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.

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.

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.

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 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.

Policies Affecting Medicaid Beneficiaries' Smoking Cessation Behaviors.

Introduction: Smoking rates for Medicaid beneficiaries have remained flat in recent years. Medicaid may support smokers in quitting by covering a broad array of tobacco cessation services without barriers such as copays. This study examines the impact of increasing generosity in Medicaid tobacco cessation coverage policies on smoking and cessation behaviors. Methods: We used 2010 and 2015 National Health Interview Survey data merged with information on state tobacco, Medicaid cessation, and Medicaid eligibility policies to estimate state fixed effects models of cessation medication use, counseling use, quit attempts, and current smoking. Results: Smokers living in states that cover cessation medications but not counseling services were less likely to use counseling. Smokers were more likely to report having tried to quit in states with higher rates of use of cessation medications among Medicaid beneficiaries. We found no impact of Medicaid policies on use of cessation medications. States that impose copays had higher rates of smoking, while those that require counseling as a condition of receiving medication had lower rates of smoking. Additionally, we found that expanding Medicaid eligibility under the Affordable Care Act is associated with decreased smoking prevalence among Medicaid beneficiaries. Conclusion: Covering cessation counseling may encourage smokers that want to quit to use this service. Promoting the use of cessation medications may improve the likelihood that smokers try to quit. Medicaid coverage of cessation services is an important but incomplete strategy in addressing smoking among low-income populations. Implications: States may be able to improve utilization of cessation counseling by providing Medicaid reimbursement for this service. Encouraging utilization of tobacco cessation medications may help more smokers quit. States should consider how to promote effective cessation methods among clinicians and patients.

"Pay for Success" Financing and Home-Based Multicomponent Childhood Asthma Interventions: Modeling Results From the Detroit Medicaid Population.

Policy Points: The Pay for Success (PFS) financing approach has potential for scaling the implementation of evidence-based prevention interventions in Medicaid populations, including a range of multicomponent interventions for childhood asthma that combine home environment risk mitigation with medical case management. Even though this type of intervention is efficacious and cost-saving among high-risk children with asthma, the main challenges for implementation in a PFS context include legal and regulatory barriers to capturing federal Medicaid savings and using them as a source of private investor repayment. Federal-level policy change and guidance are needed to support PFS financing of evidence-based interventions that would reduce expensive acute care among Medicaid enrollees. CONTEXT: Pay for Success has emerged as a potential financing mechanism for innovative and cost-effective prevention programs. In the PFS model, interventions that provide value to the public sector are implemented with financing from private investors who receive a payout from the government only if the metrics identified in a performance-based contract are met. In this nascent field, little has been written about the potential for and challenges of PFS initiatives that produce savings and/or value for Medicaid. METHODS: In order to elucidate the basic economics of a PFS intervention in a Medicaid population, we modeled the potential impact of an evidence-based multicomponent childhood asthma intervention among low-income children enrolled in Medicaid in Detroit. We modeled outcomes and a comparative benefit-cost analysis in 3 risk-based target groups: (1) all children with an asthma diagnosis; (2) children with an asthma-related emergency department visit in the past year; and (3) children with an asthma-related hospitalization in the past year. Modeling scenarios for each group produced estimates of potential state and federal Medicaid savings for different types or levels of investment, the time frames for savings, and some overarching challenges. FINDINGS: The PFS economics of a home-based asthma intervention are most viable if it targets children who have already experienced an expensive episode of asthma-related care. In a 7-year demonstration, the overall (undiscounted) modeled potential savings for Group 2 were $1.4 million for the federal Medicaid and $634,000 for the state Medicaid programs, respectively. Targeting children with at least 1 hospitalization in the past year (Group 3) produced estimated potential savings of $2.8 million to federal Medicaid and $1.3 million to state Medicaid. However, current Medicaid rules and regulations pose significant challenges for capturing federal Medicaid savings for PFS payouts. CONCLUSIONS: A multicomponent intervention that provides home remediation and medical case management to high-risk children with asthma has significant potential for PFS financing in urban Medicaid populations. However, there are significant administrative and payment challenges, including the limited ability to capture federal Medicaid savings and to use them as a source of investor repayment. Without some policy reform and clear guidance from the federal government, the financing burden of PFS outcome payments will be on the state Medicaid program or some other state-level funding source.

Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?

Issue: The Centers for Medicare and Medicaid Services approved Medicaid work requirement demonstration projects in four states, and other states also have applied. However, the future of these projects has been clouded by legal and policy challenges. Goal: To assess whether state Medicaid work requirement projects are designed for success in promoting employment among unemployed Medicaid beneficiaries. Methods: To examine the design of new work requirement projects, we reviewed the evidence, analyzed the overlap of Medicaid and Supplemental Nutrition Assistance Program (SNAP) work requirements, and convened a roundtable of seven experts who have research or implementation experience with work programs for Medicaid and public assistance recipients. Findings and Conclusion: Mandatory work programs would be less effective and efficient than well-administered voluntary programs. Far more people will be subject to Medicaid work requirements than are currently subject to them in SNAP. This surge could overwhelm the limited resources of existing employment training and support programs. Medicaid demonstration projects contribute almost no additional funding to train the unemployed or provide necessary social supports. Medicaid work requirement programs are not well designed to help people get jobs or improve health and are more likely to lead to a loss of health insurance coverage.

Evidence-Based Policy Making: Assessment of the American Heart Association's Strategic Policy Portfolio: A Policy Statement From the American Heart Association.

BACKGROUND: American Heart Association (AHA) public policy advocacy strategies are based on its Strategic Impact Goals. The writing group appraised the evidence behind AHA's policies to determine how well they address the association's 2020 cardiovascular health (CVH) metrics and cardiovascular disease (CVD) management indicators and identified research needed to fill gaps in policy and support further policy development. METHODS AND RESULTS: The AHA policy research department first identified current AHA policies specific to each CVH metric and CVD management indicator and the evidence underlying each policy. Writing group members then reviewed each policy and the related metrics and indicators. The results of each review were summarized, and topic-specific priorities and overarching themes for future policy research were proposed. There was generally close alignment between current AHA policies and the 2020 CVH metrics and CVD management indicators; however, certain specific policies still lack a robust evidence base. For CVH metrics, the distinction between policies for adults (age ≥20 years) and children (<20 years) was often not considered, although policy approaches may differ importantly by age. Inclusion of all those <20 years of age as a single group also ignores important differences in policy needs for infants, children, adolescents, and young adults. For CVD management indicators, specific quantitative targets analogous to criteria for ideal, intermediate, and poor CVH are lacking but needed to assess progress toward the 2020 goal to reduce deaths from CVDs and stroke. New research in support of current policies needs to focus on the evaluation of their translation and implementation through expanded application of implementation science. Focused basic, clinical, and population research is required to expand and strengthen the evidence base for the development of new policies. Evaluation of the impact of targeted improvements in population health through strengthened surveillance of CVD and stroke events, determination of the cost-effectiveness of policy interventions, and measurement of the extent to which vulnerable populations are reached must be assessed for all policies. Additional attention should be paid to the social determinants of health outcomes. CONCLUSIONS: AHA's public policies are generally robust and well aligned with its 2020 CVH metrics and CVD indicators. Areas for further policy development to fill gaps, overarching research strategies, and topic-specific priority areas are proposed.

Repealing Federal Health Reform: Economic and Employment Consequences for States.

Issue: The incoming Trump administration and Republicans in Congress are seeking to repeal the Affordable Care Act (ACA), likely beginning with the law's insurance premium tax credits and expansion of Medicaid eligibility. Research shows that the loss of these two provisions would lead to a doubling of the number of uninsured, higher uncompensated care costs for providers, and higher taxes for low-income Americans. Goal: To determine the state-by-state effect of repeal on employment and economic activity. Methods: A multistate economic forecasting model (PI+ from Regional Economic Models, Inc.) was used to quantify for each state the effects of the federal spending cuts. Findings and Conclusions: Repeal results in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.

The American Health Care Act: economic and employment consequences for states.

ISSUE: The American Health Care Act (AHCA), passed by the U.S. House of Representatives, would repeal and replace the Affordable Care Act. The Congressional Budget Office indicates that the AHCA could increase the number of uninsured by 23 million by 2026. GOAL: To determine the consequences of the AHCA on employment and economic activity in every state. METHODS: We compute changes in federal spending and revenue from 2018 to 2026 for each state and use the PI+ model to project the effects on states' employment and economies. FINDINGS AND CONCLUSIONS: The AHCA would raise employment and economic activity at first, but lower them in the long run. It initially raises the federal deficit when taxes are repealed, leading to 864,000 more jobs in 2018. In later years, reductions in support for health insurance cause negative economic effects. By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses.

Projecting the Unmet Need and Costs for Contraception Services After the Affordable Care Act.

OBJECTIVES: We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. METHODS: We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. RESULTS: The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states' current Medicaid expansion plans. CONCLUSIONS: The Affordable Care Act increases women's insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed.

How Medicaid and Other Public Policies Affect Use of Tobacco Cessation Therapy, United States, 2010-2014.

INTRODUCTION: State Medicaid programs can cover tobacco cessation therapies for millions of low-income smokers in the United States, but use of this benefit is low and varies widely by state. This article assesses the effects of changes in Medicaid benefit policies, general tobacco policies, smoking norms, and public health programs on the use of cessation therapy among Medicaid smokers. METHODS: We used longitudinal panel analysis, using 2-way fixed effects models, to examine the effects of changes in state policies and characteristics on state-level use of Medicaid tobacco cessation medications from 2010 through 2014. RESULTS: Medicaid policies that require patients to obtain counseling to get medications reduced the use of cessation medications by approximately one-quarter to one-third; states that cover all types of cessation medications increased usage by approximately one-quarter to one-third. Non-Medicaid policies did not have significant effects on use levels. CONCLUSIONS: States could increase efforts to quit by developing more comprehensive coverage and reducing barriers to coverage. Reductions in barriers could bolster smoking cessation rates, and the costs would be small compared with the costs of treating smoking-related diseases. Innovative initiatives to help smokers quit could improve health and reduce health care costs.

Sharing a Playbook: Integrated Care in Community Health Centers in the United States.

OBJECTIVES: We investigated basic measures used to assess collaboration between colocated providers and to gauge the extent to which health centers practice integrated care. METHODS: We used the Assessment of Behavioral Health Services survey and the 2010 Uniform Data System to explore the elements of integrated care for behavioral health conditions. We used multivariable regression models to examine the correlates of integrated care. RESULTS: More than 85% of health centers provided mental health services in 2010, and almost half offered substance use treatment. Health centers commonly reported shared access to information among behavioral health and medical providers and joint care planning. A higher degree of integrated care involving joint case conferences was less common. Health centers without electronic health records and those with lower percentages of total staff composed of behavioral health workers were less likely to provide integrated care. CONCLUSIONS: A 2-pronged strategy involving financial incentives and technical assistance to spread best practices might increase integrated care, particularly among health centers that are not maximizing the potential of electronic health records and health centers with low behavioral health staffing levels.

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.

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.

Health care reform and women's insurance coverage for breast and cervical cancer screening.

INTRODUCTION: The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services. METHODS: We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services. RESULTS: Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for NBCCEDP cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care. CONCLUSION: Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.