Access to care provided by better safety net systems for the uninsured: measuring and conceptualizing adequacy

Association Between State Medicaid Expansion and Emergency Access to Acute Care Hospitals in the United States

IMPORTANCE

State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals.

OBJECTIVE

To determine the relationship between state Medicaid expansion and emergency access to acute care hospitals in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study linked hospital-level data from the Centers for Medicare & Medicaid Services from 2007 to 2017 to US Census data for all 50 US states and the District of Columbia. Geospatial analyses and difference-in-differences regression models were used to compare temporal changes in the size of the population without 30-minute access to acute care hospitals between 32 states that expanded Medicaid with the population without access in 19 that did not, before and after expansion. Analyses focused on the total population and those with low incomes; secondary analyses examined emergency access to safety-net hospitals.

EXPOSURES

State-level Medicaid expansion.

MAIN OUTCOMES AND MEASURES

Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital.

RESULTS

States that did not expand Medicaid experienced an increase in the population without access to hospitals overall (without expansion: 6.76% to 6.79% [0.03%]; vs with expansion: 5.65% to 5.35% [-0.30%]; difference-in-differences, 0.33%; 95% CI, 0.33%-0.34%; P < .001) and for low-income persons (without expansion: 7.43% to 7.39% [-0.04%]; vs with expansion: 6.25% to 6.15% [-0.10%]; difference-in-differences, 0.06%; 95% CI, 0.05%-0.07%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 421 000 more persons overall and 48 000 more low-income persons would have retained access. States that did not expand Medicaid experienced an increase in the population without access to safety-net hospitals overall (46.91% to 47.70% [0.79%] vs 33.94% to 33.07% [-0.87%]; difference-in-differences, 1.66%; 95% CI, 1.64%-1.66%; P < .001) and for low-income persons (45.28% to 46.14% [0.86%] vs 33.00% to 32.23% [-0.77%]; difference-in-differences, 1.63%; 95% CI, 1.63%-1.67%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 2 242 000 more persons overall and 364 000 more low-income persons would have retained access.

CONCLUSIONS AND RELEVANCE

States that did not expand Medicaid under the Patient Protection and Affordable Care Act were associated with worse emergency access to acute care hospitals compared with states that expanded Medicaid.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

Background

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

Methods

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

Results

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

Conclusion

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO–academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

Hispanics' Satisfaction with Free Clinic Providers: An Analysis of Patient-Centered Medical Home Characteristics

Hispanic Americans are less likely to be insured and they experience cultural and linguistic barriers that may prevent them from obtaining necessary and preventive healthcare. Adoption of Patient Centered Medical Home (PCMH) concepts in healthcare settings utilized by Hispanics could improve Hispanic patients' satisfaction with their healthcare providers. This study examined the association between Spanish-speaking and non-Spanish-speaking patients' perceptions of PCMH characteristics and satisfaction with the provider. Data were collected using a self-administered survey from two unaffiliated free clinics. Logistic regression modeled the associations between patients' perceptions of PCMH and their satisfaction with their provider, and their desire to see the same provider in the future. The sample consisted of 367 adults; 44 % were Spanish-speaking. Spanish-speaking patients were younger, less educated, and had fewer chronic conditions than non-Spanish-speaking patients. In adjusted analyses for each population, better ratings of the provider's communication skills were associated with increased satisfaction with the provider (Spanish-speaking: OR = 8.33, 95 % CI = 2.19-31.76; non-Spanish-speaking: OR = 31.39, 95 % CI = 6.91-142.62), and willingness to see the provider again (Spanish-speaking: OR = 12.54, 95 % CI = 2.80-56.24; non-Spanish-speaking: OR = 8.77, 95 % CI = 2.40-31.96). Among Spanish-speakers, lower perceived discrimination was associated with 137 % increased odds and higher perceived staff helpfulness had 212 % increased odds of seeing the provider again. Relative to other PCMH components, interpersonal skills were the most important factors in patient satisfaction with free clinics. Increased training for clinicians on cultural competence and clinician-patient communication may lead to improved patient satisfaction for both Spanish and non-Spanish speakers seen at free clinics, particularly clinics in states without Medicaid expansion.

The mission of safety net organizations following national insurance reform

National health insurance reform will pose considerable challenges to the core missions of safety net organizations that serve the uninsured. Those who currently donate money or time will, rightly or wrongly, view uninsured recipients as less deserving on the whole. Nevertheless, safety net organizations can serve several critical functions that continue to justify their existence and support.One important mission is to maintain access for low-income uninsured until all elements of insurance reform are fully in place. Second, once the reform is implemented, people will need a great deal of assistance and encouragement to determine what they are supposed to do and where they are supposed to sign up. Third, substantial portions of the remaining uninsured will continue to lack affordable insurance options, and large numbers of people eligible for coverage will unavoidably undergo temporary gaps in coverage as their family and financial circumstances change. Finally, not all people with insurance will have affordable access to all needed care. Market conditions will continue pushing higher levels of patient cost-sharing through deductibles and co-payments.To serve these multiple needs, safety net organizations should consider adapting their missions and business models so that they accept both insured and uninsured patients under a sliding fee scale that varies charges according to ability to pay.