Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults

Objectives. We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.Methods. We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992–2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.Results. The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.Conclusions. Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.Implemented in 1965, Medicaid was designed as publicly funded health insurance coverage for indigent US citizens and legal permanent residents. The program is jointly funded by the state and federal governments, and states are mandated to provide coverage for children younger than 6 years whose family incomes fall below 133%, children between ages 6 and 17 years whose family incomes fall below 100%, and pregnant women whose incomes fall below 133% of the federal poverty level, as defined by the US Department of Health and Human Services1; individuals who are aged, blind, or disabled and who are eligible for Supplemental Security Income; and low-income Medicare beneficiaries. This program has provided health insurance access to a significant number of previously uninsured low-income Americans and continues to be the only route to health care coverage for many people.Nationwide, Medicaid coverage has been found to be associated with several positive outcomes. Medicaid recipients have greater access to medical treatment than uninsured individuals and, therefore, fewer emergency department visits.2–6 Medicaid enrollees have better overall health and lower mortality rates over time than uninsured persons, likely because they have increased access to treatment.7–10 As a result, their medical care is significantly less costly to society, because health problems are more likely to be addressed before the onset of complications and adverse outcomes.11Although the implementation of the Medicaid program has been a largely successful attempt to provide medical insurance, a significant number of low-income adults remain uninsured, mainly because childless adults without qualifying disabilities are ineligible.12–14 In response to this disparity, some states have developed programs to broaden eligibility criteria through a Section 1115 waiver. Massachusetts was among the first states to implement such an initiative, establishing the MassHealth program in July 1997. Among other provisions, the program extended Medicaid eligibility to families and childless adults whose incomes fell below 200% and 133% of the federal poverty level, respectively. MassHealth was jointly funded by the federal and state governments, with Massachusetts paying for roughly 46% of the program.15,16Outcome evaluations of the MassHealth program demonstrated it to be remarkably successful, with significant declines in uninsured rates, particularly among childless adults who would otherwise be ineligible for Medicaid coverage.17,18 Research by Long et al. found that the MassHealth program resulted in a 33% decrease in the rate of uninsured Massachusetts residents.19 Furthermore, Quigley et al. reported that the MassHealth program covers nearly 1 in 6 Massachusetts residents.15 Consequently, it is estimated that only 6% of adults and 3% of children in Massachusetts remained uninsured after implementation of the program.Although evaluations of MassHealth have provided strong support for the program, some evidence suggests that certain marginalized populations are less affected by Medicaid expansion policies than others.16,20 Despite meeting the income eligibility criteria, many people living in poverty remain uninsured because they don''t know they are eligible, they don''t know how to obtain coverage, or they lack any form of identification.21,22 Homeless adults are disproportionately affected by lack of insurance and are reportedly difficult to enroll in public insurance programs.23,24 Although Massachusetts developed several approaches for targeting this hard-to-reach population, evidence suggests that the effort to enroll homeless adults and keep them enrolled faces many logistical barriers.16These challenges are even greater among homeless individuals with substance use disorders. These disorders are common among homeless persons, with prevalence estimates of 40% to 60%.25,26 These individuals generally have significantly greater health care needs, for treatment of, for example, psychiatric disorders, HIV and other sexually transmitted infections, hepatitis, liver disease, lung disease, and wound and skin infections.27–30 The premature mortality rate is significantly higher for homeless individuals than for the general population,27,31 and homeless people with substance use disorders are even more disproportionately affected.31,32 Finally, substance abuse is among the strongest predictors of returning to homelessness among formerly homeless individuals.33–36 Therefore, homeless adults'' lack of the Medicaid coverage necessary to obtain treatment is a significant public health concern.Assessing the impact of MassHealth is especially important in the context of national policy initiatives. Currently, many low-income childless adults qualify for Medicaid benefits because of a physical or mental health disability, but substance abuse is not among the conditions that confer eligibility, so many substance-abusing homeless adults who do not have children are ineligible for Medicaid coverage. However, a major provision of the Affordable Care Act is that all individuals with incomes that fall at or below 133% of the federal poverty level will be eligible for Medicaid effective January 2014, irrespective of parental or disability status. Although a Supreme Court ruling in June 2012 rejected a mandate for states to expand coverage,37 it is still expected that a significant portion of individuals with substance use disorders will benefit tremendously from the law''s expanded eligibility.To date, no large-scale quantitative evaluation has attempted to determine whether marginalized population groups, such as homeless substance-abusing adults, still have difficulty obtaining coverage under the Medicaid expansion.16,20–24 Data from state programs such as MassHealth are useful in assessing whether these groups will benefit from Medicaid expansion to the same extent as other population groups or may be in need of targeted interventions to improve their access. We examined administrative data on admissions to substance abuse treatment programs from 1992 to 2009 to assess the uptake of Medicaid coverage by substance-abusing homeless adults after the implementation of MassHealth in 1997. We assessed whether homeless adults entering substance use disorder treatment programs were less likely than housed adults to be covered by Medicaid. To rule out the potential impact of secular trends in national Medicaid coverage, we compared uptake of Medicaid coverage in adults entering substance abuse programs after 1997 in Massachusetts with rates in other states.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Latino Population Growth and Hospital Uncompensated Care in California

Objectives. We examined the association between the size and growth of Latino populations and hospitals’ uncompensated care in California.Methods. Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models.Results. We found a significant association between the growth of California’s Latino population and hospitals’ uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant.Conclusions. Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals’ uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.Uncompensated hospital care for the uninsured and underinsured imposes a significant financial burden on the US health care system. The American Hospital Association reported that uncompensated care rose to $45.9 billion in 2012, which accounted for 6.1% of total hospital expenses that year.1 This problem affects hospitals’ financial stability and ability to recoup losses from reduced payments, which in turn can hurt their ability to care for the local population, operate emergency department and specialty services to meet patient needs, and maintain optimal nurse staffing ratios.2–4Hospitals have typically responded to increased uncompensated care by increasing prices for paying patients5; however, Medicaid and Medicare payments have been reduced, and it has become more difficult to shift costs to private payers. Uncompensated care also affects all levels of government, which provide subsidies to offset these losses through other programs.6 The largest source of federal funding for uncompensated care—Medicaid Disproportionate Share Hospital (DSH) payments—totaled $11.4 billion in 2012.7 Despite these mechanisms that indirectly subsidize hospitals’ provision of uncompensated care, hospital closures have been linked to uncompensated care.8Hospital administrators, policymakers, and advocates for the uninsured hoped that the Patient Protection and Affordable Care Act (ACA) would provide health insurance to many of the almost 50 million previously uninsured Americans and thereby significantly reduce uncompensated care. The Supreme Court’s decision on the ACA allows states to opt out of the mostly federally funded Medicaid expansion, which will likely lower the projected numbers of Americans who obtain coverage and potentially undermine the predicted decreases in future uncompensated care by hospitals.9 Existing policy efforts focus on decreasing hospital payments to reduce health care spending,10 and DSH payments are being reduced in anticipation of increases in insurance coverage in all states.11 These recent health policy developments have brought the problem of uncompensated hospital care into a new focus, generating increasing interest in understanding what factors affect hospitals’ financial stress.Some have suggested that immigrants use large amounts of uncompensated care,12 potentially implicating the Latino population—the nation’s largest immigrant group13—in rising uncompensated care. However, hospital uncompensated care may also decrease because of Latinos’ low health care utilization14–21 and expenditures,22–25 which have been described in the context of the healthy immigrant effect (i.e., Latino immigrants are usually younger and healthier than Latinos born in the United States)26 and other factors (e.g., fewer available health care resources, lack of linguistically appropriate care, discrimination in health care settings, and fear of deportation among undocumented Latinos).27,28 Empirical evidence for the potential impact of changing Latino demographics on hospitals’ uncompensated care is limited at best. A study of Oregon state data found weak evidence of an association between the size of the Latino population and hospital uncompensated care.27 A nonsignificant relationship might have reflected Latinos’ immigrant status, limited health care access, and unwillingness or inability to seek health care.California’s hospitals account for more than 10% of uncompensated care nationally.29 California has the largest Latino population of any state, as well as the largest growth rate in its Latino population.29 In 2012, 44.5% of California''s uninsured population was Latino.30 Among the uninsured Latino population in the state, more than 1 million will remain uninsured, even after the ACA’s coverage expansions.31,32 Although some are able to temporarily access emergency Medicaid services for significant, emergent health issues, the majority are uninsured and require help from local indigent care programs, hospital charity care, federally qualified health centers, or other safety net providers. Hence, California, because of its high number (7 million) and percentage (20%) of uninsured residents prior to the ACA,33 offers an excellent setting to study the impact of the Latino population on the uninsured rate, uncompensated care need, and local safety net providers.We examined the association between Latino population growth rates and hospitals’ uncompensated care in California between 2000 and 2010. These growth rates not only reflected the marginal increases in uncompensated care and Latino population estimates, but also took into account baseline levels of these variables. Because growth rates are considered to be better than the level measures for predicting future population growth trends,34 our findings could have important policy implications regarding the allocation of health care resources.     

Older Jail Inmates and Community Acute Care Use

Objectives. We examined older jail inmates’ predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release.Methods. We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use.Results. We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89).Conclusions. The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.Jail has become a critical site for linking medically vulnerable older adults to community health care. Approximately 12 million Americans pass through jails each year and nearly all return to the community within 6 months where many struggle to access nonemergency medical care. Between 1996 and 2008 the number of “older” or “geriatric” inmates (aged 55 years or older) increased 278% compared with a 53% growth in the overall jail population.1,2 Now, approximately 550 000 older adults spend time in jail each year, comprising 10% of all inmates. Yet little is known about their health care and social service needs.Reducing acute care use (hospitalizations and emergency department [ED] use) and improving insurance access for former inmates is a priority in the Affordable Care Act (ACA).3 Although most inmates are without health insurance,4 those with insurance demonstrate reduced recidivism and better access to mental health and substance abuse treatment when released.5–7 The ACA expands Medicaid eligibility for low-income adults and allows eligible inmates to apply for coverage while in jail.3,8 As most persons passing through jails will be eligible for Medicaid in states participating in the expansion, an estimated 4 to 6 million jail inmates will gain new coverage by the end of 2014 through outreach and patient navigator assistance.9For community-dwelling older adults, health and social factors beyond insurance drive community acute care use, such as functional impairment, uncontrolled symptoms, and housing instability.10–12 This may also be true for older former inmates, many of whom experience “accelerated aging” because of high rates of disability and chronic disease at relatively young ages.13 Therefore, we conducted a study of older jail inmates to describe predetainment acute care use and anticipated plans for using acute care after release, and to assess the factors associated with use.     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

The Impact of Increasing Health Insurance Coverage on Disparities in Mortality: Health Care Reform in Colombia, 1998–2007

Objectives. We examined the impact of expanding health insurance coverage on socioeconomic disparities in total and cardiovascular disease mortality from 1998 to 2007 in Colombia.Methods. We used Poisson regression to analyze data from mortality registries (633 905 deaths) linked to population census data. We used the relative index of inequality to compare disparities in mortality by education between periods of moderate increase (1998–2002) and accelerated increase (2003–2007) in health insurance coverage.Results. Disparities in mortality by education widened over time. Among men, the relative index of inequality increased from 2.59 (95% confidence interval [CI] = 2.52, 2.67) in 1998–2002 to 3.07 (95% CI = 2.99, 3.15) in 2003–2007, and among women, from 2.86 (95% CI = 2.77, 2.95) to 3.12 (95% CI = 3.03, 3.21), respectively. Disparities increased yearly by 11% in men and 4% in women in 1998–2002, whereas they increased by 1% in men per year and remained stable among women in 2003–2007.Conclusions. Mortality disparities widened significantly less during the period of increased health insurance coverage than the period of no coverage change. Although expanding coverage did not eliminate disparities, it may contribute to curbing future widening of disparities.Recent health care reform in the United States has sparked debate on the potential impact of expanding health insurance coverage on access to care and disparities in health care.1 People with lower socioeconomic status are at increased risk of many conditions and are therefore more likely to benefit from an expansion in health insurance coverage.1 Previous observational studies in the United States have suggested that a lack of health insurance was associated with an increased risk of subsequent mortality in all socioeconomic groups.2 However, little is known about the impact of health insurance coverage on socioeconomic disparities in mortality following a major expansion in insurance coverage. In 1993, the Colombian government implemented a major health care reform that introduced mandatory health insurance.3 As a result, coverage increased from 47% in 19944 to 98% in 2010.5 Although the social and economic context of Colombia differs substantially from that in the United States, lessons from the Colombian reform can shed light on the potential impact of increased health insurance coverage on health disparities in the United States and middle-income countries currently expanding insurance coverage.A desirable outcome of coverage expansion is that it will have a larger impact on the health of the poor and will contribute to a reduction in health disparities.3,6 The reform in Colombia established a scheme of subsidies targeted to the poor, assigning citizens to 2 schemes on the basis of income: (1) the contributory scheme, which covers workers and their families with an income above the cut-off and is financed through payroll and employer’s contributions, and (2) the subsidized scheme, which covers the poor as identified through a proxy means test.6In the poorest income quartile, health insurance coverage increased from 6% in 1993 to more than 70% in 2007,6 an increase attributable to the subsidized scheme.5 Increased coverage among the poor is expected to improve health outcomes by ensuring timely care and bringing them into closer contact with the health care system.7 However, the reform also increased the complexity of the system potentially leading to delays in some types of care8 and reducing spending in prevention and public health.9 Previous dynamic simulations for the United States have suggested that expanding health insurance coverage is cost-effective, but failing to also expand the primary care capacity for the disadvantaged could lead to increasing health disparities.10 There have been no empirical studies examining these issues in the context of a major health care reform.Most previous studies have focused on the impact of health care reform on utilization and access to health care services, with only some studies examining the impact on population health.7,11–13 A recent review of available evidence concluded that expanding health insurance coverage generally improves access to care and population health particularly for lower income groups, but health gains may be dependent on the institutional framework and governance arrangements.14 On the other hand, the World Health Organization Commission on Social Determinants of Health concluded that, although inequity in health care is critical, the largest burden of illness arises in large part because of the conditions in which people are born, grow, live, work, and age.15We examined whether expanding health insurance coverage is associated with trends in socioeconomic disparities in mortality in the aftermath of the health care reform in Colombia. Findings from this study are of potential interest to the United States and middle-income countries that have recently implemented reforms to achieve universal access. We hypothesized that expanding health insurance coverage will contribute to curbing unfavorable trends in mortality disparities. To assess the impact of this expansion, we examined trends in mortality disparities by educational level separately for 2 divergent periods. In 2002, a process of decentralization led to a sharp increase in resource allocation to the subsided scheme in regional areas.16 As a result, whereas in the period 1998–2002 there was a moderate increase in total health insurance coverage (coverage went from 59.8% in 1998 to 64.1% in 2002), thereafter total coverage increased rapidly from 65.9% (2003) to 92.5% (2007; Figure 1). This corresponds to a statistically significant increase of 5.1% per year (P < .001) in the period 2003–2007. As illustrated in Figure 1, this increase was driven by a particularly steep increase in affiliates to the subsidized scheme in 2003–2007 (15.1% per year; P < .001), as opposed to a much smaller increase in the period 1998–2002 (6.4% per year; P < .001), suggesting that it may have particularly reached the lower socioeconomic groups. The discrepancy in health insurance coverage trends between these 2 periods thus provides a natural experiment to examine the impact of health insurance coverage on socioeconomic disparities in mortality.Open in a separate windowFIGURE 1—Percentage of population with health insurance coverage: Colombia, 1998–2007.Note. Other schemes include primarily members of the military and teacher and oil workers syndicate members.Source. Annual reports of the Ministry of Health and Social Protection.5,17–19Our specific aim was to evaluate to what extent increased health insurance coverage has contributed to diminishing socioeconomic inequalities in mortality in Colombia. If socioeconomic differences in mortality were responsive to increased health insurance coverage, we would expect a more favorable trend in socioeconomic differences in mortality during the second than the first period. If increased insurance coverage had no impact on socioeconomic disparities in mortality, we would expect similar trends in socioeconomic disparities in mortality between the 2 periods.     

Rates of Insurance for Injured Patients Before and After Health Care Reform in Massachusetts: A Possible Case of Double Jeopardy

Objectives. We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform.Methods. We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004–2005) and after (2009–2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes.Results. Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% (P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients.Conclusions. Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in “double jeopardy” of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate.The burden of uncompensated care on the health care system and risk of personal financial ruin of uninsured individuals who experience a health shock (unexpected serious illness or accident)1 are among the leading arguments in favor of an individual mandate in the 2010 federal health care reform legislation. Modeled after the Massachusetts health care reform implemented in 2006,2,3 comprehensive federal health care reform is presumed to result in the greatest gains of health insurance among able-bodied adults aged 18 to 64 years mandated to enroll in subsidized or unsubsidized insurance plans. Although opponents of an individual mandate may argue that otherwise healthy adults with minimal health care needs should not be required to purchase health insurance,4 no individual, irrespective of age or baseline health status, is immune to risk of injury. Trauma represents a significant health shock experienced by able-bodied, community-dwelling adults aged 18 to 64 years and is a leading cause of death and disability in this demographic group.5,6Another federal mandate enacted by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency care to individuals experiencing a health shock, regardless of whether they are insured.7 Not surprisingly, emergency department (ED) resource use in response to health shocks has been shown to be independent of insurance status.8 In Massachusetts, implementation of health care reform did not affect trends in ED use.9 Patient care in the face of a health shock, however, rarely stops in the ED.When injured patients without insurance arrive at a trauma center, they are not only stabilized, as mandated by EMTALA, but also provided comprehensive trauma care as required of verified trauma centers in our proven national and state-level trauma systems.10,11 Even after stabilization, injured patients often cannot be released because they are critically ill or require treatments (e.g., intravenous antibiotics, chest tube monitoring) that for practical reasons or out-of-pocket costs cannot be rendered outside of the hospital. These uninsured patients are often provided ongoing free care at the presenting hospital or transferred once stabilized to safety-net hospitals that typically do not refuse patients on the basis of insurance.12 Depending on governance structure (publicly managed, publicly funded, or private nonprofit), 5% to 16% of patients at safety-net hospitals are provided free care.13 Data from the 2004 Medical Expenditure Panel Survey suggested that only 35% (95% confidence interval [CI] = 26%, 45%) of charges to uninsured patients for non–life-threatening emergency services were recouped by hospitals.14 In the case of injuries too severe to be treated and released, the burden of the cost of care is therefore assumed one way or another by the health care system, raising costs for everyone. Furthermore, uninsured patients often incur greater costs of care compared with their insured counterparts, as they must remain hospitalized until they can be safely discharged home because no similar laws mandate uncompensated home health services, skilled nursing, or rehabilitation often required by medically stable injured patients.15–17Proponents of an individual mandate might presume that improved rates of insurance in the general population would result in fewer uninsured injured patients treated at trauma centers, but the effect of an individual mandate on insurance coverage among injured patients is unknown. Therefore, the effects of health care reform on the burden of uncompensated trauma care in Massachusetts may have important national implications on the potential effect of national health care reform on our nation’s trauma system. We undertook this study to determine how an individual mandate affected insurance status among injured Massachusetts residents. We hypothesized that we would have treated fewer uninsured patients after implementation of Massachusetts health care reform. Presumably, the individual mandate would have resulted in rates of insurance among our patients as observed statewide.     

Impact of Health Insurance Type on Trends in Newborn Circumcision,United States, 2000 to 2010

Objectives. We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision.Methods. Hospital discharge data from the 2000–2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence.Results. Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend < .001), suggesting 390 000 additional circumcisions might have occurred nationwide had insurance coverage remained constant.Conclusions. Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure.There is renewed interest in circumcision in the United States because of the increasing evidence for reduced risks of sexually transmitted infections, including human papillomavirus (HPV), genital herpes, and HIV; urinary tract infections in infancy; balanoposthitis; and penile cancer for males and cervical cancer in their female partners.1,2 The procedure is not completely without risk, however, as circumcision may result in minor complications (most commonly bleeding and infection) and, albeit rarely, serious complications that require surgery.3,4Recent recognition of the benefits of circumcision has rekindled discussion about the need for updated recommendations for newborn circumcision in the United States.5 Because the health benefits outweigh the risks and therefore warrant reimbursement, the American Academy of Pediatrics (AAP) issued guidance in 2012 that explicitly recommended access to newborn circumcision for families who desired the procedure.3 In addition, the Centers for Disease Control and Prevention (CDC) recently issued the agency’s first-ever draft guidelines on circumcision, which state that parents of newborn males should be informed of the medical benefits of the procedure as well as the risks involved.6Circumcision incidence has decreased in the United States from around 60% in 2000 to 56% in 20087,8 after increasing during the late 1980s and 1990s.9,10 The decrease in circumcision nationwide since 2000 coincides with the release of an earlier, more neutral position statement regarding the risk–benefit ratio for neonatal circumcision issued by AAP5 that was reaffirmed in 2005.11 The previous AAP statement, although acknowledging the potential medical benefits of circumcision, indicated that the procedure was not essential to the child’s well-being and that the decision was best left to parents. After the earlier guidance was released, many states ceased Medicaid coverage for circumcision procedures. Overall, at the time of this writing, 18 states have discontinued Medicaid coverage, including 12 that have ceased such coverage since 1999 (Figure 1).12,13 Whereas states that discontinued coverage were initially concentrated in the West, in recent years states across all regions have discontinued Medicaid coverage, particularly in the South, where 5 states have ceased coverage. This change in Medicaid coverage may be in response to earlier recommendations regarding newborn circumcision from AAP5 and other professional organizations.12,14–17Open in a separate windowFIGURE 1—Medicaid coverage of newborn circumcision procedures by state: United States.Because little research to date has explored factors that could explain this decline, we examined trends in circumcision during the period between issuance of the previous and current AAP guidance and assessed how shifts in insurance coverage (from private insurance to Medicaid) may have contributed to the recent nationwide decrease in newborn circumcision.     

Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model

Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States.1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons.1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States.2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill.3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States.Workplace screening,4,5 mandatory criminal justice system screening,6–8 screening for entry into medication-assisted therapy and drug treatment programs,9 and refugee and naturalization programs10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care.Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk.12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine.13 Whereas other studies have focused on traditional clinics or statewide programs,14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening.New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively.15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care.16The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program,17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV,18–21 buprenorphine maintenance therapy,22–25 community transitional programs from the criminal justice system,26–33 hepatitis B vaccination,34 rapid hepatitis C screening,35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections,36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services.37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program.9     

Visiting the Emergency Department for Dental Problems: Trends in Utilization, 2001 to 2008

Objectives. We tested the hypothesis that between 2001 and 2008, Americans increasingly relied upon emergency departments (EDs) for dental care.Methods. Data from 2001 through 2008 were collected from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Population-based visit rates for dental problems, and, for comparison, asthma, were calculated using annual US Census Bureau estimates. As part of the analysis, we described patient characteristics associated with large increases in ED dental utilization.Results. Dental visit rates increased most dramatically for the following subpopulations: those aged 18 to 44 years (7.2–12.2 per 1000, P < .01); Blacks (6.0–10.4 per 1000, P < .01); and the uninsured (9.5–13.2 per 1000, P < .01). Asthma visit rates did not change although dental visit rates increased 59% from 2001 to 2008.Conclusions. There is an increasing trend in ED visits for dental issues, which was most pronounced among those aged 18 to 44 years, the uninsured, and Blacks. Dental visit rates increased significantly although there was no overall change in asthma visit rates. This suggests that community access to dental care compared with medical care is worsening over time.Medically underserved patients are increasing their reliance upon emergency departments (EDs) as a safety net provider because of absent or inadequate access to other sources of medical care.1 Many Americans turn to the ED for a variety of health care needs, including dental care, when access to professional dental care is limited.2 Visits to the ED for dental issues have been shown to increase as Medicaid reimbursement declines or is eliminated.3,4 Recent literature has linked the loss of state Medicaid dental benefits along with increases in dental ED use and expenditures to the decrease in utilization of preventive services.5,6 Age-related trends in dental disease may contribute to an overall increased need for dental services over time. Specifically, middle-aged and older adults are experiencing greater rates of tooth retention, thus increasing the demand for care in this cohort.To date, there are no published reports that quantify temporal trends in national ED utilization patterns for dental issues, although there are several reasons to believe dental care is more difficult to access than medical care. Dental insurance coverage, in addition to provider workforce, health beliefs, and social determinants of health, is one of many important factors in promoting dental care utilization, particularly for vulnerable populations.7–10 First, a greater number of Americans have medical insurance compared with dental insurance, with estimates of as many as 130 million Americans without dental coverage.11 Second, public and private insurance programs tend to cover medical care more extensively than dental care for adults, resulting in higher out-of-pocket cost for dental care.12–14 Medicaid-covered adult dental benefits vary between states but generally are limited to individuals with incomes well below the poverty line and to emergency dental care. Recent state budget cuts have further limited adult dental care options. The majority of low-income adults do not receive basic dental care and experience limited coverage, access, and use of dental care.15 As a result, access to dental care is dependent on both insurance coverage and sufficient discretionary income. Third, although medical care for the uninsured and underinsured is supported by an extensive public health safety net, the dental public health infrastructure is quite limited.16 Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes (community health centers that resemble FQHCs but do not receive grant funding) serve an increasing role in providing primary care to underserved areas. From 2007 to 2010 the number of FQHCs increased from 1067 (16 050 835 patients) to 1124 (19 469 467 patients).17 The FQHC patient demographic comprises mostly low-income, underinsured patients or those on public insurance programs. FQHCs and Look-Alikes that receive federal grant funding must provide access to dental services for their patients. However, FQHCs face difficulties in recruitment and retention of dental providers.18In the absence of adequate community-based dental care, another source of dental care for vulnerable populations are EDs, which are staffed by medical providers and rarely employ dentists. Seeking care in the ED for a dental issue often results in temporizing treatment through symptomatic relief (antibiotics and narcotics), which does not definitively treat the underlying disease process.19a Therefore, use of the ED for dental problems is a marker for disparities in dental care quality and access.We hypothesized that with secular changes over time (e.g., economic downturn, increased unemployment, budget deficits, public program reductions), access to appropriate sources of dental care would decrease, resulting in increased ED utilization for dental problems. The unemployment rate, according to the Bureau of Labor Statistics, was 4.6% before the most recent recession (2006) and peaked at 10.3% (2009).19b We hypothesized that there is a positive relationship between the recent economic recession and higher utilization of EDs for untreated dental problems, which serves as a marker for reduced access to preventive dental care. We also hypothesized that, although similar factors would also impact access to medical care, there would be a more substantial rise in ED dental visits for the reasons discussed above. Therefore, we expected a greater increase in ED dental utilization compared with ED use for ambulatory-care sensitive conditions.     

Effects of Early Dental Office Visits on Dental Caries Experience

Objectives. We determined the association between timing of a first dentist office visit before age 5 years and dental disease in kindergarten.Methods. We used North Carolina Medicaid claims (1999–2006) linked to state oral health surveillance data to compare caries experience for kindergarten students (2005–2006) who had a visit before age 60 months (n = 11 394) to derive overall exposure effects from a zero-inflated negative binomial regression model. We repeated the analysis separately for children who had preventive and tertiary visits.Results. Children who had a visit at age 37 to 48 and 49 to 60 months had significantly less disease than children with a visit by age 24 months (incidence rate ratio [IRR] = 0.88; 95% confidence interval [CI] = 0.81, 0.95; IRR = 0.75; 95% CI = 0.69, 0.82, respectively). Disease status did not differ between children who had a tertiary visit by age 24 months and other children.Conclusions. Medicaid-enrolled children in our study followed an urgent care type of utilization, and access to dental care was limited. Children at high risk for dental disease should be given priority for a preventive dental visit before age 3 years.Early childhood caries, or tooth decay in children younger than 6 years, is the most common chronic disease among children. Its prevalence increased to 28% among 2- to 4-year-old children between 1988 to 1994 and 1999 to 2004, and its impact on children is becoming better known.1,2 Tooth decay can impair young children’s overall health, speech, growth, and school performance; it can also negatively affect families’ quality of life.2–6Because of concern about the impact of dental disease on overall health and the stagnant rate of dental care use over the past decade, Healthy People 2020 identified the annual use of dental care for every person aged 2 years and older as 1 of 24 leading health indicators.7 Dental use was selected from as many as 1200 objectives as a high-priority health issue.Early childhood tooth decay is preventable and largely reversible in its early stages through self-care, use of professional services, and exposure to community interventions such as water fluoridation.8,9 During dental visits, children can receive an assessment for disease risk, early detection and treatment services, preventive care such as fluoride therapy, and anticipatory guidance.8,10–12 To ensure exposure to prevention early in life, professional organizations recommend that children have a dental home by 12 months of age.10,12–14 North Carolina Medicaid, along with Medicaid in most other states, also recommends a first dental visit by age 12 months; however, North Carolina Medicaid does not require a visit until age 3 years because of a limited supply of dentists.Despite evidence that professional preventive dental care leads to good oral health outcomes, no strong evidence indicates the most effective age for the first visit. A previous study found no difference in the severity of disease at age 6 to 7 years between children whose first dental visit occurred before age 2 years and those who were aged 2 to 5 years at their first visit.15 Another study found that early dentist visits that included prevention were associated with fewer treatments from the time the children were aged zero to 5 years.16 Three studies found no relationship between early visits and dental costs or treatment use,17–19 but one found that children with existing disease who received preventive services earlier had fewer subsequent treatments and expenditures.19Previous studies on the age of the first dental visit have primarily focused on treatment and cost outcomes, with conflicting results. It is unclear from studies on treatment outcomes whether children with early visits have differences in disease status. Unlike medical claims, dental claims do not include diagnosis codes, so the extent of disease cannot be determined from claims files alone. We combined claims files with public health surveillance files of oral health status to estimate the effect of the timing of the first dental visit on dental disease history and untreated disease in kindergarten students in North Carolina.     

The Brazilian Family Health Program and Secondary Stroke and Myocardial Infarction Prevention: A 6-Year Cohort Study

Objectives. We compared the incidence of recurrent or fatal cardiovascular disease in patients using Brazil’s government-run Family Health Program (FHP) with those using non-FHP models of care.Methods. From 2005 to 2010, we followed outpatients discharged from city public hospitals after a first ever stroke for stroke recurrence and myocardial infarction, using data from all city hospitals, death certificates, and outpatient monitoring in state-run and private units.Results. In the follow-up period, 103 patients in the FHP units and 138 in the non-FHP units had exclusively state-run care. Stroke or myocardial infarction occurred in 30.1% of patients in the FHP group and 36.2% of patients in non-FHP care (rate ratio [RR] = 0.85; 95% confidence interval [CI] = 0.61, 1.18; P = .39); 37.9% of patients in FHP care and 54.3% in non-FHP care (RR = 0.68; 95% CI = 0.50, 0.92; P = .01) died. FHP use was associated with lower hazard of death from all causes (hazard ratio [HR] = 0.58; P = .005) after adjusting for age and stroke severity. The absolute risk reduction for death by all causes was 16.4%.Conclusions. FHP care is more effective than is non-FHP care at preventing death from secondary stroke and myocardial infarction.Most strokes occur in low- and middle-income countries, where the disability-adjusted life-years and hospitalization costs are high.1,2 As the young populations of these countries age, stroke incidence and burden will probably rise.3,4 Therefore, it is important to evaluate and implement the best strategy for the primary and secondary prevention of stroke and myocardial infarction in these countries.5In Brazil, the state-run health care system is universal. Three quarters of the population use it exclusively and one quarter uses both public and private health services. In 1994 the Unified National Health System was reorganized to prioritize a new model of care called the Family Health Program (FHP).6 The Brazilian FHP model is centered on a family and community approach in which a multiprofessional team (consisting of a doctor, a nurse, an auxiliary nurse, and 4–6 community health workers) provides comprehensive care.6,7 Family health care teams are assigned to specific geographical areas and populations of 600 to 1000 families and are responsible for permanent and systematic follow-up of a given number of families living in a circumscribed area and for establishing ties of commitment and shared responsibility.6–8 The program was expanded from a minor pilot program covering very few selected areas in 1994 to a nationwide large-scale program in 2006. Today, the FHP covers more than 100 million people in more than 90% of Brazilian municipalities.6–8 From 1996 to 2004, in Brazilian cities where the FHP had intermediate city population coverage (30.0%–69.9% coverage, or > 70.0% coverage and duration of < 4 years), the adjusted infant mortality rate decreased 16%. In cities with complete city coverage (coverage of > 70.0% and duration of > 4 years), it decreased by 22%.9 The remaining population is covered by the traditional model of primary care. In this model, created before the FHP, a multidisciplinary team, composed of general practitioners, gynecologists, pediatricians, dentists, nurses, and auxiliary nurses, works on demand. This is still the most prevalent model in the country and, unlike the FHP model, has no community health workers and no limits to the number of families it can care for.9,10To our knowledge, there is no clear evidence of the effectiveness of Brazil’s FHP model for preventing secondary stroke and myocardial infarction.10 Joinville is an industrial city in southern Brazil, where two thirds of the citizens are covered exclusively by the state-run health care system and the remaining third by both state-run and private care, mostly through employers. We have shown that the incidence, mortality, and 30-day case fatality of first ever stroke decreased in Joinville by one third from 1995 to 2005.11 To determine what happens to those patients when they return to the state-run health units, we compared stroke recurrence, myocardial infarction, and death among patients surviving their first ever stroke who were followed in the FHP units with those followed in non-FHP units.     

Massachusetts Inpatient Medicaid Cost Response to Increased Supplemental Nutrition Assistance Program Benefits

Objectives. To investigate the impact of an increase in Supplemental Nutrition Assistance Program (SNAP) benefits on Medicaid costs and use in Massachusetts.Methods. Using single and multigroup interrupted time series models, I examined the effect of an April 2009 increase in SNAP benefits on inpatient Medicaid cost and use patterns. I analyzed monthly Medicaid discharge data from 2006 to 2012 collected by the Massachusetts Center for Health Information and Analysis.Results. Inpatient costs for the overall Massachusetts Medicaid population grew by 0.55 percentage points per month (P < .001) before the SNAP increase. After the increase, cost growth fell by 73% to 0.15 percentage points per month (–0.40; P = .003). Compared with the overall Medicaid population, cost growth for people with the selected chronic illnesses was significantly greater before the SNAP increase, as was the decline in growth afterward. Reduced hospital admissions after the SNAP increase drove the cost declines.Conclusions. Medicaid cost growth fell in Massachusetts after SNAP benefits increased, especially for people with chronic illnesses with high sensitivity to food insecurity.People in 1 in 7 US households experience food insecurity,1 meaning they experience hunger, insufficient food, or concerns about having enough food.2 Food insecurity is associated with a large set of health problems for both children and adults.3–11 People with chronic illnesses, who usually have heightened costs of care, are both more likely to experience food insecurity12–14 and more vulnerable to its health effects.15 Understanding the contribution of this problem to health care utilization and costs, however, has been difficult with available data.16One approach to doing so is to look at the inverse question; that is, examining the effects of alleviating food insecurity. The Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamps Program) is the largest domestic antihunger program.17 Despite some methodological difficulties,18,19 SNAP has been shown to at least partially alleviate food insecurity for recipients,20,21 making it a good candidate for study. Unfortunately, changes to the program usually occur slowly, limiting the ability to detect broad changes in food insecurity levels and their potential impact on health. However, as part of the American Recovery and Reinvestment Act, maximum monthly SNAP allotments to beneficiaries were temporarily increased by 13.6% from April 2009 to October 2013.22 This larger change to the status quo provided a unique opportunity to examine the effects of alleviating food insecurity on recipients.I analyzed the relationship between the timing of the increase in SNAP benefits and patterns of health care utilization and costs. Massachusetts provided an ideal setting for this investigation. The Massachusetts Center for Health Information and Analysis collects detailed information on each admission to every hospital in the state, allowing analyses of both the general Medicaid population and those with chronic illnesses. Moreover, the state expanded Medicaid coverage as part of its health reform law in 2006, well before the April 2009 SNAP increase, and it passed a wide-ranging payment reform law that came into effect in 2012, well after the SNAP increase. Between these reforms was a time when economic growth was stagnant for low-income populations, even after the formal end of the Great Recession.23 This provided an ample study period from October 2006 to August 2012.     

Change in Health Insurance Coverage in Massachusetts and Other New England States by Perceived Health Status: Potential Impact of Health Reform

Objectives. We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health.Methods. We used 2003–2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform.Results. The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states—from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs.Conclusions. On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.The sweeping health reform initiative in Massachusetts, An Act Providing Access to Affordable, Quality, Accountable Health Care (enacted April 12, 2006),1 provides a natural experiment with outcomes that may foreshadow those of the comprehensive national health reform President Obama signed into law 4 years later. The Patient Protection and Affordable Care Act (enacted March 23, 2010)2 and amendments in the Health Care and Education Reconciliation Act (enacted March 30, 2010),3 are collectively referred to as the Affordable Care Act (ACA).This landmark federal law includes provisions to strengthen the public health system, provide mandatory funding for prevention and wellness programs and activities, strengthen the Medicare program, implement insurance market reforms, bolster public health and primary care workforce, and improve the overall quality of the nation’s health system. The act focuses on expanding health insurance coverage and improving the health care delivery system beginning with incremental reforms in 2010 and following up with more substantial changes such as individual mandates, employer requirements, expansion of public programs, premium and cost-sharing subsidies to individuals, premium subsidies to employers, tax changes, and health insurance exchanges in 2014. Importantly, the law also prevents insurers from denying health insurance coverage or charging higher premiums on the basis of health status.4,5 The Congressional Budget Office estimates that, when fully implemented in 2019, ACA will provide coverage to an additional 32 million Americans leaving about 23 million nonelderly people uninsured.6Systematic reviews of the literature on the impact of health insurance on health care utilization and health outcomes provide some convincing and some nuanced conclusions. These reviews consistently report evidence of increased utilization of physician and preventive services, improvements in the health of vulnerable populations, and lower mortality, conditional on injury and disease; however, how health insurance affects health outcomes for nonelderly adults remains unclear.7,8From a public health perspective, monitoring implementation of ACA at federal, state, and local levels will be important because this act will change health insurance coverage and access to care, and uptake of care, including preventive services and needed treatment; may alter health care finance and payment structures and care delivery systems as well as health expenditures; and may modify individual and population outcomes of care and health status. Studying the effects of health insurance would ideally rely on experimental evidence7 where health insurance was randomly assigned like the RAND Health Insurance Experiment and the Oregon Medicaid Lottery.9,10 In the absence of randomized experiments, owing to ethical and practical considerations, the need for conducting some social experiments or other approaches to infer causal conclusions from observational data are essential.7,11Fortunately, a natural experiment of near universal health insurance coverage combined with a targeted public health intervention has been unfolding in Massachusetts for more than 3 years and has been the subject of many studies. Researchers have studied various aspects of the impact of Massachusetts health reform, after 1 year,12 over the short term, comparing 18 months before and 18 months after the reform,13 on young adults and children,14,15 and even the effects of the recession.16 This evolving new body of research leaves a gap in our understanding of the impact of health reform by perceived health care need. We examined the impact of the Massachusetts health reform and its public health component on change in health insurance coverage by perceived health. We examined the impact of the natural experiment in Massachusetts as a model to predict likely outcomes of implementing ACA. Because Medicare already covers most of those aged 65 years and older we compared the effectiveness of mandatory versus optional health insurance among only the nonelderly adult population (aged 18–64 years) residing in Massachusetts and other New England states (Connecticut, Maine, New Hampshire, Rhode Island, and Vermont).To do this, we compared data between the 3 years (2003–2005) before and the 3 years (2007–2009) after Massachusetts enacted the health reform law and between Massachusetts and other New England states that had no similar health reform laws. Massachusetts and other New England states had similar sociodemographic population characteristics and macroeconomic profiles (e.g., gross domestic product, unemployment rates) over this time period, including a similar impact of 2 years of recession (2007–2009).17,18 This allows not only “before-versus-after” but also “with-versus-without” analyses, a strategy employed by other researchers to explicate the impact of health reform laws and policy as a control for other elements.16,19We used the Behavioral Risk Factor Surveillance System (BRFSS), the largest and longest-running state-representative, population-based telephone survey that has asked questions about health insurance coverage, health-promoting and health-compromising behaviors, and doctor-diagnosed chronic conditions. Existing federal government and state-sponsored surveys generate different estimates of uninsurance possibly explained by differences in survey design including coverage, reference period, mode, and questionnaire design (wording and placement of questions).20–22 First, we established the quality and the consistency of BRFSS health insurance coverage estimates by comparing these estimates for selected demographic and socioeconomic characteristics with other federal surveys that gather data on health insurance—the American Community Survey (ACS), the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC), and the National Health Interview Survey (NHIS). The US Census Bureau added a question about health insurance to the 2008 ACS leading to the release of the first set of estimates in September 2009.23 The CPS ASEC is the most widely cited source for health insurance statistics. It is annual, timely, relatively large, and has a state-based design. The NHIS is a continuing nationwide survey conducted by the National Center for Health Statistics.23We hypothesized a greater increase in the proportion of nonelderly adults with health insurance coverage in Massachusetts than in other New England states. We further hypothesized that nonelderly adults with greater perceived health care needs would be more likely to obtain health insurance coverage. Groups with greater perceived health care need would show a larger increase in health insurance coverage from prereform to postreform and in Massachusetts compared with other New England states.     

Neighborhood Social Capital,Neighborhood Attachment,and Dental Care Use for Los Angeles Family and Neighborhood Survey Adults

Objectives. We tested the hypothesis that neighborhood-level social capital and individual-level neighborhood attachment are positively associated with adult dental care use.Methods. We analyzed data from the 2000–2001 Los Angeles Family and Neighborhood Survey that were linked to US Census Bureau data from 2000 (n = 1800 adults aged 18–64 years across 65 neighborhoods). We used 2-level hierarchical logistic regression models to estimate the odds of dental use associated with each of 4 forms of social capital and neighborhood attachment.Results. After adjusting for confounders, the odds of dental use were significantly associated with only 1 form of social capital: social support (adjusted odds ratio [AOR] = 0.85; 95% confidence interval [CI] = 0.72, 0.99). Individual-level neighborhood attachment was positively associated with dental care use (AOR = 1.05; 95% CI = 1.01, 1.10).Conclusions. Contrary to our hypothesis, adults in neighborhoods with higher levels of social capital, particularly social support, were significantly less likely to use dental care. Future research should identify the oral health–related attitudes, beliefs, norms, and practices in neighborhoods and other behavioral and cultural factors that moderate and mediate the relationship between social capital and dental care use.Oral health is an indicator of general health and social justice.1,2 Common dental diseases such as tooth decay and gum disease are linked to chronic health conditions, including cardiovascular disease, stroke, diabetes, obesity, and kidney disease.3–7 When left untreated, dental diseases can lead to difficulties chewing food, pain, systemic infections, hospitalization, and, in rare cases, death. Less visible are the social consequences of poor oral health, such as lost work hours,8 functional limitations,9,10 and poor quality of life.11A comprehensive strategy for optimal oral health involves exposure to topical fluorides (e.g., in optimally fluoridated water, toothpaste), limited fermentable carbohydrate intake, tobacco use prevention, and regular dental visits.12 Professional dental care is particularly important because dentists have opportunities to assess a patient’s risk level for oral health problems, provide diagnostic and preventive care as well as needed restorative care, deliver patient-centered anticipatory guidance, and screen for systemic health conditions.13–16 However, not all individuals in the United States have equal access to dental care.17Most dental utilization studies focus on children younger than 18 years and seniors aged 65 years and older, even though data from the National Health and Nutrition Examination Survey indicate a decline in dental care use for US adults aged 18 to 64 years.18 Between 1988 and 1994 and 1999 and 2004, there were significant drops in the proportions of adults who had an annual dental visit for those aged 20 to 34 years (from 63.5% to 54.6%) and those aged 35 to 49 years (from 69.0% to 62.5%).18 The factors related to these declines are unknown.The 2008 World Health Organization report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health calls for policies and interventions targeting the social determinants of health to reduce and eliminate health disparities.19 Social determinants of health are the structural and environmental conditions that shape human welfare and well-being,20 with health inequalities attributed to unequal distribution of and access to power, money, and resources.21 Although social factors contribute to disparities in dental care use,22 relevant studies focus mostly on individual-level determinants.23–37 There has been less emphasis on the area-level social determinants of adult dental care use.Social capital is an important health determinant38–41 and is defined as the material, affective, and informational resources inherent in social networks. Most health research has focused on social capital in neighborhoods. Neighborhood-based social capital can be operationalized into 4 forms: (1) social support (provisions that help residents cope with everyday challenges), (2) social leverage (sharing information on health- and non–health-related issues), (3) informal social control (maintenance of safety and norms), and (4) neighborhood organization participation (organized efforts that address community quality of life and personal well-being).42 Social capital has direct and interactive associations with a range of positive and negative health-related outcomes.43,44 In some cases, these resources may not help individuals pursue a desirable health outcome or may inhibit an individual’s efforts through negative influences in the community.45Although investigators have examined social capital and access to health care services,46 fewer oral health–related studies have focused on social capital. In 2 multilevel studies of elderly persons in Japan, number of teeth was positively associated with higher levels of neighborhood friendship networks47 and a higher prevalence of neighborhood peer group activities.48 Neighborhood social capital also moderated the relationship between income inequality and self-reported oral health but not the number of teeth present among the Japanese elderly.49 A study of Japanese students aged 18 to 19 years found that poor self-reported oral health was associated with lower levels of neighborhood trust and with higher levels of neighborhood informal social control.50 Among Brazilians aged 14 to 15 years, a 5-dimension measure showed that social capital (social trust, social control, empowerment, neighborhood security, and political efficacy) was inversely associated with odds of dental injury.51Although social capital was not the primary focus, there are 2 relevant US publications. The first reported positive associations between neighborhood social capital and self-reported oral health for children younger than 18 years.52 In the second, neighborhood social capital was identified as a potential source of oral health disparities between Black children and White children aged 3 to 17 years (measured as having a dental problem and poor self-reported oral health) but not for disparities in preventive dental care use.53 Collectively, these studies suggest that neighborhood social capital is an important determinant of oral health.54–56 However, they have 2 main limitations: (1) none of the operationalizations of social capital considered the extent of neighborhood social ties, the resources linked to these ties, or unequal access to resources42; and (2) none focused on dental care use for adults aged 18 to 64 years, a US population subgroup that has exhibited declines in dental care use.18We addressed previous limitations by adopting a multilevel conceptual model of social capital42,43,45 to examine how neighborhood social capital is associated with dental care use for US adults (Figure 1). We operationalized neighborhood-level social capital as the 4 forms identified earlier (social support, social leverage, informal social control, and neighborhood organization participation). Individual-level neighborhood attachment is the extent to which an individual knows and socializes with neighbors42–44; this moderates the effects of social capital.57 On the basis of this model, we tested 3 hypotheses: (1) higher levels of each form of neighborhood social capital are associated with greater odds of dental use, (2) neighborhood attachment is associated with greater odds of dental care use, and (3) there are interactions between social capital and neighborhood attachment. This study represents an important first step in understanding the social determinants of an important oral health behavior. Our long-term goal is to develop and test neighborhood-based interventions and policies aimed at improving the oral health of individuals at greatest risk for disparities in dental care use.Open in a separate windowFIGURE 1—Conceptual model and proposed study hypotheses tested using data from the Los Angeles Family and Neighborhood Survey, 2000–2001.Note. H1 = hypothesis 1 (there is a direct relationship between the 4 social capital forms and adult dental care use); H2 = hypothesis 2 (there is a direct relationship between neighborhood attachment and adult dental care use); H3 = hypothesis 3 (in modeling adult dental care use, there is an interaction between the four forms of social capital and neighborhood attachment).