Contributions of Key Components of a Medical Home on Child Health Outcomes.

OBJECTIVES: The medical home model is a widely accepted model of team-based primary care. We examined five components of the medical home model in order to better understand their unique contributions to child health outcomes. METHODS: We analyzed data from the 2016-2017 National Survey of Children's Health (NSCH) to assess five key medical home components - usual source of care, personal doctor/nurse, family-centered care, referral access, and coordinated care - and their associations with child outcomes. Health outcomes included emergency department (ED) visits, unmet health care needs, preventive medical visits, preventive dental visits, health status, and oral health status. We used multivariate regression controlling for child characteristics including age, sex, primary household language, race/ethnicity, income, parental education, health insurance coverage, and special healthcare needs. RESULTS: Children who were not white, living in non-English households, with less family income or education, or who were uninsured had lower rates of access to a medical home and its components. A medical home was associated with beneficial child outcomes for all six of the outcomes and the family-centered care component was associated with better results in five outcomes. ED visits were less likely for children who received care coordination (aOR 0.81, CI 0.70-0.94). CONCLUSIONS FOR PRACTICE: Our study highlights the role of key components of the medical home and the importance of access to family-centered health care that provides needed coordination for children. Health care reforms should consider disparities in access to a medical home and specific components and the contributions of each component to provide quality primary care for all children.

The Future of State All-Payer Claims Databases.

State policy makers are under increasing pressure to address the prohibitive cost of health care given the lack of action at the federal level. In 2020, the United States spent more on health care than any other country in the world-$4.1 trillion, representing 19.7% of the nation's gross domestic product. States are trying to better understand their role in health care spending and to think creatively about strategies for addressing health care cost growth. One way they are doing this is through the development and use of state-based all-payer claims databases (APCDs). APCDs are health data organizations that hold transactional information from public (Medicare and Medicaid) and private health insurers (commercial plans and some self-insured employers). APCDs transform this data into useful information on health care costs and trends. This article describes states' use of APCDs and recent efforts that have provided benefits and challenges for states interested in this unique opportunity to inform health policy. Although challenges exist, there is new funding for state APCD improvements in the No Surprises Act, and potential new federal interest will help states enhance their APCD capacity so they can better understand their markets, educate consumers, and create actionable market information.

Modeling Financial Eligibility for Medicaid Long-term Services and Supports.

Medicaid plays a significant role in financing long-term services and supports (LTSS) for low-income elderly (65+) in the United States. We modeled the impact of changing income, home equity, and asset limitations on Medicaid eligibility across states. We found that one in five elderly adults (10 million individuals) meet all three tests and would be financially eligible for Medicaid LTSS. Imposing additional restrictions on income allowances and eligibility thresholds had greatest impact on financial eligibility for Medicaid LTSS. Few states have opted to restrict financial eligibility and are instead looking for ways to keep people living independently in the community.

Emergency Flexibility for States to Increase and Maintain Medicaid Eligibility for LTSS under COVID-19.

Medicaid provides essential coverage for health care and long-term services and supports (LTSS) to low-income older adults and disabled individuals but eligibility is complicated and restrictive. In light of the current public health emergency, states have been given new authority to streamline and increase the flexibility of Medicaid LTSS eligibility, helping them enroll eligible individuals and ensure that current beneficiaries are not inadvertently disenrolled. Though state budgets are under increased pressure during the economic crisis created by the coronavirus, we caution states against cutting Medicaid LTSS eligibility or services to balance their budgets. These services are critical to an especially vulnerable population during a global pandemic.

Addressing the Rural Opioid Addiction and Overdose Crisis Through Cross-Sector Collaboration: Little Falls, Minnesota.

Morrison County Community-Based Care Coordination is a collaborative, cross-sector effort in Little Falls, Minnesota, that began in 2014 to reduce the use and abuse of opioids among patients at the local hospital and clinic and within the broader local rural community. As of March 2018, 453 clinic patients discontinued use of controlled substances (a reduction of 44 952 doses each month), and law enforcement stakeholders have reported a decrease in drug crimes related to the sale of narcotics.

Data Resources for Conducting Health Services and Policy Research.

Rich federal data resources provide essential data inputs for monitoring the health and health care of the US population and are essential for conducting health services policy research. The six household surveys we document in this article cover a broad array of health topics, including health insurance coverage (American Community Survey, Current Population Survey), health conditions and behaviors (National Health Interview Survey, Behavioral Risk Factor Surveillance System), health care utilization and spending (Medical Expenditure Panel Survey), and longitudinal data on public program participation (SIPP). New federal activities are linking federal surveys with administrative data to reduce duplication and response burden. In the private sector, vendors are aggregating data from medical records and claims to enhance our understanding of treatment, quality, and outcomes of medical care. Federal agencies must continue to innovate to meet the continuous challenges of scarce resources, pressures for more granular data, and new multimode data collection methodologies.

Affordable Care Act Impact in Kentucky: Increasing Access, Reducing Disparities.

OBJECTIVES: To examine health insurance disparities since Kentucky's implementation of the Affordable Care Act (ACA). METHODS: Using the American Community Survey, we estimated coverage rates by race/ethnicity before and after implementation of the ACA (2013 and 2015), and we estimated whether groups were over- or underrepresented among the uninsured, compared with their share of the state population. RESULTS: Kentucky's uninsurance rate declined from 14.4% in 2013 to 6.1% in 2015 (P < .001). Uninsurance rates also declined for most racial/ethnic groups, including Blacks (16.7% to 5.5%; P < .001) and Whites (13.3% to 5.3%; P < .001). In 2015, Blacks were no longer overrepresented among Kentucky's uninsured, with a significant decline in the ratio of Blacks among the state uninsured population compared with their share of the state population (1.16-0.91; P = .045). CONCLUSIONS: In Kentucky, which mounted a robust implementation of the ACA-including Medicaid expansion, a state-based marketplace, and an extensive outreach and enrollment campaign-the state experienced not only a decline in the overall uninsurance rate but also an elimination in coverage disparities among Blacks, who historically were overrepresented among the uninsured.

Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

Objectives The United States is one of only three countries worldwide with no national policy guaranteeing paid leave to employed women who give birth. While maternity leave has been linked to improved maternal and child outcomes in international contexts, up-to-date research evidence in the U.S. context is needed to inform current policy debates on paid family leave. Methods Using data from Listening to Mothers III, a national survey of women ages 18-45 who gave birth in 2011-2012, we conducted multivariate logistic regression to predict the likelihood of outcomes related to infant health, maternal physical and mental health, and maternal health behaviors by the use and duration of paid maternity leave. Results Use of paid and unpaid leave varied significantly by race/ethnicity and household income. Women who took paid maternity leave experienced a 47% decrease in the odds of re-hospitalizing their infants (95% CI 0.3, 1.0) and a 51% decrease in the odds of being re-hospitalized themselves (95% CI 0.3, 0.9) at 21 months postpartum, compared to women taking unpaid or no leave. They also had 1.8 times the odds of doing well with exercise (95% CI 1.1, 3.0) and stress management (95% CI 1.1, 2.8), compared to women taking only unpaid leave. Conclusions for Practice Paid maternity leave significantly predicts lower odds of maternal and infant re-hospitalization and higher odds of doing well with exercise and stress management. Policies aimed at expanding access to paid maternity and family leave may contribute toward reducing socio-demographic disparities in paid leave use and its associated health benefits.

Minnesota Integrated Health Partnership Demonstration: Implementation of a Medicaid ACO Model.

In recent years, accountable care organizations (ACOs) have become more prevalent in the United States. This study describes the origins, implementation, and early results of Minnesota's Medicaid ACO payment model, the Integrated Health Partnership (IHP) demonstration project. We describe the structure of the program and present preliminary evaluation results to document the state's important work and to provide lessons for other states interested in implementing Medicaid ACOs. The IHP program has expanded in size over time, the state has reported significant savings, and evidence exists of capacity building among participating providers. We identify factors that may have contributed to the program's early success, but more work is needed to investigate the specific drivers of quality improvement and savings within Minnesota's ACO program and to compare the design and effects of the IHP with other Medicaid and Medicare ACO programs. We conclude with comments about the future of the state's Medicaid ACO program and situate Minnesota's findings within the context of the broader ACO movement.

Changes to the Design of the National Health Interview Survey to Support Enhanced Monitoring of Health Reform Impacts at the State Level.

Pursuant to passage of the Patient Protection and Affordable Care Act, the National Center for Health Statistics has enhanced the content of the National Health Interview Survey (NHIS)-the primary source of information for monitoring health and health care use of the US population at the national level-in several key areas and has positioned the NHIS as a source of population health information at the national and state levels. We review recent changes to the NHIS that support enhanced health reform monitoring, including new questions and response categories, sampling design changes to improve state-level analysis, and enhanced dissemination activities. We discuss the importance of the NHIS, the continued need for state-level analysis, and suggestions for future consideration.

Accountable care for the poor and underserved: Minnesota's Hennepin Health model.

Hennepin Health provides integrated medical and social services to low-income Medicaid patients in a large county located in Minneapolis, Minnesota. Data sharing is critical to program operations along with care coordination provided by community health workers. Early evidence indicates fewer emergency department visits and increased use of outpatient primary care. By focusing on prevention, coordination, and team-based care, the county hopes to improve individuals' quality of life while reducing costs through better care management and reductions in emergency department use.

Putting out the welcome mat-targeting outreach efforts under the Affordable Care Act: Evidence from the Minnesota Community Application Agent Program.

CONTEXT: An evaluation of the Minnesota Community Application Agent (MNCAA) Program was conducted for the MN Minnesota Department of Human Services and funded by the Health Resources and Services Administration's State Health Access Program grant. OBJECTIVE: The MNCAA evaluation assessed effectiveness in reaching disparate populations, explored overall program value, and sought lessons applicable to the Navigator programs required under the Affordable Care Act. DESIGN: Mixed-methods approach using quantitative analysis of tracking and payment data and interviews with key informants to elicit "lessons learned" about the MNCAA program. SETTING: The MNCAA program offers incentive payments and technical assistance to community partner organizations that assist individuals in applying for public health care coverage. PARTICIPANTS: A total of 140 unique community organizations participated in the MNCAA program in 2008 to 2012. Outreach staff and directors from participating MNCAAs and state/local government officials were interviewed. MAIN OUTCOME MEASURE(S): The article highlights a strategy for targeting outreach to individuals eligible for Medicaid coverage or subsidies under the Affordable Care Act by presenting evaluation findings from a unique outreach program to increase access to care for vulnerable populations in Minnesota. RESULTS: Almost two-thirds of applicants were successfully enrolled but lengthy waiting periods persisted. Seventy percent of applications came from health care organizations. Only 13% of applicants assisted by MNCAAs were new to public health care programs. Most MNCAAs believed that the incentive payment-$25 per successful enrollee-was insufficient. CONCLUSIONS: Significant expertise in enrolling individuals in public health care programs exists within a core group of community organizations. Incentives to leverage the capacity of community organizations must be accompanied by recruiting and training. Outreach providers and navigators also need timely access to client information. More investment in financial incentives will be required.

National and state-specific health insurance disparities for adults in same-sex relationships.

OBJECTIVES: We examined national and state-specific disparities in health insurance coverage, specifically employer-sponsored insurance (ESI) coverage, for adults in same-sex relationships. METHODS: We used data from the American Community Survey to identify adults (aged 25-64 years) in same-sex relationships (n = 31,947), married opposite-sex relationships (n = 3,060,711), and unmarried opposite-sex relationships (n = 259,147). We estimated multinomial logistic regression models and state-specific relative differences in ESI coverage with predictive margins. RESULTS: Men and women in same-sex relationships were less likely to have ESI than were their married counterparts in opposite-sex relationships. We found ESI disparities among adults in same-sex relationships in every region, but we found the largest ESI gaps for men in the South and for women in the Midwest. ESI disparities were narrower in states that had extended legal same-sex marriage, civil unions, and broad domestic partnerships. CONCLUSIONS: Men and women in same-sex relationships experience disparities in health insurance coverage across the country, but residing in a state that recognizes legal same-sex marriage, civil unions, or broad domestic partnerships may improve access to ESI for same-sex spouses and domestic partners.

Monitoring health reform efforts: which state-level data to use?

This study compares estimates of health insurance coverage from the American Community Survey (ACS) to those in twelve state-specific surveys. Uninsurance estimates for the nonelderly are consistently higher in the ACS than in state surveys, as are direct purchase insurance estimates. Estimates for employer-sponsored insurance are similar, but public coverage rates are lower in the ACS. The ACS meets some but not all of the states' data needs; its large sample size and inclusion of all U.S. counties in the sample allow for comparison of insurance coverage within and across states. State-specific surveys provide the flexibility to add policy-relevant questions, including questions needed to examine how health insurance translates into access, use, and affordability of health services.

Health reform and the US Virgin Islands: high-need-limited impact.

OBJECTIVES: There are 4.1 million residents living in the US territories, which is more than the combined population of many US states, yet the territories and their citizens are often overlooked from a policy perspective, because most individual territories are relatively small, geographically isolated, and have been treated differently than the states historically. This tendency to fall beneath the radar is clear in the realm of health policy, especially in the area of insurance coverage. This article provides an initial assessment of the potential impact of health reform on the US Virgin Islands (USVI) and, in light of this assessment, considers how the results of a USVI household survey conducted in 2003 and 2009 might be used as a baseline for future monitoring of the impact of national reform. METHODS: A study by the Virgin Island's Bureau of Economic Research, Office of the Governor, and the University of Minnesota, was conducted in 2003 and 2009. The Virgin Islands Health Insurance telephone Surveys were random digit dial landline telephone surveys of households in the USVI. A stratified sample was drawn to produce precise estimates of insurance coverage for the USVI as a whole and for the 3 islands separately. RESULTS: Almost one-third of the residents (28.7%) in the Virgin Islands were uninsured in 2009. This rate is twice the US average (15.4%) and significantly higher than the uninsured rate of 24.1% when a similar survey was last conducted the Virgin Islands in 2003. CONCLUSIONS: The Patient Protection and Affordable Care Act of 2010 provides special funding to the territories through a mix of increased Medicaid caps for each territory and the provision of premium subsidies through newly established health insurance exchanges to low-income populations. However, the Affordable Care Act's Medicaid expansions to newly eligible adults--primarily adults without children--are limited to current eligibility levels in the territories, which is $5,500 in annual income for adult coverage in the USVI. Within these abbreviated parameters, the Medicaid expansion can go so far only toward mitigating uninsurance among the lowest income groups in the territories. With certain low-income childless adults overlooked, the Affordable Care Act does not fully address the high need for affordable health insurance coverage in the territories.

Use of the integrated health interview series: trends in medical provider utilization (1972-2008).

The Integrated Health Interview Series (IHIS) is a public data repository that harmonizes four decades of the National Health Interview Survey (NHIS). The NHIS is the premier source of information on the health of the U.S. population. Since 1957 the survey has collected information on health behaviors, health conditions, and health care access. The long running time series of the NHIS is a powerful tool for health research. However, efforts to fully utilize its time span are obstructed by difficult documentation, unstable variable and coding definitions, and non-ignorable sample re-designs. To overcome these hurdles the IHIS, a freely available and web-accessible resource, provides harmonized NHIS data from 1969-2010. This paper describes the challenges of working with the NHIS and how the IHIS reduces such burdens. To demonstrate one potential use of the IHIS we examine utilization patterns in the U.S. from 1972-2008.

Rescued by the safety net.

The recent recession had a significant impact on the nation and Minnesota both in terms of the number of jobs lost and the loss of employer-sponsored health insurance (ESI). In this article, we present national and Minnesota-specific data on the loss of ESI. We also explore how government-sponsored programs provided a safety net that enabled many people with low incomes to retain health insurance coverage, lessening the recession's impact in Minnesota. We conclude with general comments about the role of the safety net in a health care system in which the majority of people have health care coverage through voluntary employer-based programs.

Changes in Material Hardship During the First Year of the COVID-19 Pandemic.

This article discusses the public's spending of the stimulus checks issued by the US government during 2020 and 2021.

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.