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Bronstein JM, Huang L, Shelley JP, Levitan EB, Presley CA, Agne AA, Mondesir FL, Riggs KR, Pisu M, Cherrington AL. Primary care visits and ambulatory care sensitive diabetes hospitalizations among adult Alabama Medicaid beneficiaries. Prim Care Diabetes 2022; 16:116-121. [PMID: 34772648 PMCID: PMC8840986 DOI: 10.1016/j.pcd.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE To describe patterns of care use for Alabama Medicaid adult beneficiaries with diabetes and the association between primary care utilization and ambulatory care sensitive (ACS) diabetes hospitalizations. METHODS This retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19-64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use on the occurrence of an ACS hospitalization. RESULTS One third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (odds ratio comparing 1-2 visits versus none 0.79, 95% confidence interval 0.73-0.85). CONCLUSIONS Program and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes.
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Affiliation(s)
- Janet M Bronstein
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham AL, 35294, United States
| | - Lei Huang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham AL, 35294, United States
| | - John P Shelley
- School of Medicine, Vanderbilt University, 2209 Garland Ave, Nashville TN, 37232, United States
| | - Emily B Levitan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham AL, 35294, United States
| | - Caroline A Presley
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, Birmingham AL, 35205, United States
| | - April A Agne
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, Birmingham AL, 35205, United States
| | - Favel L Mondesir
- Division of Cardiovascular Medicine, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Kevin R Riggs
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, Birmingham AL, 35205, United States
| | - Maria Pisu
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, Birmingham AL, 35205, United States
| | - Andrea L Cherrington
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, Birmingham AL, 35205, United States.
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Saks BR, Ouyang VW, Domb ES, Jimenez AE, Maldonado DR, Lall AC, Domb BG. Equality in Hip Arthroscopy Outcomes Can Be Achieved Regardless of Patient Socioeconomic Status. Am J Sports Med 2021; 49:3915-3924. [PMID: 34739305 DOI: 10.1177/03635465211046932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Access to quality health care and treatment outcomes can be affected by patients' socioeconomic status (SES). PURPOSE To evaluate the effect of patient SES on patient-reported outcome measures (PROMs) after arthroscopic hip surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Demographic, radiographic, and intraoperative data were prospectively collected and retrospectively reviewed on all patients who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear between February 2008 and September 2017 at one institution. Patients were divided into 4 cohorts based on the Social Deprivation Index (SDI) of their zip code. SDI is a composite measure that quantifies the level of disadvantage in certain geographical areas. Patients had a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), International Hip Outcome Tool-12, and visual analog scale (VAS) for both pain and satisfaction. Rates of achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for the mHHS, NAHS, and VAS pain score. Rates of secondary surgery were also recorded. RESULTS A total of 680 hips (616 patients) were included. The mean follow-up time for the entire cohort was 30.25 months. Division of the cohort into quartiles based on the SDI national averages yielded 254 hips (37.4%) in group 1, 184 (27.1%) in group 2, 148 (21.8%) in group 3, and 94 (13.8%) in group 4. Group 1 contained the most affluent patients. There were significantly more men in group 4 than in group 2, and the mean body mass index was greater in group 4 than in groups 1 and 2. There were no differences in preoperative radiographic measurements, intraoperative findings, or rates of concomitant procedures performed. All preoperative and postoperative PROMs were similar between the groups, as well as in the rates of achieving the MCID or PASS. No differences in the rate of secondary surgeries were reported. CONCLUSION Regardless of SES, patients were able to achieve significant improvements in several PROMs after hip arthroscopy for FAIS and labral tear at the minimum 2-year follow-up. Additionally, patients from all SES groups achieved clinically meaningful improvement at similar rates.
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Affiliation(s)
- Benjamin R Saks
- American Hip Institute Research Foundation, Chicago, Illinois, USA.,Core Physicians, Exeter, New Hampshire, USA
| | - Vivian W Ouyang
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | - Elijah S Domb
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | - Andrew E Jimenez
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | | | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, Illinois, USA.,Core Physicians, Exeter, New Hampshire, USA.,American Hip Institute, Chicago, Illinois, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois, USA.,Core Physicians, Exeter, New Hampshire, USA.,American Hip Institute, Chicago, Illinois, USA
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Determinants of Diabetes Disease Management, 2011-2019. Healthcare (Basel) 2021; 9:healthcare9080944. [PMID: 34442081 PMCID: PMC8393363 DOI: 10.3390/healthcare9080944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/17/2021] [Accepted: 07/21/2021] [Indexed: 11/25/2022] Open
Abstract
This study estimated the effects of Medicaid Expansion, demographics, socioeconomic status (SES), and health status on disease management of diabetes over time. The hypothesis was that the introduction of the ACA and particularly Medicaid Expansion would increase the following dependent variables (all proportions): (1) provider checks of HbA1c, (2) provider checks of feet, (3) provider checks of eyes, (4) patient education, (5) annual physician checks for diabetes, (6) patient self-checks of blood sugar. Data were available from the Behavioral Risk Factor Surveillance System for 2011 to 2019. We filtered the data to include only patients with diagnosed non-gestational diabetes of age 45 or older (n = 510,991 cases prior to weighting). Linear splines modeled Medicaid Expansion based on state of residence as well as implementation status. Descriptive time series plots showed no major changes in proportions of the dependent variables over time. Quasibinomial analysis showed that implementation of Medicaid Expansion had a statistically negative effect on patient self-checks of blood sugar (odds ratio = 0.971, p < 0.001), a statistically positive effect on physician checks of HbA1c (odds ratio = 1.048, p < 0.001), a statistically positive effect on feet checks (odds ratio = 1.021, p < 0.001), and no other significant effects. Evidence of demographic, SES, and health status disparities existed for most of the dependent variables. This finding was especially significant for HbA1c checks by providers. Barriers to achieving better diabetic care remain and require innovative policy interventions.
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Yan LD, Ali MK, Strombotne KL. Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis. Am J Prev Med 2021; 60:189-197. [PMID: 33191065 PMCID: PMC10420391 DOI: 10.1016/j.amepre.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/31/2020] [Accepted: 08/06/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. METHODS A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008-2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18-64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. RESULTS In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= -16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. CONCLUSIONS Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.
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Affiliation(s)
- Lily D Yan
- Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts; Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts.
| | - Mohammed K Ali
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia; Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kiersten L Strombotne
- Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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Varadarajan A, Walker RJ, Williams JS, Bishu K, Nagavally S, Egede LE. Relationship between insurance and access and cost of care in patients with diabetes before and after the affordable care act. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2020. [DOI: 10.1108/ijhg-02-2020-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to examine the influence of insurance coverage changes over time for patients with diabetes on expenditures and access to care before and after the Affordable Care Act (ACA).Design/methodology/approachThe Medical Expenditure Panel Survey (MEPS) from 2002–2017 was used. Access included having a usual source of care, having delay in care or having delay in obtaining prescription medicine. Expenditures included inpatient, outpatient, office-based, prescription and emergency costs. Panels were broken into four time categories: 2002–2005 (pre-ACA), 2006–2009 (pre-ACA), 2010–2013 (post-ACA) and 2014–2017 (post-ACA). Logistic models for access and two-part regression models for cost were used to understand differences by insurance type over time.FindingsType of insurance changed significantly over time, with an increase for public insurance from 30.7% in 2002–2005 to 36.5% in 2014–2017 and a decrease in private insurance from 62.4% in 2002–2005 to 58.2% in 2014–2017. Compared to those with private insurance, those who were uninsured had lower inpatient ($2,147 less), outpatient ($431 less), office-based ($1,555 less), prescription ($1,869 less) and emergency cost ($92 less). Uninsured were also more likely to have delay in getting medical care (OR = 2.22; 95% CI 1.86, 3.06) and prescription medicine (OR = 1.85; 95% CI 1.53, 2.24) compared with privately insured groups.Originality/valueThough insurance coverage among patients with diabetes did not increase significantly, the type of insurance changed overtime and fewer individuals reported having a usual source of care. Uninsured individuals spent less across all cost types and were more likely to report delay in care despite the passage of the ACA.
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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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Fernandes R, Chinn CC, Li D, Frankland TB, Wang CM, Smith MD, Ozaki RR. A Randomized Controlled Trial of Financial Incentives for Medicaid Beneficiaries with Diabetes. Perm J 2018; 22:17-080. [PMID: 29401049 DOI: 10.7812/tpp/17-080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Medicaid Incentives for Prevention of Chronic Diseases program was authorized by the Affordable Care Act to determine the effectiveness of providing financial incentives. OBJECTIVE To examine the impact of incentives on adult Medicaid beneficiaries' diabetes self-management using the Hawaii Patient Reward And Incentives to Support Empowerment project. METHODS A randomized controlled trial study was conducted at Kaiser Permanente Hawaii with 320 participants (159 intervention group/161 control group). Participants could earn up to $320/y of financial incentives, distributed in the form of a debit card. Evaluation measures included 1) clinical outcomes of change in hemoglobin A1C, blood pressure, and cholesterol; 2) compliance with American Diabetes Association standards; 3) cost effectiveness; 4) quality of life; 5) self-management activities; and 6) satisfaction with incentives. RESULTS No significant differences in clinical outcomes were found between groups. There were no differences in observance of American Diabetes Association standards of medical care between the intervention and control group. The project also did not show reduction in health cost. However, participants in the intervention group reported significantly higher adherence with the recommended general diet than those in the control group during the course of the study. They also reported statistically better physical health than their control counterparts at the midpoint of the study; however, the perception of increased physical health didn't sustain to the end of the study. Participants' satisfaction with incentives was high. CONCLUSION Overall, this study found no conclusive evidence that financial incentives alone had beneficial effects on improving standards of medical care in diabetes.
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Affiliation(s)
- Ritabelle Fernandes
- Associate Professor in the Department of Geriatric Medicine at the University of Hawaii in Honolulu. E mail:
| | - Chuan C Chinn
- Associate Specialist at the Center on Disability Studies at the University of Hawaii in Honolulu.
| | - Dongmei Li
- Associate Professor in the School of Medicine and Dentistry at the University of Rochester Medical Center in New York.
| | | | - Christina Mb Wang
- Data Analyst at the Center on Disability Studies at the University of Hawaii in Honolulu.
| | - Myra D Smith
- Data Analyst at the Center on Disability Studies at the University of Hawaii in Honolulu.
| | - Rebecca Rude Ozaki
- Associate Professor at the Center on Disability Studies at the University of Hawaii in Honolulu.
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Bloodworth R, Chen J, Mortensen K. Variation of preventive service utilization by state Medicaid coverage, cost-sharing, and Medicaid expansion status. Prev Med 2018; 115:97-103. [PMID: 30145344 DOI: 10.1016/j.ypmed.2018.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/09/2018] [Accepted: 08/21/2018] [Indexed: 12/25/2022]
Abstract
Preventive services can help reduce costs associated with chronic conditions. Medicaid beneficiaries have high rates of chronic conditions, but state Medicaid coverage and cost-sharing of preventive services varies widely. States that chose to expand Medicaid under the ACA were incentivized to cover recommended preventive services at no cost-sharing. This study evaluates whether state Medicaid policy and Medicaid expansion were associated with overall utilization, and disparities in utilization of preventive services among vulnerable populations. We used Medicaid policy data from Kaiser Family Foundation and MEPS data (2009-2014, n = 15,610), collected and analyzed in 2017. We used multivariable logistic regression, difference-in-differences, and difference-in-difference-in-differences models to examine the association between state Medicaid preventive service policy and Medicaid expansion on overall utilization, and disparities in utilization among race/ethnicity and income groups for blood pressure check, cholesterol screening, and flu shot. Medicaid coverage of flu shot was significantly associated with utilization (p < 0.001). Medicaid expansion significantly increased flu shot utilization among near-poor individuals (p < 0.01), Asians, and Latinos and blood pressure screening among African Americans (p < 0.05). For flu shot, the ACA is reaching its target audience: those in the coverage gap between Medicaid and private insurance. Increasing access to preventive services may not be enough to increase utilization, especially for vulnerable populations and/or the previously uninsured. Focusing on provider adherence to preventive service guidelines and education around who is eligible for what service and when could help increase utilization of preventive services in the future.
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Affiliation(s)
- Robin Bloodworth
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, United States of America.
| | - Jie Chen
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, United States of America
| | - Karoline Mortensen
- Department of Health Sector Management and Policy, University of Miami Business School, Coral Gables, FL, United States of America
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Ng BP, Shrestha SS, Lanza A, Smith B, Zhang P. Medical Expenditures Associated With Diabetes Among Adult Medicaid Enrollees in Eight States. Prev Chronic Dis 2018; 15:E116. [PMID: 30264691 PMCID: PMC6178897 DOI: 10.5888/pcd15.180148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Little information is available on state-specific financial burdens of diabetes in the Medicaid population, yet such information is essential for state Medicaid programs to plan diabetes care and evaluate the benefits of diabetes prevention. We estimated medical expenditures associated with diabetes among adult Medicaid enrollees in 8 states. Methods We analyzed the latest available 2012 CMS Medicaid claims data for 1,193,811 adult enrollees aged 19–64 years in 8 states: Alabama, California, Connecticut, Florida, Illinois, Iowa, New York, and Oklahoma. For each state, we stratified the study population by Medicaid eligibility criteria: disability and nondisability. For each group, we estimated per capita annual medical expenditures on outpatient care, inpatient care, and prescription drugs by using a 2-part model, adjusted for age, sex, race/ethnicity, and comorbidities. We calculated the expenditures associated with diabetes as the difference in predicted expenditures for enrollees with and without diabetes. Analyses were done in 2017. Results For disability-based enrollees, the estimated total per capita annual diabetes expenditures ranged from $6,183 in Alabama to $15,319 in New York (all P < .001). For nondisability-based enrollees, the corresponding estimates ranged from $4,985 in Alabama to $15,366 in New York (all P < .001). The proportion of individual components varied by state and eligibility criteria. Conclusion Medical expenditures associated with diabetes among adults on Medicaid were substantial and varied across studied states. Our estimates can be used by the 8 state Medicaid programs to prepare health care resources needed for diabetes care and assess the financial benefits of diabetes prevention programs.
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Affiliation(s)
- Boon Peng Ng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, GA 30341. E-mail:
| | - Sundar S Shrestha
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andrew Lanza
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bryce Smith
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
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Benitez JA, Adams EK, Seiber EE. Did Health Care Reform Help Kentucky Address Disparities in Coverage and Access to Care among the Poor? Health Serv Res 2018; 53:1387-1406. [PMID: 28439903 PMCID: PMC5980370 DOI: 10.1111/1475-6773.12699] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the impact of Kentucky's full rollout of the Affordable Care Act on disparities in access to care due to poverty. DATA SOURCE Restricted version of the Behavioral Risk Factor Surveillance System (BRFSS) for Kentucky and years 2011-2015. STUDY DESIGN We use a difference-in-differences framework to compare trends before and after implementation of the Affordable Care Act (ACA) in health insurance coverage, several access measures, and health care utilization for residents in higher versus lower poverty ZIP codes. PRINCIPAL FINDINGS Much of the reduction in Kentucky's uninsured rate appears driven by large uptakes in coverage from areas with higher concentrations of poverty. Residents in high-poverty communities experienced larger reductions, 8 percentage points (pp) in uninsured status and 7.5 pp in reporting unmet needs due to costs, than residents of lower poverty areas. These effects helped remove pre-ACA disparities in uninsured rates across these areas. CONCLUSION Because we observe positive effects on coverage and reductions in financial barriers to care among those from poorer communities, our findings suggest that expanding Medicaid helps address the health care needs of the impoverished.
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Affiliation(s)
- Joseph A. Benitez
- Commonwealth Institute of KentuckyDepartment of Health Management and System SciencesSchool of Public Health and Information SciencesUniversity of LouisvilleLouisvilleKY
| | - E. Kathleen Adams
- Department of Health Policy and ManagementRollins School of Public HealthEmory UniversityAtlantaGA
| | - Eric E. Seiber
- Department of Health Services Management and PolicyCollege of Public HealthOhio State UniversityColumbusOH
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Dickman SL, Himmelstein DU, Woolhandler S. Inequality and the health-care system in the USA. Lancet 2017; 389:1431-1441. [PMID: 28402825 DOI: 10.1016/s0140-6736(17)30398-7] [Citation(s) in RCA: 338] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 11/29/2022]
Abstract
Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.
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Affiliation(s)
- Samuel L Dickman
- Department of Medicine, University of California, San Francisco, CA, USA
| | - David U Himmelstein
- City University of New York School of Urban Public Health at Hunter College, New York, NY, USA; Harvard Medical School, Boston, MA, USA.
| | - Steffie Woolhandler
- City University of New York School of Urban Public Health at Hunter College, New York, NY, USA; Harvard Medical School, Boston, MA, USA
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12
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Affiliation(s)
- William H Herman
- Department of Internal Medicine, Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI
| | - William T Cefalu
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
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Horvitz-Lennon M, Volya R, Garfield R, Donohue JM, Lave JR, Normand SLT. Where You Live Matters: Quality and Racial/Ethnic Disparities in Schizophrenia Care in Four State Medicaid Programs. Health Serv Res 2015; 50:1710-29. [PMID: 25759240 DOI: 10.1111/1475-6773.12296] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine whether (a) quality in schizophrenia care varies by race/ethnicity and over time and (b) these patterns differ across counties within states. DATA SOURCES Medicaid claims data from California, Florida, New York, and North Carolina during 2002-2008. STUDY DESIGN We studied black, Latino, and white Medicaid beneficiaries with schizophrenia. Hierarchical regression models, by state, quantified person and county effects of race/ethnicity and year on a composite quality measure, adjusting for person-level characteristics. PRINCIPAL FINDINGS Overall, our cohort included 164,014 person-years (41-61 percent non-whites), corresponding to 98,400 beneficiaries. Relative to whites, quality was lower for blacks in every state and also lower for Latinos except in North Carolina. Temporal improvements were observed in California and North Carolina only. Within each state, counties differed in quality and disparities. Between-county variation in the black disparity was larger than between-county variation in the Latino disparity in California, and smaller in North Carolina; Latino disparities did not vary by county in Florida. In every state, counties differed in annual changes in quality; by 2008, no county had narrowed the initial disparities. CONCLUSIONS For Medicaid beneficiaries living in the same state, quality and disparities in schizophrenia care are influenced by county of residence for reasons beyond patients' characteristics.
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Affiliation(s)
| | - Rita Volya
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | | | - Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Judith R Lave
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA
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Ndumele CD, Mor V, Allen S, Burgess JF, Trivedi AN. Effect of expansions in state Medicaid eligibility on access to care and the use of emergency department services for adult Medicaid enrollees. JAMA Intern Med 2014; 174:920-6. [PMID: 24710866 PMCID: PMC5567677 DOI: 10.1001/jamainternmed.2014.588] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid. OBJECTIVE To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid. MAIN OUTCOMES AND MEASURES Self-reported access to care and annualized emergency department use. RESULTS Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance. CONCLUSIONS AND RELEVANCE We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.
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Affiliation(s)
- Chima D Ndumele
- Department of Health Management and Policy, Yale School of Public Health, New Haven, Connecticut2Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island3Center of Innovation in Long-term Services and Supports for Vulnerable Veterans, Providence Veterans Affairs Medical Center, Providence
| | - Susan Allen
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island3Center of Innovation in Long-term Services and Supports for Vulnerable Veterans, Providence Veterans Affairs Medical Center, Providence
| | - James F Burgess
- Center for Organization, Leadership and Management Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts5Department of Health Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Amal N Trivedi
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island3Center of Innovation in Long-term Services and Supports for Vulnerable Veterans, Providence Veterans Affairs Medical Center, Providence
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Wang TF, Shi L, Nie X, Zhu J. Race/ethnicity, insurance, income and access to care: the influence of health status. Int J Equity Health 2013; 12:29. [PMID: 23663514 PMCID: PMC3654947 DOI: 10.1186/1475-9276-12-29] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/17/2013] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To examine health care access disparities with regard to health status and presence of functional limitations, a common measure of disability and multimorbidity, after controlling for individual's race/ethnicity, insurance status and income in the U.S. using the latest survey data. METHODS Using data from the 2009 Family Core component of the National Health Interview Survey (NHIS), we examined six measures of access to care in the twelve months prior to the interview. Covariates included self-perceived health status and the presence of functional limitations, race/ethnicity, insurance status, income, and other socioeconomic characteristics. Multiple logistic regressions were used to examine the associations. RESULTS People with functional limitations or worse health status experience greater barriers to access. Insurance status was the single factor that was associated with all six measures of access. Disparities among racial/ethnic groups in most access indicators as well as income levels were insignificant after taking into account individuals' health status measures. CONCLUSIONS Interventions to expand insurance coverage and the Patient Protection and Affordable Care Act are expected to contribute to reducing disparities in access to care. However, to further improve access to care, emphasis must be placed on those with poorer health status and functional limitations.
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Affiliation(s)
- Tze-Fang Wang
- School of Nursing, National Yang Ming University, Taipei 112, Taiwan
| | - Leiyu Shi
- Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Baltimore MD 21205, USA
| | - Xiaoyu Nie
- Primary Care Policy Center, Johns Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Jinsheng Zhu
- Primary Care Policy Center, Johns Hopkins University, 624 N. Broadway, Baltimore, MD 21205, USA
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