Medicaid-eligible Population Research Articles

Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid.

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial

(Abstracted from JAMA 2022:328(1):27–37) Mortality, morbidity, and childhood developmental challenges can all result from adverse birth outcomes. In regard to these outcomes, the United States exhibits significant racial and socioeconomic inequities, and effective interventions targeting low-income pregnant people are necessary.

What Constitutes a Competitive Environment? A Case Study of the FQHCs Industry In California

Objective: This study aims to identify competitive forces in the FQHCs environment using Porter’s Five Force model. Data Sources: The study utilized various secondary data sources. The Health Resources and Services Administration (HRSA) requires FQHCs to submit a performance report using the measures defined in the Uniform Data System (UDS). The UDS provides data such as the scope and volume of services provided by FQHCs, staffing, number of delivery sites, and finances. The UDS consider being a census of aggregate level health center data for FQHCs. Secondly, the American Hospital Association Annual Survey (AHA), which provides organizational details regarding hospitals. The third dataset is the Area Health Resources File (AHRF). It includes county-level data about health services volume, demographics, and health professional supply. The fourth dataset is the Internal Revenue Service (IRS) Form 990, which was used was used to calculate FQHCs’ total margin. The fifth dataset is the California Health and Human Services Open Data Portal (CHHS), which includes county-level data such as the number of Medicaid eligible populations and the number of primary care clinics. Finally, the study used the U.S. Department of Housing and Urban Development (HUD) United States Postal Service Zip Code Crosswalk Files. The Crosswalk Files was used to allocate both FQHC’s and FQHC’s sites Zip-Codes to counties. Method: this was a descriptive study. Descriptive statistics included frequencies and percentages to describe categorical variables. In addition, means (standard deviations, SD) will describe continuous variables. The study utilized bivariate analysis, including the chi-square test and ANOVA test, to find differences regarding the competitive forces variables among counties that had a new established FQHCs and counties that did not have newly established FQHCs in California for the years 2014 and 2015. Result: the study found that the number of FQHCs sites and primary care clinics in a county is statistically different between counties that had a newly established FQHC compared to counties that did not have a newly established FQHC. Counties that had newly established FQHCs had on an average a lower number of FQHCs sites and primary care clinics. Competition for FQHCs might arise when more FQHCs exist in a market. More research can be conducted to understand how FQHCs behave in a competitive environment.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population

Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. ClinicalTrials.gov Identifier: NCT03360539.

Comparison of Income Eligibility for Medicaid vs Marketplace Coverage for Insurance Enrollment Among Low-Income US Adults.

The Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option. To assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado. Using 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020. The main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage. The primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively. In this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Graph literacy matters: Examining the association between graph literacy, health literacy, and numeracy in a Medicaid eligible population.

ObjectivesGraphic display formats are often used to enhance health information. Yet limited attention has been paid to graph literacy in people of lower education and lower socioeconomic status (SES). This study aimed to: 1) examine the relationship between graph literacy, numeracy, health literacy and sociodemographic characteristics in a Medicaid-eligible population 2) determine the impact of graph literacy on comprehension and preference for different visual formats.MethodsWe conducted a cross-sectional online survey among people in the US on Medicaid, and of presumed lower education and SES.ResultsThe mean graph literacy score among 436 participants was 1.47 (SD 1.05, range: 0 to 4). Only graph literacy was significantly associated with overall comprehension (p < .001). Mean comprehension scores were highest for the table format (1.91), closely followed by bar graph (1.85) and icon array (1.80). Information comprehension was aligned with preference scores.ConclusionsGraph literacy in a Medicaid-eligible population was lower than previous estimates in the US. Tables were better understood, with icon arrays yielding the lowest score. Preferences aligned with comprehension.Practice implicationsIt may be necessary to reconsider the use of graphic display formats when designing information for people with lower educational levels. Further research is needed.

Impacts of the ACA Medicaid expansion on health behaviors: Evidence from household panel data.

A motivation for increasing health insurance coverage is to improve health outcomes for impacted populations. However, health insurance coverage may alternatively increase risky health behaviors due to ex ante moral hazard, and past research on this issue has led to mixed conclusions. This paper uses a panel of household purchases to estimate the effects of the recent state-level Medicaid expansions resulting from the Affordable Care Act (ACA) on consumption goods that present adverse health risks. We utilize within-household variation to identify whether increases in Medicaid availability impacted household purchase patterns of alcohol, nicotine-related, snack food, and carbonated beverage products. Overall, we find little evidence that the ACA Medicaid expansion led to ex ante moral hazard across any of these products, but we find compelling evidence that the Medicaid expansions reduced cigarette consumption and increased smoking cessation product use among the Medicaid-eligible population.

The Cost of Cost-Sharing: The Impact of Medicaid Benefit Design on Influenza Vaccination Uptake.

Prior research indicates that cost-sharing and lack of insurance coverage reduce preventive services use among low-income persons. State Medicaid policy may affect the uptake of recommended adult vaccinations. We examined the impact of three aspects of Medicaid benefit design (coverage for vaccines, prohibiting cost-sharing, and copayment amounts) on vaccine uptake in the fee-for-service Medicaid population 19–64 years old. We combined previously published reports to obtain state Medicaid policy information from 2003 and 2012. Data on influenza vaccination uptake were taken from the Behavioral Risk Factor Surveillance System. We used a differences-in-differences framework, controlling for national trends and state differences, to estimate the effect of each benefit design factor on vaccination uptake in different Medicaid-eligible populations. Each additional dollar of copayment for vaccination decreased influenza vaccination coverage 1–6 percentage points. The effects of covering vaccines or prohibiting cost-sharing were mixed. Imposing copayments for vaccination is associated with lower vaccination coverage. These findings have implications for the implementation of Medicaid expansion in states that currently impose copayments.

Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013.

Efforts to expand Medicaid while controlling spending must be informed by a deeper understanding of the extent to which the high medical costs associated with severe obesity (having a body mass index of [Formula: see text] or higher) determine spending at the state level. Our analysis of population-representative data indicates that in 2013, severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. Approximately 11 percent of the cost of severe obesity was paid for by Medicaid, 30 percent by Medicare and other federal health programs, 27 percent by private health plans, and 30 percent out of pocket. Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations' access to cost-effective treatment for severe obesity should be part of each state's strategy to mitigate rising obesity-related health care costs.

More states address pharmacists’ provider status recognition

As state legislatures across America look for ways to improve constituents'health and lower health care costs, interest in pharmacist-provided care evidently is increasing. Compared with this timelast year, related state legislative activity is up. Last year, 26 billshad been introduced. So far this year, 75 state bills addressing someaspect of patient access to pharmacists' care have been introduced,as Pharmacy Today went to press. Even more activity is possiblethis year because many states still have time to introduce bills in thissession (see Figure 1).

Making the case for medicaid funding of smoking cessation treatment programs: an application to state-level health care savings.

In spite of cost-saving tobacco-dependence treatments, many state Medicaid programs offer only limited coverage for these treatments. This report builds a case for state-level financial benefits from funding smoking cessation treatment for Medicaid-eligible populations. Applying published cost estimates to state-specific data, we assessed potential health care savings from tobacco-dependence treatments for pregnant women, mothers exposing young children to secondhand smoke, and other adult Medicaid beneficiaries. Across all three populations there was evidence for short-term positive returns on investment. Including counseling and nicotine replacement therapy, estimated net savings were $157,000 annually for pregnant women and their newborns, $33,000 annually within four years for children exposed to smoke at home, and $5 million annually within two years for the general adult Medicaid population in Alabama. Findings suggest that making tobacco-dependence treatment freely available to low-income smokers can produce net savings for state governments within a short period of time.

Journal Digest

Journal Digest

Ensuring equitable access to public health care: Two steps forward, one step back

Advancements by the federal government to extend access to health care to Medicaid eligible populations have been countered by state government efforts to curtail program benefits and eligibility. Fiscally and philosophically-based legislation and Medicaid waivers have created a patchwork of state policies that contradict the original civil rights orientation of the program. This examination of equitable access to Medicaid programs and services reviews individual and community factors and fiscal and institutional barriers that contribute to discriminatory practices and then explores ways in which the Patient Protection and Affordable Care Act (ACA) addresses those issues. We find that the ACA funding authorizations for numerous innovative programs strives to substantially redress issues of discriminatory and inequitable service provision.

Tensions and Teamwork in Nursing and Midwifery Relationships

To explore the practice of midwifery within a busy urban tertiary hospital birth setting and to present findings on the relationships between nurses and midwives in providing maternity care. A focused ethnography on midwifery practice conducted over 2 years (2004-2006) in a teaching hospital serving a primarily Medicaid-eligible population in Northern California. Data were collected through participant observations and in-depth interviews with midwives (N=11) and nurses (N=14). Practices and relationships among the midwives and nurses were examined in an ethnographic framework through thematic analysis. Two themes described the nature of nursing-midwifery relationships: tension and teamwork. Tension existed in philosophic approaches to care, definitions of safe practice, communication, and respect. Teamwork existed when the midwives and nurses worked in partnership with the woman to develop a plan of care. Changes were brought about to improve the midwife-nurse relationship during the conduct of the study. Midwives and nurses experienced day-to-day challenges in providing optimal care for childbearing women. The power of effective teamwork was profound, as was the tension when communication broke down. Failure to include nurses resulted in impaired translation of evidence into practice. All stakeholders in birth practices and policy development must be involved in future research in order to develop effective maternity care models.

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Using the vital records of all infants born alive in Puerto Rico from the year 1995-2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.

State Medicaid Reforms Place More Responsibility on Patients

State Medicaid Reforms Place More Responsibility on Patients

Update on the Effect of a Multidisciplinary Team Clinic on Asthma Outcome for Medicaid-Eligible Inner City Children with Moderate to High-Risk Asthma

RATIONALE: To evaluate hospitalizations/ER visits, oral steroid bursts, and pulmonary function tests (PFT's) in moderate to high-risk, asthmatic children enrolled in a multidisciplinary team (MDT) clinic compared to pre-study values. METHODS: Medicaid-eligible children (5-18 years) with moderate to severe asthma were recruited from the inpatient and outpatient asthma service at Children's Hospital of Michigan. The MDT clinic involves additional resources with access to educational, psychological, pharmacological and social work components. Data is collected at six-month intervals and includes hospitalizations/ER visits, oral steroid bursts, and PFT's. RESULTS: 126 children have been enrolled in the study. 67 have completed 6 months; 54 have completed one year, and 18 have completed two years of the study. At six months the total number of hospitalizations/ER visits for the group of 67 patients was 18, compared to 50 (p = <0.001) pre-enrollment. Steroid bursts for the same group was 38 post enrollment compared to 67 (p = 0.006) pre-enrollment. At 12 months, hospitalizations/ER visits for the group of 54 was 20 versus 81 (p = <0.001) pre-enrollment, and steroid bursts was 46 versus 97 (p = 0.001) pre-enrollment. At 2 years, hospitalizations/ER visits for the group of 18 was 15 versus 49 (p = 0.715) pre-enrollment, and steroid bursts was 37 versus 55 (p = 0.255) pre-enrollment. No difference was detected in PFT results at any point. CONCLUSION: MDT clinic enrollment is shown to decrease hospitalizations and oral steroid bursts in a Medicaid eligible Pediatric population at six and twelve months. This trend also continues at the 2-year mark, however the sample size is not large enough to achieve statistical significance.

Reducing Tobacco Use and Risky Drinking in Underserved Populations: The Need for Better Implementation Models

The prevalence of many health behavior risk factors (eg, smoking, risky drinking, physical inactivity) are highest among uninsured and Medicaid-eligible populations.[1][1] Screening and brief behavioral counseling in high-volume Federally Qualified Health Centers (FQHCs) are key elements of a cost-

The effect of adding Pap smear information to a mammography reminder system in an HMO: results of randomized controlled trial

Background While reminders can promote cancer screening in primary care, little is known about the potential interaction between multiple reminders. Methods We conducted a randomized controlled trial to compare the effect of combined Pap smear plus mammogram reminders and mammogram-only reminders among 2471 women 40 years of age or older enrolled in a health maintenance organization serving a predominately Medicaid-eligible population. Reminders included both a mailed letter for the woman and a medical record prompt. Results Intervention assignment was unassociated with differences in rates of visitation to family medicine or internal medicine or completion of mammography during the study year. Compared to women assigned to mammogram-only reminder treatment, those assigned to the combined Pap smear plus mammogram reminder intervention were more likely to visit a gynecologist (34% compared to 29%, adjusted odds ratio = 1.33, 95% confidence interval 1.08–1.63) and to complete a Pap smear (30% compared to 23%, adjusted odds ratio = 1.39, 95% confidence interval 1.07–1.89). Conclusions In the study setting, the addition of Pap smear to mammography reminders has a procedure-specific effect, increasing gynecology visits and Pap smear use while neither increasing nor decreasing other primary care visits or mammography. We find no evidence of reinforcement or competition between these reminders.

Prevalence of thyroid diseases in Nevada counties with respect to perchlorate in drinking water.

Perchlorate is well-known to inhibit the uptake of iodine by the thyroid and has been shown to do so at doses in the milligrams-per-day range and higher. Perchlorate has been found in the water supply of Clark County (Las Vegas), Nevada, at 4 to 24 micrograms/L (parts per billion) and may provide exposure dosages in the tens of micrograms per day. An analysis of the Medicaid database from Nevada was undertaken to determine whether an increase in the prevalence of any thyroid disease was associated with that level of perchlorate content. The prevalence of persons being seen for thyroid disease or for specific thyroid diseases (goiter, nodule, thyrotoxicosis, congenital hypothyroidism, acquired hypothyroidism, thyroiditis, and other thyroid disorders) and for thyroid cancer among the Medicaid-eligible population of each county was calculated for the 2-year period 1997 to 1998. The prevalences in Clark County were compared with those in Washoe County (i.e., Reno), the second most populous county in the state, and with those for the rest of the state. There was no evidence of an increased rate of thyroid disease (or of any specific thyroid disease) associated with perchlorate exposure. Generally, the prevalences in the metropolitan parts of the state were lower than for the rest of the state, particularly for acquired hypothyroidism. This analysis found no evidence that perchlorate-containing drinking water at the given level increased the prevalence of acquired hypothyroidism or of any other thyroid condition.