Acculturation, Hispanic ethnicity, and trust: Verifying and explaining racial/ethnic differences in trust in health providers in North Carolina Medicaid.

Three North Carolina Medicaid surveys conducted from 2000 to 2012 reported increasing numbers of Hispanic children enrolled in Medicaid and much lower trust in providers expressed by their adult caregiver respondents compared with responses for non-Hispanic Black and White children. To verify and explain this apparent trust chasm, we used bivariate and regression analyses. The variables employed included trust (dependent variable); child's race/ethnicity, age, and sex; satisfaction and health status scales; two utilization measures; respondent's age, sex, and education; geographical region; and population density of county of residence. Race/ethnicity was strongly associated with trust (p < .001), controlling for other independent variables. Access, satisfaction, and respondent's age and education were also significant. Our results fit the Behavioral Model for Vulnerable Populations, which maps the role of significant variables in health-seeking behavior. After analyzing the concept of trust, we argue that lower acculturation explains lower Hispanic trust compared with non-Hispanic Blacks. We suggest policies to improve acculturation.

Flattening Epidemic Curves and COVID-19: Policy Rationales, Inequality, and Racism.

This commentary first provides lists of rationales for and against intervening to flatten an epidemic curve instead of letting the natural spike occur. The context is the U.S. COVID-19 experience, but the analyses apply to any communicable disease epidemic. After briefly exploring various reasons for flatter instead of spiked curves, it explores in detail the observation that flattened curves increase risks to essential workers and low-income and minority populations. Racism is the specific form of inequality highlighted, because discussions of race currently dominate civic discourse and have generated important new literature. Three forms of racism/inequality are distinguished: simple, systemic or institutional, and structural. Structural racism is distinct from the other forms by lacking intentionality, rendering praise or blame inappropriate. The commentary concludes that flattening exacerbates structural inequality. Nonetheless, societies should mitigate and compensate victims of inequality due to prolonging an epidemic.

Federalize Medicaid to Fix the Affordable Care Act: For Efficiency, Equity, and Social Justice.

Federalizing Medicaid (thereby eliminating state program variation) is a bold and affordable alternative to Medicare for all (M4A) and proposed ACA public options. Making Medicaid an entirely federal program using Congress' budget reconciliation process will reverse the U.S. Supreme Court ruling that enabled states to reject Medicaid expansion. Such legislation achieves Congress' original intention to create universal entitlements for low-income persons who lack health coverage and concentrate new federal health spending on them (unlike M4A). Arguments for federalizing Medicaid involve state budget relief, efficiency, social justice and the history that created national industries from local and state-based health systems. Theory suggests that liberal democracies are generally more successful when path dependent, building incrementally on existing policies instead of plunging into new, untested innovations no matter how rational. In addition to realizing the congressional intent of the ACA, federalizing Medicaid can be a cost-effective, incremental path to single-payer health coverage.

Securing Social Security Solvency Addressing an important social determinant of the health of seniors and the American polity.

Adequate income is a social determinant of health. In the United States, only Social Security beneficiaries receive inflation-protected guaranteed income. Social Security needs another 1983 compromise in which stakeholders accepted "shared pain" to avoid insolvency. We propose indexing the benefit using the chained consumer price index (CPI) for all urban consumers and providing a one-time bonus of 8% to 10% for beneficiaries in their mid-80s, when needs become greater. The chained CPI has little impact when beneficiaries start receiving benefits, but older beneficiaries need protection. The estimated 75-year savings from this restructured benefit amount to 14.2% to 18% of Social Security deficits. Modest increases in payroll taxes and maximum earnings taxed should make up most of the shortfall. Including unearned income with wages and salaries subject to the 6.2% individual tax would produce much more revenue. The discussion explores the proposal's political feasibility, grounding in current policy and political science literature, and the role of income as a social determinant of health.

Physicians, Physician Extenders and Health Outcomes: Race, Gender and Patient-Health Provider Concordance in North Carolina Medicaid.

BACKGROUND: No studies were found that consider the role of race and gender concordance in patient-physician extender relationships. METHODS: A telephone survey in summer 2012 allowed measures of the relationship between physicians and physician extenders with race and gender concordance. Randomized stratified sampled adults (n = 1,401) enrolled in North Carolina Medicaid's managed care networks met the study's criteria. FINDINGS: The analysis determined the association of provider type and race and gender concordance. It also explored the association of race and gender concordance with trust, satisfaction, and decision-making propensity. Separate logistic regression models were constructed for each dependent variable. Race concordance was associated with significantly higher trust scores among respondents in the physician subgroup when race was not included in the predictive model. However, in those models where race and gender were included as control variables, provider type was not associated with race and gender concordance in the logistic regressions.

Social determinants of health and community needs: implications for health legacy foundations.

Mergers and acquisitions of nonprofit hospitals are on the rise. Proceeds from many of these transactions will endow new health legacy foundations (HLFs). These philanthropic entities have substantial potential for charitable investment in US communities. Research indicates that the greatest improvements in population health can be achieved by addressing underlying social factors. Determining whether communities served by HLFs are characterized by poor social determinants of health would provide new information for developing effective grant-making strategies. Our study compared socioeconomic, demographic, and health care access indicators in HLF versus non-HLF counties. Compared with non-HLF counties, HLF counties had significantly higher proportions of racial minorities and multiple socioeconomic factors that rendered them more vulnerable to health disparities and poor health. However, HLF counties had better access to health care. These findings have direct implications for HLF leadership, planning, and grant making.

Federal health insurance reform and "exchanges": recent history.

The major national innovation of the Affordable Care Act (ACA) is the insurance exchange or health insurance marketplace (HIM). We begin by briefly reviewing the ACA's chief features and detailing its HIM provisions. Section two explores the policy history of exchanges, beginning with Clinton's proposals and Massachusetts' Connector and concluding by contrasting the House-passed bill with one national exchange and the Senate bill with state-based exchanges. The Senate bill became the ACA. The evolution of policy ideas about exchanges suggests three critical conditions for a successful exchange: commodification (of insurance products), competition (between insurers), and communication (to potential buyers and the public about insurance). The penultimate section compares the rollout of the state-run Kentucky exchange and the federally facilitated exchange in North Carolina in light of what we will call the 3 Cs. The conclusion reflects more widely upon the unique form that the pro-competition or deregulatory strategy has taken in health policy.

Health legacy foundations: a new census.

Health care merger and acquisition activity has increased since enactment of the Affordable Care Act in 2010. Proceeds from transactions involving nonprofit hospitals, health systems, and health plans will endow philanthropic foundations, collectively known as health legacy foundations. Building on work by Grantmakers In Health, we undertook a systematic search for these foundations and generated a newly updated, comprehensive database. We found 306 organizations in forty-three states that have been endowed with proceeds from the sale, merger, lease, joint venture, or other restructuring of nonprofit health care assets. These health legacy foundations had $26.2 billion in assets in 2010. Concentrated in the southern United States, foundations originating from hospitals and specialty care facilities (86.6 percent) held mean assets of $64.7 million per funder and typically restricted grants to local communities. Foundations formed from health plans (13.4 percent) held higher mean assets ($222 million), usually served larger areas, and were more likely to engage in health care advocacy. Recent transactions involving smaller and stand-alone nonprofit hospitals will infuse many more communities with unprecedented charitable wealth.

Medicaid transformed: why ACA opponents should keep expanded Medicaid.

The next potential disaster facing the Affordable Care Act (ACA) is the November 2012 elections: Its opponents, who promise to "repeal and replace," may gain sufficient control of the federal government in 2013 to carry out their pledge. This commentary aims to promote understanding of the fundamental transformation that the ACA makes in Medicaid and to urge ACA opponents desiring some health reform after repeal to let the ACA's Medicaid provisions stand. After an introduction to the ACA and its vulnerabilities the commentary examines the evolution of Medicaid since its 1965 origins as a means-tested concomitant of cash welfare. It shows that Medicaid has been very adaptable as it morphed into a complex categorical program for specific populations or types of care. The ACA transforms Medicaid into a universal means-tested entitlement for anyone below 138 percent FPL. The conclusion explains why ACA opponents should retain its Medicaid provisions.

Multiple switching in Medicaid managed care: a proportional hazards model.

This case study (n=41,969) aims to discover managerially useful predictors of multiple switching among HMOs in a Medicaid managed care population observed over 33 months. Cox's proportional hazards model was used to analyze eligibility data for the entire population, claims data for Medicaid services received during six months prior to HMO enrollment (sample n=2,474) and telephone interviews (sample n=656). Each analytic stage involved four comparisons: (1) enrollees with one switch compared with enrollees with no switches; (2) enrollees with multiple switches compared with those having no switches; (3) in relation to making the first switch, enrollees with multiple switches compared with those having one switch; and (4) in relation to making the second switch, multiple compared with those having one switch. Interruptions (which were independent of switches) predicted switching versus non-switching. Medical claims and, weakly, greater age were associated with multiple switching. Managers can use these three predictors to reduce switching and multiple switching. The finding that switching was associated with greater utilization before HMO enrollment contradicts findings for employer-sponsored insurance, but a possible explanation is offered.

Medicaid enrollee switching among managed care plans.

This case-study (n=41,969) of voluntary switching among Mecklenburg County, North Carolina Medicaid managed care plans showed a low switching rate of 14.5 per 100 member-years over 33 months, or 5.3 averaged annually. Population, plan and plan characteristics, claims and telephone survey data were examined to better understand this important behavioral measure. Switching in Medicaid managed care, which is little studied, is contrasted with the extensive literature on middle class switching. Policy implications included the suitability of Medicaid populations for managed care and the need for more research on switching and disenrollment and the Medicaid innovation of neutral health benefits advising.

A cohort study of former and current Medicaid recipients in two North Carolina counties, 1996-1999.

This article presents findings of a 1998-99 resurvey of Medicaid recipients (adults and children) who were first surveyed in 1996 in Mecklenburg and New Hanover Counties in North Carolina. It reports the insurance status and health care of former Medicaid recipients and compares them with those still on Medicaid in 1998-99 in respect to access to care and satisfaction. Just under half of those who had left Medicaid were without employer-sponsored health insurance (ESI) at the time of the second survey. Former Medicaid recipients without ESI rated their access to healthcare lower than those with Medicaid and former Medicaid recipients with ESI. Over 50% of target respondents in all groups were more positive than negative on access-related variables. But only those on Medicaid in Mecklenburg County had significant increases in satisfaction with health care between 1996 and 1998-99. Those in the control county who were off Medicaid and those still receiving it and former recipients in Mecklenburg showed no significant change. The study has great policy relevance in light of recent national welfare reform.

Medicaid managed care and racial differences in satisfaction and access.

Many researchers have suggested that the implementation of managed care may lower access to, and quality of, health care services for minorities. However, very little empirical data examining this issue exists. To examine it, the authors used a study design that was both cross-sectional and longitudinal in that they surveyed Medicaid recipients in two counties at two points in time; one of the counties began delivering services through managed care between the two survey periods. Their results indicate that, overall, managed care had neither a positive nor a negative effect on African Americans' access to health care services in either absolute terms or relative to whites'. In addition, race was not found to be associated with satisfaction. However, a Medicaid recipient's race was found to negatively affect his or her access to service under both managed care and fee-for-service systems.

Caring for patients under Medicaid mandatory managed care: perspectives of primary care physicians.

The purpose of the study was to describe the experiences of primary care physicians caring for Medicaid recipients in a demonstration mandatory health maintenance organization (HMO) managed care program. The authors collected data through semistructured individual or focus group interviews with 14 physicians and through interviews with the chief executive officers of the three HMOs participating in the demonstration program. Interview questions, developed initially from a review of the literature, addressed physicians' experiences as primary care providers for Medicaid recipients under traditional fee-for-service and under managed care arrangements through the demonstration program. Four themes emerged: providers' hassles and burdens, the complex needs of Medicaid patients, improved access to care under managed care, and individual providers' disconnect from the processes of health policy implementation and program evaluation.