Medicaid And SNAP Advance Equity But Sometimes Have Hidden Racial And Ethnic Barriers.

Medicaid and the Supplemental Nutrition Assistance Program were developed during the Civil Rights era to help poor people and reduce racial and ethnic differences in health care access and food security. Although the two programs have succeeded in narrowing health and nutrition disparities, certain policies hinder goals of racial and ethnic equity, even though they do not explicitly mention race or ethnicity. These policies, including administrative policies (such as work requirements) and more basic decisions about whether to cover immigrants or expand Medicaid, can create barriers that promote racial and ethnic disparities, contrary to the programs' underlying goals.

The Association of Racial and Ethnic Concordance in Primary Care with Patient Satisfaction and Experience of Care.

BACKGROUND: The lack of racial and ethnic concordance between patients and their physicians may contribute to American health disparities. OBJECTIVE: To examine the level of racial and ethnic concordance for patients and primary care clinicians and its association with measures of patient experience. DESIGN: Multivariate cross-sectional analysis of nationally representative data. PARTICIPANTS: Adults 18 to 64 in the 2019 Medical Expenditure Panel Survey who had at least one medical visit in the past year. MAIN MEASURES: Key independent variables include having a racially/ethnically concordant primary care clinician, lacking a usual source of care, and having a usual source that is a place rather than a person. Outcomes include overall satisfaction with health care, number of medical visits, having enough time in care, ease of understanding the clinician, and receiving respect. KEY RESULTS: The comparison between the actual level of concordance with an expected distribution if all patients had the same probability of having a clinician of a given race or type indicates that Black, Latino, and Asian patients are three or more times as likely to have a concordant clinician than expected, suggesting a strong preference for clinicians of the same race or ethnicity. Racial or ethnic concordance has a modest positive association with overall health care satisfaction and respect but is not significantly associated with the number of medical visits or other outcomes. Poor health status, being uninsured, and lacking a usual source of care are more strongly associated with patient experience. DISCUSSION: Efforts to increase the diversity of the primary care workforce could increase racial/ethnic concordance but may have only modest effects on patients' experience of care. Policies like lowering the number of uninsured or increasing those with a usual source of care may be more salient in improving experience of care.

Still no differences in the length or scope of primary and ambulatory care for Medicaid and commercial patients.

Many seek to improve the quality of primary care in the United States, particularly for Medicaid patients. This paper revisits the question of whether Medicaid patients receive less primary care, such as the length or scope of services per visit, than commercial patients. Analyses of 2016-2019 National Ambulatory Medical Care Survey data, the most recent available, find there were no significant differences in the average length of ambulatory care visits, or of primary care visits in particular, between Medicaid and commercial care, nor differences in the scope, based on the number of diagnostic and treatment services, health education topics covered, or the number of medications prescribed in the visit. Only small differences were found for uninsured patients. The duration and scope of ambulatory and primary care visits were primarily related to the characteristics of patients, visits, and the physicians' practices. To improve primary and ambulatory care for disadvantaged patients, it may be more important to focus on increasing access to care by reducing insurance and cost-related barriers and on broad-based efforts to improve quality.

Duration and Continuity of Medicaid Enrollment Before the COVID-19 Pandemic.

Importance: COVID-19 relief legislation created a temporary moratorium on Medicaid disenrollment, but when the public health emergency ends, states will begin to "unwind" Medicaid enrollment. Prepandemic data shed light on factors that can affect Medicaid coverage stability. Objective: To assess factors associated with the duration and continuity of Medicaid enrollment. Design, Setting, and Participants: In this cross-sectional analyses of a Medicaid data set for 2016 that was released by the Agency for Healthcare Research and Quality in June of 2022, we analyze a nationally representative data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016. We focus on 22 million nondisabled, nonelderly adults for this analysis. The data were analyzed between July and September of 2022. Main Outcomes and Measures: The main outcomes were the average months of Medicaid enrollment in 2016 and the probability of churning, defined as a break in coverage between 2 periods of enrollment during the calendar year. We compared these outcomes by eligibility category, state, demographic characteristics, and key Medicaid policies, including whether the state expanded Medicaid and whether it used ex parte reviews (automated reviews of other administrative data to reduce renewal paperwork burdens). Results: In this cross-sectional analysis, we analyze a nationally representative Medicaid data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016, released by the Agency for Healthcare Research and Quality in June of 2022. The analysis focused on nonelderly, nondisabled adults (aged 18-64 years) with a weighted population size of 22.7 million, of which 18.4% were Black, 19.2% were Latino, 39.5% were White, 7.3% were other/Asian/Native American, and 15.5% had unknown race. Multivariable regression analysis indicated that those living in states that expanded Medicaid but did not use ex parte reviews had longer average duration (0.31 months longer; 95% CI, 0.03-0.59) and lower risk of churning(odds ratio [OR], .40; 95% CI, 0.39-0.40), whereas those living in nonexpansion states that used ex parte reviews had lower odds of churning (OR, .68; 95% CI, 0.66-0.70) but also had shorter average duration (3.1 months shorter; 95% CI, -3.4 to -2.8). Those living in expansion states that used ex parte reviews also had reduced churning (OR, .83; 95% CI, 0.82-0.85). The average duration varied widely by state, even after adjustments for demographic and state policy factors. Conclusions and Relevance: If state Medicaid programs revert to prepandemic policies after the temporary moratorium ends, Medicaid coverage, particularly for nondisabled, nonelderly adults, is likely to become less stable again. Medicaid expansions are associated with improved continuity, but ex parte review may have a more complex role.

Continuous Eligibility for Medicaid Associated With Improved Child Health Outcomes.

Fluctuating insurance coverage, or churning, is a recognized barrier to health care access. We assessed whether state policies that allow children to remain covered in Medicaid for a 12-month period, regardless of fluctuations in income, are associated with health and health care outcomes, after controlling for individual factors and other Medicaid policies. This cross-sectional study uses a large, nationally representative database of children ages 0 to 17. Continuous eligibility was associated with improved rates of insurance, reductions in gaps in insurance and gaps due to application problems, and lower probability of being in fair or poor health. For children with special health care needs, it was associated with increases in use of medical care and preventive and specialty care access. However, continuous eligibility was not associated with health care utilization outcomes for the full sample. Continuous eligibility may be an effective strategy to reduce gaps in coverage for children and reduce paperwork burden on Medicaid agencies.

The Association of Social Factors and Health Insurance Coverage with COVID-19 Vaccinations and Hesitancy, July 2021.

BACKGROUND: There are racial differences in COVID-19 vaccination rates, but social factors, such as lack of health insurance or food insecurity, may explain some of the racial disparities. OBJECTIVE: To assess social factors, including insurance coverage, that may affect COVID-19 vaccination as of June-July 2021 and vaccine hesitancy among those not yet vaccinated, and how these may affect racial equity in vaccinations. DESIGN: Cross-sectional analysis of nationally representative survey data. PARTICIPANTS: Adults 18 to 64 participating in the Census Bureau's Household Pulse Survey for June 23 to July 5, 2021. MAIN MEASURES: Vaccination: receipt of at least one dose of a COVID-19 vaccine. Vaccine hesitancy: among those not yet vaccinated, intent to definitely or probably not get vaccinated. KEY RESULTS: In unadjusted analyses, black adults were less likely to be vaccinated than other respondents, but, after social factors were included, including health insurance status, food sufficiency, income and education, and state-level political preferences, differences between black and white adults were no longer significant and Hispanics were more likely to be vaccinated (OR = 1.87, p < .001). Among those not yet vaccinated, black and Hispanic adults were vaccine hesitant than white adults (ORs = .37 and .45, respectively, both p < .001) and insurance status and food insufficiency were not significantly associated with vaccine hesitancy. The percent of state voters for former President Trump in 2020 was significantly associated with lower vaccination rates and with increased vaccine hesitancy. DISCUSSION: The results indicate that much of the gap in COVID vaccination rates for minority adults are due to social barriers, rather than differences in racial attitudes. Unvaccinated minority adults expressed less vaccine hesitancy than white adults. Social barriers like food insecurity and insurance coverage could have deterred prompt COVID-19 vaccinations. Reducing these problems might help increase vaccination rates.

Associations of Expanding Parental Medicaid Eligibility and Parental Health and Family Functioning.

OBJECTIVE: To examine the effects of parental Medicaid eligibility on parental health, parenting practices, and child development in low-income families. METHODS: Longitudinal analysis using data from the Early Child Longitudinal Study-Kindergarten: 2011 to 2016. Outcomes included parental self-rated health, parental depressive symptoms, parents' communication and warmth toward children, and children's social skills and externalizing and internalizing behaviors. We estimated 2-way (individual and year) fixed effects models using Medicaid eligibility as a continuous variable, controlling for changing economic conditions, changes in family structure, and state-specific trends. We then estimated triple difference models comparing lower income families to those with higher incomes. Finally, we estimated difference-in-difference models and used entropy weights in order to account for differences in trends prior to 2014 for some outcomes. RESULTS: In fixed effects models, expanding Medicaid eligibility by 100% of the federal poverty line is associated with a 12.7 percentage point reduction in parents' report of having fair or poor health (95% confidence interval [CI], -23.9, -1.5) and a 1.15-point improvement on a 12-point scale of parental warmth towards children (95% CI, 0.15, 2.16). Results were substantively similar in entropy-balanced difference-in-differences models. In triple difference models, expanded Medicaid eligibility is associated with a 0.46 point improvement in warmth (95% CI, 0.10, 0.83) but not improved parental health. No significant effects for child behavior or other outcomes were detected. CONCLUSIONS: Expanding Medicaid for parents may have implications for intergenerational family functioning that could lead to broader social benefits.

The Effect of National Health Service Corps Clinician Staffing on Medical and Behavioral Health Care Costs in Community Health Centers.

OBJECTIVE: Prior studies of community health centers (CHCs) have found that clinicians supported by the National Health Service Corps (NHSC) provide a comparable number of primary care visits per full-time clinician as non-NHSC clinicians and provide more behavioral health care visits per clinician than non-NHSC clinicians. This present study extends prior research by examining the contribution of NHSC and non-NHSC clinicians to medical and behavioral health costs per visit. METHODS: Using 2013-2017 data from 1022 federally qualified health centers merged with the NHSC participant data, we constructed multivariate linear regression models with health center and year fixed effects to examine the marginal effect of each additional NHSC and non-NHSC staff full-time equivalent (FTE) on medical and behavioral health care costs per visit in CHCs. RESULTS: On average, each additional NHSC behavioral health staff FTE was associated with a significant reduction of 3.55 dollars of behavioral health care costs per visit in CHCs and was associated with a larger reduction of 7.95 dollars in rural CHCs specifically. In contrast, each additional non-NHSC behavioral health staff FTE did not significantly affect changes in behavioral health care costs per visit. Each additional NHSC primary care staff FTE was not significantly associated with higher medical care costs per visit, while each additional non-NHSC clinician contributed to a slight increase of $0.66 in medical care costs per visit. CONCLUSIONS: Combined with previous findings on productivity, the present findings suggest that the use of NHSC clinicians is an effective approach to improving the capacity of CHCs by increasing medical and behavioral health care visits without increasing costs of services in CHCs, including rural health centers.

Noncitizen Children Face Higher Health Harms Compared With Their Siblings Who Have US Citizen Status.

Immigrant children in the US have very limited health insurance coverage and health care access. Immigration status is not static: Census data show that the majority of census respondents who enter as noncitizen children eventually become citizens. Eligibility restrictions that prevent noncitizen children from being publicly insured can contribute to their experiencing poorer health and higher medical costs in their adult lives. We isolate the impact of lack of citizenship from socioeconomic factors by comparing citizen and noncitizen siblings living in mixed-status families, using fixed-effects models to net out socioeconomic factors shared within families. Lacking citizenship increased a child's risk of being uninsured and lowered by 26 percentage points the chances that they would have Medicaid or Children's Health Insurance Program coverage. Noncitizen children had significantly more delays in needed medical care because of cost, primarily mediated by the lack of insurance coverage. The US should reexamine policies that exclude noncitizen children from public health insurance programs.

Receipt of Cessation Treatments Among Medicaid Enrollees Trying to Quit Smoking.

INTRODUCTION: Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown. AIMS AND METHODS: Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis. RESULTS: Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease. CONCLUSIONS: The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states. IMPLICATIONS: Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees' use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.

The association of dental education with pediatric Medicaid participation.

PURPOSE: This study examines whether characteristics of dental education, practice characteristics and state Medicaid policies are associated with dentists' pediatric Medicaid participation. METHODS: Cross-sectional analysis of data about dentists' Medicaid participation in 2016, based on current practice characteristics and characteristics of dental schools they attended 5 to 10 years earlier. We analyze data about 22,500 general and pediatric dentists, drawn from the American Dental Association's Masterfile for 2016 and its dental school survey for 2009-10. The primary outcome is whether dentists participated in Medicaid-enrolled to accept Medicaid patients and payments-in at least 1 of their practice sites in 2016. RESULTS: A majority (55%) of dentists accepted Medicaid in at least 1 practice site, while a quarter (24%) accepted Medicaid in all their sites. Dentists who attended schools with higher tuition rates were less likely to serve Medicaid patients at any site several years later (adjusted odds ratio [AOR] = .761). Dental schools' receipt of grants that encourage community-based training were associated with increased Medicaid participation at all sites (AOR = 1.22). Those practicing in rural areas also had higher Medicaid participation (AOR = 2.62). A 10% increase in Medicaid reimbursement rates was associated with increased Medicaid participation at any site (AOR = 1.24). CONCLUSIONS: Dental school practices and state Medicaid policies are associated with whether dentists care for Medicaid patients. Changes in dental school or Medicaid policies, such as higher reimbursement rates, could help encourage more dentists to accept Medicaid patients, thereby increasing access to care.

Association of Work Requirements With Supplemental Nutrition Assistance Program Participation by Race/Ethnicity and Disability Status, 2013-2017.

Importance: Increased work requirements have been proposed throughout federal safety net programs, including the Supplemental Nutrition Assistance Program (SNAP). Participation in SNAP is associated with reduced food insecurity and improved health. Objectives: To determine whether SNAP work requirements are associated with lower rates of program participation and to examine whether there are racial/ethnic disparities or spillover effects for people with disabilities, who are not intended to be affected by work requirements. Design, Setting, and Participants: This nationally representative, pooled cross-sectional study examined how changes in SNAP work requirements at state and local levels in the US are associated with changes in food voucher program participation. The study combined information on state and local SNAP work requirements with repeated cross-sections from the 2012 through 2017 American Community Survey (with outcomes covering 2013 to 2017). The analytical approaches were based on difference-in-difference and triple-difference methods, after controlling for other economic and social factors. The sample included low-income adults without dependents, stratified by racial/ethnic group and disability status. The study also included parents who would otherwise meet work requirement criteria as a comparison group to estimate triple-difference models. This accounted for otherwise unobserved factors affecting trends in SNAP participation within local areas. Data were analyzed from January 2019 through March 2020. Exposure: Residence in areas where SNAP work requirements apply. Main Outcomes and Measures: The primary outcome is SNAP participation measured by whether anyone in the household received food vouchers at any point over the prior 12 months. Results: The final analytical sample included 866 000 low-income adults (weighted mean [SE] age, 33.6 [0.01] years; 42.5% [SE, 0.07%] men). The racial/ethnic breakdown was 56.5% (SE, 0.07%) non-Hispanic white respondents, 19.4% (SE, 0.06%) non-Hispanic black respondents, 17.7% (SE, 0.06%) Hispanic respondents, 2.5% (SE, 0.02%) Asian respondents, and 3.9% (SE, 0.03%) respondents of other or multiple races. In final triple-difference models, work requirements were associated with a 4.0 percentage point decrease in participation (95% CI, -0.048 to -0.032; P < .001) for childless adults without disability, equivalent to a 21.2% reduction in SNAP participation (95% CI, -25.5% to -17.0%). For childless adults with disability, work requirements were associated with a 4.0 percentage point reduction (95% CI, -0.058 to -0.023; P < .001), equivalent to 7.8% fewer SNAP participants with disability (95% CI, -11.2% to -4.4%). When the final models were stratified by race/ethnicity, benefit reductions were larger for non-Hispanic black adults (7.2 percentage points; 95% CI, -0.092 to -0.051; P < .001) and Hispanic adults (5.5 percentage points; 95% CI, -0.072 to -0.038; P < .001) than for non-Hispanic white adults (2.6 percentage points; 95% CI, -0.035 to -0.016; P < .001). Conclusions and Relevance: Because of the association of SNAP with food security and health, work requirements that lead to benefit loss may create nutritional and health harm for low-income Americans. These findings suggest that there may be racially disparate consequences and unintended harm for those with disability.

Enhancing Staffing In Rural Community Health Centers Can Help Improve Behavioral Health Care.

Community health centers are a vital part of the primary and behavioral health care systems in rural areas. We compared behavioral health care staffing and services in rural and urban centers. In the period 2013-17 the overall staff-to-patient ratio in behavioral health rose by 66 percent in rural centers, faster than growth in urban centers (49 percent). Growth in both settings was mostly driven by clinical social workers and other licensed mental health providers; staffing by psychiatrists and psychologists changed only slightly. In rural centers the average adjusted increase in annual visits per additional behavioral health staff member was 411 for substance use disorders, slightly higher than at urban centers. Additional annual visits per additional staff member in rural centers were 539 for depression, 466 for anxiety, and 300 for other mental disorders, similar to the numbers in urban centers. Behavioral health staff currently participating in the National Health Service Corps (NHSC) contributed more to visits for depression and anxiety in rural centers, compared to both their urban counterparts and non-NHSC staff in rural centers. Enhancing behavioral health staffing in rural community health centers could help reduce the urban-rural gap in the availability of behavioral health services, but still more could be done.

The Role of the National Health Service Corps Clinicians in Enhancing Staffing and Patient Care Capacity in Community Health Centers.

OBJECTIVE: The National Health Service Corps (NHSC) is a federal program to increase the supply of health professionals in underserved communities, but its role in enhancing the capacity of community health centers (CHCs) has not been investigated. This study examined the role of NHSC clinicians in improving staffing and patient care capacity in primary, dental, and mental health care in CHCs. METHODS: Using 2013-2016 administrative data from CHCs and the NHSC, we used a generalized estimating equation approach to examine whether NHSC clinicians [staff full-time equivalents (FTEs)] complement non-NHSC clinicians in CHCs and whether their productivity (patient visits per staff FTE) was greater than that of non-NHSC clinicians in primary, dental, and mental health care. RESULTS: Each additional NHSC clinician FTE was associated with a significant gain of 0.72 non-NHSC clinician FTEs in mental health care in CHCs and an increase of 0.04 non-NHSC FTEs in primary care in CHCs with more severe staffing shortages. On average, every additional NHSC clinician was associated with an increase of 2216 primary care visits, 2802 dental care visits, and 1296 mental health care visits per center-year. The adjusted visits per additional staff for NHSC clinicians were significantly greater in dental (difference=992) and mental health (difference=423) care, compared with non-NHSC clinicians. CONCLUSIONS: The NHSC clinicians complement non-NHSC clinicians in primary care and mental health care. They help enhance the provision of patient care in CHCs, particularly in dental and mental health services, the 2 major areas of service gaps.

The Effects of SNAP Work Requirements in Reducing Participation and Benefits From 2013 to 2017.

Objectives. To assess the effects of work requirements for able-bodied adults without dependents in the Supplemental Nutrition Assistance Program (SNAP).Methods. We used changes in waivers of work requirements to assess the impact of requiring work on the number of SNAP participants and benefit levels in 2410 US counties from 2013 to 2017 using 2-way fixed effects models.Results. Adoption of work requirements was followed by reductions of 3.0% in total SNAP participation, 4.5% in SNAP households, and 3.8% in SNAP benefit dollars, after controlling for the unemployment, poverty, and Medicaid expansions. Because able-bodied adults without dependents comprise 8% to 9% of all SNAP participants, our findings indicate that work requirements caused more than one third of able-bodied adults without dependents to lose benefits.Conclusions. Expansions of work requirements caused about 600 000 participants to lose SNAP benefits from 2013 to 2017 and caused a reduction of about $2.5 billion in federal SNAP benefits in 2017. The losses occurred rapidly, beginning a few months after work requirements were imposed.Public Health Implications. SNAP work requirements rapidly reduce caseloads and benefits, reducing food and health access. Effects on participation could be similar for work requirements in Medicaid or other programs.

The Effects of Community Health Center Care on Medical Expenditures for Children and Adults: Propensity Score Analyses.

This study examines whether community health center (CHC) patients have lower medical expenditures. Using 2011-2012 Medical Expenditure Panel Survey data, propensity score methods are used to compare annual expenditures for adults and children receiving at least half their ambulatory care at CHCs versus those who did not. For children, CHC use was associated with 35.3% lower total medical expenditures ($627), 40.0% lower ambulatory expenditures ($279), and 49.1% lower prescription drug expenditures ($157) (all Ps < .05). For adults, the reduction in hospital expenditures for CHC users ($529) was statistically significant at a P < .10 threshold. Estimated differences in total expenditures and other expenditure categories were not statistically significant for adults.