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So M, Makofane J, Hernandez M. "We want to be heard": A Qualitative Study of Mental Health Care Access among Patients of an Urban Federally Qualified Health Center. MENTAL HEALTH SCIENCE 2023; 1:261-269. [PMID: 38774821 PMCID: PMC11104551 DOI: 10.1002/mhs2.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/12/2023] [Indexed: 05/24/2024]
Abstract
Introduction Although depression is common in primary care, challenges to timely intervention exist, particularly for communities of color and lower socioeconomic status. Our objective was to understand barriers and facilitators to mental healthcare access among a sample of patients receiving care at a federally qualified health center (FQHC) in Minnesota, United States. Methods We qualitatively interviewed 34 patients of an urban FQHC, purposively sampled on race/ethnicity, insurance status, language, and depression symptom status (based on Patient Health Questionnaire-9 responses). We inductively and deductively analyzed interview data, leveraging theory in both the codebook development and analysis processes. Results Participants, who were predominantly English-speaking, female, not privately insured, and people of color, shared numerous barriers and facilitators to accessing mental healthcare. Prominent barriers primarily concerned healthcare providers, including perceived dismissal of mental health concerns and challenges with provider continuity. Additional barriers included the costs of mental health care, communication breakdowns, the patient portal, and community-specific perceptions of mental health. Prominent facilitators included clinic organizational factors (internal and external) and staff friendliness and warmth. Other factors including consideration of patients' financial situation, integrated management of behavioral and physical health conditions, language concordant staff, the telehealth visit modality, and the clinic's social mission were also raised as facilitating access. Conclusion Patient voices from a single FQHC illustrate the challenges and possibilities of providing mental healthcare in safety net settings. Clinical, strategy, and policy solutions can be tailored to minimize barriers and optimize facilitators documented herein.
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Affiliation(s)
- Marvin So
- University of Minnesota Medical School, Minneapolis, MN
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Lyu W, Wehby GL. The effects of Medicaid expansions on dental services at federally qualified health centers. J Am Dent Assoc 2023; 154:215-224.e10. [PMID: 36635206 DOI: 10.1016/j.adaj.2022.11.005] [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: 07/13/2022] [Revised: 10/27/2022] [Accepted: 11/12/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Federally qualified health centers (FQHCs) have become safety-net providers of dental services for low-income patients. The authors examined the effects of the Patient Protection and Affordable Care Act Medicaid expansions, according to level of dental benefits, on the number of visits for dental services at FQHCs. METHODS The authors used publicly available facility-level data on 1,400 FQHCs across the United States from the 2011 through 2019 Uniform Data System. The authors used an event-study difference-in-difference design to examine the effects of expanding Medicaid in 2014, according to the level of dental benefits, compared with nonexpansion states. Outcomes included the number of dental visits for any dental service and separately for preventive and other services. Regression models adjusted for the demographic characteristics of the FQHC's patient population, county-level factors, and center and year fixed effects. RESULTS Expanding Medicaid with extensive dental benefits has increased the number of dental visits provided at FQHCs in 2014 through 2019 from 2013 by 1,329 to 7,647 visits per FQHC on average compared with FQHCs in nonexpansion states. There was an increase in visits for both preventive and other dental services. In contrast, there was no evidence of such an increase from expanding Medicaid with limited or emergency-only dental benefits. CONCLUSIONS Expanding Medicaid eligibility with extensive dental benefits has increased the number of dental visits at FQHCs, including for both preventive and other dental services. PRACTICAL IMPLICATIONS As safety-net providers, FQHCs might be able to provide more oral health care for low-income patients after Medicaid expansions that offer extensive dental benefits.
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Sacarny A, Baicker K, Finkelstein A. Out of the Woodwork: Enrollment Spillovers in the Oregon Health Insurance Experiment. AMERICAN ECONOMIC JOURNAL. ECONOMIC POLICY 2022; 14:273-295. [PMID: 36259049 PMCID: PMC9576198 DOI: 10.1257/pol.20200172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
We analyze the impact of expanded adult Medicaid eligibility on the enrollment of already-eligible children. We analyze the 2008 Oregon Medicaid lottery, in which some low-income uninsured adults were randomly selected to be allowed to apply for Medicaid. Children in these households were eligible for Medicaid irrespective of the lottery outcome. We estimate statistically significant but transitory impacts of adult lottery selection on child Medicaid enrollment: at three months after the lottery, for every 9 adults who enrolled in Medicaid due to winning the lottery, one additional child also enrolled. Our results shed light on the existence, magnitude, and nature of so-called "woodwork effects".
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Affiliation(s)
- Adam Sacarny
- Department of Health Policy and Management, Columbia University
Mailman School of Public Health, 722 West 168 Street, New York,
NY 10032, NBER, and J-PAL
| | - Katherine Baicker
- Harris School of Public Policy, University of Chicago, 1307 East
60 Street, Chicago, IL 60637, NBER, and J-PAL
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Luo Q, Moghtaderi A, Markus A, Dor A. Financial impacts of the Medicaid expansion on community health centers. Health Serv Res 2021; 57:634-643. [PMID: 34658030 DOI: 10.1111/1475-6773.13897] [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: 04/14/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the impacts of the Medicaid expansion on revenues, costs, assets, and liabilities of federally funded community health centers. DATA SOURCES We combined data from the Uniform Data System, Internal Revenue Service nonprofit tax returns, and county-level characteristics from the Census Bureau. Our final dataset included 5841 center-year observations. STUDY DESIGN We used difference-in-differences model to estimate the fiscal impacts of the Medicaid expansion on community health centers. We employed event study models, state-specific trend models, and placebo law tests as robustness checks. DATA COLLECTION METHODS Not applicable. PRINCIPAL FINDINGS On the revenue side, we found a $2.08 million relative increase (p = 0.002) in Medicaid revenues, offset by a $0.44 million decrease (p = 0.015) in total grants among community health centers in expansion states compared with centers in non-expansion states. On the expenditure side, we found a large but not statistically significant $0.98 million relative increase (p = 0.201) in total expenditures among centers in expansion states. Uncompensated care for health centers in expansion states decreased by $1.19 million (p < 0.001) relative to their counterparts in non-expansion states. CONCLUSIONS Community health centers in expansion states benefited from the increased, stable revenue stream from Medicaid expansions. While Medicaid revenue increased as a result of the policy, we find no major evidence of substitution away from other revenue lines, with one notable exception (i.e., substitution away from state and local government grants). From a policy perspective, these results are encouraging as the Biden Administration starts to implement the safety-net enhancements from the American Rescue Plan Act of 2021 and as more non-expansion states are considering opting into Medicaid expansions. It is anticipated that these added revenue streams will help to sustain health centers in the delivery of health care services to the underserved population.
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Affiliation(s)
- Qian Luo
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA.,Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Ali Moghtaderi
- Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Anne Markus
- Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Avi Dor
- Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
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Saloner B, Wilk AS, Levin J. Community Health Centers and Access to Care Among Underserved Populations: A Synthesis Review. Med Care Res Rev 2019; 77:3-18. [DOI: 10.1177/1077558719848283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community health centers (CHCs) deliver affordable health services to underserved populations, especially uninsured and Medicaid enrollees. Since the early 2000s, CHCs have grown because of federal investments in CHC capacity and expansions of Medicaid eligibility. We review 24 relevant studies from 2000 to 2017 to evaluate the relationship between CHCs, policies that invest in services for low-income individuals, and access to care. Most included studies use quasi-experimental designs. Greater spending on CHCs improves access to care, especially for low-income and minority individuals. Medicaid expansions also increase CHC use. Some studies indicate that CHC investments complement Medicaid expansions to increase access cost-effectively. Further research should explore patient preferences and patterns of CHC utilization versus other sites of care and population subgroups for which expanding CHC capacity improves access to care most. Researchers should endeavor to use measures and sample definitions that facilitate comparisons with other estimates in the literature.
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Affiliation(s)
- Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adam S. Wilk
- Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Jonathan Levin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Cole MB, Wright B, Wilson IB, Galárraga O, Trivedi AN. Medicaid Expansion And Community Health Centers: Care Quality And Service Use Increased For Rural Patients. Health Aff (Millwood) 2019; 37:900-907. [PMID: 29863920 DOI: 10.1377/hlthaff.2017.1542] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid expansion had great potential to affect community health centers (CHCs), particularly in rural areas, because their patients are predominantly low income and disproportionately uninsured. Using data for 2011-15 on all CHCs, we found that after two years Medicaid expansion was associated with an 11.44-percentage-point decline in the share of CHC patients who were uninsured and a 13.15-percentage-point increase in the share with Medicaid. Changes in quality and volume were consistently observed in rural CHCs in expansion states, which had relative improvements in asthma treatment, body mass index screening and follow-up, and hypertension control, along with substantial increases in volumes for eighteen of twenty-one types of visits-particularly those for mammograms, abnormal breast findings, alcohol-related disorder, and other substance abuse disorder. Similar relative gains were not observed in urban CHCs in expansion states. Repealing or phasing out Medicaid expansion could reverse observed gains in quality and service use and could be particularly detrimental to low-income rural populations.
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Affiliation(s)
- Megan B Cole
- Megan B. Cole ( ) is an assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health, in Massachusetts
| | - Brad Wright
- Brad Wright is an associate professor in the Department of Health Management and Policy at the University of Iowa College of Public Health, in Iowa City
| | - Ira B Wilson
- Ira B. Wilson is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Omar Galárraga
- Omar Galárraga is an associate professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
| | - Amal N Trivedi
- Amal N. Trivedi is an associate professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
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Barnes H, Richards MR, McHugh MD, Martsolf G. Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners. Health Aff (Millwood) 2019; 37:908-914. [PMID: 29863933 DOI: 10.1377/hlthaff.2017.1158] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008-16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.
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Affiliation(s)
- Hilary Barnes
- Hilary Barnes ( ) is an assistant professor in the School of Nursing, University of Delaware, in Newark
| | - Michael R Richards
- Michael R. Richards is an assistant professor of health policy at Vanderbilt University, in Nashville, Tennessee
| | - Matthew D McHugh
- Matthew D. McHugh is a professor of nursing; the Independence Chair for Nursing Education, Center for Health Outcomes and Policy Research; and a senior fellow at the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, in Philadelphia
| | - Grant Martsolf
- Grant Martsolf is a professor in the Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, and an adjunct policy researcher at the RAND Corporation in Pittsburgh, both in Pennsylvania
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Glen ET, Hostetter G, Ruff RM, Roebuck-Spencer TM, Denney RL, Perry W, Fazio RL, Garmoe WS, Bianchini KJ, Scott JG. Integrative Care Models in Neuropsychology: A National Academy of Neuropsychology Education Paper. Arch Clin Neuropsychol 2018; 34:141-151. [DOI: 10.1093/arclin/acy092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/02/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Ronald M Ruff
- San Francisco Clinical Neurosciences, San Francisco, CA, USA
| | | | - Robert L Denney
- Missouri Memory Center, Citizen’s Memorial Healthcare, Bolivar, MO, USA
| | | | | | | | | | - James G Scott
- University of Oklahoma Health Science Center, Oklahoma City, OK, USA
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Garber AM, Azad TD, Dixit A, Farid M, Sung E, Vail D, Bhattacharya J. Medicare savings from conservative management of low back pain. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e332-e337. [PMID: 30325195 PMCID: PMC9810112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP. STUDY DESIGN We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis. METHODS We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management. RESULTS Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more. CONCLUSIONS Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.
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Health Insurance Coverage and Access to Care for Community Health Center Patients: Evidence Following the Affordable Care Act. J Gen Intern Med 2018; 33:1444-1446. [PMID: 29845464 PMCID: PMC6108997 DOI: 10.1007/s11606-018-4499-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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11
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The Impact of a Change in the Price of VA Health Care on Utilization of VA and Medicare Services. Med Care 2018; 56:569-576. [DOI: 10.1097/mlr.0000000000000922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Guo L, Bao Y, Ma J, Li S, Cai Y, Sun W, Liu Q. Quality of community basic medical service utilization in urban and suburban areas in Shanghai from 2009 to 2014. PLoS One 2018; 13:e0195987. [PMID: 29791470 PMCID: PMC5965823 DOI: 10.1371/journal.pone.0195987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/20/2018] [Indexed: 11/18/2022] Open
Abstract
Urban areas usually display better health care services than rural areas, but data about suburban areas in China are lacking. Hence, this cross-sectional study compared the utilization of community basic medical services in Shanghai urban and suburban areas between 2009 and 2014. These data were used to improve the efficiency of community health service utilization and to provide a reference for solving the main health problems of the residents in urban and suburban areas of Shanghai. Using a two-stage random sampling method, questionnaires were completed by 73 community health service centers that were randomly selected from six districts that were also randomly selected from 17 counties in Shanghai. Descriptive statistics, principal component analysis, and forecast analysis were used to complete a gap analysis of basic health services utilization quality between urban and suburban areas. During the 6-year study period, there was an increasing trend toward greater efficiency of basic medical service provision, benefits of basic medical service provision, effectiveness of common chronic disease management, overall satisfaction of community residents, and two-way referral effects. In addition to the implementation effect of hypertension management and two-way referral, the remaining indicators showed a superior effect in urban areas compared with the suburbs (P<0.001). In addition, among the seven principal components, four principal component scores were better in urban areas than in suburban areas (P = <0.001, 0.004, 0.036, and 0.022). The urban comprehensive score also exceeded that of the suburbs (P<0.001). In summary, over the 6-year period, there was a rapidly increasing trend in basic medical service utilization. Comprehensive satisfaction clearly improved as well. Nevertheless, there was an imbalance in health service utilization between urban and suburban areas. There is a need for the health administrative department to address this imbalance between urban and suburban institutions and to provide the required support to underdeveloped areas to improve resident satisfaction.
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Affiliation(s)
- Lijun Guo
- Shanghai University of Medicine & Health Sciences, College of Health Information Technology and Management, Pudong New District, Shanghai, China
| | - Yong Bao
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
- Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Changning District, Shanghai, China
- * E-mail:
| | - Jun Ma
- Shanghai Tongren Hospital, Changning District, Shanghai, China
| | - Shujun Li
- Zhengzhou Fifteenth People’s Hospital, Shangjie District, Zhengzhou City, Henan Province, China
| | - Yuyang Cai
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Wei Sun
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Qiaohong Liu
- Shanghai University of Medicine & Health Sciences, College of Health Information Technology and Management, Pudong New District, Shanghai, China
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13
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Impacts of the Affordable Care Act on Community Health Centers: Characteristics of New Patients and Early Changes in Delivery of Care. J Ambul Care Manage 2018; 41:250-261. [PMID: 29771741 DOI: 10.1097/jac.0000000000000244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study was to assess the impact of the Affordable Care Act (ACA) on community health centers (CHCs). Using electronic health records from the Community Health Applied Research Network, we assessed new patient characteristics, office visit volume, and payer distribution among CHC patients before and after ACA implementation, 2011-2014 (n = 442 455). New patients post-ACA were younger, more likely to be female and have chronic health conditions, and utilized more primary care (P < .05 for each). Post-ACA, clinics delivered 19% more office visits and more visits were reimbursed by Medicaid. The support of CHCs is needed to meet increased demand post-ACA.
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14
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Cole MB, Galárraga O, Wilson IB, Wright B, Trivedi AN. At Federally Funded Health Centers, Medicaid Expansion Was Associated With Improved Quality Of Care. Health Aff (Millwood) 2018; 36:40-48. [PMID: 28069845 DOI: 10.1377/hlthaff.2016.0804] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2014 many uninsured, low-income nonelderly adults gained access to health insurance in states that expanded Medicaid eligibility under the Affordable Care Act. Federally funded community health centers were likely to be particularly affected by this expansion because many of their patients were uninsured and low income. We used a difference-in-differences approach to compare changes among 1,057 such centers in expansion versus nonexpansion states from 2011 to 2014, in terms of their patients' insurance coverage, the number of patients they served, and the quality of care they provided. Medicaid expansion was associated with large increases (12 percentage points) in Medicaid coverage and corresponding declines (11 percentage points) in uninsurance rates. The numbers of patients served increased in both expansion and nonexpansion states, and the magnitude of increase did not differ significantly between the groups of states. Medicaid expansion was associated with improved quality on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control. This analysis suggests that states' decisions about Medicaid expansion have important consequences for health center patients, with expansion improving treatment and outcomes of chronic disease and bolstering the use of recommended preventive services.
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Affiliation(s)
- Megan B Cole
- Megan B. Cole is a PhD candidate in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Omar Galárraga
- Omar Galárraga is an assistant professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Ira B Wilson
- Ira B. Wilson is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Brad Wright
- Brad Wright is an assistant professor in the Department of Health Management and Policy at the University of Iowa College of Public Health, in Iowa City
| | - Amal N Trivedi
- Amal N. Trivedi is an associate professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
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Han X, Luo Q, Ku L. Medicaid Expansion And Grant Funding Increases Helped Improve Community Health Center Capacity. Health Aff (Millwood) 2018; 36:49-56. [PMID: 28069846 DOI: 10.1377/hlthaff.2016.0929] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Through the expansion of Medicaid eligibility and increases in core federal grant funding, the Affordable Care Act (ACA) sought to increase the capacity of community health centers to provide primary care to low-income populations. We examined the effects of the ACA Medicaid expansion and changes in federal grant levels on the centers' numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015. In the period after expansion (2014-15), health centers in expansion states had a 5 percent higher total patient volume, larger shares of Medicaid patients, smaller shares of uninsured patients, and increases in overall visits and mental health visits, compared to centers in nonexpansion states. Increases in federal grant funding levels were associated with increases in numbers of patients and of overall, medical, and preventive service visits. If federal grant levels are not sustained after 2017, there could be marked reductions in health center capacity in both expansion and nonexpansion states.
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Affiliation(s)
- Xinxin Han
- Xinxin Han is a graduate research assistant in the Department of Health Policy and Management, Milken Institute School of Public Health, at George Washington University, in Washington, D.C
| | - Qian Luo
- Qian Luo is a research associate in the Department of Health Policy and Management, Milken Institute School of Public Health, at George Washington University
| | - Leighton Ku
- Leighton Ku is a professor in the Department of Health Policy and Management, Milken Institute School of Public Health, and director of the Center for Health Policy Research, both at George Washington University
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Duru OK, Mangione CM, Rodriguez HP, Ross-Degnan D, Wharam JF, Black B, Kho A, Huguet N, Angier H, Mayer V, Siscovick D, Kraschnewski JL, Shi L, Nauman E, Gregg EW, Ali MK, Thornton P, Clauser S. Introductory Overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the Impact of US Health Policies and Practices to Prevent Diabetes and Its Complications. Curr Diab Rep 2018; 18:8. [PMID: 29399715 PMCID: PMC8910460 DOI: 10.1007/s11892-018-0977-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.
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Affiliation(s)
- O Kenrik Duru
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine, UCLA, 10940 Wilshire Blvd., Suite 700, Los Angeles, CA, 90024, USA.
| | - Carol M Mangione
- David Geffen School of Medicine at UCLA and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Hector P Rodriguez
- School of Public Health - Health Policy and Management, University of California, Berkeley, Berkeley, CA, USA
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - J Frank Wharam
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Bernard Black
- Pritzker School of Law, Institute for Policy Research, and Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | - Abel Kho
- Institute of Public Health & Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Victoria Mayer
- Department of Population Health Science and Policy, Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jennifer L Kraschnewski
- Department of Medicine, Pediatrics and Public Health Sciences, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | | | - Edward W Gregg
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA
| | - Mohammed K Ali
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pamela Thornton
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD, USA
| | - Steven Clauser
- Health Care Delivery and Disparities Research Program, Patient-Centered Outcomes Research Institute, Washington, DC, USA
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Hatch B, Marino M, Killerby M, Angier H, Hoopes M, Bailey SR, Heintzman J, O'Malley JP, DeVoe JE. Medicaid's Impact on Chronic Disease Biomarkers: A Cohort Study of Community Health Center Patients. J Gen Intern Med 2017; 32:940-947. [PMID: 28374214 PMCID: PMC5515790 DOI: 10.1007/s11606-017-4051-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/05/2016] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Understanding the impact of health insurance is critical, particularly in the era of Affordable Care Act Medicaid expansion. The electronic health record (EHR) provides new opportunities to quantify health outcomes. OBJECTIVE To assess changes in biomarkers of chronic disease among community health center (CHC) patients who gained Medicaid coverage with the Oregon Medicaid expansion (2008-2011). DESIGN Prospective cohort. Patients were followed for 24 months, and rate of mean biomarker change was calculated. Time to a controlled follow-up measurement was compared using Cox regression models. SETTING/PATIENTS Using EHR data from OCHIN (a non-profit network of CHCs) linked to state Medicaid data, we identified three cohorts of patients with uncontrolled chronic conditions (diabetes, hypertension, and hyperlipidemia). Within these cohorts, we included patients who gained Medicaid coverage along with a propensity score-matched comparison group who remained uninsured (diabetes n = 608; hypertension n = 1244; hyperlipidemia n = 546). MAIN MEASURES Hemoglobin A1c (HbA1c) for the diabetes cohort, systolic and diastolic blood pressure (SBP and DBP, respectively) for the hypertension cohort, and low-density lipoprotein (LDL) for the hyperlipidemia cohort. KEY RESULTS All cohorts improved over time. Compared to matched uninsured patients, adults in the diabetes and hypertension cohorts who gained Medicaid coverage were significantly more likely to have a follow-up controlled measurement (hazard ratio [HR] =1.26, p = 0.020; HR = 1.35, p < 0.001, respectively). No significant difference was observed in the hyperlipidemia cohort (HR = 1.09, p = 0.392). CONCLUSIONS OCHIN patients with uncontrolled chronic conditions experienced objective health improvements over time. In two of three chronic disease cohorts, those who gained Medicaid coverage were more likely to achieve a controlled measurement than those who remained uninsured. These findings demonstrate the effective care provided by CHCs and the importance of health insurance coverage within a usual source of care setting. CLINICAL TRIALS REGISTRATION NCT02355132 [ https://clinicaltrials.gov/ct2/show/NCT02355132 ].
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Affiliation(s)
- Brigit Hatch
- Oregon Health & Science University, Portland, OR, USA.,OCHIN, Inc., Portland, OR, USA
| | - Miguel Marino
- Oregon Health & Science University, Portland, OR, USA
| | | | | | | | | | | | | | - Jennifer E DeVoe
- Oregon Health & Science University, Portland, OR, USA.,OCHIN, Inc., Portland, OR, USA
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Health Care Utilization Rates After Oregon's 2008 Medicaid Expansion: Within-Group and Between-Group Differences Over Time Among New, Returning, and Continuously Insured Enrollees. Med Care 2017; 54:984-991. [PMID: 27547943 DOI: 10.1097/mlr.0000000000000600] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status. OBJECTIVES (1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization. METHODS Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region. RESULTS PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period. CONCLUSIONS Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.
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Basu S, Meghani A, Siddiqi A. Evaluating the Health Impact of Large-Scale Public Policy Changes: Classical and Novel Approaches. Annu Rev Public Health 2017; 38:351-370. [PMID: 28384086 PMCID: PMC5815378 DOI: 10.1146/annurev-publhealth-031816-044208] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Large-scale public policy changes are often recommended to improve public health. Despite varying widely-from tobacco taxes to poverty-relief programs-such policies present a common dilemma to public health researchers: how to evaluate their health effects when randomized controlled trials are not possible. Here, we review the state of knowledge and experience of public health researchers who rigorously evaluate the health consequences of large-scale public policy changes. We organize our discussion by detailing approaches to address three common challenges of conducting policy evaluations: distinguishing a policy effect from time trends in health outcomes or preexisting differences between policy-affected and -unaffected communities (using difference-in-differences approaches); constructing a comparison population when a policy affects a population for whom a well-matched comparator is not immediately available (using propensity score or synthetic control approaches); and addressing unobserved confounders by utilizing quasi-random variations in policy exposure (using regression discontinuity, instrumental variables, or near-far matching approaches).
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Affiliation(s)
- Sanjay Basu
- Centers for Health Policy, Primary Care and Outcomes Research; Center on Poverty and Inequality; and Institute for Economic Policy Research, Stanford University, Stanford, California 94305;
- Department of Medicine, Stanford University, Stanford, California 94305;
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts 02115
| | - Ankita Meghani
- Department of Medicine, Stanford University, Stanford, California 94305;
| | - Arjumand Siddiqi
- Department of Epidemiology and Department of Social and Behavioral Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada;
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina 27599
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WU Y, HUANG Y, LU J. Potential Effect of Medical Insurance on Medicare: Evidence from China. IRANIAN JOURNAL OF PUBLIC HEALTH 2016; 45:1247-1260. [PMID: 27957431 PMCID: PMC5149488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND With the increased range of medical insurance coverage in China, the proportion of medical expenditure shouldered by individuals is declining. The problem is the rapidly growing scale of medical expenditures challenges the sustainability of medical insurance funds. METHODS This study used the Heckman selection model, survival analysis, and ordered probit model to evaluate the effect of medical insurance on the expenditures in outpatient and inpatient health care, survival time, and improvement of self-rated health of test subjects, respectively. RESULTS Medical insurance exerts a differential effect on the expenditures in outpatient and inpatient health care. On average, the expenditures in outpatient and inpatient health care of test subjects participating in premium health insurance plans increased by 38.6% and 72.6%, respectively. Participation in medical insurance plans exhibits no significant correlation with the survival time of test subjects, but their self-rated health shows a significant correlation (P < 0.01). CONCLUSION Although medical insurance does not significantly reduce mortality or prolong the survival time of test subjects, it improves their health status. This study suggests that the Chinese government should eliminate deductible medical insurance payments and utilize medical resources on minor ailment treatment and disease prevention to improve the health status of people.
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Affiliation(s)
- Yongqiu WU
- College of Economics and Business Administration, Chongqing University, Chongqing, China,Corresponding Author:
| | - Yi HUANG
- College of Economics and Business Administration, Chongqing University, Chongqing, China
| | - Jintao LU
- School of Management, Northwestern Polytechnical University, Xi’an, China
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Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study. J Gen Intern Med 2016; 31:1198-205. [PMID: 27329121 PMCID: PMC5023615 DOI: 10.1007/s11606-016-3781-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/27/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population. OBJECTIVE We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers. DESIGN Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data. PATIENTS Cohort of patients who smoke and who gained Medicaid coverage in 2008-2011 after ≥ 6 months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n = 4140 matched pairs; 8280 patients). INTERVENTION Gaining Medicaid after being uninsured for ≥ 6 months. MAIN MEASURES 'Quit' smoking status (baseline smoking status was 'current every day' or 'some day' and status change to 'former smoker' at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period. KEY RESULTS The newly insured had 40 % increased odds of quitting smoking (aOR = 1.40, 95 % CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR = 2.94, 95 % CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR = 2.12, 95 % CI:1.94, 2.32) compared to their uninsured counterparts. CONCLUSIONS Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation.
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Hatch B, Bailey SR, Cowburn S, Marino M, Angier H, DeVoe JE. Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act. Am J Public Health 2016; 106:645-50. [PMID: 26890164 DOI: 10.2105/ajph.2016.303060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess longitudinal patterns of community health center (CHC) utilization and the effect of insurance discontinuity after Oregon's 2008 Medicaid expansion (the Oregon Experiment). METHODS We conducted a retrospective cohort study with electronic health records and Medicaid data. We divided individuals who gained Medicaid in the Oregon Experiment into those who maintained (n = 788) or lost (n = 944) insurance coverage. We compared these groups with continuously insured (n = 921) and continuously uninsured (n = 5416) reference groups for community health center utilization rates over a 36-month period. RESULTS Both newly insured groups increased utilization in the first 6 months. After 6 months, use among those who maintained coverage stabilized at a level consistent with the continuously insured, whereas it returned to baseline for those who lost coverage. CONCLUSIONS Individuals who maintained coverage through Oregon's Medicaid expansion increased long-term utilization of CHCs, whereas those with unstable coverage did not. POLICY IMPLICATIONS This study predicts long-term increase in CHC utilization following Affordable Care Act Medicaid expansion and emphasizes the need for policies that support insurance retention.
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Affiliation(s)
- Brigit Hatch
- Brigit Hatch, Steffani R. Bailey, Miguel Marino, Heather Angier, and Jennifer E. DeVoe are with Oregon Health and Science University, Portland. Stuart Cowburn and Jennifer E. DeVoe are with OCHIN, Portland
| | - Steffani R Bailey
- Brigit Hatch, Steffani R. Bailey, Miguel Marino, Heather Angier, and Jennifer E. DeVoe are with Oregon Health and Science University, Portland. Stuart Cowburn and Jennifer E. DeVoe are with OCHIN, Portland
| | - Stuart Cowburn
- Brigit Hatch, Steffani R. Bailey, Miguel Marino, Heather Angier, and Jennifer E. DeVoe are with Oregon Health and Science University, Portland. Stuart Cowburn and Jennifer E. DeVoe are with OCHIN, Portland
| | - Miguel Marino
- Brigit Hatch, Steffani R. Bailey, Miguel Marino, Heather Angier, and Jennifer E. DeVoe are with Oregon Health and Science University, Portland. Stuart Cowburn and Jennifer E. DeVoe are with OCHIN, Portland
| | - Heather Angier
- Brigit Hatch, Steffani R. Bailey, Miguel Marino, Heather Angier, and Jennifer E. DeVoe are with Oregon Health and Science University, Portland. Stuart Cowburn and Jennifer E. DeVoe are with OCHIN, Portland
| | - Jennifer E DeVoe
- Brigit Hatch, Steffani R. Bailey, Miguel Marino, Heather Angier, and Jennifer E. DeVoe are with Oregon Health and Science University, Portland. Stuart Cowburn and Jennifer E. DeVoe are with OCHIN, Portland
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