Is patients' trust in clinicians related to patient-clinician racial/ethnic or gender concordance?

OBJECTIVE: To examine the relationship between patient-clinician concordance (racial/ethnic and gender) and patients' trust in their regular clinician. METHODS: This mixed methods study used the 2019 U.S. Health Reform Monitoring Survey to examine concordance and patient trust in clinicians, and semi-structured interviews with 24 participants to explore patients' perceptions of how concordance relates to trust in their clinician. RESULTS: Almost six in ten adults (59.8%) who had a regular clinician reported having trust in their clinician. White, Black, and Latino participants were similarly likely to report trust. Those with racial/ethnic concordant clinicians were 7.5 percentage points more likely to report trust than were those with non-concordant clinicians (62.4% vs 54.9%). This finding was consistent for men and women, and did not differ significantly across racial and ethnic groups. In interviews, while almost all participants described having trusted non-racial/ethnic concordant clinicians, several described immediately trusting concordant clinicians. In contrast, we did not observe a consistent relationship between patient-clinician gender concordance and trust. CONCLUSION: The findings underscore the importance of increasing the number of Black and Latino clinicians, and also highlight that all clinicians need to work hard to build trust with patients from different racial/ethnic backgrounds.

Effects of Integrating Care for Medicare-Medicaid Dually Eligible Seniors in Minnesota.

Individuals dually eligible for Medicare and Medicaid often receive fragmented and inefficient care. Using Minnesota fee-for-service claims, managed care encounters, and enrollment data for 2010-2012, we estimated the likely impact of Minnesota Senior Health Option (MSHO)-seen as the first statewide fully integrated Medicare-Medicaid model-on health care and long-term services and supports use, relative to Minnesota Senior Care Plus (MSC+), a Medicaid-only managed care plan with Medicare fee for service. Estimates suggest that MSHO enrollees had significantly higher use of primary care and, potentially, of community-based services, combined with lower use of hospital-based care than similar MSC+ enrollees. Adopting fully integrated care models like MSHO may have merit in other states.

Using Data From the Healthcare Cost and Utilization Project for State Health Policy Research.

BACKGROUND: The Healthcare Cost and Utilization Project (HCUP), the nation's most complete source of all-payer hospital care data, supports analyses at the national, regional, state and community levels. However, national HCUP data are often used in inappropriate ways in studies of state-specific issues. OBJECTIVE: To describe the opportunities and challenges of using HCUP data to conduct state health policy research and to provide empirical examples of what can go wrong when using the national HCUP data inappropriately. RESEARCH DESIGN: Comparison of results from state-level analyses using national HCUP data and the state-specific HCUP data recommended by the Agency for Healthcare Research and Quality (AHRQ). Analyses included trends in state-specific rates of cesarean delivery and a difference-in-differences analysis of Connecticut's Medicaid expansion. SUBJECTS: Hospital discharges from the 2004 to 2011 HCUP Nationwide Inpatient Samples (NIS) and State Inpatient Databases (SID). MEASURES: Cesarean delivery rates, discharges per capita, and discharges by the payer. RESULTS: State-level estimates derived from the NIS are volatile and often provide misleading policy conclusions relative to estimates from the SID. CONCLUSIONS: The NIS should not be used for state-level research. AHRQ provides resources to assist analysts with state-specific studies using SID files.

The Affordable Care Act's Marketplaces Expanded Insurance Coverage For Adults With Chronic Health Conditions.

The Affordable Care Act (ACA) made private nongroup health insurance more accessible to nonelderly adults with chronic conditions, with enrollment growth occurring through the federal and state-based Marketplaces. During the July through December reference period in 2014-15, 45 percent of Marketplace enrollees ages 18-64 were treated for chronic conditions, compared with 35 percent of non-Marketplace nongroup enrollees and 38 percent of adults with employer-sponsored insurance. Marketplace enrollees also had higher service use than other privately insured adults did, which likely contributed to rising premiums in the nongroup market. As repeal of the ACA individual mandate takes effect in 2019, protecting coverage gains for adults with chronic conditions while stabilizing nongroup premiums may depend on state-level efforts to spread the risk of Marketplace enrollees' health care costs across a balanced insurance pool.

Evidence of Pent-Up Demand for Care After Medicaid Expansion.

We compared new Medicaid enrollees with similar ongoing enrollees for evidence of pent-up demand using claims data following Minnesota's 2014 Medicaid expansion. We hypothesized that if new enrollees had pent-up demand, utilization would decline over time as testing and disease management plans are put in place. Consistent with pent-up demand among new enrollees, the probability of an office visit, a new patient office visit, and an emergency department visit declines over time for new enrollees relative to ongoing Medicaid enrollees. The pattern of utilization suggests that the newly insured are connecting with primary care after the 2014 Medicaid expansion and, unlike ongoing Medicaid enrollees; the newly insured have a declining reliance on the emergency department over time.

Sustained Gains In Coverage, Access, And Affordability Under The ACA: A 2017 Update.

The significant gains in health insurance coverage and improvements in health care access and affordability that followed the implementation of the key coverage provisions of the Affordable Care Act in 2014 have persisted into 2017. Adults in all parts of the country, of all ages, and across all income groups have benefited from a large and sustained increase in the percentage of the US population that has health insurance. The gains have been particularly striking among low- and moderate-income Americans living in states that expanded Medicaid. Our latest survey data from the Urban Institute's 2017 Health Reform Monitoring Survey shows that only 10.2 percent of nonelderly adults are now uninsured-a decline of almost 41 percent from the period before implementation of the ACA. Nonetheless, repealing and replacing the ACA remained under consideration during the summer of 2017, along with more systematic changes to the financing of the Medicaid program. Many people will be at substantial risk if key components of the law are repealed or otherwise changed without carefully considering the health and financial consequences for those projected to lose coverage. Though the politics of health reform are challenging, opportunities exist to create a more equitable and efficient health care system.

Medicaid Expansion Increased Coverage, Improved Affordability, And Reduced Psychological Distress For Low-Income Parents.

Despite receiving less attention than their childless counterparts, low-income parents also experienced significant expansions of Medicaid eligibility under the Affordable Care Act (ACA). We used data for the period 2010-15 from the National Health Interview Survey to examine the impacts of the ACA's Medicaid expansion on coverage, access and use, affordability, and health status for low-income parents. We found that eligibility expansions increased coverage, reduced problems paying medical bills, and reduced severe psychological distress. We found only limited evidence of increased use of care among parents in states with the smallest expansions, and no significant effects of the expansions on general health status or problems affording prescription drugs or mental health care. Together, our results suggest that the improvements in mental health status may be driven by reduced stress associated with improved financial security from insurance coverage. We also found large missed opportunities for low-income parents in states that did not expand Medicaid: If these states had expanded Medicaid, uninsurance rates for low-income parents would have fallen by an additional 28 percent.

Moving Beyond Blind Men and Elephants: Providing Total Estimated Annual Costs Improves Health Insurance Decision Making.

Health insurance is among the most important financial and health-related decisions that people make. Choosing a health insurance plan that offers sufficient risk protection is difficult, in part because total expected health care costs are not transparent. This study examines the effect of providing total costs estimates on health insurance decisions using a series of hypothetical choice experiments given to 7,648 individuals responding to the fall 2015 Health Reform Monitoring Survey. Participants were given two health scenarios presented in random order asking which of three insurance plans would best meet their needs. Half received total estimated costs, which increased the probability of choosing a cost-minimizing plan by 3.0 to 10.6 percentage points, depending on the scenario ( p < .01). With many consumers choosing or failing to switch out of plans that offer insufficient coverage, incorporating insights on consumer decision making with personalized information to estimate costs can improve the quality of health insurance choices.

Marketplaces Helped Drive Coverage Gains In 2015; Affordability Problems Remained.

Health insurance coverage through the Marketplaces increased in 2015, with more nonelderly adult enrollees insured all year and fewer reporting health care affordability problems than in 2014. In 2015 more Marketplace enrollees in Medicaid nonexpansion states reported trouble paying family medical bills, compared to those in expansion states (23 percent versus 15 percent).

Massachusetts Health Reform At Ten Years: Great Progress, But Coverage Gaps Remain.

Massachusetts's 2006 health reform legislation was intended to move the state to near-universal health insurance coverage and to improve access to affordable health care. Ten years on, a large body of research demonstrates sustained gains in coverage. But many vulnerable populations and communities in the state have high uninsurance rates, and among those with coverage, gaps in access and affordability persist.

Medicaid Expansions from 1997 to 2009 Increased Coverage and Improved Access and Mental Health Outcomes for Low-Income Parents.

OBJECTIVE: To assess the effects of past Medicaid eligibility expansions to parents on coverage, access to care, out-of-pocket (OOP) spending, and mental health outcomes, and consider implications for the Affordable Care Act (ACA) Medicaid expansion. DATA SOURCES: Person-level data from the National Health Interview Survey (1998-2010) is used to measure insurance coverage and related outcomes for low-income parents. Using state identifiers available at the National Center for Health Statistics Research Data Center, we attach state Medicaid eligibility thresholds for parents collected from a variety of sources to NHIS observations. STUDY DESIGN: We use changes in the Medicaid eligibility threshold for parents within states over time to identify the effects of changes in eligibility on low-income parents. PRINCIPAL FINDINGS: We find that expanding Medicaid eligibility increases insurance coverage, reduces unmet needs due to cost and OOP spending, and improves mental health status among low-income parents. Moreover, our findings suggest that uninsured populations in states not currently participating in the ACA Medicaid expansion would experience even larger improvements in coverage and related outcomes than those in participating states if they chose to expand eligibility. CONCLUSIONS: The ACA Medicaid expansion has the potential to improve a wide variety of coverage, access, financial, and health outcomes for uninsured parents in states that choose to expand coverage.

Access To Care And Affordability Have Improved Following Affordable Care Act Implementation; Problems Remain.

There is growing evidence that millions of adults have gained insurance coverage under the Affordable Care Act, but less is known about how access to and affordability of care may be changing. This study used data from the Health Reform Monitoring Survey to describe changes in access and affordability for nonelderly adults from September 2013, just prior to the first open enrollment period in the Marketplace, to March 2015, after the end of the second open enrollment period. Overall, we found strong improvements in access to care for all nonelderly adults and across income and state Medicaid expansion groups. We also found improvements in the affordability of care for all adults and for low- and moderate-income adults. Despite this progress, there were still large gaps in access and affordability in March 2015, particularly for low-income adults.

California's Early Coverage Expansion under the Affordable Care Act: A County-Level Analysis.

OBJECTIVE: To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an "early expansion" under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes. DATA SOURCES/STUDY SETTING: 2008-2012 American Community Survey (ACS). The sample contained California adults ages 19-64 years (n = 237,876) and children 0-18 years (n = 113,159) with incomes below 200 percent of the federal poverty level. STUDY DESIGN: Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children. PRINCIPAL FINDINGS: Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment. CONCLUSIONS: California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA.

Primary Care Providers Ordered Fewer Preventive Services For Women With Medicaid Than For Women With Private Coverage.

As the number of beneficiaries in the Medicaid program grows under the Affordable Care Act, with over half of the states opting to expand Medicaid eligibility, it is important to understand more about the care provided to Medicaid patients. Using visit-level data for 2006-10 from the National Ambulatory Medical Care Survey, we examined the provision of recommended preventive services to women with Medicaid and those with private insurance at visits to primary care providers in private office-based practices. We found that after patient and provider characteristics were controlled for, Medicaid-insured visits were less likely than privately insured visits to include several preventive services, including clinical breast exams and Pap tests. The differences in provision of services by payer were generally driven by the differences in care at visits classified as preventive and at visits to obstetrician-gynecologists. Further investigation is required to determine what may be driving the differences in content of care across payers and their implications for quality of care.