community Health and Sociology, Case Western Reserve University, Cleveland, OH
| | - Martha Sajatovic
- Departments of Neurology and Psychiatry, University Hospitals Cleveland Medical Center and School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Siran M. Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
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Myerson R, Tilipman N, Feher A, Li H, Yin W, Menashe I. Personalized Telephone Outreach Increased Health Insurance Take-Up For Hard-To-Reach Populations, But Challenges Remain. Health Aff (Millwood) 2022; 41:129-137. [PMID: 34982628 PMCID: PMC8844881 DOI: 10.1377/hlthaff.2021.01000] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We tested the impact of personalized telephone calls from service center representatives on health plan enrollment in California's Affordable Care Act Marketplace, Covered California, using a randomized controlled trial. The study sample included 79,522 consumers who had applied but not selected a plan. Receiving a call increased enrollment by 2.7 percentage points (22.5 percent) overall. Among subgroups, receiving a call significantly increased enrollment among consumers with income below 200 percent of the federal poverty level (4.0 percentage points or 47.6 percent for consumers with incomes below 150 percent of poverty and 4.0 percentage points or 36.4 percent for consumers with incomes of 150-199 of poverty), as well as those who were referred from Medicaid (2.9 percentage points or 53.7 percent), those ages 30-50 (2.4 percentage points or 23.3 percent) or older than age 50 (5.1 percentage points or 34.2 percent), those who were Hispanic (2.3 percentage points or 31.1 percent), and those whose preferred spoken language was Spanish (3.2 percentage points or 74.4 percent) or English (2.6 percentage points or 18.6 percent). The intervention provided a two-to-one return on investment. Yet absolute enrollment in the target population remained low; persistent enrollment barriers may have limited the intervention's impact. These findings inform implementation of the American Rescue Plan Act of 2021, which expands eligibility for subsidized coverage.
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Affiliation(s)
- Rebecca Myerson
- Rebecca Myerson, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nicholas Tilipman
- Nicholas Tilipman, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew Feher
- Andrew Feher, Covered California, Sacramento, California
| | - Honglin Li
- Honglin Li, University of Wisconsin-Madison
| | - Wesley Yin
- Wesley Yin, University of California Los Angeles, Los Angeles, California
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14
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Xie E, Colditz GA, Lian M, Greever-Rice T, Schmaltz C, Lucht J, Liu Y. OUP accepted manuscript. JNCI Cancer Spectr 2022; 6:6570595. [PMID: 35583139 PMCID: PMC9113434 DOI: 10.1093/jncics/pkac031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/01/2022] [Accepted: 03/21/2022] [Indexed: 12/03/2022] Open
Abstract
Background Disrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear. Methods Using the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment. Results Patients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold. Conclusions Women with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.
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Affiliation(s)
- Evaline Xie
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Min Lian
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Chester Schmaltz
- Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia, MO, USA
| | - Jill Lucht
- Center for Health Policy, University of Missouri, Columbia, MO, USA
| | - Ying Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
- Correspondence to: Ying Liu, MD, PhD, 660 South Euclid Ave, Campus Box 8100, St. Louis, MO 63110, USA (e-mail: )
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15
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Cholera R, Anderson D, Raman SR, Hammill BG, DiPrete B, Breskin A, Wiener C, Rathnayaka N, Landi S, Brookhart MA, Whitaker RG, Bettger JP, Wong CA. Medicaid Coverage Disruptions Among Children Enrolled in North Carolina Medicaid From 2016 to 2018. JAMA HEALTH FORUM 2021; 2:e214283. [PMID: 35977295 PMCID: PMC8796937 DOI: 10.1001/jamahealthforum.2021.4283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/23/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Rushina Cholera
- Duke Margolis Center for Health Policy, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - David Anderson
- Duke Margolis Center for Health Policy, Durham, North Carolina
| | - Sudha R. Raman
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Bradley G. Hammill
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Bethany DiPrete
- NoviSci, Durham, North Carolina
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
| | | | | | | | | | - M. Alan Brookhart
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- NoviSci, Durham, North Carolina
| | | | - Janet Prvu Bettger
- Duke Margolis Center for Health Policy, Durham, North Carolina
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Charlene A. Wong
- Duke Margolis Center for Health Policy, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
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16
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Haimovich JS, Cui J, Yeh RW, Ferris TG, Hsu J, Wasfy JH. Expansion of insurance under the affordable care act and invasive management of acute myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 39:90-96. [PMID: 34756520 DOI: 10.1016/j.carrev.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The Affordable Care Act of 2010 extended health insurance through expansion of Medicaid and subsidies for commercial insurance. Prior work has produced differing results in associating expanded insurance with improvements in health care processes and outcomes. Evaluating specific mechanisms of care processes and their association with insurance expansion may help reconcile those results. METHODS AND RESULTS We used inpatient hospitalization data in the Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 1/1/2008 to 9/30/2015. We included all hospitalizations for acute myocardial infarction (AMI). As a primary outcome, we defined percent rate of AMI hospitalizations receiving percutaneous coronary intervention (PCI) per month. In the non-Medicare (intervention) group, there was a relative decrease of 0.2% of the monthly trend before and after expansion (95% CI [-0.3%, -0.1%]). In the Medicare group, there was a relative decrease of 0.1% of the monthly trend before and after expansion (95% CI [-0.2%, 0%]). CONCLUSIONS We did not detect a relative difference in PCI for AMI associated with insurance expansion under health reform.
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Affiliation(s)
- Julian S Haimovich
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jinghan Cui
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Yeh
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Physicians Organization, Boston, MA, USA
| | - John Hsu
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Physicians Organization, Boston, MA, USA.
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17
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Golberstein E, Busch SH, Sint K, Rosenheck RA. Insurance Status and Continuity for Young Adults With First-Episode Psychosis. Psychiatr Serv 2021; 72:1160-1167. [PMID: 33971726 PMCID: PMC8488003 DOI: 10.1176/appi.ps.201900571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Insurance status and continuity may affect access to and quality of care. The authors characterized patterns of and changes in insurance status over 1 year among people with first-episode psychosis (FEP), comparing insurance patterns with adults of similar age in the general population. METHODS Longitudinal data on insurance status and predictors of insurance status among adults with FEP were obtained from RAISE-ETP (Recovery After an Initial Schizophrenia Episode-Early Treatment Program) study participants with complete 1-year data (N=288). The frequencies of insurance status and transitions are presented. Bivariate comparisons were used to assess the impact of the comprehensive coordinated care intervention in RAISE-ETP on insurance changes. These data were compared with contemporaneous longitudinal data in the 2011 Medical Expenditures Panel Study. RESULTS The RAISE-ETP experimental intervention did not significantly change insurance status. At baseline, levels of uninsurance (47%) and public insurance (31%) were higher among RAISE-ETP participants than among a similar age group in the general public (29% and 13%, respectively). Insurance transitions were common among people with FEP, although 79% of those with public insurance at baseline also had public insurance at 1 year. Of studied RAISE-ETP participants, 60% had a period of uninsurance during the year studied. CONCLUSIONS Compared with a national sample, people with FEP were more likely to use public insurance but still had high persistence of 12-month uninsurance. That over half of the RAISE-ETP participants had a period of uninsurance suggests that more research is needed on whether these periods affect treatment continuity and medication adherence.
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Affiliation(s)
- Ezra Golberstein
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis (Golberstein); Yale School of Public Health, Yale University, New Haven, Connecticut (Busch); Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut (Sint); Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, and Mental Illness Research, Education and Clinical Center of New England, U.S. Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (Rosenheck)
| | - Susan H Busch
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis (Golberstein); Yale School of Public Health, Yale University, New Haven, Connecticut (Busch); Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut (Sint); Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, and Mental Illness Research, Education and Clinical Center of New England, U.S. Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (Rosenheck)
| | - Kyaw Sint
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis (Golberstein); Yale School of Public Health, Yale University, New Haven, Connecticut (Busch); Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut (Sint); Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, and Mental Illness Research, Education and Clinical Center of New England, U.S. Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (Rosenheck)
| | - Robert A Rosenheck
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis (Golberstein); Yale School of Public Health, Yale University, New Haven, Connecticut (Busch); Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut (Sint); Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, and Mental Illness Research, Education and Clinical Center of New England, U.S. Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (Rosenheck)
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18
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Brantley E, Ku L. Continuous Eligibility for Medicaid Associated With Improved Child Health Outcomes. Med Care Res Rev 2021; 79:404-413. [PMID: 34525877 DOI: 10.1177/10775587211021172] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fluctuating insurance coverage, or churning, is a recognized barrier to health care access. We assessed whether state policies that allow children to remain covered in Medicaid for a 12-month period, regardless of fluctuations in income, are associated with health and health care outcomes, after controlling for individual factors and other Medicaid policies. This cross-sectional study uses a large, nationally representative database of children ages 0 to 17. Continuous eligibility was associated with improved rates of insurance, reductions in gaps in insurance and gaps due to application problems, and lower probability of being in fair or poor health. For children with special health care needs, it was associated with increases in use of medical care and preventive and specialty care access. However, continuous eligibility was not associated with health care utilization outcomes for the full sample. Continuous eligibility may be an effective strategy to reduce gaps in coverage for children and reduce paperwork burden on Medicaid agencies.
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Affiliation(s)
- Erin Brantley
- The George Washington University, Washington, DC, USA
| | - Leighton Ku
- The George Washington University, Washington, DC, USA
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19
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Yabroff KR, Zhao J, Halpern MT, Fedewa SA, Han X, Nogueira LM, Zheng Z, Jemal A. Health Insurance Disruptions and Care Access and Affordability in the U.S. Am J Prev Med 2021; 61:3-12. [PMID: 34148626 DOI: 10.1016/j.amepre.2021.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Health insurance is associated with better care in the U.S., but little is known about the associations of coverage disruptions (i.e., periods without insurance) with care access, receipt, and affordability. METHODS Adults aged 18-64 years with current private (n=124,746), public (n=30,932), or no (n=31,802) insurance coverage were identified from the 2011-2018 National Health Interview Survey. Data were analyzed in 2020. Separate multivariable logistic regressions evaluated the associations of having coverage disruptions or being uninsured with care access, receipt, and affordability. RESULTS Overall, 5.0% of currently insured adults with private and 10.7% with public insurance reported a coverage disruption in the previous year, representing nearly 9.1 million adults in 2018. Among currently uninsured, 24.9% reported coverage loss within the previous year, representing nearly 8.1 million adults in 2018. Among adults with current private or current public coverage, disruptions were associated with lower receipt of all preventive services (AOR=0.42, 95% CI=0.37, 0.46 and AOR=0.48, 95% CI=0.40, 0.58, respectively), with forgoing any needed care because of cost (AOR=4.79, 95% CI=4.44, 5.17 and AOR=4.28, 95% CI=3.86, 4.75), and with medication nonadherence because of cost (AOR=3.55, 95% CI=3.13, 4.03 and AOR=4.09, 95% CI=3.43, 4.88) compared with that among adults with continuous coverage (p<0.05). Longer disruptions among currently insured adults were significantly associated with worse care access, receipt, and affordability, with dose-response patterns. Currently uninsured adults, especially those with longer uninsured periods, reported significantly worse care access, receipt, and affordability than currently insured adults with coverage disruptions or continuous coverage. CONCLUSIONS Findings highlight the importance of continuous insurance coverage; disruptions owing to the COVID-19 pandemic will likely have adverse consequences for care access and affordability.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia.
| | - Jingxuan Zhao
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Michael T Halpern
- Division of Cancer Control & Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Stacey A Fedewa
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Leticia M Nogueira
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia
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20
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Mirza M, Harrison EA, Quiñones L, Kim H. Medicaid Redetermination and Renewal Experiences of Limited English Proficient Beneficiaries in Illinois. J Immigr Minor Health 2021; 24:145-153. [PMID: 33755840 DOI: 10.1007/s10903-021-01178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
Medicaid beneficiaries in most states must go through a redetermination process every 6-12 months to demonstrate continued eligibility. This study sought to examine Medicaid redetermination experiences among beneficiaries with Limited English Proficiency (LEP). A sequential mixed methods study was conducted involving quantitative phone surveys and semi-structured, in-person interviews with Arabic, Chinese, Korean, and Vietnamese speaking beneficiaries in Illinois. Survey respondents experienced notable barriers during the redetermination process. Quantitative data showed LEP respondents to have 5.3 times the odds of losing their Medicaid benefits as compared to English proficient respondents. Qualitative interviews illustrated the impact of Medicaid loss on individuals and families, as well as strategies for successfully navigating redetermination. Findings suggest that language barriers hinder Medicaid redetermination and play a role in cancellation of benefits. Recommendations for better language supports during the Medicaid redetermination process are discussed.
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Affiliation(s)
- Mansha Mirza
- Department of Occupational Therapy, University of Illinois at Chicago, Chicago, IL, USA. .,Department of Occupational Therapy, University of Illinois at Chicago, 1919 W. Taylor St., M/C 811; Room 309, Chicago, IL, 60612, USA.
| | | | - Luvia Quiñones
- Illinois Coalition for Immigrant and Refugee Rights, Chicago, IL, USA
| | - Hajwa Kim
- Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago, IL, USA
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21
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Ng BP, Laxy M, Shrestha SS, Soler RE, Cannon MJ, Smith BD, Zhang P. Prevalence and medical expenditures of diabetes-related complications among adult Medicaid enrollees with diabetes in eight U.S. states. J Diabetes Complications 2021; 35:107814. [PMID: 33419632 DOI: 10.1016/j.jdiacomp.2020.107814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/26/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
AIMS To estimate the prevalence and medical expenditures of diabetes-related complications (DRCs) among adult Medicaid enrollees with diabetes. METHODS We estimated the prevalence and medical expenditures for 12 diabetes-related complications by Medicaid eligibility category (disability-based vs. non-disability-based) in eight states. We used generalized linear models with log link and gamma distribution to estimate the total per-person annual medical expenditures for DRCs, controlling for demographics, and other comorbidities. RESULTS Among non-disability-based enrollees (NDBEs), 40.1% (in California) to 47.5% (in Oklahoma) had one or more DRCs, compared to 53.6% (in Alabama) to 64.8% (in Florida) among disability-based enrollees (DBEs). The most prevalent complication was neuropathy (16.1%-27.1% for NDBEs; 20.2%-30.4% for DBEs). Lower extremity amputation (<1% for both eligibilities) was the least prevalent complication. The costliest per-person complication was dialysis (per-person excess annual expenditure of $22,481-$41,298 for NDBEs; $23,569-$51,470 for DBEs in 2012 USD). Combining prevalence and per-person excess expenditures, the three costliest complications were nephropathy, heart failure, and ischemic heart disease (IHD) for DBEs, compared to neuropathy, nephropathy, and IHD for NDBEs. CONCLUSIONS Our study provides data that can be used for assessing the health care resources needed for managing DRCs and evaluating cost-effectiveness of interventions to prevent and management DRCs.
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Affiliation(s)
- Boon Peng Ng
- College of Nursing & Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL, United States of America; Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
| | - Michael Laxy
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Germany; German Center of Diabetes Research (DZD), Neuherberg-Munich, Germany; Global Diabetes Research Center, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America; Technical University of Munich, Department of Sport and Health Science, Munich, Germany
| | - Sundar S Shrestha
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Robin E Soler
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Michael J Cannon
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Bryce D Smith
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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22
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Abstract
Objectives To identify ICD-10-CM diagnostic codes associated with the social determinants of health (SDOH), determine frequency of use of the code for homelessness across time, and examine the frequency of interrupted periods of Medicaid eligibility (ie, Medicaid churn) for beneficiaries with and without this code. Design Retrospective data analyses of New York State (NYS) Medicaid claims data for years 2006-2017 to determine reliable indicators of SDOH hypothesized to affect Medicaid churn, and for years 2016-2017 to examine frequency of Medicaid churn among patients with and without an indicator for homelessness. Main Outcome Measures Any interruption in the eligibility for Medicaid insurance (Medicaid churn), assessed via client identification numbers (CIN) for continuity. Methods Analyses were conducted to assess the frequency of use and pattern of New York State Medicaid claims submission for SDOH codes. Analyses were conducted for Medicaid claims submitted for years 2016-2017 for Medicaid patients with and without a homeless code (ie, ICD-10-CM Z59.0) in 2017. Results ICD-9-CM / ICD-10-CM codes for lack of housing / homelessness demonstrated linear reliability over time (ie, for years 2006-2017) with increased usage. In 2016-2017, 22.9% of New York Medicaid patients with a homelessness code in 2017 experienced at least one interruption of Medicaid eligibility, while 18.8% of Medicaid patients without a homelessness code experienced Medicaid churn. Conclusions Medicaid policies would do well to take into consideration the barriers to continued enrollment for the Medicaid population. Measures ought to be enacted to reduce Medicaid churn, especially for individuals experiencing homelessness.
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Affiliation(s)
- Isaac Dapkins
- Family Health Centers at NYU Langone, Brooklyn, NY.,Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Saul B Blecker
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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23
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Brown AG, Kressin N, Terrin N, Hanchate A, Suzukida J, Kher S, Price LL, LeClair AM, Krzyszczyk D, Byhoff E, Freund KM. The Influence of Health Insurance Stability on Racial/Ethnic Differences in Diabetes Control and Management. Ethn Dis 2021; 31:149-158. [PMID: 33519165 PMCID: PMC7843051 DOI: 10.18865/ed.31.1.149] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective This study examined whether health insurance stability was associated with improved type 2 diabetes mellitus (DM) control and reduced racial/ethnic health disparities. Methods We utilized electronic medical record data (2005-2013) from two large, urban academic health systems with a racially/ethnically diverse patient population to examine insurance coverage, and three DM outcomes (poor diabetes control, A1c ≥8.0%; very poor diabetes control A1c >9.0%; and poor BP control, ≥ 130/80 mm Hg) and one DM management outcome (A1c monitoring). We used generalized estimating equations adjusting for age, sex, comorbidities, site of care, education, and income. Additional analysis examined if insurance stability (stable public or private insurance over the six-month internal) moderates the impact of race/ethnicity on DM outcomes. Results Nearly 50% of non-Hispanic (NH) Whites had private insurance coverage, compared with 33.5% of NH Blacks, 31.5% of Asians, and 31.1% of Hispanics. Overall, and within most racial/ ethnic groups, insurance stability was associated with better glycemic control compared with those with insurance switches or always being uninsured, with uninsured NH Blacks having significantly worse BP control. More NH Black and Hispanic patients had poorly controlled (A1c≥8%) and very poorly controlled (A1c>9%) diabetes across all insurance stability types than NH Whites or Asians. The interaction between insurance instability and race/ethnic groups was statistically significant for A1c monitoring and BP control, but not for glycemic control. Conclusion Stable insurance coverage was associated with improved DM outcomes for all racial / ethnic groups, but did not eliminate racial ethnic disparities.
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Affiliation(s)
| | - Nancy Kressin
- Boston University School of Medicine, Boston, MA
- Veterans Affairs Boston Healthcare System, Brockton, MA
| | - Norma Terrin
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | | | - Jillian Suzukida
- Division of Internal Medicine and Primary Care, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Sucharita Kher
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Tufts Medical Center, Tufts University, Boston, MA
| | - Lori Lyn Price
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Amy M. LeClair
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Danielle Krzyszczyk
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Elena Byhoff
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Division of Internal Medicine and Primary Care, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Karen M. Freund
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Division of Internal Medicine and Primary Care, Department of Medicine, Tufts Medical Center, Boston, MA
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24
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Berkowitz SA, Gold R, Domino ME, Basu S. Health insurance coverage and self-employment. Health Serv Res 2020; 56:247-255. [PMID: 33146406 DOI: 10.1111/1475-6773.13598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Self-employed workers are 10% of the US labor force, with growth projected over the next decade. Whether existing policy mechanisms are sufficient to ensure health insurance coverage for self-employed workers, who do not have access to employer-sponsored coverage, is unclear. OBJECTIVE To determine whether self-employment is associated with lack of health insurance coverage. DATA SOURCES Secondary analysis of Medical Expenditure Panel Survey (MEPS) data collected 2014-2017. STUDY DESIGN Participants were working age (18-64 years), employed, civilian noninstitutionalized US adults with two years of Medical Expenditure Panel Survey (MEPS) participation in 2014-2017. We compared those who were employees vs those who were self-employed. Key outcomes were self-report of health insurance coverage, and of delaying needed medical care. DATA EXTRACTION METHODS Longitudinal design among individuals who were employees during study year 1, comparing health insurance coverage among those who did vs did not transition to self-employment in year 2. PRINCIPAL FINDINGS 16 335 individuals, representing 121 473 345 working-age adults, met inclusion criteria; of these, 147, representing 1 097 582 individuals, transitioned to self-employment. In unadjusted analyses, 25.7% of those who became self-employed were uninsured in year 2, vs 8.1% of those who remained employees (P < .0001). In adjusted models, self-employment was associated with greater risk of being uninsured (26.1% vs 8.0%, risk difference 18.0%, 95% confidence interval [CI] 9.2% to 26.9%, P = .0001). A time-by-employment type product term suggests that 10.0 percentage points (95%CI 0.3 to 19.7 percentage points, P = .04) of the risk difference may be attributable to the change to self-employment. Self-employment was also associated with delaying needed medical care (12.0% vs 3.1%, risk difference: 8.9%, 95% CI 3.1% to 14.6%, P = .003). CONCLUSIONS One in four self-employed workers lack health insurance coverage. Given the rise in self-employment, it is imperative to identify ways to improve health care insurance access for self-employed working-age US adults.
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Affiliation(s)
- Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rachel Gold
- Center for Health Research, Kaiser Permanente, Portland, Oregon, USA.,Department of Research, OCHIN Inc., Portland, Oregon, USA
| | - Marisa Elena Domino
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Sanjay Basu
- Research and Analytics, Collective Health, San Francisco, California, USA.,Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA.,School of Public Health, Imperial College London, London, UK
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Yabroff KR, Reeder-Hayes K, Zhao J, Halpern MT, Lopez AM, Bernal-Mizrachi L, Collier AB, Neuner J, Phillips J, Blackstock W, Patel M. Health Insurance Coverage Disruptions and Cancer Care and Outcomes: Systematic Review of Published Research. J Natl Cancer Inst 2020; 112:671-687. [PMID: 32337585 PMCID: PMC7357319 DOI: 10.1093/jnci/djaa048] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/12/2020] [Accepted: 03/27/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival. METHODS We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively. RESULTS Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions. CONCLUSIONS Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Michael T Halpern
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Ana Maria Lopez
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Anderson B Collier
- Children’s Cancer Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Joan Neuner
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Manali Patel
- Stanford University School of Medicine, Stanford, CA, USA
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Burns ME, Dague L, Saloner B, Voskuil K, Kim NH, Serna Borrero N, Look K. Implementing parity for mental health and substance use treatment in Medicaid. Health Serv Res 2020; 55:604-614. [PMID: 32578233 DOI: 10.1111/1475-6773.13309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To estimate the association between the implementation of parity in coverage for mental health and substance use disorder (MHSUD) services within the Medicaid program and MHSUD service use. DATA SOURCES/STUDY SETTING Wisconsin Medicaid enrollment and claims data from 2013 to 2015. In April 2014, Wisconsin Medicaid transitioned childless adult beneficiaries from coverage with limited MHSUD services to parity-consistent coverage. Preparity, they only had Medicaid coverage for MHSUD visits to psychiatrists and the emergency department, while parent beneficiaries had parity-consistent coverage. STUDY DESIGN The study uses a difference-in-differences design to compare outcome changes for childless adult and parent beneficiaries. DATA COLLECTION/EXTRACTION METHODS We identified 76, 569 childless adult and parent beneficiaries aged 18-64 who were continuously enrolled for the 2-year study period. PRINCIPAL FINDINGS Introducing parity-consistent coverage within Medicaid was associated with increased utilization of Medicaid-reimbursed MHSUD services: outpatient, prescription medication, ED, and inpatient. Increased MHSUD outpatient visits were driven by increased visits to nonpsychiatrists. CONCLUSIONS Parity's effects on MHSUD service use have been studied in the context of private insurance, but its impact among Medicaid beneficiaries has not. Our findings suggest that parity implementation in Medicaid could increase access to effective MHSUD services in a high-need population.
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Affiliation(s)
- Marguerite E Burns
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Laura Dague
- Texas A&M University, College Station, Texas
| | - Brendan Saloner
- Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristen Voskuil
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nam Hyo Kim
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Kevin Look
- Social & Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
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Bocour A, Moore MS, Winters A. Impact of the Centers for Disease Control and Prevention Recommendation and State Law on Birth Cohort Hepatitis C Screening of New York City Medicaid Recipients. Am J Prev Med 2020; 58:832-838. [PMID: 32444001 DOI: 10.1016/j.amepre.2019.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 12/09/2022]
Abstract
INTRODUCTION The Centers for Disease Control and Prevention estimated that, during 1999-2008, people born in 1945-1965 (the baby boomer generation) represented approximately 75% of people infected with hepatitis C virus and 73% of hepatitis C virus-associated deaths and are at greatest risk for hepatocellular carcinoma and liver disease. In 2012, the Centers for Disease Control and Prevention recommended one-time hepatitis C virus screening for people born during 1945-1965. In addition, New York State enacted a Hepatitis C Virus Testing Law in 2014. This analysis assesses the impacts of the 2012 recommendation and 2014 New York State Testing Law on hepatitis C virus screening rates among New York City Medicaid-enrolled recipients born during 1945-1965. METHODS The eligible population was determined quarterly as the number of Medicaid recipients continuously enrolled for 12 months with neither a prior hepatitis C virus diagnosis nor antibody test since 2005. Quarterly screening rates during 2010-2017 were examined using interrupted time series analysis. Data were analyzed in 2018-2019. RESULTS In 2010-2017, the highest screening rate occurred in the quarter immediately after the law (33.64 per 1,000 Medicaid recipients). There was no change in screening rates after the Centers for Disease Control and Prevention recommendation and a significant increase after the New York State Law, which was not sustained. CONCLUSIONS Hepatitis C virus screening rates increased in the quarter after the 2014 New York State Hepatitis C Virus Testing Law became effective. Additional efforts are needed to screen baby boomers and people who were recently infected with hepatitis C virus related to opioid use.
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Affiliation(s)
- Angelica Bocour
- Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Long Island City, New York.
| | - Miranda S Moore
- Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Long Island City, New York
| | - Ann Winters
- Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Long Island City, New York
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Duru OK, Harwood J, Moin T, Jackson N, Ettner S, Vasilyev A, Mosley DG, O’Shea DL, Ho S, Mangione CM. Evaluation of a National Care Coordination Program to Reduce Utilization Among High-cost, High-need Medicaid Beneficiaries With Diabetes. Med Care 2020; 58 Suppl 6 Suppl 1:S14-S21. [PMID: 32412949 PMCID: PMC10653047 DOI: 10.1097/mlr.0000000000001315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations. OBJECTIVE The objective of this study was to evaluate a care coordination program designed to provide combined "whole-person care," integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants. RESEARCH DESIGN Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis. SUBJECTS A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare. MEASURES Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome's time trend after program enrollment. RESULTS Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -6.6%; 95% confidence interval: -11.2%, -2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -5.8%; 95% confidence interval: -11.4%, -0.2%). CONCLUSION A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.
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Affiliation(s)
- O. Kenrik Duru
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | - Jessica Harwood
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | - Tannaz Moin
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
- VA Greater Los Angeles Healthcare System,11301 Wilshire Boulevard Los Angeles, CA 90073-1003
| | - Nick Jackson
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | - Susan Ettner
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
- UCLA Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA 90095
| | - Arseniy Vasilyev
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
| | | | | | - Sam Ho
- UnitedHealthcare, Minnetonka, MN 55343
| | - Carol M. Mangione
- David Geffen School of Medicine, UCLA, 1100 Glendon Ave Suite 850, Los Angeles, CA 90024
- UCLA Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA 90095
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Trends in Costs of Care and Utilization for Medicaid Patients With Diabetes in Accountable Care Communities. Med Care 2020; 58 Suppl 6 Suppl 1:S40-S45. [PMID: 32412952 DOI: 10.1097/mlr.0000000000001318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVES Medicaid beneficiaries with diabetes have complex care needs. The Accountable Care Communities (ACC) Program is a practice-level intervention implemented by UnitedHealthcare to improve care for Medicaid beneficiaries. We examined changes in costs and utilization for Medicaid beneficiaries with diabetes assigned to ACC versus usual care practices. RESEARCH DESIGN Interrupted time series with concurrent control group analysis, at the person-month level. The ACC was implemented in 14 states, and we selected comparison non-ACC practices from those states to control for state-level variation in Medicaid program. We adjusted the models for age, sex, race/ethnicity, comorbidities, seasonality, and state-by-year fixed effects. We examined the difference between ACC and non-ACC practices in changes in the time trends of expenditures and hospital and emergency room utilization, for the 4 largest categories of Medicaid eligibility [Temporary Assistance to Needy Families, Supplemental Security Income (without Medicare), Expansion, Dual-Eligible]. SUBJECTS/MEASURES Eligibility and claims data from Medicaid adults with diabetes from 14 states between 2010 and 2016, before and after ACC implementation. RESULTS Analyses included 1,200,460 person-months from 66,450 Medicaid patients with diabetes. ACC implementation was not associated with significant changes in outcome time trends, relative to comparators, for all Medicaid categories. CONCLUSIONS Medicaid patients assigned to ACC practices had no changes in cost or utilization over 3 years of follow-up, compared with patients assigned to non-ACC practices. The ACC program may not reduce costs or utilization for Medicaid patients with diabetes.
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Lazar M, Thomas S, Davenport L. Seeking Care at Free Episodic Health Care Clinics in Appalachia. JOURNAL OF APPALACHIAN HEALTH 2020; 2:67-79. [PMID: 35769864 PMCID: PMC9138721 DOI: 10.13023/jah.0202.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background People who live in rural Appalachia experience a wide variety of problems when seeking access to health care. Health care disparities continue to be one of the most complex and prevalent problems, and many barriers exist for impoverished men and women such as a lack of education, complications with health insurance, and personal distrust of healthcare providers. Purpose A critical gap in the literature is the unheard voice of persons in rural underserved areas. The purpose of this study was to explore the perspectives of persons in rural Appalachia who seek healthcare services at free episodic health care clinics, a common alternative source of care. Methods In Fall 2017, a qualitative approach was used to discover the perceptions of 12 men and women in rural Appalachia who were seeking medical care at a Remote Area Medical Clinic. A transdisciplinary research group provided insight and assistance with thematic analysis in Spring 2018–Spring 2019. Results Five overall themes emerged capturing the essence of how rural Appalachians view the experience of seeking healthcare, which include difficulties with insurance/finances, inconsistency in care, isolation in rural areas, seeking solutions, and need to feel valued. Implications A rich description of participant experiences portrays real-life complexities for Appalachian men and women who seek healthcare. Understanding the perceptions of persons who seek healthcare and the essence of their experiences is the first step in determining future sustainable solutions for social justice.
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Where Do Oregon Medicaid Enrollees Seek Outpatient Care Post-affordable Care Act Medicaid Expansion? Med Care 2020; 57:788-794. [PMID: 31513138 DOI: 10.1097/mlr.0000000000001189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. OBJECTIVES To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. RESEARCH DESIGN A retrospective cohort study. SUBJECTS Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. MEASURES Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. RESULTS The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18-0.19] and returning insured (OR, 0.22; 95% CI, 0.22-0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01-2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. CONCLUSIONS Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.
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Resilience and Behavioral Health Parity Key to Disaster Preparedness. Disaster Med Public Health Prep 2020; 15:3-4. [PMID: 31955722 DOI: 10.1017/dmp.2019.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Baum A, Barnett ML, Wisnivesky J, Schwartz MD. Association Between a Temporary Reduction in Access to Health Care and Long-term Changes in Hypertension Control Among Veterans After a Natural Disaster. JAMA Netw Open 2019; 2:e1915111. [PMID: 31722027 PMCID: PMC6902789 DOI: 10.1001/jamanetworkopen.2019.15111] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Temporary disruptions in health care access are common, but their associations with chronic disease control remain unknown. OBJECTIVE To evaluate whether long-term changes in chronic disease control were associated with a temporary 6-month decrease in access to health care services. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined the long-term changes in chronic disease control associated with the 6-month closure of the Manhattan facility of the Veterans Affairs (VA) New York Harbor Healthcare System after superstorm Sandy, which caused a significant disruption in health care access for veterans in the region. Electronic health records from the VA Healthcare System between October 29, 2010, and October 29, 2014, were used to identify a total of 81 544 veterans who were and were not exposed to the 6-month closure of the VA Manhattan Medical Center after superstorm Sandy. Of those, 19 207 veterans were included in the exposed cohort and 62 337 were included in the nonexposed control cohort, which included veterans who were equally exposed to the storm but who retained regular access to health care from 3 VA medical centers (Brooklyn and the Bronx in New York and New Haven in Connecticut) during and after the storm. A difference-in-differences analysis was used to assess within-patient changes in chronic disease control over time between a cohort that was exposed to decreased health care access compared with a similar cohort that was not exposed to decreased access. All analyses adjusted for individual demographic and socioeconomic characteristics, between-zip code differences, and common time trends. Data analyses were conducted between February 1, 2016, and September 30, 2019. EXPOSURE The 6-month closure of the VA Manhattan Medical Center after superstorm Sandy on October 29, 2012. MAIN OUTCOMES AND MEASURES The outcomes measured were uncontrolled blood pressure (defined as mean blood pressure per patient per quarter >140/90 mm Hg), uncontrolled diabetes (defined as mean hemoglobin A1c per patient per quarter >8%), uncontrolled cholesterol (defined as mean low density lipoprotein per patient per quarter >140 mg/dL), and patient weight. RESULTS Among the 81 544 veterans included in the study, the mean (SD) age was 62.1 (17.6) years, and 93.6% were men, 62.7% were white, and 31.8% were black. At the 3-month midpoint of the 6-month facility closure of the VA Manhattan Medical Center, an absolute decrease of 24.8% (95% CI, -26.5% to -23.0%; P < .001) was observed in the percentage of veterans who had any VA primary care visit per quarter compared with a baseline of 47.8% before the closure (relative decrease, 51.9%; 95% CI, -55.4% to -48.1%; P < .001). One year after the facility reopened, no differential change was observed in the percentage of patients with a primary care visit between the exposed vs nonexposed cohorts (absolute decrease, -0.1%; 95% CI, -1.5% to 1.4%; P = .94); however, patients in the exposed cohort were 25.9% more likely to have uncontrolled blood pressure than patients in the nonexposed cohort (unadjusted increase, 5.5% in the exposed cohort vs 1.3% in the nonexposed cohort; adjusted absolute increase, 5.0%; 95% CI, 3.5%-6.0%; P < .001). Two years after superstorm Sandy, patients in the exposed cohort were 10.9% more likely to experience uncontrolled blood pressure than those in the nonexposed cohort (unadjusted increase, 5.2% in the exposed cohort vs 3.5% in the nonexposed cohort; adjusted absolute increase, 2.1%; 95% CI, 0.5%-3.6%; P < .001). Compared with the nonexposed cohort, the exposed cohort also experienced a decrease in filled medication prescriptions per patient per quarter of 6.9% during the facility closure (absolute decrease, -0.7 prescriptions filled per patient per quarter; 95% CI, -0.9 to -0.5; P < .001) and of 2.2% a year after the facility reopened (absolute decrease, -0.2 prescriptions filled per patient per quarter; 95% CI, -0.4 to -0.1; P = .04). No differential changes were observed in uncontrolled diabetes, uncontrolled cholesterol, or patient weight. CONCLUSIONS AND RELEVANCE In this study, a temporary period of decreased access to health care services was associated with increased rates of uncontrolled hypertension, but not with increased rates of uncontrolled diabetes or hyperlipidemia, more than 1 year after the Manhattan VA facility reopened. Temporary gaps in access to health care may be associated with long-term increases in uncontrolled blood pressure among patients with hypertension.
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Affiliation(s)
- Aaron Baum
- Department of Health System Design and Global Health, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
- Veterans Affairs New York Harbor Healthcare System, New York, New York
| | - Michael L. Barnett
- Department of Health Policy and Management. Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Juan Wisnivesky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark D. Schwartz
- Veterans Affairs New York Harbor Healthcare System, New York, New York
- Department of Population Health, New York University School of Medicine, New York, New York
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Rogers MAM, Lee JM, Tipirneni R, Banerjee T, Kim C. Interruptions In Private Health Insurance And Outcomes In Adults With Type 1 Diabetes: A Longitudinal Study. Health Aff (Millwood) 2019; 37:1024-1032. [PMID: 29985705 DOI: 10.1377/hlthaff.2018.0204] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Type 1 diabetes mellitus, which often originates during childhood, is a lifelong disease that requires intensive daily medical management. Because health care services are critical to patients with this disease, we investigated the frequency of interruptions in private health insurance, and the outcomes associated with them, for working-age adults with type 1 diabetes in the United States in the period 2001-15. We designed a longitudinal study with a nested self-controlled case series, using the Clinformatics Data Mart Database. The study sample consisted of 168,612 adults ages 19-64 with type 1 diabetes who had 2.6 mean years of insurance coverage overall. Of these adults, 24.3 percent experienced an interruption in coverage. For each interruption, there was a 3.6 percent relative increase in glycated hemoglobin. The use of acute care services was fivefold greater after an interruption in health insurance compared to before the interruption and remained elevated when stratified by age, sex, or diabetic complications. An interruption was associated with lower perceived health status and lower satisfaction with life. We conclude that interruptions in private health insurance are common among adults with type 1 diabetes and have serious consequences for their well-being.
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Affiliation(s)
- Mary A M Rogers
- Mary A. M. Rogers ( ) is a research associate professor of internal medicine at the University of Michigan, in Ann Arbor
| | - Joyce M Lee
- Joyce M. Lee is a professor of pediatrics and communicable diseases at the University of Michigan
| | - Renuka Tipirneni
- Renuka Tipirneni is a clinical lecturer in internal medicine at the University of Michigan
| | - Tanima Banerjee
- Tanima Banerjee is a statistician senior at the Institute of Healthcare Policy and Innovation, University of Michigan
| | - Catherine Kim
- Catherine Kim is an associate professor of internal medicine at the University of Michigan
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Anderson VR, Ouyang F, Tu W, Rosenman MB, Wiehe SE, Aalsma MC. Medicaid Coverage and Continuity for Juvenile Justice–Involved Youth. JOURNAL OF CORRECTIONAL HEALTH CARE 2019; 25:45-54. [DOI: 10.1177/1078345818820043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Fangqian Ouyang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Wanzhu Tu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Marc B. Rosenman
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sarah E. Wiehe
- Children’s Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew C. Aalsma
- Division of Adolescent Medicine, Adolescent Behavioral Health Research Program, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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Kavanaugh ML, Zolna MR, Burke KL. Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X-Funded Facilities in 2016. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2018; 50:101-109. [PMID: 29894024 PMCID: PMC6135668 DOI: 10.1363/psrh.12061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X-funded facilities under ACA guidelines is essential to understanding what is at stake. METHODS A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X-funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi-square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. RESULTS Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign-born clients were less likely than U.S.-born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one-quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out. CONCLUSION Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.
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Affiliation(s)
| | - Mia R. Zolna
- Senior research associate, at the Guttmacher Institute, New York
| | - Kristen L. Burke
- Senior research assistant, at the Guttmacher Institute, New York
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Lazar M, Davenport L. Barriers to Health Care Access for Low Income Families: A Review of Literature. J Community Health Nurs 2018; 35:28-37. [DOI: 10.1080/07370016.2018.1404832] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Malerie Lazar
- College of Nursing, The University of Tennessee, Knoxville, Tennessee
| | - Lisa Davenport
- College of Nursing, The University of Tennessee, Knoxville, Tennessee
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Discontinuity of Medicaid Coverage: Impact on Cost and Utilization Among Adult Medicaid Beneficiaries With Major Depression. Med Care 2017; 55:735-743. [PMID: 28700457 DOI: 10.1097/mlr.0000000000000751] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gaps in Medicaid coverage may disrupt access to and continuity of care. This can be detrimental for beneficiaries with chronic conditions, such as major depression, for whom disruptions in access to outpatient care may lead to increased use of acute care. However, little is known about how Medicaid coverage discontinuities impact acute care utilization among adults with depression. OBJECTIVE Examine the relationship between Medicaid discontinuities and service utilization among adults with major depression. SUBJECTS A total of 139,164 adults (18-64) with major depression was identified using the 2003-2004 Medicaid Analytic eXtract Files. METHODS We used generalized linear and two-part models to examine the effect of Medicaid discontinuity on service utilization. To establish causality in this relationship, we used instrumental variables analysis, relying on exogenous variation in a state-level policy for identification. OUTCOME MEASURES Emergency department (ED) visits, inpatient episodes, inpatient days, and Medicaid-reimbursed costs. RESULTS Approximately 29.4% of beneficiaries experienced coverage disruptions. In instrumental variables models, those with coverage disruptions incurred an increase of $650 in acute care costs per-person per Medicaid-covered month compared with those with continuous coverage, evidenced by an increase in ED use (0.1 more ED visits per-person-month) and inpatient days (0.6 more days per-person-month). The increase in acute costs contributed to an overall increase in all-cause costs by $310 per-person-month (all P-values<0.001). CONCLUSIONS Among depressed adults, those experiencing coverage disruptions have, on average, significantly greater use of costly ED/inpatient services than those with continuous coverage. Maintenance of continuous Medicaid coverage may help prevent acute episodes requiring high-cost interventions.
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Tumin D, Foraker RE, Smith S, Tobias JD, Hayes D. Health Insurance Trajectories and Long-Term Survival After Heart Transplantation. Circ Cardiovasc Qual Outcomes 2016; 9:576-84. [PMID: 27625403 DOI: 10.1161/circoutcomes.116.003067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/08/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health insurance status at heart transplantation influences recipient survival, but implications of change in insurance for long-term outcomes are unclear. METHODS AND RESULTS Adults aged 18 to 64 receiving first-time orthotopic heart transplants between July 2006 and December 2013 were identified in the United Network for Organ Sharing registry. Patients surviving >1 year were categorized according to trajectory of insurance status (private compared with public) at wait listing, transplantation, and 1-year follow-up. The most common insurance trajectories were continuous private coverage (44%), continuous public coverage (27%), and transition from private to public coverage (11%). Among patients who survived to 1 year (n=9088), continuous public insurance (hazard ratio =1.36; 95% confidence interval 1.19, 1.56; P<0.001) and transition from private to public insurance (hazard ratio =1.25; 95% confidence interval 1.04, 1.50; P=0.017) were associated with increased mortality hazard relative to continuous private insurance. Supplementary analyses of 11 247 patients included all durations of post-transplant survival and examined post-transplant private-to-public and public-to-private transitions as time-varying covariates. In these analyses, transition from private to public insurance was associated with increased mortality hazard (hazard ratio =1.25; 95% confidence interval 1.07, 1.47; P=0.005), whereas transition from public to private insurance was associated with lower mortality hazard (hazard ratio =0.78; 95% confidence interval 0.62, 0.97; P=0.024). CONCLUSIONS Transition from private to public insurance after heart transplantation is associated with worse long-term outcomes, compounding disparities in post-transplant survival attributed to insurance status at transplantation. By contrast, post-transplant gain of private insurance among patients receiving publicly funded heart transplants was associated with improved outcomes.
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Affiliation(s)
- Dmitry Tumin
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH.
| | - Randi E Foraker
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
| | - Sakima Smith
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
| | - Don Hayes
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
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