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Cheng TC, Lo CC. Factors Associated with Insured Children's Use of Physician Visits, Dentist Visits, Hospital Care, and Prescribed Medications in the United States: An Application of Behavioral Model of Health-Services Use. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:427. [PMID: 38673338 PMCID: PMC11050310 DOI: 10.3390/ijerph21040427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024]
Abstract
This study is the first to examine factors in the utilization of physician services, dentist services, hospital care, and prescribed medications focusing exclusively on insured children in the United States. Data describing 48,660 insured children were extracted from the 2021 National Survey of Children's Health. Children in the present sample were covered by private health insurance, public health insurance, or other health insurance. Logistic regression results showed self-reported health to be negatively associated with physician visits, hospital-care use, and prescription use, but teeth condition to be positively associated with dentist visits. Physician visits were associated negatively with age, Hispanic ethnicity, Asian ethnicity, family income at or below 200% of the federal poverty level, and other health insurance, but positively with parental education and metropolitan residency. Dentist visits were associated positively with girls, age, and parental education, but negatively with Asian ethnicity and public health insurance. Use of hospital care was associated negatively with age and Asian ethnicity, but positively with parental education and public health insurance. Use of prescriptions was associated positively with age, Black ethnicity, parental education, and public health insurance, but negatively with Hispanic ethnicity, Asian ethnicity, and family income at or below 200% of the federal poverty level. Implications included the expansion of public health insurance, promotion of awareness of medicine discount programs, and understanding of racial/ethnic minorities' cultural beliefs in health and treatment.
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Affiliation(s)
- Tyrone C. Cheng
- Little Hall, School of Social Work, University of Alabama, Tuscaloosa, AL 35401, USA
| | - Celia C. Lo
- Defense Personnel and Security Research Center, Peraton, Seaside, CA 93955, USA;
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Nguyen TH, De Leo G, Barefield A. Factors Associated with Controlled Glycemic Levels in Type 2 Diabetes Patients: Study from a Large Medical Center and Its Satellite Clinics in Southeast Region in the USA. Healthcare (Basel) 2023; 12:26. [PMID: 38200932 PMCID: PMC10779028 DOI: 10.3390/healthcare12010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Diabetes, including type 1, type 2, and gestational, is a significant public health issue responsible for various clinical, economic, and societal issues. Most of the consequences, if uncontrolled, can result in serious health problems, such as heart disease, vision loss, and kidney disease. Approximately 37.3 million Americans have diabetes, including 37.1 million adults 18 years or older, with 90-95% type 2 diabetes (T2D). The purpose of this study is (1) to explore the profile of patients with T2D and (2) to identify the associated factors of diabetic status. Examined factors included sociodemographic characteristics, social factors, and comorbidities. The study analyzed a primary dataset from a retrospective chart review of adult patients with T2D who were seen at a large medical center and its satellite clinics in the southeast region of the United States in 2019. Sex, dyslipidemia, and the number of concordant comorbidities were found to be significant associated factors of diabetic status. In the era of intertwined patient-centered approach and public health, the study's findings can guide treatment plans and interventions targeting individuals and communities.
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Affiliation(s)
- Tran Ha Nguyen
- Department of Health Management, Economics and Policy, Augusta University, Augusta, GA 30912, USA;
| | - Gianluca De Leo
- Department of Health Management, Economics and Policy, Augusta University, Augusta, GA 30912, USA;
| | - Amanda Barefield
- Department of Undergraduate Health Professions, Augusta University, Augusta, GA 30912, USA;
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Ramapriyan R, Ramesh T, Yu H, Richardson LG, Nahed BV, Carter BS, Barker FG, Curry WT, Choi BD. County-level disparities in care for patients with glioblastoma. Neurosurg Focus 2023; 55:E12. [PMID: 37913538 PMCID: PMC10624113 DOI: 10.3171/2023.8.focus23454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/25/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Racial and socioeconomic disparities in neuro-oncological care for patients with brain tumors remain underexplored. This study aimed to analyze county-level disparities in glioblastoma (GBM) care in the United States, focusing on access to surgery and the use of adjuvant temozolomide chemotherapy and radiation therapy. METHODS Using repeated cross-sectional data from the Surveillance, Epidemiology, and End Results 17 database; the Area Health Resources File; and the American Community Survey, from 2010 to 2019, the authors performed multivariate regression analyses to understand the associations between county-level racial and socioeconomic characteristics, as well as the rates of surgery performed, delays in surgery, and use of adjuvant chemotherapy and radiation therapy for newly diagnosed GBM. RESULTS In total, 29,609 GBM patients from 602 different US counties over a decade were included in this study. Counties with lower rates of surgery for GBM were associated with a higher percentage of Black residents (coefficient [CE] -0.001, 95% CI -0.002 to 0; p < 0.05) and being located in the Midwest (CE -0.132, 95% CI -0.195 to -0.069; p < 0.001) or West (CE -0.127, 95% CI -0.189 to -0.065; p < 0.001) relative to the Northeast. Counties with delayed surgical treatment were more likely to lack neurosurgeons (adjusted OR [aOR] 2.52, 95% CI 1.77-3.60; p < 0.001), have a higher percentage of Black residents (aOR 1.011, 95% CI 1.00-1.02; p < 0.05), and be located in the Midwest (aOR 3.042, 95% CI 1.12-8.24; p < 0.05) or West (aOR 3.175, 95% CI 1.12-8.97 p < 0.05). Counties with high rates of adjuvant radiation therapy were less likely to have higher percentages of Black residents (aOR 0.987, 95% CI 0.980-0.995; p < 0.01) and uninsured individuals (aOR 0.962, 95% CI 0.937-0.987; p < 0.01). CONCLUSIONS Counties without neurosurgeons and those with a higher percentage of Black patients have delays in surgical care and demonstrate lower overall rates of surgery and adjuvant therapy for GBM. This study underscores the need for targeted interventions and policies that address structural barriers in healthcare access, improve equitable distribution of the neurosurgery workforce, and ensure timely and comprehensive GBM care to all populations.
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Affiliation(s)
- Rishab Ramapriyan
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tarun Ramesh
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Hao Yu
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Leland G. Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Brian V. Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Bob S. Carter
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Fred G. Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - William T. Curry
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Bryan D. Choi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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Frimpong EY, Ferdousi W, Rowan GA, Chaudhry S, Swetnam H, Compton MT, Smith TE, Radigan M. Racial and Ethnic Disparities in Health Care Access and Utilization among Medicaid Managed Care Beneficiaries. J Behav Health Serv Res 2023; 50:194-213. [PMID: 35945481 DOI: 10.1007/s11414-022-09811-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/27/2022]
Abstract
This quasi-experimental study examined the impact of a statewide integrated special needs program Health and Recovery Plan (HARP) for individuals with serious mental illness and identified racial and ethnic disparities in access to Medicaid services. Generalized estimating equation negative binomial models were used to estimate changes in service use, difference-in-differences, and difference-in-difference-in-differences in the pre- to post-HARP periods. Implementation of the special needs plan contributed to reductions in racial/ethnic disparities in access and utilization. Notable among those enrolled in the special needs plan was the declining Black-White disparities in emergency room (ER) visits and inpatient stays, but the disparity in non-behavioral health clinic visits remains. Also, the decline of Hispanic-White disparities in ER, inpatient, and clinic use was more evident for HARP-enrolled patients. Health equity policies are needed in the delivery of care to linguistically and culturally disadvantaged Medicaid beneficiaries.
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Affiliation(s)
| | | | - Grace A Rowan
- New York State Office of Mental Health, New York, NY, USA
| | - Sahil Chaudhry
- New York State Office of Mental Health, New York, NY, USA
| | - Hannah Swetnam
- New York State Office of Mental Health, New York, NY, USA
| | - Michael T Compton
- Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA.,New York State Psychiatric Institute, New York, NY, USA
| | - Thomas E Smith
- New York State Office of Mental Health, New York, NY, USA.,Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
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Friedman AS, Thomas S, Suttiratana SC. Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019. Am J Public Health 2022; 112:1630-1639. [PMID: 36223588 PMCID: PMC9558180 DOI: 10.2105/ajph.2022.307027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).
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Affiliation(s)
- Abigail S Friedman
- Abigail S. Friedman and Sakinah C. Suttiratana are with the Yale School of Public Health, New Haven, CT. Sasha Thomas is with Yale College, New Haven
| | - Sasha Thomas
- Abigail S. Friedman and Sakinah C. Suttiratana are with the Yale School of Public Health, New Haven, CT. Sasha Thomas is with Yale College, New Haven
| | - Sakinah C Suttiratana
- Abigail S. Friedman and Sakinah C. Suttiratana are with the Yale School of Public Health, New Haven, CT. Sasha Thomas is with Yale College, New Haven
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Darney BG, Biel FM, Hoopes M, Rodriguez MI, Hatch B, Marino M, Templeton A, Oakley J, Schmidt T, Cottrell EK. Title X Improved Access To Most Effective And Moderately Effective Contraception In US Safety-Net Clinics, 2016-18. Health Aff (Millwood) 2022; 41:497-506. [PMID: 35377749 PMCID: PMC10033226 DOI: 10.1377/hlthaff.2021.01483] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Community health centers are a crucial source of health care for reproductive-age women. Some community health centers receive funding from the federal Title X program, which provides funding for family planning services for low-income women. We describe the provision of the most effective (intrauterine devices and implants) and moderately effective (short-acting hormonal methods) contraceptive methods in a large network of 384 community health center clinics across twenty states in 2016-18. Title X clinics provided more most and moderately effective contraception at all time points and for all age groups (adolescent, young adult, and adult). They provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X. This finding was especially notable for adolescents (58 percent more). Title X clinics play a key role in access to effective contraception across the US safety net. Strengthening the Title X program should continue to be a policy priority for public health for the Biden-Harris administration.
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Affiliation(s)
- Blair G Darney
- Blair G. Darney , Oregon Health & Science University, Portland, Oregon
| | | | | | | | - Brigit Hatch
- Brigit Hatch, Oregon Health & Science University
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Fortney S, Tassé MJ. Urbanicity, Health, and Access to Services for People With Intellectual Disability and Developmental Disabilities. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2021; 126:492-504. [PMID: 34700348 DOI: 10.1352/1944-7558-126.6.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/13/2021] [Indexed: 06/13/2023]
Abstract
Previous research suggests that residence in non-metropolitan areas is associated with lower access to preventive care and poorer health. However, this research has been largely restricted to the general population, despite data demonstrating disparities in health status and access to healthcare services for people with intellectual and developmental disabilities (IDD). The current study examined several hypotheses involving the effects of rurality on access to preventive healthcare and services and health status: (1) individuals in non-metropolitan areas will have lower preventive healthcare utilization, (2) individuals in non-metropolitan areas will have poorer health outcomes, and (3) individuals in non-metropolitan areas will have poorer access to services. The current study uses data from the National Core Indicators (NCI) Adult Consumer Survey 2015-2016: Final Report which included Rural-Urban Commuting Area (RUCA) Codes for the first time. Results of logistic regression suggest that, despite connection to disability services, the health status and access to preventive healthcare services of people with IDD generally follow patterns similar to those observed in the general population. Namely, people with IDD in non-metropolitan areas have decreased access to healthcare services, preventive healthcare utilization, and health status. Despite some exceptions, it appears effects of rurality are not completely mitigated by current state and federal efforts.
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Affiliation(s)
- Stoni Fortney
- Stoni Fortney and Marc J. Tassé, The Ohio State University
| | - Marc J Tassé
- Stoni Fortney and Marc J. Tassé, The Ohio State University
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Alang S, Pando C, McClain M, Batts H, Letcher A, Hager J, Person T, Shaw A, Blake K, Matthews-Alvarado K. Survey of the Health of Urban Residents: a Community-Driven Assessment of Conditions Salient to the Health of Historically Excluded Populations in the USA. J Racial Ethn Health Disparities 2021; 8:953-972. [PMID: 32839897 PMCID: PMC7444865 DOI: 10.1007/s40615-020-00852-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Data from the Survey of the Health of Urban Residents (SHUR) identified connections between police brutality and medical mistrust, generating significant media, policy, and research attention. Amidst intersecting crises of COVID-19, racism, and police brutality, this report describes survey development and data collection procedures for the SHUR. BASIC PROCEDURES We conducted focus groups with Black men, Latinxs, and immigrants in Allentown, Pennsylvania. Findings were used to develop and refine measures of conditions salient to the health of urban residents across the country. Quota sampling was employed; oversampling people of color and persons whose usual source of care was not a doctor's office. MAIN FINDINGS Non-Hispanic Whites made up just under two thirds of the sample (63.65%, n = 2793). Black/African American respondents accounted for 14.2% of the sample (n = 623), while 11.62% (n = 510) were Latinx. Only 43.46% of respondents reported a doctor's office as their usual source of care. Novel measures of population-specific stressors include a range of negative encounters with the police, frequency of these encounters, and respondents' assessments of whether the encounters were necessary. SHUR assessed the likelihood of calling the police if there is a problem, worries about incarceration, and cause-specific stressors such as race-related impression management. PRINCIPAL CONCLUSIONS SHUR (n = 4389) is a useful resource for researchers seeking to address the health implications of experiences not frequently measured by national health surveillance surveys. It includes respondents' zip codes, presenting the opportunity to connect these data with zip code-level health system, social and economic characteristics that shape health beyond individual factors.
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Affiliation(s)
- Sirry Alang
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA.
| | - Cynthia Pando
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Malcolm McClain
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- Greater Newark Conservancy, Newark, NJ, USA
| | - Hasshan Batts
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- Promise Neighborhoods of the Lehigh Valley, Allentown, PA, USA
| | - Abby Letcher
- Lehigh Valley Health Network, Allentown, PA, USA
- Neighborhood Health Centers of the Lehigh Valley, Allentown, PA, USA
| | - Janelle Hager
- Neighborhood Health Centers of the Lehigh Valley, Allentown, PA, USA
| | - Taylor Person
- Promise Neighborhoods of the Lehigh Valley, Allentown, PA, USA
| | - Adama Shaw
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
- Digestive Care, Inc., Bethlehem, PA, USA
| | - Kwamaine Blake
- Promise Neighborhoods of the Lehigh Valley, Allentown, PA, USA
| | - Kevelis Matthews-Alvarado
- Department of Sociology and Program in Health Medicine and Society, Lehigh University, 31 Williams Drive #280, Bethlehem, PA, USA
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Boniface ER, Rodriguez MI, Heintzman J, Knipper S, Jacobs R, Darney BG. Contraceptive provision in Oregon school-based health centers: Method type trends and the role of Title X. Contraception 2021; 104:206-210. [PMID: 33781759 DOI: 10.1016/j.contraception.2021.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/17/2021] [Accepted: 03/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We describe provision of contraception to adolescents at Oregon school-based health centers (SBHCs). We examine trends over time, by race/ethnicity, and by Title X clinic status and test whether these factors are associated with provision of long-acting reversible contraception (LARC; intrauterine devices/IUDs and implants). STUDY DESIGN We conducted a retrospective cohort study of 33 SBHCs participating in a shared electronic health record 2012-2016. We identified 20,339 contraception provision visits to 5,934 adolescent females ages 14-19 using diagnosis and procedure codes. We used logistic regression to evaluate the association of clinic Title X status, race/ethnicity, and year with receipt of LARC, controlling for individual-, clinic-, and residence-level factors. We calculated adjusted probabilities. RESULTS Provision of IUDs and implants increased at Oregon SBHCs between 2012 and 2016. IUD provision increased almost 5-fold, (from 0.9% to 4.4% of contraception provision visits), and implants increased approximately 6.5-fold (from 1.1% to 7.2%). More adolescent contraception provision visits occurred at Title X SBHCs, which had greater than twice the adjusted probability of providing LARCs than non-Title X SBHCs (4.4% versus 1.7%). After adjusting for adolescent-, clinic-, and residence-level covariates, non-white adolescents had lower probabilities of receiving LARC methods than white adolescents. CONCLUSIONS SBHCs play an important role in providing access to contraceptive services to adolescents in Oregon. Access to IUDs and implants is increasing over time in SBHCs, particularly those that participate in the Title X program. IMPLICATIONS Adolescents have expanding access to IUDs and implants in SBHCs over time in Oregon. Participation in the Title X program can help further increase access to effective contraception in SBHCs.
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Affiliation(s)
- Emily R Boniface
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States.
| | - Maria I Rodriguez
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Sarah Knipper
- Public Health Division, Oregon Health Authority, Portland, OR, United States
| | - Rebecca Jacobs
- Public Health Division, Oregon Health Authority, Portland, OR, United States
| | - Blair G Darney
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States; OHSU-Portland State University School of Public Health, Portland, OR, United States; Center for Population Health Research, National Institute of Public Health, Morelos, Mexico
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Goldstein EV. Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2021; 58:469580211022618. [PMID: 34088240 PMCID: PMC8182175 DOI: 10.1177/00469580211022618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/27/2021] [Accepted: 05/13/2021] [Indexed: 12/05/2022]
Abstract
The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) providing primary care in medically-underserved communities. However, beyond evidence of initial policy effects, little is understood in the scholarly literature about whether the ACA Medicaid expansion affected longer-lasting changes in CHC patient insurance mix. This study's objective was to examine whether the ACA Medicaid expansion was associated with lasting increases in the annual percentage of adult CHC patients covered by Medicaid and decreases in the annual percentage of uninsured adult CHC patients at expansion-state CHCs, compared to non-expansion-state CHCs. This observational study examined 5353 CHC-year observations from 2012 to 2018 using Uniform Data System data and other national data sources. Using a 2-way fixed-effects multivariable regression approach and marginal analysis, intermediate-term policy effects of the Medicaid expansion on annual CHC patient coverage outcomes were estimated. By 5-years post-expansion, the Medicaid expansion was associated with an overall average increase of 11.7 percentage points in the percentage of adult patients with Medicaid coverage at expansion-state CHCs, compared to non-expansion-state CHCs. Among expansion-state CHCs, 39.8% of adult patients were predicted to have Medicaid coverage 5-years post-expansion, compared to 19.0% of non-expansion-state adult CHC patients. A state's decision to expand Medicaid was similarly associated with decreases in the annual percentage of uninsured adult CHC patients. Primary care operations at CHCs critically depend on patient Medicaid revenue. These findings suggest the ACA Medicaid expansion may provide longer-term financial security for expansion-state CHCs, which maintain increases in Medicaid-covered adult patients even 5-years post-expansion. However, these financial securities may be jeopardized should the ACA be ruled unconstitutional in 2021, a year after CHCs experienced new uncertainties caused by COVID-19.
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Hatch B, Hoopes M, Darney BG, Marino M, Templeton AR, Schmidt T, Cottrell E. Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States. Womens Health Issues 2021; 31:9-16. [PMID: 33023807 PMCID: PMC9206529 DOI: 10.1016/j.whi.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 01/28/2023]
Abstract
Background: The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers. Methods: Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 non-expansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid. Results: Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51–2.60; and 1.98; 95% confidence interval, 0.91–3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: −4.21; 95% confidence interval, −6.98 to −1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states. Conclusions: Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.
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H A, Bb G, K F, M M, N H, A L, Je D. Role of health insurance and neighborhood-level social deprivation on hypertension control following the affordable care act health insurance opportunities. Soc Sci Med 2020; 265:113439. [PMID: 33168270 DOI: 10.1016/j.socscimed.2020.113439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To understand if neighborhood-level social deprivation moderates the association between gaining health insurance and improved hypertension control. METHODS We used electronic health record (EHR) data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical data research network from five states that expanded Medicaid eligibility (CA, OH, OR, WA, WI). We include patients with hypertension aged 19-64. Controlled hypertension was assessed for four groups pre-(1/1/2012-12/31/2013) to post-(1/1/2014-12/31/2017) Affordable Care Act (ACA) Medicaid expansion: (1) newly insured, (2) continuously insured, (3) discontinuously insured, and (4) continuously uninsured. We also used Social Deprivation Index score to derive predicted probability of controlled hypertension using logistic mixed effects. RESULTS N = 28,485 patients. All groups experienced improved hypertension control: the newly insured saw a greater increase than the other groups (8.6% vs. 0.9% for the continuously uninsured, 1.3% for the continuously and 3.0% for the discontinuously insured). The likelihood of hypertension control rose more for the newly insured (vs. the other insurance groups) for patients living in the most deprived neighborhoods (16% from pre- to post-ACA). CONCLUSIONS Gaining health insurance was related to hypertension control; individuals living in the most disadvantaged communities experienced the greatest benefit. POLICY IMPLICATIONS Ensuring health insurance access is important for cardiovascular health, especially among disadvantaged communities.
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Affiliation(s)
- Angier H
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States.
| | - Green Bb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98110, United States
| | - Fankhauser K
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
| | - Marino M
- Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
| | - Huguet N
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
| | - Larson A
- Research Department, OCHIN Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States
| | - DeVoe Je
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
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Bailey SR, Marino M, Ezekiel-Herrera D, Schmidt T, Angier H, Hoopes MJ, DeVoe JE, Heintzman J, Huguet N. Tobacco Cessation in Affordable Care Act Medicaid Expansion States Versus Non-expansion States. Nicotine Tob Res 2020; 22:1016-1022. [PMID: 31123754 DOI: 10.1093/ntr/ntz087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/21/2019] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Community health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states. METHODS Using electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ≥6 visits within the post-expansion period among patients in expansion versus non-expansion states. RESULTS Patients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28-1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44-1.62), and having ≥6 follow-up visits (aOR = 1.34, 95% CI: 1.28-1.41) compared to patients from non-expansion states. CONCLUSIONS Increased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population. IMPLICATIONS CHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,Division of Biostatistics, School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR
| | | | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Inc., Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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14
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Marino M, Angier H, Springer R, Valenzuela S, Hoopes M, O'Malley J, Suchocki A, Heintzman J, DeVoe J, Huguet N. The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers. Diabetes Care 2020; 43:2074-2081. [PMID: 32611609 PMCID: PMC7440906 DOI: 10.2337/dc19-1571] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 05/14/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; P < 0.001), DBP (DID -1.0 mmHg; P < 0.001), and LDL (DID -3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONS Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.
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Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR .,Biostatistics Group, Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Jean O'Malley
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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15
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Network Engagement in Action: Stakeholder Engagement Activities to Enhance Patient-centeredness of Research. Med Care 2020; 58 Suppl 6 Suppl 1:S66-S74. [PMID: 32412955 DOI: 10.1097/mlr.0000000000001264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stakeholders (ie, patients, policymakers, clinicians, advocacy groups, health system leaders, payers, and others) offer critical input at various stages in the research continuum, and their contributions are increasingly recognized as an important component of effective translational research. Natural experiments, in particular, may benefit from stakeholder feedback in addressing real-world issues and providing insight into future policy decisions, though best practices for the engagement of stakeholders in observational studies are limited in the literature. METHODS The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) network utilizes rigorous methods to evaluate natural experiments in health policy and program delivery with a focus on diabetes-related outcomes. Each of the 8 partnering institutions incorporates stakeholder engagement throughout multiple study phases to enhance the patient-centeredness of results. NEXT-D2 dedicates a committee to Engagement for resource sharing, enhancing engagement approaches, and advancing network-wide engagement activities. Key stakeholder engagement activities include Study Meetings, Proposal Development, Trainings & Educational Opportunities, Data Analysis, and Results Dissemination. Network-wide patient-centered resources and multimedia have also been developed through the broad expertise of each site's stakeholder group. CONCLUSIONS This collaboration has created a continuous feedback loop wherein site-level engagement approaches are informed via the network and network-level engagement efforts are shaped by individual sites. Emerging best practices include: incorporating stakeholders in multiple ways throughout the research, building on previous relationships with stakeholders, enhancing capacity through stakeholder and investigator training, involving stakeholders in refining outcome choices and understanding the meaning of variables, and recognizing the power of stakeholders in maximizing dissemination.
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16
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Dickins KA, Buchholz SW, Ingram D, Braun LT, Hamilton RJ, Earle M, Karnik NS. Supporting Primary Care Access and Use among Homeless Persons. SOCIAL WORK IN PUBLIC HEALTH 2020; 35:335-357. [PMID: 32865153 DOI: 10.1080/19371918.2020.1809589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.
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Affiliation(s)
- Kirsten A Dickins
- Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research , Boston, Massachusetts, USA
| | | | - Diana Ingram
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Lynne T Braun
- Rush University College of Nursing , Chicago, Illinois, USA
| | | | - Melinda Earle
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Niranjan S Karnik
- Rush Medical College Department of Psychiatry, Rush University College of Nursing , Chicago, Illinois, USA
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17
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Disparities in Biomarkers for Patients With Diabetes After the Affordable Care Act. Med Care 2020; 58 Suppl 6 Suppl 1:S31-S39. [PMID: 32412951 DOI: 10.1097/mlr.0000000000001257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial and ethnic minorities are disproportionately affected by diabetes and at greater risk of experiencing poor diabetes-related outcomes compared with non-Hispanic whites. The Affordable Care Act (ACA) was implemented to increase health insurance coverage and reduce health disparities. OBJECTIVE Assess changes in diabetes-associated biomarkers [hemoglobin A1c (HbA1c) and low-density lipoprotein] 24 months pre-ACA to 24 months post-ACA Medicaid expansion by race/ethnicity and insurance group. RESEARCH DESIGN Retrospective cohort study of community health center (CHC) patients. SUBJECTS Patients aged 19-64 with diabetes living in 1 of 10 Medicaid expansion states with ≥1 CHC visit and ≥1 HbA1c measurement in both the pre-ACA and the post-ACA time periods (N=13,342). METHODS Linear mixed effects and Cox regression modeled outcome measures. RESULTS Overall, 33.5% of patients were non-Hispanic white, 51.2% Hispanic, and 15.3% non-Hispanic black. Newly insured Hispanics and non-Hispanic whites post-ACA exhibited modest reductions in HbA1c levels, similar benefit was not observed among non-Hispanic black patients. The largest reduction was among newly insured Hispanics versus newly insured non-Hispanic whites (P<0.05). For the subset of patients who had uncontrolled HbA1c (HbA1c≥9%) within 3 months of the ACA Medicaid expansion, non-Hispanic black patients who were newly insured gained the highest rate of controlled HbA1c (hazard ratio=2.27; 95% confidence interval, 1.10-4.66) relative to the continuously insured group. CONCLUSIONS The impact of the ACA Medicaid expansion on health disparities is multifaceted and may differ across racial/ethnic groups. This study highlights the importance of CHCs for the health of minority populations.
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18
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Darney BG, Biel FM, Rodriguez MI, Jacob RL, Cottrell EK, DeVoe JE. Payment for Contraceptive Services in Safety Net Clinics: Roles of Affordable Care Act, Title X, and State Programs. Med Care 2020; 58:453-460. [PMID: 32049877 PMCID: PMC7148195 DOI: 10.1097/mlr.0000000000001309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs. METHODS Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities. RESULTS We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states. CONCLUSIONS Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.
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Affiliation(s)
- Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
- National Institute of Public Health, Population Research Center (INSP/CISP), Cuernavaca, Morelos, Mexico
- OHSU-PSU School of Public Health
| | - Frances M Biel
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | | | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, OR
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19
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Angier HE, Marino M, Springer RJ, Schmidt TD, Huguet N, DeVoe JE. The Affordable Care Act improved health insurance coverage and cardiovascular-related screening rates for cancer survivors seen in community health centers. Cancer 2020; 126:3303-3311. [PMID: 32294251 PMCID: PMC7340351 DOI: 10.1002/cncr.32900] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023]
Abstract
Background This study assessed the impact of Affordable Care Act (ACA) Medicaid expansion on health insurance rates and receipt of cardiovascular‐related preventive screenings (body mass index, glycated hemoglobin [HbA1c], low‐density lipoproteins, and blood pressure) for cancer survivors seen in community health centers (CHCs). Methods This study identified cancer survivors aged 19 to 64 years with at least 3 CHC visits in 13 states from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). Via inverse probability of treatment weighting multilevel multinomial modeling, insurance rates before and after the ACA were estimated by whether a patient lived in a state that expanded Medicaid, and changes between a pre‐ACA time period and 2 post‐ACA time periods were assessed. Results The weighted estimated sample size included 409 cancer survivors in nonexpansion states and 2650 in expansion states. In expansion states, the proportion of uninsured cancer survivors decreased significantly from 20.3% in 2012‐2013 to 4.5%in 2016‐2017, and the proportion of those with Medicaid coverage increased significantly from 38.8% to 55.6%. In nonexpansion states, there was a small decrease in uninsurance rates (from 33.6% in 2012‐2013 to 22.5% in 2016‐2017). Cardiovascular‐related preventive screening rates increased over time in both expansion and nonexpansion states: HbA1c rates nearly doubled from the pre‐ACA period (2012‐2013) to the post‐ACA period (2016‐2017) in expansion states (from 7.2% to 12.8%) and nonexpansion states (from 9.3% to 16.8%). Conclusions This study found a substantial decline in uninsured visits among cancer survivors in Medicaid expansion states. Yet, 1 in 5 cancer survivors living in a state that did not expand Medicaid remained uninsured. Several ACA provisions likely worked together to increase cardiovascular‐related preventive screening rates for cancer survivors seen in CHCs. The Affordable Care Act (ACA) provides coverage options for cancer survivors seen in community health centers, especially in states that have expanded Medicaid; unfortunately, 1 in 5 cancer survivors living in a state that has not expanded Medicaid coverage eligibility remains uninsured. The ACA Medicaid expansion provision change, likely in tandem with other ACA changes, has also contributed to modest improvements in rates of cardiovascular‐related screenings for cancer survivors.
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Affiliation(s)
- Heather E Angier
- Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rachel J Springer
- Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Nathalie Huguet
- Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jennifer E DeVoe
- Family Medicine, Oregon Health & Science University, Portland, Oregon
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20
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Tilhou AS, Huguet N, DeVoe J, Angier H. The Affordable Care Act Medicaid Expansion Positively Impacted Community Health Centers and Their Patients. J Gen Intern Med 2020; 35:1292-1295. [PMID: 31898120 PMCID: PMC7174462 DOI: 10.1007/s11606-019-05571-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
Community health centers (CHCs) provide primary care for underserved children and adults. The Patient Protection and Affordable Care Act (ACA) aimed to strengthen the CHC network by increasing federal funds and expanding Medicaid eligibility. The ACA also aimed to boost preventive and mental health services and to reduce health and healthcare disparities. Here, we summarize our results to-date as experts in investigating the impact of ACA Medicaid expansion on CHCs and the patients they serve. We found the ACA Medicaid expansion increased access to care and preventive services, primarily in Medicaid expansion states. Rates of physical and mental health conditions rose substantially from pre- to post-ACA in expansion states, suggesting underdiagnosis pre-ACA. Disparities in health insurance coverage by race/ethnicity decreased at CHCs, yet some remain. These findings indicate that the ACA Medicaid expansion significantly helped CHCs and patients. Insurance expansion buoyed CHCs' financial viability by increasing reimbursement. Therefore, the ACA Medicaid expansion enhanced the health of underserved patients and repeal would jeopardize these advances for CHCs and their patients.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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21
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Lindner SR, Marino M, O'Malley J, Angier H, Bailey SR, Hoopes M, Springer R, McConnell KJ, DeVoe J, Huguet N. Health Care Expenditures Among Adults With Diabetes After Oregon's Medicaid Expansion. Diabetes Care 2020; 43:572-579. [PMID: 31857442 PMCID: PMC7035584 DOI: 10.2337/dc19-1343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/27/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare trends in Medicaid expenditures among adults with diabetes who were newly eligible due to the Affordable Care Act (ACA) Medicaid expansion to trends among those previously eligible. RESEARCH DESIGN AND METHODS Using Oregon Medicaid administrative data from 1 January 2014 to 30 September 2016, a retrospective cohort study was conducted with propensity score-matched Medicaid eligibility groups (newly and previously eligible). Outcome measures included total per-member per-month (PMPM) Medicaid expenditures and PMPM expenditures in the following 12 categories: inpatient visits, emergency department visits, primary care physician visits, specialist visits, prescription drugs, transportation services, tests, imaging and echography, procedures, durable medical equipment, evaluation and management, and other or unknown services. RESULTS Total PMPM Medicaid expenditures for newly eligible enrollees with diabetes were initially considerably lower compared with PMPM expenditures for matched previously eligible enrollees during the first postexpansion quarter (mean values $561 vs. $793 PMPM, P = 0.018). Within the first three postexpansion quarters, PMPM expenditures of the newly eligible increased to a similar but slightly lower level. Afterward, PMPM expenditures of both groups continued to increase steadily. Most of the overall PMPM expenditure increase among the newly eligible was due to rapidly increasing prescription drug expenditures. CONCLUSIONS Newly eligible Medicaid enrollees with diabetes had slightly lower PMPM expenditures than previously eligible Medicaid enrollees. The increase in PMPM prescription drug expenditures suggests greater access to treatment over time.
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Affiliation(s)
- Stephan R Lindner
- Center for Health Systems Effectiveness and Department of Emergency Medicine, Oregon Health & Science University, Portland, OR .,OHSU-PSU School of Public Health, Portland, OR
| | - Miguel Marino
- OHSU-PSU School of Public Health, Portland, OR.,Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - K John McConnell
- Center for Health Systems Effectiveness and Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,OHSU-PSU School of Public Health, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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22
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Ogle SB, Inge TH, Campbell EG. Comment on: Beyond insurance: race-based disparities in the use of metabolic and bariatric surgery for the management of severe pediatric obesity. Surg Obes Relat Dis 2020; 16:419-421. [PMID: 32007434 DOI: 10.1016/j.soard.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sarah B Ogle
- University of Colorado, Denver, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Thomas H Inge
- University of Colorado, Denver, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Eric G Campbell
- University of Colorado, Denver, Colorado; Center for Bioethics and Humanities, University of Colorado, Denver, Colorado
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Angier H, Ezekiel-Herrera D, Marino M, Hoopes M, Jacobs EA, DeVoe JE, Huguet N. Racial/Ethnic Disparities in Health Insurance and Differences in Visit Type for a Population of Patients with Diabetes after Medicaid Expansion. J Health Care Poor Underserved 2019; 30:116-130. [PMID: 30827973 DOI: 10.1353/hpu.2019.0011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This quasi-experimental study evaluated racial/ethnic disparities in health insurance and differences in visits post-versus pre-Affordable Care Act (ACA) Medicaid expansion. We utilized electronic health record data from a population of patients with diabetes aged 19-64 seen in community health centers (CHCs). We used generalized estimating equation Poisson models to estimate incidence rates of insurance type and visits post-(1/1/2014-12/31/2015) versus pre-(1/1/13-12/31/13) ACA, stratified by racial/ethnic group. We assessed difference-in-differences (DD) and difference-in-difference-in-differences (DDD). The relative disparity in uninsured visits increased between Hispanic and non-Hispanic Whites in expansion states (DD=1.93; 95% CI=1.41, 2.64); the magnitude was greater in expansion compared with non-expansion states (DDD=1.84, 95% CI=1.32, 2.56), yet uninsured rates were lower in expansion compared with non-expansion states. We found few changes in visits. Results suggest that the ACA Medicaid expansion increased health insurance coverage and that while some racial/ethnic disparities were improved, some remained.
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24
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Huguet N, Angier H, Hoopes MJ, Marino M, Heintzman J, Schmidt T, DeVoe JE. Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act. J Am Board Fam Med 2019; 32:883-889. [PMID: 31704757 PMCID: PMC7001872 DOI: 10.3122/jabfm.2019.06.190087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/03/2019] [Accepted: 06/21/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To assess the prevalence of pre-existing conditions for community health center (CHC) patients who gained insurance coverage post-Affordable Care Act (ACA). METHODS We analyzed electronic health record data from 78,059 patients aged 19 to 64 uninsured at their last visit pre-ACA from 386 CHCs in 19 states. We compared the prevalence and types of pre-existing conditions pre-ACA (2012 to 2013) and post-ACA (2014 to 2015), by insurance status and race/ethnicity. RESULTS Pre-ACA, >50% of patients in the cohort had ≥1 Pre-existing condition. Post-ACA, >70% of those who gained insurance coverage had ≥1 condition. Post-ACA, all racial/ethnic subgroups showed an increase in the number of pre-existing conditions, with non-Hispanic Black and Hispanic patients experiencing the largest increases (adjusted prevalence difference, 18.9; 95% CI, 18.2 to 19.6 and 18.3; 95% CI, 17.8 to 18.7, respectively). The most common conditions post-ACA were mental health disorders with the highest prevalence among patients who gained Medicaid (45.6%) and lowest among those who gained private coverage (30.5%). CONCLUSIONS This study emphasizes the high prevalence of pre-existing conditions among CHC patients and the large increase in the proportion of patients with at least 1 of these diagnoses post-ACA. Given how common these conditions are, repealing pre-existing condition protections could be extremely harmful to millions of patients and would likely exacerbate health care and health disparities.
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Affiliation(s)
- Nathalie Huguet
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM).
| | - Heather Angier
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Megan J Hoopes
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Miguel Marino
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - John Heintzman
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Teresa Schmidt
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Jennifer E DeVoe
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
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Jin H, Marshall BD, Raifman J, Montgomery M, Maynard MA, Chan PA. Changes in Patient Visits After the Implementation of Insurance Billing at a Sexually Transmitted Diseases Clinic in a Medicaid Expansion State. Sex Transm Dis 2019; 46:502-506. [PMID: 31295216 PMCID: PMC6636341 DOI: 10.1097/olq.0000000000001014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Medicaid expansion has led to unique opportunities for sexually transmitted disease (STD) clinics to improve the sustainability of services by billing insurance. We evaluated changes in patient visits after the implementation of insurance billing at a STD clinic in a Medicaid expansion state. METHODS The Rhode Island STD Clinic offered HIV/STD screening services at no cost to patients until October 2016, when insurance billing was implemented. Care for uninsured patients was still provided for free. We compared the clinic visits in the preinsurance period with the postinsurance period using t-tests, Poisson regressions, and a logistic regression. RESULTS A total of 5560 patients were seen during the preinsurance (n = 2555) and postinsurance (n = 3005) periods. Compared with the preinsurance period, the postinsurance period had a significantly higher average number of patient visits/month (212.9 vs. 250.4, P = 0.0016), including among patients who were black (36.8 vs. 50.3, P = 0.0029), Hispanic/Latino (50.8 vs. 65.8, P = 0.0018), and insured (106.3 vs. 130.1, P = 0.0025). The growth rate of uninsured (+0.10 vs. +4.11, P = 0.0026) and new patients (-4.28 vs. +1.07, P = 0.0007) also increased between the two periods. New patients whose first visit was before the billing change had greater odds (adjusted odds ratio, 2.68, 95% confidence interval, 2.09-3.44; P < 0.0001) of returning compared with new patients whose first visit was after the billing change. CONCLUSIONS Implementation of insurance billing at a publicly funded STD clinic, with free services provided to uninsured individuals, was associated with a modest increase in patient visits and a decline in patients returning for second visits.
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Affiliation(s)
- Harry Jin
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Brandon D.L. Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Julia Raifman
- Boston University School of Public Health, Boston, MA
| | - Madeline Montgomery
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
| | | | - Philip A. Chan
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
- Department of Medicine, Brown University, Providence, RI
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Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion. Prev Med 2019; 124:91-97. [PMID: 31077723 PMCID: PMC6578572 DOI: 10.1016/j.ypmed.2019.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.
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Cheng TC, Lo CC. What the Group Threat Hypothesis Notes About States' Medicaid Spending. J Racial Ethn Health Disparities 2019; 6:1062-1067. [PMID: 31228098 DOI: 10.1007/s40615-019-00608-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/24/2019] [Accepted: 06/07/2019] [Indexed: 11/29/2022]
Abstract
This secondary data analysis examined the relationship between state Medicaid spending in 2000-2014 and the perspective of the group threat hypothesis. The hypothesis posits that as any racial minority group grows in size, the increase is perceived by the racial majority group to threaten its dominant status. The employed data described states' Medicaid spending, racial makeup, and poverty and unemployment rates and came from reports compiled by several federal agencies. It was processed first in 2 discrete date-based groups. Results with 2000-2009 data showed states' per capita Medicaid spending to be associated negatively with their racial makeup. Specifically, states with proportionally larger Hispanic populations appeared to spend less on Medicaid versus states with fewer Hispanic residents, as did states with proportionally larger other non-African American minority populations (versus states with fewer such residents). Our findings with 2010-2014 data indicated no association between Hispanic population and states' per capita Medicaid spending. Combining data from both periods, we observed no significant association between state Medicaid spending and each of the following: proportion of African Americans in state population, poverty rate, and unemployment rate. In general, state Medicaid spending increased gradually throughout the years studied. Policy implications are discussed.
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Affiliation(s)
- Tyrone C Cheng
- Department of Social Work and Human Services, Kennesaw State University, Prillaman Hall, Kennesaw, GA, 30144, USA.
| | - Celia C Lo
- Department of Sociology and Social Work, Texas Woman's University, P. O. Box 425887, CFO 306, Denton, TX, 76204, USA
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Saloner B, Wilk AS, Levin J. Community Health Centers and Access to Care Among Underserved Populations: A Synthesis Review. Med Care Res Rev 2019; 77:3-18. [DOI: 10.1177/1077558719848283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community health centers (CHCs) deliver affordable health services to underserved populations, especially uninsured and Medicaid enrollees. Since the early 2000s, CHCs have grown because of federal investments in CHC capacity and expansions of Medicaid eligibility. We review 24 relevant studies from 2000 to 2017 to evaluate the relationship between CHCs, policies that invest in services for low-income individuals, and access to care. Most included studies use quasi-experimental designs. Greater spending on CHCs improves access to care, especially for low-income and minority individuals. Medicaid expansions also increase CHC use. Some studies indicate that CHC investments complement Medicaid expansions to increase access cost-effectively. Further research should explore patient preferences and patterns of CHC utilization versus other sites of care and population subgroups for which expanding CHC capacity improves access to care most. Researchers should endeavor to use measures and sample definitions that facilitate comparisons with other estimates in the literature.
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Affiliation(s)
- Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adam S. Wilk
- Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Jonathan Levin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kino S, Kawachi I. The impact of ACA Medicaid expansion on socioeconomic inequality in health care services utilization. PLoS One 2018; 13:e0209935. [PMID: 30596763 PMCID: PMC6312270 DOI: 10.1371/journal.pone.0209935] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/13/2018] [Indexed: 11/18/2022] Open
Abstract
Objective We examined whether the Affordable Care Act (ACA) Medicaid expansion reduced socioeconomic inequalities in health care utilization. Methods We used data from the Behavioral Risk Factor Surveillance System, covering the 50 U.S. states and the District of Columbia, between 2011 and 2016. We selected outcome indicators, viz. ability to afford needed health care, having a personal doctor, use of health services in the past year (routine check-up, flu shot and dental visits), and attending screenings for breast, cervical, and colon cancers. Socioeconomic status was measured by household income. We calculated two indices of inequality by household income for each outcome: Slope Index of Inequality (SII) and Relative Index of Inequality (RII). We estimated difference-in-differences models to examine the impact of ACA Medicaid expansion on socioeconomic inequality in use of health care services. Results The ACA Medicaid expansion appeared to reduce the socioeconomic gap in individuals reporting financial ability in accessing health care (difference-in-differences estimators, -0.045 for SII and RII), having a personal doctor (-0.037 for SII and RII), and receiving routine check-ups (-0.027 for SII and -0.039 for RII). However, the expansion was not associated with reduction in the socioeconomic gap for preventive health care visits or dental care. Conclusions The ACA Medicaid expansion had mixed effects on socioeconomic disparities in health care utilization. Medicaid expansion may not be sufficient to address socioeconomic disparities in preventive services uptake.
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Affiliation(s)
- Shiho Kino
- Department of Social Behavioral Sciences, Harvard. T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Ichiro Kawachi
- Department of Social Behavioral Sciences, Harvard. T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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30
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Impact of a Direct Bedding Initiative on Left Without Being Seen Rates. J Emerg Med 2018; 55:850-860. [DOI: 10.1016/j.jemermed.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/25/2018] [Accepted: 09/01/2018] [Indexed: 12/19/2022]
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Huguet N, Springer R, Marino M, Angier H, Hoopes M, Holderness H, DeVoe JE. The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers. J Am Board Fam Med 2018; 31:905-916. [PMID: 30413546 PMCID: PMC6329010 DOI: 10.3122/jabfm.2018.06.180075] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/25/2018] [Accepted: 07/30/2018] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion. METHODS Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes. RESULTS Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97-2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80-2.19) in expansion states. CONCLUSION The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.
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Affiliation(s)
- Nathalie Huguet
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
| | - Rachel Springer
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH)
| | - Miguel Marino
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH)
| | - Heather Angier
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH)
| | - Megan Hoopes
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH)
| | - Heather Holderness
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH)
| | - Jennifer E DeVoe
- From Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University - Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH)
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32
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Advocacy for Health Care Policy in Case Management: An Ethical Mandate. Prof Case Manag 2018; 23:282-287. [DOI: 10.1097/ncm.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yue D, Rasmussen PW, Ponce NA. Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access. Health Serv Res 2018; 53:3640-3656. [PMID: 29468669 DOI: 10.1111/1475-6773.12834] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess racial/ethnic differential impacts of the ACA's Medicaid expansion on low-income, nonelderly adults' access to primary care. DATA SOURCES Behavioral Risk Factor Surveillance System, State Physicians Workforce Data Book, and Bureau of Labor Statistics, in 2013 and 2015. STUDY DESIGN Quasi-experimental design with difference-in-differences analyses. Outcomes included health insurance coverage, having personal doctor(s), being unable to see doctors because of cost, and receiving a flu shot. We tested racial/ethnic differential impacts using the "Seemingly unrelated estimation" method. Multiple imputations and survey weights were used. DATA COLLECTION/EXTRACTION METHODS Low-income, nonelderly adults were identified based on age, household income, and family size. PRINCIPAL FINDINGS Among the low-income, nonelderly adults, Medicaid expansion was associated with statistically significant gains in health insurance coverage, having personal doctors, and affordability. Hispanics got the fewest benefits, which significantly widened racial/ethnic disparities for the Hispanic group. Racial/ethnic disparity in having personal doctors narrowed for non-Hispanic black and non-Hispanic others, although not statistically significant. CONCLUSION Medicaid expansion improved access to primary care, but it had differential effects among racial/ethnic groups resulting in mixed effects on disparities. Further research is necessary to develop tailored policy tools for racial/ethnic groups.
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Affiliation(s)
- Dahai Yue
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, Los Angles, CA
| | - Petra W Rasmussen
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, Los Angles, CA
| | - Ninez A Ponce
- Department of Health Policy and Management, UCLA Center for Health Policy Research, UCLA Fielding School of Public Health, Los Angles, CA
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