Prenatal care use and health insurance status.

Many observers explain the prevalence of inadequate prenatal care in the United States by citing demographic or psychosocial factors. But few have evaluated the barriers faced by women with different health insurance status and socioeconomic backgrounds. In this study of 149 women at six hospitals in Minneapolis, insurance status was significantly related to the source of prenatal care (p less than .0001). Private physicians cared for 52 percent of privately insured, 23 percent of Medicaid-insured, and two percent of uninsured women. Public clinics were the primary source of care for Medicaid and uninsured women, who, compared to privately insured women, experienced longer waiting times (p less than .001) during prenatal visits and were more likely (p less than .01) to lack continuity of care with a provider. Multiple measures, including expanding Medicaid eligibility, may help correct these problems.     

Reconsidering the effect of Medicaid on health care services use.

OBJECTIVE: Our research compares health care use by Medicaid beneficiaries with that of the uninsured and the privately insured to measure the program's effect on access to care. DATA SOURCES/STUDY SETTING: Data include the 1987 National Medical Expenditure Survey and the Survey of Income and Program Participation for 1984-1988. STUDY DESIGN: We predict annual use of ambulatory care and inpatient hospital care for Medicaid beneficiaries receiving AFDC cash assistance and compare it to what their use would be if uninsured or if covered by private insurance. Comparisons are based on multivariate models of health care use that control for demographic and economic characteristics and for health status. Our model distinguishes among Medicaid beneficiaries on the basis of eligibility to account for the poor health of beneficiaries in some eligibility groups. PRINCIPAL FINDINGS: AFDC Medicaid beneficiaries use considerably more ambulatory care and inpatient care than they would if they remained uninsured. Use among the AFDC Medicaid population is about the same as use among otherwise similar, privately insured persons. Use rates differ substantially among different Medicaid beneficiary groups, supporting the expectation that some beneficiary groups are in poor health. CONCLUSIONS: Although Medicaid has increased access to health care services for beneficiaries to rates now comparable to those for the privately insured population, because of lower cost sharing in Medicaid we would expect higher service use than we are finding. This suggests possible barriers to Medicaid patients in receiving the care they demand. Enrollment of less healthy individuals into some Medicaid beneficiary groups suggests that pooled purchasing arrangements that include Medicaid populations must be designed to ensure adequate access for the at-risk populations and, at the same time, to ensure that private employers do not opt out because of high community-rated premiums.     

Uninsured vs. insured population: variations among nonelderly Americans

This study identified the underlying demographic and socioeconomic factors associated with insurance status among nonelderly Americans (age 19-64), as well as compared health care utilization between insured and uninsured. Data from the Community Tracking Study 1996-1997 Household Survey were analyzed. Approximately 74 percent of uninsured Americans are nonelderly Americans. Among the nonelderly Americans, about 17 percent are uninsured. Our findings show that insurance status varies significantly by region, age, race, gender, marital status, income, education, employment status, and health status. Also, the insured nonelderly Americans were found to have better access to health care than the uninsured nonelderly.     

Insurance status and access to primary health care:disparate outcomes for potentially preventable hospitalization

This study examines associations between hospitalization for ambulatory care sensitive (ACS) conditions and insurance status for working age adults, and for people age 65 and older. ACS hospitalization is a recognized indicator of access to primary care. Using data from the 1997 U.S. Nationwide Inpatient Sample and the U.S. Census, we calculate population-based rates of ACS hospitalization. We also use the 1997 Medical Expenditure Panel Survey to calculate the prevalence of ACS conditions in the groups studied. Among working age adults, those receiving Medicaid and the uninsured had higher ACS hospitalization rates than insured individuals, even after adjusting for the prevalence of ACS conditions. Among Medicare beneficiaries, those who also received Medicaid benefits had higher ACS hospitalization rates than others, again after adjusting for the prevalence of ACS conditions; those with private insurance supplementing Medicare had lower ACS hospitalization rates.     

National trends in health insurance coverage of pregnant and reproductive-age women, 2000 to 2009

PurposeHealth insurance facilitates financial access to health services, including prenatal and preconception care. This study characterized changes in health insurance coverage among reproductive-age women in the United States from 2000 to 2009.MethodsData from female respondents (ages 18–49) to the National Health Interview Surveys, 2000 to 2009 (n = 207,968), including those pregnant when surveyed (n = 3,204), were used in a repeated cross-sectional design. Changes over time were estimated using longitudinal regression models.Main FindingsOf the reproductive-age women in this study, 25% were uninsured at some point in the prior year. Ten percent of pregnant women reported currently being uninsured, and 27% and 58% reported Medicaid coverage or private health insurance, respectively. Among women who were not pregnant, 19% were currently uninsured, 8% had Medicaid, and 68% had private coverage. From 2000 to 2009, an increasing percentage of reproductive-age women reported having gone without health insurance in the past year. Controlling for sociodemographic and health variables, the chances that a reproductive-age woman had been uninsured increased by approximately 1.5% annually (p < .001), and did not differ between pregnant women and those who were not pregnant. The odds that an insured pregnant woman had Medicaid coverage increased 7% per year over the study period (p < .001), whereas the odds of private coverage decreased.ConclusionReproductive-age women are increasingly at risk of being uninsured, which raises concerns about access to prenatal and preconception care. Among pregnant women, access to private health insurance has decreased, and state Medicaid programs have covered a growing percentage of women. Health reform will likely impact future trends.     

How Well Does Medicaid Work in Improving Access to Care?

OBJECTIVE: To provide an assessment of how well the Medicaid program is working at improving access to and use of health care for low-income mothers. DATA SOURCE/STUDY SETTING: The 1997 and 1999 National Survey of America's Families, with state and county information drawn from the Area Resource File and other sources. STUDY DESIGN: Estimate the effects of Medicaid on access and use relative to private coverage and being uninsured, using instrumental variables methods to control for selection into insurance status. DATA COLLECTION/EXTRACTION METHOD: This study combines data from 1997 and 1999 for mothers in families with incomes below 200 percent of the federal poverty level. PRINCIPAL FINDINGS: We find that Medicaid beneficiaries' access and use are significantly better than those obtained by the uninsured. Analysis that controls for insurance selection shows that the benefits of having Medicaid coverage versus being uninsured are substantially larger than what is estimated when selection is not accounted for. Our results also indicate that Medicaid beneficiaries' access and use are comparable to that of the low-income privately insured. Once insurance selection is controlled for, access and use under Medicaid is not significantly different from access and use under private insurance. Without controls for insurance selection, access and use for Medicaid beneficiaries is found to be significantly worse than for the low-income privately insured. CONCLUSIONS: Our results show that the Medicaid program improved access to care relative to uninsurance for low-income mothers, achieving access and use levels comparable to those of the privately insured. Our results also indicate that prior research, which generally has not controlled for selection into insurance coverage, has likely understated the gains of Medicaid relative to uninsurance and overstated the gains of private coverage relative to Medicaid.     

Comparing the medical expenses of adults with Medicaid and commercial insurance in a health maintenance organization

The objective of this study was to compare the health care costs of adults with Medicaid aged 19 to 65 years (n = 29,680) and adults in the same age range with commercial insurance (n = 29,680) who were members of the same health maintenance organization between 1996 and 1998. After adjusting for age and sex, income-eligible Medicaid-insured adults were $35 (29 percent) per month more expensive than commercially insured adults. The medically needy/indigent (excluding "spend-down") were $61 (51 percent) per month more expensive than commercially insured adults, and the blind or disabled were $289 (240 percent) per month more expensive. When the analysis adjusted for health status as well as age and sex, however, income-eligible Medicaid adults were $12 (p = 0.01) per month less costly than commercially insured adults. The costs of Medicaid-insured adults were substantially higher than those of commercially insured adults; these differences were likely due to higher rates of pregnancy and to worse health status among the Medicaid cohort.     

Access to care for low-income women: the impact of Medicaid

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.     

The vanishing health care safety net: new data on uninsured Americans.

New data obtained from the Census Bureau shows that the number of Americans without any health insurance increased by 1.3 million between 1989 and 1990, bringing the total number of uninsured to 34.7 million, more than at any time since the passage of Medicare and Medicaid 25 years ago. This increase coincided with a 10.5 percent increase in health spending, the second largest in the past three decades. The number of people covered by Medicaid grew by 3.1 million, due to a one-time expansion of eligibility mandated by Congress, but this was more than counter-balanced by a population growth of 3 million and a decrease of 1.3 million in people covered by private insurance. Had Medicaid not been expanded, the number of uninsured would have increased by 4.4 million. The increase in the uninsured affected virtually all parts of the nation. Seven states had increases of more than 100,000 persons each. Only Texas experienced a decrease of that magnitude, but still had the second highest rate of uninsurance of any state. Of the 1.3 million additional uninsured in 1990, 77 percent were male, 32 percent had family incomes in excess of $50,000 per year, and 74 percent had annual family incomes above $25,000. Fewer than 9 percent had incomes below the poverty line. The numbers of uninsured children and senior citizens fell slightly (but not significantly), while the number of uninsured working-age adults rose by 1.4 million. The number of uninsured workers in each of four of 20 major industry groups increased by more than 100,000 in 1990. None of the industry groups showed a significant decline in the number of uninsured. Among professionals, there were substantial numbers of uninsured doctors, engineers, teachers, college professors, clergy, and others, but all legislators and judges were insured. The data presented here largely predate the recession and understate current problems. In 1991 the number of uninsured will likely reach nearly 40 million. Also, these estimates are based on the number of people uninsured at a single time during 1990; a far higher number were temporarily uninsured at some point during the year. Moreover the Census Bureau survey ignores the problem of the underinsurance of at least 50 million insured Americans. Patchwork public programs are grossly inadequate to plug the holes. A national health program covering all Americans could assure access to care and contain costs.     

State Medicaid fees and access to primary care physicians

Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients. Appointment offers and wait times for Medicare and privately insured patients were unaffected by Medicaid fees. At mean state Medicaid fees, our analysis predicts a 27‐percentage‐point disadvantage for Medicaid versus Medicare in appointment offers. This decreases to 6 percentage points when Medicaid and Medicare fees are equal, suggesting that permanent fee parity with Medicare could eliminate most of the disparity in appointment offers for Medicaid patients. The predicted decrease in the disparity is smaller for Black and Hispanic patients than for White patients. Our research highlights the importance of considering the effects of policy on nontarget patient groups, and the consequences of seemingly race‐neutral policies on racial/ethnic and sex‐based disparities.     

The impact of Medicaid on physician use by low-income children.

This study evaluated the determinants of physician use by low-income children, with an emphasis on the effect of Medicaid. Data are from the 1980 National Medical Care Utilization and Expenditure Survey. Regression analysis revealed that Medicaid children were more likely than both privately insured and uninsured children to visit an office-based physician. Also, Medicaid children with at least one visit to any setting had a higher number of visits than uninsured children. Such factors as age, health status, number of children in the family, educational status, and income also accounted for differences within the low-income population. The results suggest that access to physicians' services (including office-based physicians) can be increased by expanding Medicaid eligibility to uninsured low-income children and by improving private health insurance benefits among the underinsured.     

The prevalence of low income among childbearing women in California: implications for the private and public sectors.

OBJECTIVES: This study examined the income distribution of childbearing women in California and sought to identify income groups at increased risk of untimely prenatal care. METHODS: A 1994/95 cross-sectional statewide survey of 10,132 postpartum women was used. RESULTS: Sixty-five percent of all childbearing women had low income (0%-200% of the federal poverty level), and 46% were poor (0%-100% of the federal poverty level). Thirty-five percent of women with private prenatal coverage had low income. Most low-income women with Medi-Cal (California's Medicaid) or private coverage received their prenatal care at private-sector sites. Compared with women with incomes over 400% of the poverty level, both poor and near-poor women were at significantly elevated risk of untimely care after adjustment for insurance, education, age, parity, marital status, and ethnicity (adjusted odds ratios = 5.32 and 3.09, respectively). CONCLUSIONS: This study's results indicate that low-income women are the mainstream maternity population, not a "special needs" subgroup; even among privately insured childbearing women, a substantial proportion have low income. Efforts to increase timely prenatal care initiation cannot focus solely on women with Medicaid, the uninsured, women in absolute poverty, or those who receive care at public-sector sites.     

Impact of the HealthChoice Program on Cesarean Section and Vaginal Birth after C-Section Deliveries: A Retrospective Analysis

Objective To assess the impact of the HealthChoice program in Maryland on cesarean section and vaginal birth after C-section deliveries. Study Design Pre-post design using a comparison group with Maryland State Inpatient Databases, part of the Healthcare Cost and Utilization Project, developed by the Agency for Healthcare Research and Quality. Although the combined 1995 and 2000 database contained over 1.2 million inpatient discharge records, the analysis included all hospital discharge abstracts for women in labor. To identify the delivery, Diagnoses-Related Groups (DRGs) 370–375 were used from the discharge data. Together, there were 128,743 births identified in both years. Methods Pregnant women enrolled in Medicaid managed care were compared pre-implementation and post implementation with pregnant women delivering babies under private insurance. The analysis computed difference-in-differences estimates using a logistic regression model that controlled for maternal characteristics, payment source, labor and delivery complications, and hospital characteristics. The outcome variables included Primary Cesarean, Repeat Cesarean, and Vaginal Birth after C-section. Results These results suggest that Medicaid managed care enrollees were less likely to undergo cesarean section deliveries relative to privately insured beneficiaries. Medicaid MCOs may have done a better job of limiting the growth in overused procedures than did MCOs and providers for privately insured women. Conclusion This study has shown that there has been an overall increase in the use of primary and repeat cesarean sections in Maryland hospitals. However, HealthChoice limited this increase for Medicaid enrollees relative to privately insured women. On the other hand, vaginal births after C-section have declined in Maryland.     

Surgery Wait Times and Specialty Services for Insured and Uninsured Breast Cancer Patients: Does Hospital Safety Net Status Matter?

Objective

To determine whether safety net and non-safety net hospitals influence inpatient breast cancer care in insured and uninsured women and in white and African American women.

Data Sources

Six years of Virginia Cancer Registry and Virginia Health Information discharge data were linked and supplemented with American Hospital Association data.

Study Design

Hierarchical generalized linear models and linear probability regression models were used to estimate the relationship between hospital safety net status, the explanatory variables, and the days from diagnosis to mastectomy and the likelihood of breast reconstruction.

Principal Findings

The time between diagnosis and surgery was longer in safety net hospitals for all patients, regardless of insurance source. Medicaid insured and uninsured women were approximately 20 percent less likely to receive reconstruction than privately insured women. African American women were less likely to receive reconstruction than white women.

Conclusions

Following the implementation of health reform, disparities may potentially worsen if safety net hospitals’ burden of care increases without commensurate increases in reimbursement and staffing levels. This study also suggests that Medicaid expansions may not improve outcomes in inpatient breast cancer care within the safety net system.     

Association of Insurance Status with Patient Health at New Orleans Student-Run Free Clinics

Since the closure of Charity Hospital after Hurricane Katrina, New Orleans Student-Run Free Clinics have helped fill the resulting void in healthcare access for the underserved New Orleans population. To better understand the health insurance status and health outcomes of this patient population, 1036 patient records from seven New Orleans Student-Run Free Clinics were collected and analyzed between February 2017 and March 2020. Insurance status was significantly associated with gender, race, homelessness, and prior incarceration, but not with education. Substance use rehabilitation centers had low uninsured rates, while homeless shelters had higher uninsured rates. Patients on Non-Medicaid insurance were most likely to be prescribed a medication for diabetes (p?=?.01), hypertension (p?=?.21), and psychiatric conditions (p?=?.04), followed by those on Medicaid, and then those who were uninsured. This study demonstrates the benefits of health insurance and provides important data that can inform future health insurance enrollment efforts and health policy.

     

Physician fees and procedure intensity: the case of cesarean delivery.

While there is a large literature investigating the response of treatment intensity to Medicare reimbursement differentials, there is much less work on this question for the Medicaid program. The answers for Medicare may not apply in the Medicaid context, since a smaller share of a physician's patients will be Medicaid insured, so that income effects from fee changes may be dominated by substitution effects. We investigate the effect of Medicaid fee differentials on the use of cesarean delivery over the period 1988-1992. We find, in contrast to the backward-bending supply curve implied by the Medicare literature, that larger fee differentials between cesarean and normal childbirth for the Medicaid program leads to higher cesarean delivery rates. In particular, we find that the lower fee differentials between cesarean and normal childbirth under the Medicaid program than under private insurance can explain between one half and three-quarters of the difference between Medicaid and private cesarean delivery rates. Our results suggest that Medicaid reimbursement reductions can cause real reductions in the intensity with which Medicaid patients are treated.     

Hospital financing and neonatal intensive care.

OBJECTIVE: To investigate the relationship between hospital financing patterns and hospital resources for the care of babies born at low birthweight in New York City. DATA SOURCES AND STUDY SETTING: Data on neonatal care beds in New York City hospitals for 1991, obtained from the Greater New York Hospital Association, which were matched to 1991 hospital-specific birthweight and payment distributions from the New York State Department of Health. STUDY DESIGN: Statistical analyses were used to assess the relationship between insurance and beds across all hospitals and across hospitals classified by ownership and teaching status. PRINCIPAL FINDINGS: After adjusting for low birthweight and other measures of patient need and for hospital affiliation, the study finds that hospitals with more privately insured patients, especially those with more privately insured low-birthweight newborns, have statistically significantly more neonatal intensive care beds than do those with fewer such patients. This result persists within hospital affiliation categories. CONCLUSIONS: These results suggest that differences in the care received by privately insured, Medicaid insured, and uninsured low-birthweight babies may stem from differences in the resources available to the hospitals that treat these patients.     

The roles of teaching hospitals, insurance status, and race/ethnicity in receipt of adjuvant therapy for regional-stage breast cancer in Florida

OBJECTIVES: We examined the roles of teaching hospitals, insurance status, and race/ ethnicity in women's receipt of adjuvant therapy for regional-stage breast cancer. METHODS: Data were taken from the Florida Cancer Data System for cases diagnosed from July 1997 to December 2000. We evaluated the impact of health insurance status and hospital type on use of adjuvant therapy (after adjustment for age, race/ethnicity, and marital status). Interaction terms for hospital type, insurance status, and race/ethnicity were entered in each model. RESULTS: Teaching facilities diagnosed 12.5% of the cases; however, they cared for a disproportionate percentage (21.3%) of uninsured and Medicaid-insured women. Among women who received adjuvant chemotherapy only, those diagnosed in teaching hospitals were more likely than those diagnosed in nonteaching hospitals to receive therapy regardless of insurance status or race/ethnicity. Among women who received chemotherapy with or without hormonal therapy, Hispanics were more likely than White non-Hispanic women to receive therapy, whereas women with private insurance or Medicare were less likely than uninsured and Medicaid-insured women to receive this type of therapy. CONCLUSIONS: Teaching facilities play an important role in the diagnosis and treatment of regional-stage breast cancer among Hispanics, uninsured women, and women insured by Medicaid.