Contributions of Key Components of a Medical Home on Child Health Outcomes

OBJECTIVES

The medical home model is a widely accepted model of team-based primary care. We examined five components of the medical home model in order to better understand their unique contributions to child health outcomes.

METHODS

We analyzed data from the 2016-2017 National Survey of Children's Health (NSCH) to assess five key medical home components - usual source of care, personal doctor/nurse, family-centered care, referral access, and coordinated care - and their associations with child outcomes. Health outcomes included emergency department (ED) visits, unmet health care needs, preventive medical visits, preventive dental visits, health status, and oral health status. We used multivariate regression controlling for child characteristics including age, sex, primary household language, race/ethnicity, income, parental education, health insurance coverage, and special healthcare needs.

RESULTS

Children who were not white, living in non-English households, with less family income or education, or who were uninsured had lower rates of access to a medical home and its components. A medical home was associated with beneficial child outcomes for all six of the outcomes and the family-centered care component was associated with better results in five outcomes. ED visits were less likely for children who received care coordination (aOR 0.81, CI 0.70-0.94).

CONCLUSIONS FOR PRACTICE

Our study highlights the role of key components of the medical home and the importance of access to family-centered health care that provides needed coordination for children. Health care reforms should consider disparities in access to a medical home and specific components and the contributions of each component to provide quality primary care for all children.

The Future of State All-Payer Claims Databases

State policy makers are under increasing pressure to address the prohibitive cost of health care given the lack of action at the federal level. In 2020, the United States spent more on health care than any other country in the world-$4.1 trillion, representing 19.7% of the nation's gross domestic product. States are trying to better understand their role in health care spending and to think creatively about strategies for addressing health care cost growth. One way they are doing this is through the development and use of state-based all-payer claims databases (APCDs). APCDs are health data organizations that hold transactional information from public (Medicare and Medicaid) and private health insurers (commercial plans and some self-insured employers). APCDs transform this data into useful information on health care costs and trends. This article describes states' use of APCDs and recent efforts that have provided benefits and challenges for states interested in this unique opportunity to inform health policy. Although challenges exist, there is new funding for state APCD improvements in the No Surprises Act, and potential new federal interest will help states enhance their APCD capacity so they can better understand their markets, educate consumers, and create actionable market information.

Food Security Status among U.S. Older Adults: Functional Limitations Matter

This study aimed to assess the relationship between food security and health outcomes among older adults (age 65+) in the U.S. We used a pooled sample (2011-2015, N = 37,292) from the National Health Interview Survey (NHIS) and ordered logit models to assess characteristics associated with food security including health conditions (diabetes and hypertension) and functional activity limitations. We estimated that 1.3 million individuals aged 65+ in the U.S. had low/very low food security. Having at least one functional limitation (OR = 1.717, 95% CI = 1.436, 2.054) was significantly associated with low/very low food security. Having fair or poor health status (OR = 3.315, 95% CI = 2.938, 3.739) was also a significant factor for food security among older adults, while having health insurance coverage (OR = 0.467, 95% CI = 0.341, 0.64) was negatively associated with food insecurity. Demographics and socioeconomic characteristics were significantly related to food insecurity among seniors. Seniors with functional limitations and poor health status are at risk for food insecurity. Interventions at the clinical site of care may be useful in addressing food security issues for older adults.

Access and enrollment in safety net programs in the wake of COVID-19: A national cross-sectional survey

The global COVID-19 pandemic is causing unprecedented job loss and financial strain. It is unclear how those most directly experiencing economic impacts may seek assistance from disparate safety net programs. To identify self-reported economic hardship and enrollment in major safety net programs before and early in the COVID-19 pandemic, we compared individuals with COVID-19 related employment or earnings reduction with other individuals. We created a set of questions related to COVID-19 economic impact that was added to a cross-sectional, nationally representative online survey of American adults (age ≥18, English-speaking) in the AmeriSpeak panel fielded from April 23-27, 2020. All analyses were weighted to account for survey non-response and known oversampling probabilities. We calculated unadjusted bivariate differences, comparing people with and without COVID-19 employment and earnings reductions with other individuals. Our study looked primarily at awareness and enrollment in seven major safety net programs before and since the pandemic (Medicaid, health insurance marketplaces/exchanges, unemployment insurance, food pantries/free meals, housing/renters assistance, SNAP, and TANF). Overall, 28.1% of all individuals experienced an employment reduction (job loss or reduced earnings). Prior to the pandemic, 39.0% of the sample was enrolled in ≥1 safety net program, and 50.0% of individuals who subsequently experienced COVID-19 employment reduction were enrolled in at least one safety net program. Those who experienced COVID-19 employment reduction versus those who did not were significantly more likely to have applied or enrolled in ≥1 program (45.9% versus 11.7%, p<0.001) and also significantly more likely to specifically have enrolled in unemployment insurance (29.4% versus 5.4%, p < .001) and SNAP (16.8% versus 2.8%, p = 0.028). The economic devastation from COVID-19 increases the importance of a robust safety net.

US Adults' Preferences for Public Allocation of a Vaccine for Coronavirus Disease 2019

This survey study examines public perception of high priority groups for receipt of an eventual coronavirus disease 2019 vaccine in case of shortage of supply.

Emergency Flexibility for States to Increase and Maintain Medicaid Eligibility for LTSS under COVID-19

Medicaid provides essential coverage for health care and long-term services and supports (LTSS) to low-income older adults and disabled individuals but eligibility is complicated and restrictive. In light of the current public health emergency, states have been given new authority to streamline and increase the flexibility of Medicaid LTSS eligibility, helping them enroll eligible individuals and ensure that current beneficiaries are not inadvertently disenrolled. Though state budgets are under increased pressure during the economic crisis created by the coronavirus, we caution states against cutting Medicaid LTSS eligibility or services to balance their budgets. These services are critical to an especially vulnerable population during a global pandemic.

Modeling Financial Eligibility for Medicaid Long-term Services and Supports

Medicaid plays a significant role in financing long-term services and supports (LTSS) for low-income elderly (65+) in the United States. We modeled the impact of changing income, home equity, and asset limitations on Medicaid eligibility across states. We found that one in five elderly adults (10 million individuals) meet all three tests and would be financially eligible for Medicaid LTSS. Imposing additional restrictions on income allowances and eligibility thresholds had greatest impact on financial eligibility for Medicaid LTSS. Few states have opted to restrict financial eligibility and are instead looking for ways to keep people living independently in the community.

Patient Perspectives on the Cultural Competence of US Health Care Professionals

This survey study uses data from the 2017 National Health Interview Survey to examine patients’ perspectives on the cultural competence of US health care professionals.

Estimated Costs of a Reinsurance Program to Stabilize the Individual Health Insurance Market: National- and State-Level Estimates

Reinsurance, an insurance product designed to protect health insurers against the financial risk of covering high-cost enrollees, has attracted bipartisan policy interest as a mechanism to stabilize individual health insurance markets. Three states—Alaska, Minnesota, and Oregon—have implemented state-based reinsurance programs under the Affordable Care Act’s 1332 State Innovation Waivers, and reinsurance waivers have been approved though not yet enacted in Maine, Maryland, New Jersey, and Wisconsin. In this article, we estimate the costs of implementing national and state-based reinsurance programs using health spending data from the 2007-2016 Medical Expenditure Panel Survey and state demographic and health insurance coverage data from the 2015-2017 Current Population Survey Annual Social and Economic Supplement. We project that a reinsurance program with an 80% payment rate for expenditures between $40,000 and $250,000 would cost $30.1 billion from 2020-2022. We observed considerable variation in reinsurance programs and estimated costs between the 4 states we examined: California, Florida, Illinois, and Texas. Our projections provide updated estimates of the costs of implementing federal reinsurance programs for the individual health insurance market.

Recent Changes in Health Insurance Coverage for Urban and Rural Veterans: Evidence from the First Year of the Affordable Care Act

Introduction

Prior to the Affordable Care Act, as many as 1.3 million veterans lacked health insurance. With the passage of the Affordable Care Act, veterans now have new pathways to coverage through Medicaid expansion in those states that chose to expand Medicaid and through private coverage options offered through the Health Insurance Marketplace. We examined the impact of the ACA on health insurance coverage for veterans in expansion and non-expansion states and for urban and rural veterans.

Methods

We examined changes in veterans' health insurance coverage following the first year of the ACA, focusing on whether they lived in an urban or rural area and whether they live in a Medicaid expansion state. We used data on approximately 200,000 non-elderly community-dwelling veterans, obtained from the 2013-2014 American Community Survey and estimated differences in the adjusted probability of being uninsured between 2013 and 2014 for both urban and rural areas. Adjusted probabilities were computed by fitting logistic regressions controlling for age, gender, race, marital status, poverty status, education, and employment.

Results

There were an estimated 10.1 million U.S. non-elderly veterans in 2013; 82% lived in predominantly urban areas (8.3 million), and the remaining 18% (1.8 million) lived in predominately rural areas. Most veterans lived in the South (43.6%), and rural veterans were more likely to be Southerners than their urban counterparts. On every marker of economic well-being, rural veterans fared worse than urban veterans. They had a statistically significant higher chance of having incomes below 138% of FPG (20.0% versus 17.0%), of being out of the labor force (29.1% versus 23.0%), and of having no more than a high school education (39.6% versus 28.8%). Rural veterans were also more likely to experience at least one functional limitation. Overall, veterans in Medicaid expansion states experienced a significantly larger increase in insurance compared to veterans living in non-expansion states. For rural veterans in Medicaid expansion states, the increase in insurance was 3.5 percentage points, compared with 1.2 percentage points in non-expansion states.

Conclusion

Our analysis found a substantial 24% relative decline in the rate of uninsurance for U.S. Veterans, from 9.3 to 7.1% between 2013 and 2014. We found that coverage gains in rural areas were due to gains in Medicaid and individual market coverage. Residence in a Medicaid expansion state was particularly influential for rural veterans - the increase in the insured rate was three times larger in Medicaid expansion states versus non-expansion states. The ACA has had a positive and significant impact on the ability of U.S. Veterans to obtain health insurance coverage specifically for low-income veterans living in rural areas. The poverty rate among Veterans is rising and is particularly an issue for the more recent Gulf War veterans. Providing affordable and accessible health insurance options is part of our commitment to those who have served our country. Our analysis also presents yet another reason for the 17 non-expansion states to consider a Medicaid expansion.

Paid Maternity Leave in the United States: Associations with Maternal and Infant Health

Objectives The United States is one of only three countries worldwide with no national policy guaranteeing paid leave to employed women who give birth. While maternity leave has been linked to improved maternal and child outcomes in international contexts, up-to-date research evidence in the U.S. context is needed to inform current policy debates on paid family leave. Methods Using data from Listening to Mothers III, a national survey of women ages 18-45 who gave birth in 2011-2012, we conducted multivariate logistic regression to predict the likelihood of outcomes related to infant health, maternal physical and mental health, and maternal health behaviors by the use and duration of paid maternity leave. Results Use of paid and unpaid leave varied significantly by race/ethnicity and household income. Women who took paid maternity leave experienced a 47% decrease in the odds of re-hospitalizing their infants (95% CI 0.3, 1.0) and a 51% decrease in the odds of being re-hospitalized themselves (95% CI 0.3, 0.9) at 21 months postpartum, compared to women taking unpaid or no leave. They also had 1.8 times the odds of doing well with exercise (95% CI 1.1, 3.0) and stress management (95% CI 1.1, 2.8), compared to women taking only unpaid leave. Conclusions for Practice Paid maternity leave significantly predicts lower odds of maternal and infant re-hospitalization and higher odds of doing well with exercise and stress management. Policies aimed at expanding access to paid maternity and family leave may contribute toward reducing socio-demographic disparities in paid leave use and its associated health benefits.

Addressing the Rural Opioid Addiction and Overdose Crisis Through Cross-Sector Collaboration: Little Falls, Minnesota

Morrison County Community-Based Care Coordination is a collaborative, cross-sector effort in Little Falls, Minnesota, that began in 2014 to reduce the use and abuse of opioids among patients at the local hospital and clinic and within the broader local rural community. As of March 2018, 453 clinic patients discontinued use of controlled substances (a reduction of 44 952 doses each month), and law enforcement stakeholders have reported a decrease in drug crimes related to the sale of narcotics.

Affordable Care Act Impact in Kentucky: Increasing Access, Reducing Disparities

OBJECTIVES

To examine health insurance disparities since Kentucky's implementation of the Affordable Care Act (ACA).

METHODS

Using the American Community Survey, we estimated coverage rates by race/ethnicity before and after implementation of the ACA (2013 and 2015), and we estimated whether groups were over- or underrepresented among the uninsured, compared with their share of the state population.

RESULTS

Kentucky's uninsurance rate declined from 14.4% in 2013 to 6.1% in 2015 (P < .001). Uninsurance rates also declined for most racial/ethnic groups, including Blacks (16.7% to 5.5%; P < .001) and Whites (13.3% to 5.3%; P < .001). In 2015, Blacks were no longer overrepresented among Kentucky's uninsured, with a significant decline in the ratio of Blacks among the state uninsured population compared with their share of the state population (1.16-0.91; P = .045).

CONCLUSIONS

In Kentucky, which mounted a robust implementation of the ACA-including Medicaid expansion, a state-based marketplace, and an extensive outreach and enrollment campaign-the state experienced not only a decline in the overall uninsurance rate but also an elimination in coverage disparities among Blacks, who historically were overrepresented among the uninsured.

Data Resources for Conducting Health Services and Policy Research

Rich federal data resources provide essential data inputs for monitoring the health and health care of the US population and are essential for conducting health services policy research. The six household surveys we document in this article cover a broad array of health topics, including health insurance coverage (American Community Survey, Current Population Survey), health conditions and behaviors (National Health Interview Survey, Behavioral Risk Factor Surveillance System), health care utilization and spending (Medical Expenditure Panel Survey), and longitudinal data on public program participation (SIPP). New federal activities are linking federal surveys with administrative data to reduce duplication and response burden. In the private sector, vendors are aggregating data from medical records and claims to enhance our understanding of treatment, quality, and outcomes of medical care. Federal agencies must continue to innovate to meet the continuous challenges of scarce resources, pressures for more granular data, and new multimode data collection methodologies.

Minnesota Integrated Health Partnership Demonstration: Implementation of a Medicaid ACO Model

In recent years, accountable care organizations (ACOs) have become more prevalent in the United States. This study describes the origins, implementation, and early results of Minnesota's Medicaid ACO payment model, the Integrated Health Partnership (IHP) demonstration project. We describe the structure of the program and present preliminary evaluation results to document the state's important work and to provide lessons for other states interested in implementing Medicaid ACOs. The IHP program has expanded in size over time, the state has reported significant savings, and evidence exists of capacity building among participating providers. We identify factors that may have contributed to the program's early success, but more work is needed to investigate the specific drivers of quality improvement and savings within Minnesota's ACO program and to compare the design and effects of the IHP with other Medicaid and Medicare ACO programs. We conclude with comments about the future of the state's Medicaid ACO program and situate Minnesota's findings within the context of the broader ACO movement.

Community Characteristics and Qualified Health Plan Selection during the First Open Enrollment Period

OBJECTIVE

To examine state and community factors that contributed to geographic variation in qualified health plan selection during the first open enrollment period.

DATA SOURCES/STUDY SETTING

Administrative data on qualified health plan selections at the ZIP code area merged with survey estimates from the American Community Survey.

STUDY DESIGN

Descriptive and regression analyses.

DATA COLLECTION/EXTRACTION METHODS

Data were generated by healthcare.gov and from a household survey.

PRINCIPAL FINDINGS

Thirty-one percent of the variation in qualified health plan selection ratios resulted from between-state differences, and the rest was driven by local area differences. Education, language, age, gender, and the ethnic composition of communities contributed to disparate levels of plan selection. Medicaid expansion states had a qualified health plan selection ratio that was 4.4 points lower than non-Medicaid expansion states, controlling for covariates.

CONCLUSIONS

Our results suggest community-level differences in the intensity or receptiveness to outreach and enrollment activities during the first open enrollment period.

Unstable Inferences? An Examination of Complex Survey Sample Design Adjustments Using the Current Population Survey for Health Services Research

Statistical analysis of the Current Population Survey's Annual Social and Economic Supplement is used widely in health services research. However, the statistical evidence cited from the Current Population Survey (CPS) is not always consistent because researchers use a variety of methods to produce standard errors that are fundamental to significance tests. This analysis examines the 2002 Annual Social and Economic Supplement's (ASEC) estimates of national and state average income, national and state poverty rates, and national and state health insurance coverage rates. Findings show that the standard error estimates derived from the public use CPS data perform poorly compared with the survey design-based estimates derived from restricted internal data, and that the generalized variance parameters currently used by the U.S. Census Bureau in its ASEC reports and funding formula inputs perform erratically. Because the majority of published research (both by academics and Census Bureau analysts) does not make use of the survey design-based information available only on the internal ASEC data file, we argue that the Census Bureau ought to use alternative methods for its official ASEC reports. We also argue that for public use data the Census Bureau should produce a set of replicate weights for the ASEC or release a set of sample design variables that incorporate statistical “noise” to maintain respondent confidentiality (e.g., pseudo-primary sampling units) as other federal government surveys do. This is essential to make appropriate inferences using the ASEC data regarding statistical significance and estimate variance for health policy analysis.

Changes to the Design of the National Health Interview Survey to Support Enhanced Monitoring of Health Reform Impacts at the State Level

Pursuant to passage of the Patient Protection and Affordable Care Act, the National Center for Health Statistics has enhanced the content of the National Health Interview Survey (NHIS)-the primary source of information for monitoring health and health care use of the US population at the national level-in several key areas and has positioned the NHIS as a source of population health information at the national and state levels. We review recent changes to the NHIS that support enhanced health reform monitoring, including new questions and response categories, sampling design changes to improve state-level analysis, and enhanced dissemination activities. We discuss the importance of the NHIS, the continued need for state-level analysis, and suggestions for future consideration.

Accountable care for the poor and underserved: Minnesota's Hennepin Health model

Hennepin Health provides integrated medical and social services to low-income Medicaid patients in a large county located in Minneapolis, Minnesota. Data sharing is critical to program operations along with care coordination provided by community health workers. Early evidence indicates fewer emergency department visits and increased use of outpatient primary care. By focusing on prevention, coordination, and team-based care, the county hopes to improve individuals' quality of life while reducing costs through better care management and reductions in emergency department use.

State-based Marketplaces using 'clearinghouse' plan management models are associated with lower premiums

The state-based and federally facilitated health insurance Marketplaces, or exchanges, enrolled more than eight million people during the first open enrollment period, which ended March 31, 2014. There is significant variation in how states have designed and implemented their Marketplaces. We examined how premiums varied with states' involvement in the Marketplaces through governance, plan management authority, and strategy during the first year that the exchanges have been open. State-based Marketplaces using "clearinghouse" plan management models had significantly lower adjusted average premiums for all plans within each metal level compared to state-based Marketplaces using "active purchaser" models and the federally facilitated and partnership Marketplaces. Clearinghouse management models are those in which all health plans that meet published criteria are accepted. Active purchaser models are those in which states negotiate premiums, provider networks, number of plans, and benefits. Our baseline estimates provide valuable benchmarks for evaluating future performance of states' involvement in governance, plan management, and regulatory authority of the insurance Marketplaces.

Aligning US health and immigration policy to reduce the incidence of tuberculosis

OBJECTIVES

Tuberculosis (TB) is a significant public health issue, claiming 1.4 million lives worldwide in 2011. Using data from the 2009-2010 National Health Interview Survey, we examine variation in 'having heard of TB' (HTB) by global region of birth and health insurance status.

METHODS

Cross-sectional analysis with bivariate comparisons and multivariate logistic regression to evaluate how adults differed in reported HTB, controlling for global region of birth.

RESULTS

HTB rates ranged from 63.4% of adults born in Asia to 88.6% born in Europe. Uninsured immigrants had the lowest rate of HTB, ranging from a low of 50.1% of uninsured adults born in Asia to 77.6% born in Europe and 90.8% of US-born uninsured adults. Longer length of time in the United States (>5 years) was significantly associated with increased likelihood of HTB, as did being of Asian race/ethnicity and being male. Those with private health insurance coverage had the highest rates of HTB.

CONCLUSIONS

To reduce persistent TB, public health program directors and policy makers must 1) recognize the variation in HTB by global region of birth and prioritize areas with the lowest HTB rates, and 2) reduce barriers to health insurance coverage by eliminating the 5-year ban for public program coverage for new immigrants.

Implementing federal health reform in the States: who is included and excluded and what are their characteristics?

OBJECTIVE

To estimate the characteristics and number of nonelderly adults eligible and ineligible for Affordable Care Act (ACA) expansions.

DATA SOURCES AND SETTINGS

Two secondary data sources are used in this analysis: the 2008 Panel of the Survey of Income and Program Participation (SIPP) and the 2009 American Community Survey (ACS).

STUDY DESIGN

We use multiple imputation to incorporate model-based uncertainty into the prediction of immigration status into the ACS from the SIPP. Key variables include place of birth, year of entry to the U.S., and health insurance coverage.

DATA COLLECTION/EXTRACTING METHODS

No primary data are used in this study.

PRINCIPLE FINDINGS

We estimate that potentially 3.5 million nonelderly adults will be excluded from the ACA Medicaid Expansion and 2 million from the health insurance exchanges because of their immigration status. We also find significant differences in estimates of excluded nonelderly adults across states.

CONCLUSIONS

Over 15 percent of income-eligible uninsured nonelderly adults will be potentially excluded from the ACA coverage expansions due to their immigration status. Policy makers must be careful to exclude ineligible nonelderly adults before estimating the impact of the ACA on coverage rates.

Access and cost barriers to mental health care, by insurance status, 1999-2010

The cost of mental health services has always been a great barrier to accessing care for people with mental health problems. This article documents changes in insurance coverage and cost for mental health services for people with public insurance, private insurance, and no coverage. In 2009-10 people with mental health problems were more likely to have public insurance and less likely to have private insurance than in 1999-2000. Although access to specialty care remained relatively stable for people with mental illnesses, cost barriers to care increased among the uninsured and the privately insured who had serious mental illnesses. The rise in cost barriers among those with private insurance suggests that the current financing of care in the private insurance market is insufficient to alleviate cost burdens and has implications for reforms under the Affordable Care Act. People with mental health problems who are newly eligible to purchase private insurance under the act might still encounter high cost barriers to accessing care.

Survey of high-risk pool enrollees suggests that targeted transition education and outreach should begin soon

Several provisions of the Affordable Care Act make state and federal high-risk pools unnecessary beginning in January 2014. As a result, thousands of enrollees in those pools will be transferred to Medicaid and the new state and federal insurance exchanges. Our study analyzed new survey data collected from enrollees in the country's oldest and largest state-based high-risk pool, the Minnesota Comprehensive Health Association. We estimate that approximately half of the enrollees in that pool will qualify for Medicaid or premium subsidies in the exchange. More than 60 percent of the enrollees reported being somewhat or very unfamiliar with health care reform and the resulting changes to their current coverage. Their concerns about the expected impact of health reform varied by income, geography, and level of deductible. Targeting education and outreach information to address these concerns will be critical for this population's smooth transition to new coverage.

Monitoring health reform efforts: which state-level data to use?

This study compares estimates of health insurance coverage from the American Community Survey (ACS) to those in twelve state-specific surveys. Uninsurance estimates for the nonelderly are consistently higher in the ACS than in state surveys, as are direct purchase insurance estimates. Estimates for employer-sponsored insurance are similar, but public coverage rates are lower in the ACS. The ACS meets some but not all of the states' data needs; its large sample size and inclusion of all U.S. counties in the sample allow for comparison of insurance coverage within and across states. State-specific surveys provide the flexibility to add policy-relevant questions, including questions needed to examine how health insurance translates into access, use, and affordability of health services.

National and state-specific health insurance disparities for adults in same-sex relationships

OBJECTIVES

We examined national and state-specific disparities in health insurance coverage, specifically employer-sponsored insurance (ESI) coverage, for adults in same-sex relationships.

METHODS

We used data from the American Community Survey to identify adults (aged 25-64 years) in same-sex relationships (n = 31,947), married opposite-sex relationships (n = 3,060,711), and unmarried opposite-sex relationships (n = 259,147). We estimated multinomial logistic regression models and state-specific relative differences in ESI coverage with predictive margins.

RESULTS

Men and women in same-sex relationships were less likely to have ESI than were their married counterparts in opposite-sex relationships. We found ESI disparities among adults in same-sex relationships in every region, but we found the largest ESI gaps for men in the South and for women in the Midwest. ESI disparities were narrower in states that had extended legal same-sex marriage, civil unions, and broad domestic partnerships.

CONCLUSIONS

Men and women in same-sex relationships experience disparities in health insurance coverage across the country, but residing in a state that recognizes legal same-sex marriage, civil unions, or broad domestic partnerships may improve access to ESI for same-sex spouses and domestic partners.

Disparities in health insurance among children with same-sex parents

OBJECTIVES

The objectives of this study were to examine disparities in health insurance coverage for children with same-sex parents and to investigate how statewide policies such as same-sex marriage and second-parent adoptions affect children's private insurance coverage.

METHODS

We used data from the 2008-2010 American Community Survey to identify children (aged 0-17 years) with same-sex parents (n = 5081), married opposite-sex parents (n = 1369789), and unmarried opposite-sex parents (n = 101678). We conducted multinomial logistic regression models to estimate the relationship between family type and type of health insurance coverage for all children and then stratified by each child's state policy environment.

RESULTS

Although 77.5% of children with married opposite-sex parents had private health insurance, only 63.3% of children with dual fathers and 67.5% with dual mothers were covered by private health plans. Children with same-sex parents had fewer odds of private insurance after controlling for demographic characteristics but not to the extent of children with unmarried opposite-sex parents. Differences in private insurance diminished for children with dual mothers after stratifying children in states with legal same-sex marriage or civil unions. Living in a state that allowed second-parent adoptions also predicted narrower disparities in private insurance coverage for children with dual fathers or dual mothers.

CONCLUSIONS

Disparities in private health insurance for children with same-sex parents diminish when they live in states that secure their legal relationship to both parents. This study provides supporting evidence in favor of recent policy statements by the American Academy of Pediatricians endorsing same-sex marriage and second-parent adoptions.

Use of the integrated health interview series: trends in medical provider utilization (1972-2008)

The Integrated Health Interview Series (IHIS) is a public data repository that harmonizes four decades of the National Health Interview Survey (NHIS). The NHIS is the premier source of information on the health of the U.S. population. Since 1957 the survey has collected information on health behaviors, health conditions, and health care access. The long running time series of the NHIS is a powerful tool for health research. However, efforts to fully utilize its time span are obstructed by difficult documentation, unstable variable and coding definitions, and non-ignorable sample re-designs. To overcome these hurdles the IHIS, a freely available and web-accessible resource, provides harmonized NHIS data from 1969-2010. This paper describes the challenges of working with the NHIS and how the IHIS reduces such burdens. To demonstrate one potential use of the IHIS we examine utilization patterns in the U.S. from 1972-2008.

Rescued by the safety net

The recent recession had a significant impact on the nation and Minnesota both in terms of the number of jobs lost and the loss of employer-sponsored health insurance (ESI). In this article, we present national and Minnesota-specific data on the loss of ESI. We also explore how government-sponsored programs provided a safety net that enabled many people with low incomes to retain health insurance coverage, lessening the recession's impact in Minnesota. We conclude with general comments about the role of the safety net in a health care system in which the majority of people have health care coverage through voluntary employer-based programs.

State high-risk pools: an update on the Minnesota Comprehensive Health Association

State health insurance high-risk pools are a key component of the US health care system's safety net, because they provide health insurance to the "uninsurable." In 2007, 34 states had individual high-risk pools, which covered more than 200 000 people at a total cost of $1.8 billion. We examine the experience of the largest and oldest pool in the nation, the Minnesota Comprehensive Health Association, to document key issues facing state high-risk pools in enrollment and financing. We also considered the role and future of high-risk pools in light of national health care finance reform.

Payment reform. The lynchpin of health care reform

The federal Patient Protection and Affordable Care Act that was signed into law last year includes provisions that will improve access to health care for everyone in the United States and extend insurance coverage to some 300 million people who currently do not have it. But insurance reforms and expansion of coverage are only part of the solution to the problems within our health care system.The way health care is paid for is another important element of reform.This article describes the steps we need to take to change the way we pay for health care and efforts that are underway both in the United States and Minnesota to test new payment models.

Counting uninsurance and means-tested coverage in the American community survey: a comparison to the current population survey

OBJECTIVE

To compare health insurance coverage estimates from the American Community Survey (ACS) to the Current Population Survey (CPS-ASEC).

DATA SOURCES/STUDY SETTING

The 2008 ACS and CPS-ASEC, 2009.

STUDY DESIGN

We compare age-specific national rates for all coverage types and state-level rates of uninsurance and means-tested coverage. We assess differences using t-tests and p-values, which are reported at <.05, <.01, and <.001. An F-test determines whether differences significantly varied by state.

PRINCIPAL FINDINGS

Despite substantial design differences, we find only modest differences in coverage estimates between the surveys. National direct purchase and state-level means-tested coverage levels for children show the largest differences.

CONCLUSIONS

We suggest that the ACS is well poised to become a useful tool to health services researchers and policy analysts, but that further study is needed to identify sources of error and to quantify its bias.

American Indian/Alaska Native uninsurance disparities: a comparison of 3 surveys

OBJECTIVES

We examined whether 3 nationally representative data sources produce consistent estimates of disparities and rates of uninsurance among the American Indian/Alaska Native (AIAN) population and to demonstrate how choice of data source impacts study conclusions.

METHODS

We estimated all-year and point-in-time uninsurance rates for AIANs and non-Hispanic Whites younger than 65 years using 3 surveys: Current Population Survey (CPS), National Health Interview Survey (NHIS), and Medical Expenditure Panel Survey (MEPS).

RESULTS

Sociodemographic differences across surveys suggest that national samples produce differing estimates of the AIAN population. AIAN all-year uninsurance rates varied across surveys (3%-23% for children and 18%-35% for adults). Measures of disparity also differed by survey. For all-year uninsurance, the unadjusted rate for AIAN children was 2.9 times higher than the rate for White children with the CPS, but there were no significant disparities with the NHIS or MEPS. Compared with White adults, AIAN adults had unadjusted rate ratios of 2.5 with the CPS and 2.2 with the NHIS or MEPS.

CONCLUSIONS

Different data sources produce substantially different estimates for the same population. Consequently, conclusions about health care disparities may be influenced by the data source used.

Immigrant children's access to health care: differences by global region of birth

We use data from the National Health Interview Survey (2000-2006) to examine the social determinants of health insurance coverage and access to care for immigrant children by 10 global regions of birth. We find dramatic differences in the social and economic characteristics of immigrant children by region of birth. Children from Mexico and Latin America fare worse than immigrant children born in the U.S. with significantly lower incomes and little or no education. These social determinants, along with U.S. public health policies regarding new immigrants, create significant barriers to access to health insurance coverage, and increase delayed or foregone care. Uninsured immigrant children had 6.5 times higher odds of delayed care compared with insured immigrant children.

Improving geriatric transitional care through inter-professional care teams

OBJECTIVES

The aim of this study was to examine the impact of the use of an inter-professional care team on patient length of stay and payer charges in a geriatric transitional care unit.

METHODS

An analysis of de-identified administrative records for transitional care patients for the 12-month period (2003-2004) cared for by the inter-professional team (n = 163) and cared for by traditional single provider care model (n = 176) was carried out. We conducted logistic regression on length of stay and charges controlling for patient demographics and acuity levels.

RESULTS

The inter-professional care team patients had significantly shorter lengths of stay, fewer patient days and lower total charges. Patient diagnosis and acuity were similar across groups.

CONCLUSION

This study provides empirical evidence of the impact of an inter-professional care model in providing cost-effective transitional care in a nursing home setting. Evidence of shorter lengths of stay, shorter patient days and lower charges suggests benefit in the development and financing of inter-professional care teams for transitional care services.

The importance of geographic data aggregation in assessing disparities in American Indian prenatal care

OBJECTIVES

We sought to determine whether aggregate national data for American Indians/Alaska Natives (AIANs) mask geographic variation and substantial subnational disparities in prenatal care utilization.

METHODS

We used data for US births from 1995 to 1997 and from 2000 to 2002 to examine prenatal care utilization among AIAN and non-Hispanic White mothers. The indicators we studied were late entry into prenatal care and inadequate utilization of prenatal care. We calculated rates and disparities for each indicator at the national, regional, and state levels, and we examined whether estimates for regions and states differed significantly from national estimates. We then estimated state-specific changes in prevalence rates and disparity rates over time.

RESULTS

Prenatal care utilization varied by region and state for AIANs and non-Hispanic Whites. In the 12 states with the largest AIAN birth populations, disparities varied dramatically. In addition, some states demonstrated substantial reductions in disparities over time, and other states showed significant increases in disparities.

CONCLUSIONS

Substantive conclusions about AIAN health care disparities should be geographically specific, and conclusions drawn at the national level may be unsuitable for policymaking and intervention at state and local levels. Efforts to accommodate the geographically specific data needs of AIAN health researchers and others interested in state-level comparisons are warranted.

Health care coverage and the health care industry

OBJECTIVES

We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category.

METHODS

We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype.

RESULTS

Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI]=2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI=3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR]=1.5; 95% CI=1.0, 2.4).

CONCLUSIONS

Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern.

Measuring adequacy of coverage for the privately insured: new state estimates to monitor trends in health insurance coverage

The privately insured are assuming a greater share of the costs of their health care, yet little is known about changes in out-of-pocket spending at the state level. The central problem is that national surveys with the relevant data are not designed to generate state-level estimates. The study addresses this shortcoming by using a two-sample modeling approach to estimate state-level measures of out-of-pocket spending relative to income for privately insured adults and children. National data from the Medical Expenditure Panel Survey-Household Component and state representative data from the Current Population Survey are used. Variation in out-of-pocket spending over time and across states is shown, highlighting concern about the adequacy of coverage for 2.9% of privately insured children and 7.8% of privately insured adults. Out-of-pocket spending relative to income is an important indicator of access to care and should be monitored at the state level.

Persistent disparities in health insurance coverage: Hispanic children, 1996 to 2005

OBJECTIVE

To identify how health insurance coverage trends changed for Hispanic children between 1996 and 2005.

METHODS

Data from the Current Population Survey Annual Social and Economic Supplement were analyzed to determine health insurance coverage rates for Hispanic children and logistic regression was used to determine the role of race/ethnicity on health insurance status, adjusting for citizenship status, child characteristics, migration status, and geography.

RESULTS

The proportion of uninsured Hispanic children decreased significantly. However, the increased likelihood of a Hispanic child being uninsured relative to non-Hispanic White children did not change during this period.

CONCLUSIONS

Expansions in public health insurance programs between 1996 and 2005 increased health insurance coverage for Hispanic children but disparities between Hispanic and non-Hispanic White children persist.

The American Community Survey and health insurance coverage estimates: possibilities and challenges for health policy researchers

OBJECTIVE

To introduce the American Community Survey (ACS) and its measure of health insurance coverage to researchers and policy makers.

DATA SOURCES/STUDY SETTING

We compare the survey designs for the ACS and Current Population Survey (CPS) that measure insurance coverage.

STUDY DESIGN

We describe the ACS and how it will be useful to health policy researchers.

PRINCIPAL FINDINGS

Relative to the CPS, the ACS will provide more precise state and substate estimates of health insurance coverage at a point-in-time. Yet the ACS lacks the historical data and detailed state-specific coverage categories seen in the CPS.

CONCLUSIONS

The ACS will be a critical new resource for researchers. To use the new data to the best advantage, careful research will be needed to understand its strengths and weaknesses.

Four decades of population health data: the integrated health interview series as an epidemiologic resource

The National Health Interview Survey (NHIS) is a primary source of information on the changing health of the US population over the past 4 decades. The full potential of NHIS data for analyzing long-term change, however, has rarely been exploited. Time series analysis is complicated by several factors: large numbers of data files and voluminous documentation; complexity of file structures; and changing sample designs, questionnaires, and variable-coding schemes. We describe a major data integration project that will simplify cross-temporal analysis of population health data available in the NHIS. The Integrated Health Interview Series (IHIS) is a Web-based system that provides an integrated set of data and documentation based on the NHIS public use files from 1969 to the present. The Integrated Health Interview Series enhances the value of NHIS data for researchers by allowing them to make consistent comparisons across 4 decades of dramatic changes in health status, health behavior, and healthcare.

Local access to care programs (LACPs): new developments in the access to care for the uninsured

CONTEXT

New, locally based health care access programs are emerging in response to the growing number of uninsured, providing an alternative to health insurance and traditional safety net providers. Although these programs have been largely overlooked in health services research and health policy, they are becoming an important local supplement to the historically overburdened safety net.

METHODS

This article is based on a literature review, Internet search, and key actor interviews to document programs in the United States, using a typology to classify the programs and document key characteristics.

FINDINGS

Local access to care programs (LACPs) fall outside traditional private and publicly subsidized insurance programs. They have a formal enrollment process, eligibility determination, and enrollment fees that give enrollees access to a network of providers that have agreed to offer free or reduced-price health care services. The forty-seven LACPs documented in this article were categorized into four general models: three-share programs, national-provider networks, county-based indigent care, and local provider-based programs.

CONCLUSIONS

New, locally based health access programs are being developed to meet the health care needs of the growing number of uninsured adults. These programs offer an alternative to traditional health insurance and build on the tradition of county-based care for the indigent. It is important that these locally based, alternative paths to health care services be documented and monitored, as the number of uninsured adults is continuing to grow and these programs are becoming a larger component of the U.S. health care safety net.

Access to health care and voting behavior in the United States

This study examines the relationship between difficulties accessing health care and voting behavior, in order to assess the possible impact that increasing constraints on access to care will have on future voting behavior. Using data from the American National Election Study we found that the proportion of people with difficulty accessing care increased significantly from 27% in 2000 to 35% in 2004. A larger proportion of those with difficulties in accessing care voted in 2004 than in 2000 and their preferences also changed to more heavily favor the Democratic candidate. If the number of those experiencing difficulties accessing care continues to grow, access to care could become a more salient campaign issue. In 2004, Democratic candidates were favored by this group, which is likely to be a constituency that both parties will try to capture in future elections.

When a usual source of care and usual provider matter: adult prevention and screening services

OBJECTIVE

To examine whether the usual source of preventive care, (having a usual place for care only or the combination of a usual place and provider compared with no usual source of preventive care) is associated with adults receiving recommended screening and prevention services.

DESIGN

Using cross-sectional survey data for 24,138 adults (ages 18-64) from the 1999 National Health Interview Survey (NHIS), we estimated adjusted odds ratios using separate logistic regression models for receipt of five preventive services: influenza vaccine, Pap smear, mammogram, clinical breast exam, and prostate specific antigen.

RESULTS

Having both a usual place and a usual provider was consistently associated with increased odds for receiving preventive care/screening services compared to having a place only or neither. Adults ages 50-64 with a usual place/provider had 2.8 times greater odds of receiving a past year flu shot compared with those who had neither. Men ages 50-64 with a usual place/provider had nearly 10 times higher odds of receiving a PSA test compared with men who had neither. Having a usual place/provider compared with having neither was associated with 3.9 times higher odds of clinical breast exam among women ages 20-64, 4.1 times higher odds of Pap testing among women ages 21-64, and 4.8 times higher odds of mammogram among women ages 40-64.

CONCLUSIONS

Having both a usual place and usual provider is a key variable in determining whether adults receive recommended screening and prevention services and should be considered a fundamental component of any medical home model for adults.