Preconception subsidized insurance: Prenatal care and birth outcomes by race/ethnicity

Low‐income pregnant women have been Medicaid eligible since the 1980s, but the Affordable Care Act (ACA)'s expansion of Medicaid to women preconception has the potential to improve pregnancy and birth outcomes by removing delays in Medicaid enrollment. More substantially, the ACA expanded subsidized nongroup maternity coverage. Pre‐ACA, nongroup health insurance had generally excluded maternity coverage and was prohibitively expensive for low‐income individuals, but the ACA's creation of the Marketplace made maternity coverage mandatory and provides income‐based subsidies. I use a simulated eligibility approach to measure how these two aspects of the ACA impacted pregnancy and birth outcomes for first‐time mothers, paying special attention to racial‐ethnic differences. I find expanding Medicaid to women prior to pregnancy significantly improves the share of women with a prenatal care visit in the first trimester for non‐Hispanic Whites and Blacks. Expansions in non‐Medicaid subsidized insurance, such as Marketplace insurance, significantly reduce the share of births paid by Medicaid and increased breastfeeding across all racial and ethnic groups. Neither type of subsidized insurance had significant, robust impacts on birth outcomes.     

Parents' perceptions of pediatric primary care quality: effects of race/ethnicity,language, and access

OBJECTIVE: To examine the effects of race/ethnicity, language, and potential access on parents' reports of pediatric primary care experiences. DATA SOURCES/STUDY SETTING: Primary survey data were collected (67 percent response rate) from 3,406 parents of students in kindergarten through sixth grade in a large urban school district in California during the 1999-2000 school year. DATA COLLECTION: The data were collected by mail, telephone, and in person. Surveys were administered in English, Spanish, Vietnamese, and Tagalog. STUDY DESIGN: Data were analyzed using multiple regression models. The dependent variable was parents' reports of primary care quality, assessed via the previously validated Parents' Perceptions of Primary Care measure (P3C). The independent variables were race/ethnicity, language, and potential access to care (insurance status, presence of a regular provider of care), controlling for child age, gender, and chronic health condition status, and mother's education. PRINCIPAL FINDINGS: Parents' reports of primary care quality varied according to race/ethnicity, with Asian and Latino parents reporting lower P3C scores than African Americans and whites. In multivariate analyses, both language and potential access exerted strong independent effects on primary care quality, reducing the effect of race/ethnicity such that the coefficient for Latinos was no longer significant, and the coefficient for Asians was much smaller, though still statistically significant. CONCLUSIONS: To reduce racial/ethnic disparities in primary care, attention should be paid both to policies aimed at improving potential access and to providing linguistically appropriate services.     

Access for pregnant women on Medicaid: variation by race and ethnicity

Disparities in early and adequate prenatal care and infant/maternal outcomes still exist between white and nonwhite populations. Although Medicaid expansions were intended to improve outcomes, eligible women often delay enrollment and access barriers remain. This study examines racial disparities among pregnant women in Florida, Georgia, New Jersey, and Texas. The disproportionate location of minorities enrolled in Medicaid in urban areas with greater physician supply was not found to increase office-based prenatal care among blacks. More local physicians, especially foreign medical graduates, sometimes increased access, largely for Hispanics. The presence and use of safety net providers did increase prenatal care use among minorities. This evidence lends support to policies to maintain safety net providers, which are perhaps better equipped than others to serve low-income populations. However, policies should encourage participation extending to all racial/ethnic groups by office-based physicians. The role of foreign medical graduates, who are more likely to participate in Medicaid, should be considered.     

The effects of race/ethnicity and income on early childhood asthma prevalence and health care use

OBJECTIVES: Asthma is the most common chronic illness among US children and is most prevalent in low-income and minority groups. We used multivariate models to disentangle the effects of race/ethnicity, income, and other individual-level risk factors on asthma in a population-based sample of children aged 3 years. METHODS: Data are from the 1988 National Maternal and Infant Health Survey and 1991 Longitudinal Follow-Up. Odds ratios of asthma prevalence, hospitalization, and emergency room use were estimated, with control for socioeconomic characteristics, health behaviors, and insurance. RESULTS: Asthma prevalence, hospitalization, and emergency room use declined with increasing income for non-Black but not Black children. CONCLUSIONS: Lifetime income and sociodemographic characteristics do not explain the excess risks of asthma and emergency health care use for asthma among young Black children.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance.

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is: (1) to identify problems associated with the quality of hysterectomy care accessed by members of SEWA, an Indian CBHI scheme; and (2) to discuss mechanisms that might be put in place by SEWA, and CBHI schemes more generally, to optimize quality of health care. Data on the structure and process of hysterectomy care were collected primarily through review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varies tremendously, from potentially dangerous to excellent. Seemingly dangerous aspects of structure include: operating theatres without separate hand-washing facilities or proper lighting; and the absence of qualified nursing staff. Dangerous aspects of process include: performing hysterectomy on demand; removing both ovaries without consulting or notifying the patient; and failing to send the excised organs for histopathology, even when symptoms and signs are suggestive of disease. Women pay substantial amounts of money even for care of poor, and potentially dangerous, quality. In order to improve the quality of hospital care accessed by its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate cases where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocation decisions; (3) select, and contract with, providers who provide a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better-quality care and contract directly with them.     

Person and place: the compounding effects of race/ethnicity and rurality on health

Rural racial/ethnic minorities constitute a forgotten population. The limited research addressing rural Black, Hispanic, and American Indian/Alaska Native populations suggests that disparities in health and in health care access found among rural racial/ethnic minority populations are generally more severe than those among urban racial/ethnic minorities. We suggest that disparities must be understood as both collective and contextual phenomena. Rural racial/ethnic minority disparities in part stem from the aggregation of disadvantaged individuals in rural areas. Disparities also emerge from a context of limited educational and economic opportunity. Linking public health planning to the education and economic development sectors will reduce racial/ethnic minority disparities while increasing overall well-being in rural communities.     

Paternal race/ethnicity and birth outcomes

Objectives. I sought to identify whether there were associations between paternal race/ethnicity and birth outcomes among infants with parents of same- and mixed-races/ethnicities.Methods. Using the National Center for Health Statistics 2001 linked birth and infant death file, I compared birth outcomes of infants of White mothers and fathers of different races/ethnicities by matching and weighting racial/ethnic groups following a propensity scoring approach so other characteristics were distributed identically. I applied the same analysis to infants of Black parents and infants with a Black mother and White father.Results. Variation in risk factors and outcomes was found in infants of White mothers by paternal race/ethnicity. After propensity score weighting, the disparities in outcomes by paternal or parental race/ethnicity could be largely attributed to nonracial parental characteristics. Infants whose paternal race/ethnicity was unreported on their birth certificates had the worst outcomes.Conclusions. The use of maternal race/ethnicity to refer to infant race/ethnicity in research is problematic. The effects of maternal race/ethnicity on birth outcomes are estimated to be much larger than that of paternal race/ethnicity after I controlled for all covariates. Not listing a father on the birth certificate had a strong association with outcomes, which might be a source of bias in existing data and a marker for identifying infants at risk.Despite great improvement in birth outcomes in the United States, significant and continuing differences persist across racial and ethnic groups. The low-birthweight (LBW; defined as a birthweight less than 2500 g) rate of non-Hispanic Black infants has been steadily nearly double that of non-Hispanic White infants.^1,2 Therefore, Black mothers are usually the focus of birth-outcome disparity research and policy, whereas White mothers are regarded to be at a lower risk. These disparities are believed to result from complex interactions among genetic variations, social and environmental factors, and specific health behaviors.^3–5Most previous research, when referring to an infant''s race/ethnicity, used maternal race/ethnicity instead of infant race/ethnicity both because the child''s race may not be clear in the case of mixed race and because the mother''s race/ethnicity is thought to have more influence on birthweight than the father''s race/ethnicity.⁶ Furthermore, the father''s information is often not available in the data sets of choice.This common practice might be a serious analytic shortcoming because it overlooks the father''s race/ethnicity and it treats infants of mixed-race parents and those of same-race parents equally. Furthermore, even when the father''s race/ethnicity is available and included as an indicator variable, most models don’t allow coefficients of covariates to differentiate between groups, which implicitly assumes no other difference between parents of mixed- and same-race/ethnicity except for their race/ethnicity.Many studies have shown different patterns in socioeconomic characteristics between intermarriage and endogamous marriage in the United States. On the basis of 1990 US census data, Fu found that Black or Mexican American husbands’ White wives had less schooling than did the White wives of White husbands.⁷ Fu explained this pattern by using both the status exchange and in-group preference hypotheses. Status exchange hypothesizes that in a marriage market framework, minority men marry less-desired White women (e.g., of lower education) in exchange for higher social status. The second hypothesis, in-group preference, simply suggests that people prefer members from their own group, and thus, intermarriage is the less desirable scenario.According to the National Center for Health Statistics (NCHS) natality files, between 1968 and 1996, the proportion of infants born to 1 Black and 1 White parent increased gradually from 0.33% to 1.77%, and the proportion of infants born to 1 Asian/Pacific Islander parent and 1 White parent also increased substantially, from 0.25% to 1.21%.⁸ These mixed-race infants provide a unique chance to investigate associations between both maternal and paternal race/ethnicity and infant outcomes. To date, only a few studies have examined birth outcomes of interracial infants, and all of these studies focused on Black and White mixed-race infants. Together they found that mixed-race couples differed significantly with respect to their sociodemographic characteristics from the endogamous couples. After control for those variables, biracial infants were found to have worse birth outcomes than infants with 2 White parents but better than infants with 2 Black parents.^6,8–12 (Henceforth, infant''s race/ethnicity will be referred to by the notation “maternal race/ethnicity–paternal race/ethnicity” [e.g., White–Black].)However, these studies have several limitations. First, they didn''t examine groups other than Black and White race. Second, paternal information is often missing from natality data, especially for infants of Black mothers. Although these infants are more likely to have adverse birth outcomes,^10–13 they are often omitted from studies. Third, none of these studies examined Apgar score (a routine evaluation of the general physical condition of the newborn usually performed at 1 and 5 minutes after delivery) as a birth outcome, although it has been repeatedly found to have strong predictive power for infant mortality.^14,15 In terms of method, previous studies used multivariate regressions or logistic models with a categorical variable of race combinations. A potential concern regarding this approach is that it assumes covariates have the same effects (coefficients) on outcomes of interest across all racial combinations.I investigated differences in birth outcomes (i.e., birthweight, LBW rate, 5-minute Apgar score, and infant mortality) for infants born to non-Hispanic White mothers and non-Hispanic Black fathers (henceforth, White and Black refer to non-Hispanic White and non-Hispanic Black) and those born to White mothers and fathers of 6 other selected racial/ethnic groups. I hypothesized that paternal race/ethnicity might affect birth outcome, but this influence would be smaller than that of maternal race/ethnicity because mothers play a more important role than fathers in the course of pregnancy and delivery.     

Blood cadmium levels in women of childbearing age vary by race/ethnicity

The heavy metal cadmium (Cd) is long-lived in the body and low-level cumulative exposure, even among non-smokers, has been associated with changes in renal function and bone metabolism. Women are more susceptible to the adverse effects of Cd and have higher body burdens. Due to increased dietary absorption of Cd in menstruating women and the long half-life of the metal, reproductive age exposures are likely important contributors to overall body burden and disease risk. We examined blood Cd levels in women of reproductive age in the US and assessed variation by race/ethnicity. Blood Cd concentrations were compared among female NHANES participants aged 20-44, who were neither pregnant nor breastfeeding. Sample size varied primarily based on inclusion/exclusion of smokers (n=1734-3121). Mean Cd concentrations, distributions and odds ratios were calculated using SUDAAN. For logistic regression Cd was modeled as high (the upper 10% of the distribution) vs. the remainder. Overall, Mexican Americans had lower Cd levels than other groups due to a lower smoking prevalence, smoking being an important source of exposure. Among never-smokers, Mexican Americans had 1.77 (95% CI: 1.06-2.96) times the odds of high Cd as compared to non-Hispanic Whites after controlling for age and low iron (ferritin). For non-Hispanic Blacks, the odds were 2.96 (CI: 1.96-4.47) times those of non-Hispanic Whites in adjusted models. Adjustment for relevant reproductive factors or exposure to environmental tobacco smoke had no effect. In this nationally representative sample, non-smoking Mexican American and non-Hispanic Black women were more likely to have high Cd than non-Hispanic White women. Additional research is required to determine the underlying causes of these differences.     

Health care organizations' use of race/ethnicity data to address quality disparities

Health care organizations-health plans, hospitals, community health centers, clinics, and group practices-can play an important role in the elimination of racial/ethnic disparities in health care. There are now a number of examples of organizations that have been successful in reducing or eliminating disparities, and a number of published examples of how quality improvement initiatives can improve care for members of targeted minority groups, thereby contributing to the elimination of disparities.     

Intended use of informal long-term care: the role of race and ethnicity

Objective. To examine the role of race/ethnicity in the use of informal long‐term care among African American and white elders, using an expanded Andersen model of health services use (Bradley et al., Health Services Research, vol. 37, pp. 1221–1242, 2002).

Design. Four hundred respondents (n = 200 African American; n=200 white) aged 65 and older, who had been hospitalized within the last year. Data were collected using a cross‐sectional survey analyzed with ordered logistic regression. Independent variables included individuals' predisposing factors, enabling factors, need, and psychosocial factors. Intended use of informal long‐term care was defined based on responses to a hypothetical scenario of future use of unpaid services by family members, relatives, friends, or neighbors for help with daily needs.

Results. African American respondents were more likely than white respondents to intend to use informal long‐term care. This effect persisted (p < 0.05) after controlling for predisposing, enabling, and need factors. However, race/ethnicity‐related differences in intended use were attenuated substantially (14–18%) after controlling for psychosocial differences. Further, in the fully adjusted models, race/ethnicity was no longer significantly associated with intended long‐term care use.

Conclusions. Psychosocial factors, particularly social norms concerning family caregiving, mediated the relationship between race/ethnicity and intended use of informal long‐term care. A fuller appreciation of the multiple influences on healthcare decision making of older adults has the potential to inform policy efforts to appropriately meet the respective long‐term care needs of an ethnically diverse frail older population.     

The relationship between the race/ethnicity of generalist physicians and their care for underserved populations.

OBJECTIVES: The purpose of this study was to examine empirically the relationship between physicians' race or ethnicity and their care for medically underserved populations. METHODS: Generalist physicians who received the MD degree in 1983 or 1984 (n = 1581) were surveyed. The personal and background characteristics of four racial/ethnic groups of physicians were compared with the characteristics of their patients. RESULTS: When the potentially confounding variables of gender, childhood family income, childhood residence, and National Health Services Corps financial aid obligations were controlled, generalist physicians from underrepresented minorities were more likely than their nonminority counterparts to care for medically underserved populations. CONCLUSIONS: Physicians from underrepresented minorities are more likely than others to care for medically underserved populations.     

Fast food, race/ethnicity, and income: a geographic analysis

BACKGROUND: Environmental factors may contribute to the increasing prevalence of obesity, especially in black and low-income populations. In this paper, the geographic distribution of fast food restaurants is examined relative to neighborhood sociodemographics. METHODS: Using geographic information system software, all fast-food restaurants within the city limits of New Orleans, Louisiana, in 2001 were mapped. Buffers around census tracts were generated to simulate 1-mile and 0.5-mile "shopping areas" around and including each tract, and fast food restaurant density (number of restaurants per square mile) was calculated for each area. Using multiple regression, the geographic association between fast food restaurant density and black and low-income neighborhoods was assessed, while controlling for environmental confounders that might also influence the placement of restaurants (commercial activity, presence of major highways, and median home values). RESULTS: In 156 census tracts, a total of 155 fast food restaurants were identified. In the regression analysis that included the environmental confounders, fast-food restaurant density in shopping areas with 1-mile buffers was independently correlated with median household income and percent of black residents in the census tract. Similar results were found for shopping areas with 0.5-mile buffers. Predominantly black neighborhoods have 2.4 fast-food restaurants per square mile compared to 1.5 restaurants in predominantly white neighborhoods. CONCLUSIONS: The link between fast food restaurants and black and low-income neighborhoods may contribute to the understanding of environmental causes of the obesity epidemic in these populations.     

Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care

OBJECTIVE: To test for discrimination by race/ethnicity arising from clinical uncertainty in treatment for depression, also known as "statistical discrimination." DATA SOURCES: We used survey data from 1,321 African-American, Hispanic, and white adults identified with depression in primary care. Surveys were administered every six months for two years in the Quality Improvement for Depression (QID) studies. Study DESIGN: To examine whether and how change in depression severity affects change in treatment intensity by race/ethnicity, we used multivariate cross-sectional and change models that difference out unobserved time-invariant patient characteristics potentially correlated with race/ethnicity. DATA COLLECTION/EXTRACTION METHODS: Treatment intensity was operationalized as expenditures on drugs, primary care, and specialty services, weighted by national prices from the Medical Expenditure Panel Survey. Patient race/ethnicity was collected at baseline by self-report. PRINCIPAL FINDINGS: Change in depression severity is less associated with change in treatment intensity in minority patients than in whites, consistent with the hypothesis of statistical discrimination. The differential effect by racial/ethnic group was accounted for by use of mental health specialists. CONCLUSIONS: Enhanced physician-patient communication and use of standardized depression instruments may reduce statistical discrimination arising from clinical uncertainty and be useful in reducing racial/ethnic inequities in depression treatment.