State-Level Sexism and Women's Health Care Access in the United States: Differences by Race/Ethnicity, 2014-2019.

Objectives. To quantify racial/ethnic differences in the relationship between state-level sexism and barriers to health care access among non-Hispanic White, non-Hispanic Black, and Hispanic women in the United States. Methods. We merged a multidimensional state-level sexism index compiled from administrative data with the national Consumer Survey of Health Care Access (2014-2019; n = 10 898) to test associations between exposure to state-level sexism and barriers to access, availability, and affordability of health care. Results. Greater exposure to state-level sexism was associated with more barriers to health care access among non-Hispanic Black and Hispanic women, but not non-Hispanic White women. Affordability barriers (cost of medical bills, health insurance, prescriptions, and tests) appeared to drive these associations. More frequent need for care exacerbated the relationship between state-level sexism and barriers to care for Hispanic women. Conclusions. The relationship between state-level sexism and women's barriers to health care access differs by race/ethnicity and frequency of needing care. Public Health Implications. State-level policies may be used strategically to promote health care equity at the intersection of gender and race/ethnicity. (Am J Public Health. 2021;111(10):1796-1805. https://doi.org/10.2105/AJPH.2021.306455).

A statewide program providing colorectal cancer screening to the uninsured of South Carolina.

BACKGROUND: Cancer screening rates are lowest in those without insurance or a regular provider. Since 2008, the Colorectal Cancer Prevention Network (CCPN) has provided open access colonoscopy to uninsured residents of South Carolina through established, statewide partnerships and patient navigation. Herein, we describe the structure, implementation, and clinical outcomes of this program. METHODS: The CCPN provides access to colonoscopy screening at no cost to uninsured, asymptomatic patients aged 50-64 years (African Americans age 45-64 years are eligible) who live at or below 150% of the poverty line and seek medical care in free medical clinics, federally qualified health centers, or hospital-based indigent practices in South Carolina. Screening is performed by board-certified gastroenterologists. Descriptive statistics and regression analysis are used to describe the population screened, and to assess compliance rates and colonoscopy quality metrics. RESULTS: Out of >4000 patients referred to the program, 1854 were deemed eligible, 1144 attended an in-person navigation visit, and 1030 completed a colonoscopy; 909 were included in the final sample. Nearly 90% of participants exhibited good-to-excellent bowel preparation. An overall cecal intubation rate of 99% was measured. The polyp detection rate and adenoma detection rate were 63% and 36%, respectively, with male sex and urban residence positively associated with adenoma detection. Over 13% of participants had an advanced polyp, and 1% had a cancer diagnosis or surgical intervention. CONCLUSION: The CCPN program is characterized by strong collaboration with clinicians statewide, low no-show rates, and high colonoscopy quality. Future work will assess the effectiveness of the navigation approach and will explore the mechanisms driving higher adenoma detection in urban participants. Cancer 2018;124:1912-20. © 2018 American Cancer Society.

Evaluating the Impact of the Healthy Beginnings System of Care Model on Pediatric Emergency Department Utilization.

OBJECTIVE: The aim of this study was to evaluate whether enrollment in the Healthy Beginnings System of Care (SOC) model is associated with a decrease in emergency department (ED) visits among children aged 6 months to 5.5 years. METHODS: A retrospective, longitudinal study of ED utilization was conducted among children enrolled in the Healthy Beginnings SOC model between February 2011 and May 2013. Using medical records obtained from a children's hospital in Atlanta, the rate of ED visits per quarter was examined as the main outcome. A multilevel, multivariate Poisson model, with family- and child-level random effects, compared ED utilization rates before and after enrollment. Adjusted rate ratios and 95% confidence intervals were calculated after controlling for sociodemographic confounders. RESULTS: The effect of SOC enrollment on the rate of ED visits differed by income level of the primary parent. The rate of ED visits after enrollment was not significantly different than the rate of ED visits before enrollment for children whose primary parent had an annual income of less than $5000 (P = 0.298), $20,000 to $29,999 (P = 0.199), or $30,000 or more (P = 0.117). However, for the children whose primary parent's annual income was $5000 to $19,999, the rate of ED visits after enrollment was significantly higher than the rate of ED visits before enrollment (adjusted rate ratio, 1.48; 95% confidence interval, 1.17-1.87). CONCLUSIONS: Enrollment in the SOC model does not appear to decrease the rate of ED visits among enrolled children. Additional strategies, such as education sessions on ED utilization, are needed to reduce the rate of ED utilization among SOC-enrolled children.

Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014.

Importance: State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. Objective: To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Design, Setting, and Participants: Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Exposures: Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program. Main Outcomes and Measures: Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Results: Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience. Conclusions and Relevance: Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

Fostering Psychotropic Medication Oversight for Children in Foster Care: A National Examination of States' Monitoring Mechanisms.

To describe state responses to psychotropic medication safety concerns among children in foster care, this study proposes a taxonomy for state-level psychotropic medication monitoring mechanisms and highlights state variations. Seventy-two key informants, representing state child-serving agencies within the 50 states and DC, completed semi-structured interviews. We employed modified grounded theory to develop the taxonomy, and then generated state-specific summaries that were validated by key informants. Nationally, 88.2 % of the states employed at least one of seven mechanisms. For the most frequently implemented mechanisms (collegial secondary review, prior authorization, database review), over half were implemented between January 2011 and July 2013.

Algorithm development and the clinical and economic burden of Cushing's disease in a large US health plan database.

PURPOSE: This study aimed to develop an algorithm to identify patients with CD, and quantify the clinical and economic burden that patients with CD face compared to CD-free controls. METHODS: A retrospective cohort study of CD patients was conducted in a large US commercial health plan database between 1/1/2007 and 12/31/2011. A control group with no evidence of CD during the same time was matched 1:3 based on demographics. Comorbidity rates were compared using Poisson and health care costs were compared using robust variance estimation. RESULTS: A case-finding algorithm identified 877 CD patients, who were matched to 2631 CD-free controls. The age and sex distribution of the selected population matched the known epidemiology of CD. CD patients were found to have comorbidity rates that were two to five times higher and health care costs that were four to seven times higher than CD-free controls. CONCLUSION: An algorithm based on eight pituitary conditions and procedures appeared to identify CD patients in a claims database without a unique diagnosis code. Young CD patients had high rates of comorbidities that are more commonly observed in an older population (e.g., diabetes, hypertension, and cardiovascular disease). Observed health care costs were also high for CD patients compared to CD-free controls, but may have been even higher if the sample had included healthier controls with no health care use as well. Earlier diagnosis, improved surgery success rates, and better treatments may all help to reduce the chronic comorbidity and high health care costs associated with CD.

The impact of the State Children's Health Insurance Program's unborn child ruling expansions on foreign-born Latina prenatal care and birth outcomes, 2000-2007.

The 2002 "unborn child ruling" resulted in State Children's Health Insurance Program (SCHIP) expansion for states to cover prenatal care for low-income women without health insurance. Foreign-born Latinas who do not qualify for Medicaid coverage theoretically should have benefited most from the policy ruling given their documented low rates of prenatal care utilization. This study compares prenatal care utilization and subsequent birth outcomes among foreign-born Latinas in six states that used the unborn child ruling to expand coverage to those in ten states that did not implement the expansion. This policy analysis examines cross-sectional pooled US natality data from the pre-enactment years (2000-2003) versus post-enactment years (2004-2007) to estimate the effect of the UCR on prenatal care utilization and birth outcome measures for foreign-born Latinas. Then using a difference-in-difference estimator, we assessed these differences across time for states that did or did not enact the unborn child ruling. Analyses were then replicated on a high-risk subset of the population (single foreign-born Latinas with lower levels of education). The SCHIP unborn child ruling policy expansion increased PNCU over time in the six enacting states. Foreign-born Latinas in expansion enacting states experienced increases in prenatal care utilization though only the high-risk subset were statistically significant. Birth outcomes did not change. The SCHIP unborn child ruling policy was associated with enhanced PNC for a subset of high-risk foreign-born Latinas.

Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension.

INTRODUCTION: Hypertension is a risk factor for cardiovascular disease (CVD), the leading cause of death in the United States. The treatment and control of hypertension is inadequate, especially among patients without health insurance coverage. The Affordable Care Act offered an opportunity to improve hypertension management by increasing the number of people covered by insurance. This study predicts the long-term effects of improved hypertension treatment rates due to insurance expansions on the prevalence and mortality rates of CVD of nonelderly Americans with hypertension. METHODS: We developed a state-transition model to simulate the lifetime health events of the population aged 25 to 64 years. We modeled the effects of insurance coverage expansions on the basis of published findings on the relationship between insurance coverage, use of antihypertensive medications, and CVD-related events and deaths. RESULTS: The model projected that currently anticipated health insurance expansions would lead to a 5.1% increase in treatment rate among hypertensive patients. Such an increase in treatment rate is estimated to lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and 95,000 fewer CVD-related deaths by 2050. The estimated benefits were slightly greater for men than for women and were greater among nonwhite populations. CONCLUSION: Federal and state efforts to expand insurance coverage among nonelderly adults could yield significant health benefits in terms of CVD prevalence and mortality rates and narrow the racial/ethnic disparities in health outcomes for patients with hypertension.

The value of all-payer claims databases to states.

All-payer claims databases are being developed in states across the nation to fill gaps in information about the health care system. The value of such databases is becoming more apparent as these databases mature and are used more frequently to help states better understand their health care utilization and costs.

Institutional charges and disparities in outpatient brain biopsies in four US States: the State Ambulatory Database (SASD).

Several groups have demonstrated the safety of ambulatory brain biopsies, with no patients experiencing complications related to early discharge. Although they appear to be safe, the reasons factoring into the selection of patients have not been investigated. We performed a cross-sectional study involving 504 patients who underwent outpatient and 10,328 patients who underwent inpatient brain biopsies and were registered in State Ambulatory Surgery Databases and State Inpatient Databases respectively for four US States (New York, California, Florida, North Carolina). In a multivariate analysis private insurance (OR 2.45, 95 % CI, 1.85, 3.24), was significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (OR 0.16, 95 % CI, 0.08, 0.32), high income (OR 0.37, 95 % CI, 0.26, 0.53), and high volume hospitals (OR 0.30, 95 % CI, 0.23, 0.39) were associated with a decreased chance of outpatient procedures. No sex, or racial disparities were observed. Institutional charges were significantly less for outpatient brain biopsies. There was no difference in the rate of 30-day postoperative readmissions among inpatient and outpatient procedures. The median charge for inpatient surgery was 51,316 as compared to 12,266 for the outpatient setting (P < 0.0001, Student's t test). Access to ambulatory brain biopsies appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

How do public health expansions vary by income strata? Evidence from Illinois' All Kids program.

This paper examines how income levels affected the substitution of public health insurance for private health coverage under expansions of Illinois' State Children's Health Insurance Program (SCHIP). Building on a technique developed by Abadie and Gardeazabal (2003), I estimate that among children whose family incomes are between 200% and 300% of the federal poverty level (FPL), 35% of those covered by SCHIP would have retained private coverage in the absence of SCHIP. Significant substitution also appears between 300% and 400% FPL, but surprisingly I find evidence that the introduction of SCHIP caused an increase in private health insurance coverage for those with family incomes between 400% and 500% FPL.

Clinical trial recruitment in rural South Carolina: a comparison of investigators' perceptions and potential participant eligibility.

INTRODUCTION: Participation in clinical trial (CT) research can help decrease health disparities in rural communities. The purpose of this study was to examine the perceptions of principal investigators (PIs) regarding CT participation barriers and recruitment efforts in rural South Carolina, USA and to assess the actual pool of potential CT participants in rural and urban South Carolina. The ultimate goal was to evaluate the fit between PIs' perceptions and the pool of eligible participants in rural South Carolina. METHODS: An online survey was conducted with 119 CT PIs from South Carolina's five main academic medical centers located in urban areas of the state, for a response rate of 31%. Secondary data analyses were also conducted using data from government health insurance plans, including the 2009 South Carolina Medicaid, the 2009 State Health Plan (SHP) data, and census data from the 2005-2009 American Community Survey (ACS). Both parametric and non-parametric statistics were used to analyze survey and secondary data. RESULTS: Principal investigators perceived greater recruitment barriers in rural areas than in the general population. They indicated having difficulty finding CT participants in rural areas compared to the general population (t= -2.985, p=0.004). Rural residents were significantly more likely to be perceived as lacking knowledge and understanding about CT than the general public (t= -2.105, p=0.038), having significantly lower literacy than the general public (t= -2.058, p=0.043), lacking information about available CTs (t= -2.913, p=0.005), and having limited accessibility to trial sites compared to the general population (t= -4.380, p=0.000). Patients' insurance coverage, however, was not found to be a significant barrier for CT participation (t=0.418, p=0.677). Secondary data variables were aligned with these barriers. Data revealed that rural residents have slightly lower educational attainment than urban citizens >t=5.384, p=0.000), and more people live below poverty level in rural areas (23%) than in urban areas (15%) (t=4.86, p=0.000). The secondary data analyses also showed that the majority of rural citizens covered by the SHP and Medicaid are eligible for CTs. ACS data revealed that 75% of people in rural areas meet one or more basic eligibility requirements to participate in CTs compared to 83% in urban areas. CONCLUSIONS: Some important barriers hinder CT enrollment of rural participants, such as accessibility to trial sites, poverty, lack of knowledge about CTs, among others. Data suggested that insurance coverage, however, is not a barrier to CT participation. Although CT PIs are correct in considering these barriers in rural areas, there still exists a large pool of potentially eligible CT participants in rural South Carolina. PIs, who were recruited from urban academic medical centers, may therefore be perpetuating unhelpful rural myths about CT eligibility in rural communities. Despite their remote locations, rural citizens should take part in medical research. Greater communication between PIs and rural participants and better education of PIs on communication strategies are needed to enhance CT participation in rural South Carolina.

The impact of threshold language assistance programming on the accessibility of mental health services for persons with limited English proficiency in the Medi-Cal setting.

BACKGROUND: Title VI of the 1964 Civil Rights Act prohibits federal funds recipients from providing care to limited English proficiency (LEP) persons more limited in scope or lower in quality than care provided to others. In 1999, the California Department of Mental Health implemented a "threshold language access policy" to meet its Title VI obligations. Under this policy, Medi-Cal agencies must provide language assistance programming in a non-English language where a county's Medical population contains either 3000 residents or 5% speakers of that language. RESEARCH DESIGN: We examine the impact of threshold language policy-required language assistance programming on LEP persons' access to mental health services by analyzing the county-level penetration rate of services for Russian, Spanish, and Vietnamese speakers across 34 California counties, over 10 years of quarterly data. Exploiting a time series with nonequivalent control group study design, we studied this phenomena using linear regression with random county effects to account for trends over time. RESULTS: Threshold language policy-required assistance programming led to an immediate and significant increase in the penetration rate of mental health services for Russian (8.2, P < 0.01) and Vietnamese (3.3, P < 0.01) language speaking persons. CONCLUSIONS: Threshold language assistance programming was effective in increasing mental health access for Russian and Vietnamese, but not for Spanish-speaking LEP persons.

Intergenerational enrollment and expenditure changes in Medicaid: trends from 1991 to 2005.

BACKGROUND: From its inception, Medicaid was aimed at providing insurance coverage for low income children, elderly, and disabled. Since this time, children have become a smaller proportion of the US population and Medicaid has expanded to additional eligibility groups. We sought to evaluate relative growth in spending in the Medicaid program between children and adults from 1991-2005. We hypothesize that this shifting demographic will result in fewer resources being allocated to children in the Medicaid program. METHODS: We utilized retrospective enrollment and expenditure data for children, adults and the elderly from 1991 to 2005 for both Medicaid and Children's Health Insurance Program Medicaid expansion programs. Data were obtained from the Centers for Medicare and Medicaid Services using their Medicaid Statistical Information System. RESULTS: From 1991 to 2005, the number of enrollees increased by 83% to 58.7 million. This includes increases of 33% for children, 100% for adults and 50% for the elderly. Concurrently, total expenditures nationwide rose 150% to $273 billion. Expenditures for children increased from $23.4 to $65.7 billion, adults from $46.2 to $123.6 billion, and elderly from $39.2 to $71.3 billion. From 1999 to 2005, Medicaid spending on long-term care increased by 31% to $84.3 billion. Expenditures on the disabled grew by 61% to $119 billion. In total, the disabled account for 43% and long-term care 31%, of the total Medicaid budget. CONCLUSION: Our study did not find an absolute decrease in the overall resources being directed toward children. However, increased spending on adults on a per-capita and absolute basis, particularly disabled adults, is responsible for much of the growth in spending over the past 15 years. Medicaid expenditures have grown faster than inflation and overall national health expenditures. A national strategy is needed to ensure adequate coverage for Medicaid recipients while dealing with the ongoing constraints of state and federal budgets.

Association between perinatal medical expenses and a waiver to increase Florida healthy start services within Florida medicaid programs: 1998 to 2006.

To assess the association between perinatal care expenditures and a Medicaid waiver to increase Florida Healthy Start services among Florida Medicaid non-managed care organization (non-MCO) program enrollees. We assessed perinatal care expenditures from Medicaid claims and encounter data among non-MCO enrollees with increased risk pregnancies who gave birth in Florida during 1998-2006. We used a pre-post design to compare adjusted perinatal medical expenditures among women who received Healthy Start care coordination (n = 41,067) to women who were not contacted by the Healthy Start program after screening (n = 24,282). We calculated adjusted average costs and difference-in-differences using marginal estimates from multivariable linear mixed regression models. From the pre-waiver (January 1998-July 2001) to the late-post waiver (July 2004-December 2006), all prenatal medical costs increased $274 among care coordination participants and decreased $601 among women not contacted by the Healthy Start program, equaling a $875 increased cost difference between care coordination and no contact groups. During this same time period, delivery related expenditures increased $395 less among care coordination participants compared to women not contacted by Healthy Start. Additionally, infant medical care costs during days 29-365 decreased by an average of $240 less among the care coordination compared to the no contact group. The Medicaid waiver may have decreased delivery costs, but medical costs were increased following the waiver when considering all perinatal care. Further exploration of factors associated with the decreased delivery costs may help develop more efficient prenatal support programs.

Parental eligibility and enrollment in state children's health insurance program: the roles of parental health, employment, and family structure.

We examined eligibility and enrollment among parents of children in New Jersey's State Children's Health Insurance Program following expansion of parental eligibility for NJ FamilyCare coverage. Data were from the 2003 NJ FamilyCare Family Health Survey (n = 416 families). Parental eligibility was higher in households without a full-time employed parent (odds ratio [OR] = 5.50; 95% confidence interval [CI] = 2.72, 11.14) and lower among single parents (OR = 0.38; 95% CI = 0.23, 0.61). Enrollment was higher among single parents (OR = 2.24; 95% CI = 1.17, 4.31). Roughly one third of eligible parents did not enroll, suggesting the need to increase awareness of parental eligibility and reduce barriers to enrollment.

The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan.

OBJECTIVES: We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. METHODS: We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts. RESULTS: Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits. CONCLUSIONS: Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems.

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

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

Have working-age people with disabilities shared in the gains of Massachusetts health reform?

The Massachusetts health reform, implemented in 2006 and 2007, reduced the uninsurance rate for working-age people with disabilities by nearly half Enrollment in Medicaid and subsidized insurance accounted for most of the gain in insurance coverage. The reduction in uninsurance was greatest among younger adults. The reform also reduced cost-related problems obtaining care; however, cost remains an obstacle, particularly among young adults with disabilities. The Massachusetts outcomes demonstrate that insurance subsidies, Medicaid expansions for low-income adults, individual insurance mandates, and enrollment initiatives can lead to substantial reductions in uninsurance and cost-related problems obtaining care among working-age people with disabilities.