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BACKGROUND: Numerous US patients seek the hospital emergency department (ED) for behavioral health care. Community Health Centers (CHCs) offer a potential channel for redirecting many to a more patient-centered, lower cost setting. OBJECTIVE: The aim of this study was to identify unique market areas serviced by CHCs and to examine whether CHCs are effective in offsetting behavioral health ED visits. RESEARCH DESIGN: We identified CHC-year specific service areas using patient origin zip codes. We then estimated random effects models applied to 42 federally qualified CHCs operating in New York State during 2013-2020. The dependent variables were numbers of ED mental health (substance use disorder) visits per capita in a CHC's service area, drawn from HCUP State Emergency Department Databases. Key explanatory variables measured CHC number of mental health (substance use disorder) visits, number of unique mental health (substance use disorder) patients, and mental health (substance use disorder) intensity, obtained from the HRSA Uniform Data System. RESULTS: Controlling for population, we observed small negative effects of CHC behavioral health integration in explaining ED behavioral health utilization. Measures of mental health utilization in CHCs were associated with 1.3%-9.3% fewer mental health emergency department visits per capita in Community Health Centers' service areas. Measures of substance use disorder utilization in Community Health Centers were associated with 1.3%-3.0% fewer emergency department visits per capita. CONCLUSION: Results suggest that behavioral health integration in CHCs may reduce reliance on hospital EDs, but that policymakers explore more avenues for regional coordination strategies that align services between CHCs and local hospitals.
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Centros Comunitários de Saúde , Serviço Hospitalar de Emergência , Transtornos Relacionados ao Uso de Substâncias , Humanos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Centros Comunitários de Saúde/estatística & dados numéricos , Centros Comunitários de Saúde/organização & administração , Transtornos Relacionados ao Uso de Substâncias/terapia , New York , Serviços de Saúde Mental/estatística & dados numéricos , Masculino , Feminino , Visitas ao Pronto SocorroRESUMO
Policy Points The 340B Drug Pricing Program accounts for roughly 1 out of every 100 dollars spent in the $4.3 trillion US health care industry. Decisions affecting the program will have wide-ranging consequences throughout the US safety net. Our scoping review provides a roadmap of the questions being asked about the 340B program and an initial synthesis of the answers. The highest-quality evidence indicates that nonprofit, disproportionate share hospitals may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. CONTEXT: Despite remarkable growth and relevance of the 340B Drug Pricing Program to current health care practice and policy debate, academic literature examining 340B has lagged. The objectives of this scoping review were to summarize i) common research questions published about 340B, ii) what is empirically known about 340B and its implications, and iii) remaining knowledge gaps, all organized in a way that is informative to practitioners, researchers, and decision makers. METHODS: We conducted a scoping review of the peer-reviewed, empirical 340B literature (database inception to March 2023). We categorized studies by suitability of their design for internal validity, type of covered entity studied, and motivation-by-scope category. FINDINGS: The final yield included 44 peer-reviewed, empirical studies published between 2003 and 2023. We identified 15 frequently asked research questions in the literature, across 6 categories of inquiry-motivation (margin or mission) and scope (external, covered entity, and care delivery interface). Literature with greatest internal validity leaned toward evidence of margin-motivated behavior at the external environment and covered entity levels, with inconsistent findings supporting mission-motivated behavior at these levels; this was particularly the case among participating disproportionate share hospitals (DSHs). However, included case studies were unanimous in demonstrating positive effects of the 340B program for carrying out a provider's safety net mission. CONCLUSIONS: In our scoping review of the 340B program, the highest-quality evidence indicates nonprofit, DSHs may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. Future studies should examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), characteristics, and time period of 340B enrollment. Our findings provide additional context to current health policy discussion regarding the 340B program.
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Custos de Medicamentos , Humanos , Estados UnidosRESUMO
INTRODUCTION: A disproportionate share of Federally Qualified Health Center (FQHC) users have a behavioral health condition, but there exists limited research examining changes in behavioral health provision in FQHCs. The objectives of this study were to describe how the provision of behavioral health services by FQHCs to the population of people with behavioral health conditions has changed over time in the US, how these trends varied across states, and whether the proportion of total delivered services that are behavioral health services has changed within FQHCs over time. METHODS: Descriptive analysis using the Uniform Data System and Global Burden of Disease Datasets from years 2012 to 2019. RESULTS: From 2012 to 2019, FQHC behavioral health visits per 1,000 population with any behavioral health condition grew 103%, with a 26-fold difference in average rates across states during the study period. Annual behavioral health visits per patient increased from 3.2 to 2012 to 3.4 in 2019. From 2012 to 2019, the number of behavioral health visits per 1,000 FQHC patients grew by 51%, whereas the rate of asthma visits declined by 14%, heart disease visits declined by 4%, and hypertension and diabetes related visits remained stable (changing < 1% for both). DISCUSSION/CONCLUSION: Behavioral health visit growth at FQHCs outpaced national prevalence of behavioral health conditions. This growth was driven by FQHCs serving an increasing number of patients with behavioral health conditions, without sacrificing the frequency of visits for individual patients with behavioral health conditions.
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Saúde Mental , Transtornos Relacionados ao Uso de Substâncias , Humanos , Estados Unidos/epidemiologia , Atenção Primária à Saúde , Serviços de Saúde , Acessibilidade aos Serviços de Saúde , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
OBJECTIVES: To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits. STUDY DESIGN: This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter. RESULTS: Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively. CONCLUSIONS: Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.
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Transtorno do Espectro Autista , Saúde Mental , Criança , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Massachusetts/epidemiologia , Medicaid , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Since COVID-19 first appeared in the United States (US) in January 2020, US states have pursued a wide range of policies to mitigate the spread of the virus and its economic ramifications. Without unified federal guidance, states have been the front lines of the policy response. MAIN TEXT: We created the COVID-19 US State Policy (CUSP) database ( https://statepolicies.com/ ) to document the dates and components of economic relief and public health measures issued at the state level in response to the COVID-19 pandemic. Documented interventions included school and business closures, face mask mandates, directives on vaccine eligibility, eviction moratoria, and expanded unemployment insurance benefits. By providing continually updated information, CUSP was designed to inform rapid-response, policy-relevant research in the context of the COVID-19 pandemic and has been widely used to investigate the impact of state policies on population health and health equity. This paper introduces the CUSP database and highlights how it is already informing the COVID-19 pandemic response in the US. CONCLUSION: CUSP is the most comprehensive publicly available policy database of health, social, and economic policies in response to the COVID-19 pandemic in the US. CUSP documents widespread variation in state policy decisions and implementation dates across the US and serves as a freely available and valuable resource to policymakers and researchers.
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COVID-19 , COVID-19/epidemiologia , COVID-19/prevenção & controle , Humanos , Máscaras , Pandemias/prevenção & controle , Políticas , Saúde Pública , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To estimate the effect of patient-centered medical home (PCMH) participation on cost and utilization of care for patients in Rhode Island's statewide, multipayer PCMH program, which serves over one-third of the state population. DATA SOURCES/STUDY SETTING: 2009-2014 claims data from all payers in Rhode Island, representing >743,000 unique patients. STUDY DESIGN: A propensity score-matched difference-in-differences framework was used to separately estimate the effect of the PCMH on 3 patient cohorts, which were defined by their intervention start dates and amounts of implementation time. Outcomes included patient costs (total, inpatient, outpatient, professional, pharmacy) and utilization [emergency department (ED) visits, preventable ED visits, inpatient admissions, preventable inpatient admissions, all-cause 30-day readmissions]. Interaction effects were estimated to assess heterogeneity among clinical risk groups and payers. PRINCIPAL FINDINGS: There was no evidence of a PCMH effect on total costs, though we observed evidence of an increase in the odds of PCMH patients having outpatient and professional costs, and in one cohort, a decrease in inpatient costs for those with an inpatient visit. We also observed evidence of reduced ED visits, preventable ED visits, and inpatient admissions for PCMH patients. While subgroup effects varied by cohort and measure, high-risk patients often experienced the largest reductions in ED visits. CONCLUSIONS: All PCMH cohorts experienced statistically significant reductions in some types of utilization in as little as 1.25 years. Reductions were greatest for measures included in the PCMH contractual agreement. While PCMH programs may not expect cost savings in the short-term, costs could potentially be reduced in the longer-term through avoided ED and inpatient expenses.
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Utilização de Instalações e Serviços/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Assistência Centrada no Paciente/estatística & dados numéricos , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/economia , Feminino , Implementação de Plano de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Centrada no Paciente/economia , Avaliação de Programas e Projetos de Saúde , Pontuação de Propensão , Rhode IslandRESUMO
BACKGROUND: To monitor progress towards eliminating health disparities, community health centers have reported on hypertension control, diabetes control, and birthweight by race and ethnicity since 2008. OBJECTIVE: To evaluate racial/ethnic time trends in quality outcomes in health centers and to assess both within- and between-center disparities in outcomes. DESIGN AND SAMPLE: Using 2009-2014 data from all US health centers (n = 1047 centers, serving 19.6 million patients/year), we evaluated racial/ethnic time trends in quality outcomes for health centers and assessed within- and between-center disparities. MAIN MEASURES: Percentage of patients achieving control of blood pressure < 140/90 mmHg among hypertensive persons, control of glycosylated hemoglobin ≤ 9.0% among diabetic persons, and birthweight ≥ 2500 g. All outcomes were reported by race/ethnicity. KEY RESULTS: There was no evidence of improved outcomes among racial/ethnic subgroups from 2009 to 2014, though electronic health record adoption, medical recognition, and insurance coverage rates increased substantially. Two exceptions were increased rates of normal birthweight for black patients (87.0% to 88.8%, or 0.3 percentage points/year, p = 0.02) and decreased rates of diabetes control for white patients (74.2% to 69.5%, or -1.0 percentage points/year, p < 0.01). Within centers, the largest racial/ethnic disparities in 2009 were white/black disparities in hypertension control (8.7 percentage points, 95% CI 7.4-10.1), white/black disparities in diabetes control (3.4 percentage points, 95% CI 2.0-4.7), and white/Hispanic disparities in diabetes control (4.4 percentage points, 95% CI 2.8-6.0). All disparities remained statistically unchanged from 2009 to 2014. White patients were more likely to be seen at a health center in the top performance quintile compared with black and Hispanic patients (p < 0.001). CONCLUSIONS: Though quality outcomes in health centers continued to compare favorably to other care settings, we found no evidence of improved quality or reduced disparities in diabetes control, hypertension control, or birthweight from 2009 to 2014. Within- and between-center racial/ethnic disparities in quality were evident, and both should be targeted in future interventions.
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Centros Comunitários de Saúde/normas , Acessibilidade aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/normas , Qualidade da Assistência à Saúde/normas , Grupos Raciais/etnologia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Centros Comunitários de Saúde/tendências , Etnicidade , Feminino , Acessibilidade aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/tendências , Resultado do Tratamento , Adulto JovemAssuntos
Diabetes Mellitus , Telemedicina , Humanos , Estudos Retrospectivos , Diabetes Mellitus/terapia , PacientesRESUMO
This Viewpoint discusses the Georgia Pathways to Coverage program, which is the first state program that partially expands Medicaid eligibility to low-income adults with work requirements.
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BACKGROUND: Prior studies have reported that community health centers perform as well as other sites of care, despite serving more vulnerable patient populations. However, there is little prior study of geographic variation in quality outcomes and disparities in outcomes in this setting. Quantifying geographic variation is important so as to target quality improvement efforts and funding and to learn from states where total quality is highest and racial/ethnic disparities are lowest. OBJECTIVES: To estimate between-state variation in hypertension, diabetes, and pregnancy outcomes and racial/ethnic disparities in these outcomes for health center patients. METHODS: Using data on all US health centers from 2010 to 2014 (N=1047 health centers/year, or 21.2 million patients in 2014), we used linear regression models to estimate adjusted quality outcomes and racial/ethnic disparities in quality outcomes by state for hypertension control, diabetes control, and normal birthweight. RESULTS: We found wide variation in both outcomes and racial/ethnic disparities in outcomes between states for patients seen at health centers. For instance, between states, the mean proportion of patients with hypertension control ranged from 58% to 70% for white patients, from 49% to 64% for black patients, and from 53% to 74% for Hispanic patients (P<0.001). Racial/ethnic disparities in outcomes ranged from negative or nonsignificant in some states to positive in others. CONCLUSIONS: Wide variation in health center patient outcomes and disparities in outcomes is observed between states. This variation suggests that policymakers should target funding and interventions to underperforming states, and identify determinants of high quality in higher performing states.
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Centros Comunitários de Saúde/organização & administração , Diabetes Mellitus Tipo 2/epidemiologia , Etnicidade/estatística & dados numéricos , Hipertensão/epidemiologia , Resultado da Gravidez/epidemiologia , Indicadores de Qualidade em Assistência à Saúde , Adulto , Diabetes Mellitus Tipo 2/terapia , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Humanos , Hipertensão/terapia , Masculino , Pessoa de Meia-Idade , Gravidez , Fatores Socioeconômicos , Estados Unidos , Adulto JovemRESUMO
OBJECTIVES: To examine whether community health centers (CHCs) are effective in offsetting mental health emergency department (ED) visits. DATA SOURCES AND STUDY SETTING: The HRSA Uniform Data System and the HCUP State ED Databases for Florida patients during 2012-2019. STUDY DESIGN: We identified CHC-year-specific service areas using patient origin zip codes. We then estimated panel data models for number of ED mental health visits per capita in a CHC's service area. Models measured CHC mental health utilization as number of visits, unique patients, and intensity (visits per patient). PRINCIPAL FINDINGS: CHC mental health utilization increased approximately 100% during 2012-2019. Increased CHC mental health provision was associated with small reductions in ED mental health utilization. An annual increase of 1000 CHC mental health care visits (5%) was associated with 0.44% fewer ED mental health care visits (p = 0.153), and an increase of 1000 CHC mental health care patients (15%) with 1.9% fewer ED mental health care visits (p = 0.123). An increase of 1 annual mental health visit per patient was associated with 16% fewer ED mental health care visits (p = 0.011). CONCLUSIONS: Results suggest that mental health provision in CHCs may reduce reliance on hospital EDs, albeit minimally. Policies that promote alignment of services between CHCs and local hospitals may accelerate this effect.
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Serviço Hospitalar de Emergência , Saúde Mental , Humanos , Estados Unidos , Centros Comunitários de Saúde , Florida , HospitaisRESUMO
OBJECTIVE: To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020. DATA SOURCE: 2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375). STUDY DESIGN: We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers. DATA COLLECTION: None. PRINCIPAL FINDINGS: In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%). CONCLUSIONS: Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.
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COVID-19 , Pandemias , Estados Unidos , Humanos , COVID-19/epidemiologia , Medicaid , Pessoas sem Cobertura de Seguro de Saúde , PolíticasRESUMO
Using novel national data, we examined the association between 2020 federal COVID-related funding targeted to health centers (i.e., H8 funding) and health center workforce and operational capacity measures that may be important for preserving patient access to care and staff safety. We assigned health centers to quartiles based on federal funding distribution per patient and used adjusted linear probability models to estimate differences in workforce and operational capacity outcomes across quartiles from April 2020 to June 2022. We found a nearly 6-fold difference in 2020 H8 funding per patient when comparing health centers in the lowest versus highest quartiles. Despite this difference, health centers' outcomes improved similarly across quartiles over time, with the lowest-funded health centers having the greatest staffing and service capacity challenges. Our findings suggest that COVID-related health center funding may have contributed to stabilization of health centers' workforce and operations. Amid concerns about staff turnover, sustained investments targeted to supporting workforce retention at health centers can help to ensure ongoing delivery of critical services.
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Doula services support maternal and child health, but few Medicaid programs reimburse for them. Through qualitative interviews with key policy informants (n = 20), this study explored facilitators and barriers to Medicaid reimbursement through perceptions of doula-related policies in 2 states: Oregon, where doula care is reimbursed, and Massachusetts, where reimbursement is pending. Five themes characterize the inclusion of doula services in Medicaid. In Theme 1, stakeholders recognized an imperative to expand access to doula services. Subsequent themes represent complications in accomplishing that imperative. In Theme 2, perceptions that doula services were not valued by health care providers resulted in conflict between doulas and the health care system. In Theme 3, complex billing processes created friction and impeded reimbursement. In Theme 4, internal conflict presented barriers to policymaking. In Theme 5, structural fragmentation between state government and doula communities was prominent in Massachusetts, presenting tensions during policymaking. Informants reported on problems demanding resolution to establish equitable and robust doula care policies. Medicaid coverage of doula services requires ongoing collaboration with doulas, providers, and health care advocates.
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OBJECTIVE: To determine how aging impacts healthcare utilization in persons with HIV (PWH) compared with persons without HIV (PWoH). DESIGN: Matched case-control study. METHODS: We studied Medicaid recipients in the United States, aged 18-64âyears, from 2001 to 2012. We matched each of 270â074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth. RESULTS: We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for female and male individuals, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for female individuals and 0.4 extra days for male individuals. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55 years, this represents an 81% increase in the nursing home DPM for male individuals, and a 110% increase for female individuals, compared PWoH. CONCLUSION: Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared with PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.
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Comorbidade , Infecções por HIV , Medicaid , Casas de Saúde , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Infecções por HIV/epidemiologia , Adulto , Estados Unidos/epidemiologia , Medicaid/estatística & dados numéricos , Adulto Jovem , Adolescente , Estudos de Casos e Controles , Casas de Saúde/estatística & dados numéricos , Fatores Etários , Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , HospitaisRESUMO
BACKGROUND: States use Medicaid 1915(c) waiver programs to enable access to home- and community-based services for people with intellectual and/or developmental disabilities (I/DD). However, enrollment rates and potential inequities are not well documented, impeding efforts to improve care access and quality for waiver program enrollees, especially for racially minoritized beneficiaries experiencing compounded barriers to services and supports. OBJECTIVE: To characterize year-by-year 1915(c) waiver program enrollment among Medicaid-enrolled adults with I/DD from 2016 to 2019 and to analyze population-level inequities by type of I/DD and racial/ethnic group. METHODS: Our data source was 2016-2019 Medicaid Transformed Medicaid Statistical Information System Analytic Files Demographic and Eligibility files for beneficiaries with Down syndrome, autism, and intellectual disability. We used generalized estimating equation linear models to estimate the associations of type of I/DD and racial/ethnic group with the probability of 1915(c) waiver program enrollment and reported (1) unadjusted estimates and (2) estimates adjusted for demographics with state and year fixed effects. RESULTS: From 2016 to 2019, across all types of I/DD and racial/ethnic groups, unadjusted 1915(c) waiver program enrollment rates ranged from 40 to 60 % nationwide. We found modest growth in 1915(c) I/DD waiver program enrollment but persistent inequities over time. Compared to beneficiaries with intellectual disabilities, beneficiaries with autism were less likely to enroll while beneficiaries with Down syndrome were more likely. While some racial/ethnic groups had higher unadjusted mean enrollment, after adjustment, racially minoritized beneficiaries were 3.66-12.0 percentage points less likely to enroll compared to white non-Hispanic beneficiaries. CONCLUSIONS: Given extensive waiting lists for 1915(c) waiver programs, Medicaid programs should evaluate existing enrollment and authorization processes and consider alternative HCBS program authorities.
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Evidence suggests that perinatal doula care can support maternal health and reduce racial inequities among low-income pregnant and postpartum people, prompting growing interest by state Medicaid agencies to reimburse for doula services. Emerging peer-reviewed and gray literature document factors facilitating or impeding that reimbursement. We conducted a scoping review of that literature (2012-2022) to distill key policy considerations for policymakers and advocates in the inclusion of doula care as a Medicaid-covered benefit. Fifty-three reports met the inclusion criteria. Most (53%) were published in 2021 or 2022. Their stated objectives were advocating for expanded access to doula care (17%), describing barriers to policy implementation, and/or offering recommendations to overcome the barriers (17%). A primary policy consideration among states was prioritizing partnership with doulas and doula advocates to inform robust and equitable policymaking to sustain the doula profession.
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Doulas , Política de Saúde , Medicaid , Humanos , Medicaid/economia , Estados Unidos , Gravidez , FemininoRESUMO
In 2020 and 2021, health centers received federal funding to support their COVID-19 pandemic response, yet little is known about how the funds were distributed. This study identified ten sources of funding distributed to 1,352 centers, ranging from $19 to $1.22 billion per center. When we examined patient and organizational characteristics by quartiles of funding per patient, health centers in the highest-funded quartile (quartile 4) were more likely rural and in the South; employed lower percentages of physicians; and had the highest percentages of sicker, uninsured, and unhoused patients. Centers in the lowest-funded quartile (quartile 1) were more likely urban, employed lower percentages of nurse practitioners, and had the highest percentages of Medicaid enrollees. With the end of pandemic-related funding in 2023, combined with Medicaid unwinding concerns, targeted investment is needed to mitigate a financial cliff and help maintain health centers' capacity to provide high-quality services to those most in need.
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COVID-19 , Financiamento Governamental , Medicaid , Humanos , COVID-19/economia , Estados Unidos , Medicaid/economia , Pandemias , SARS-CoV-2RESUMO
INTRODUCTION: This study aimed to examine changes in emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) among uninsured or Medicaid-covered Black, Hispanic, and White adults aged 26-64 in the first 5 years of the Affordable Care Act Medicaid expansion. METHODS: Using 2010-2018 inpatient and ED discharge data from nine expansion and five nonexpansion states, an event study difference-in-differences regression model was used to estimate changes in number of annual ACSC ED visits per 100 adults ("ACSC ED rate") associated with the 2014 Medicaid expansion, overall and by race/ethnicity. A secondary outcome was the proportion of ACSC ED visits out of all ED visits ("ACSC ED share"). Analyses were conducted in 2022-2023. RESULTS: Medicaid expansion was associated with no change in ACSC ED rates among all, Black, Hispanic, or White adults. When excluding California, where most counties expanded Medicaid before 2014, expansion was associated with a decrease in ACSC ED rate among all, Black, Hispanic, and White adults. Expansion was also associated with a decrease in ACSC ED share among all, Black, and White adults. White adults experienced the largest reductions in ACSC ED rate and share. CONCLUSIONS: Medicaid expansion was associated with reductions in ACSC ED rates in some expansion states and reductions in ACSC ED share in all expansion states combined, with some heterogeneity by race/ethnicity. Expansion should be coupled with policy efforts to better link newly insured Black and Hispanic patients to non-ED outpatient care, alongside targeted outreach and expanded primary care capacity, which may reduce disparities in ACSC ED visits.