PURPOSE Electronic Health Record (EHR) databases in community health centers (CHCs) present new opportunities for quality improvement, comparative effectiveness, and health policy research. We aimed (1) to create individual-level linkages between EHR data from a network of CHCs and Medicaid claims from 2005 through 2007; (2) to examine congruence between these data sources; and (3) to identify sociodemographic characteristics associated with documentation of services in one data set vs the other. METHODSWe studied receipt of preventive services among established diabetic patients in 50 Oregon CHCs who had ever been enrolled in Medicaid (N = 2,103). We determined which services were documented in EHR data vs in Medicaid claims data, and we described the sociodemographic characteristics associated with these documentation patterns. RESULTSIn 2007, the following services were documented in Medicaid claims but not the EHR: 11.6% of total cholesterol screenings received, 7.0% of total infl uenza vaccinations, 10.5% of nephropathy screenings, and 8.8% of tests for glycated hemoglobin (HbA 1c ). In contrast, the following services were documented in the EHR but not in Medicaid claims: 49.3% of cholesterol screenings, 50.4% of infl uenza vaccinations, 50.1% of nephropathy screenings, and 48.4% of HbA 1c tests. Patients who were older, male, Spanish-speaking, above the federal poverty level, or who had discontinuous insurance were more likely to have services documented in the EHR but not in the Medicaid claims data.CONCLUSIONS Networked EHRs provide new opportunities for obtaining more comprehensive data regarding health services received, especially among populations who are discontinuously insured. Relying solely on Medicaid claims data is likely to substantially underestimate the quality of care.

Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

Objectives. To determine the impact of introducing copayments on medical care use and expenditures for low‐income, adult Medicaid beneficiaries. Data Sources/Study Setting. The Oregon Health Plan (OHP) implemented copayments and other benefit changes for some adult beneficiaries in February 2003. Study Design. Copayment effects were measured as the “difference‐in‐difference” in average monthly service use and expenditures among cohorts of OHP Standard (intervention) and Plus (comparison) beneficiaries. Data Collection/Extraction Methods. There were 10,176 OHP Standard and 10,319 Plus propensity score‐matched subjects enrolled during November 2001–October 2002 and May 2003–April 2004 that were selected and assigned to 59 primary care‐based service areas with aggregate outcomes calculated in six month intervals yielding 472 observations. Results. Total expenditures per person remained unchanged (+2.2 percent, p=.47) despite reductions in use (−2.7 percent, p<.001). Use and expenditures per person decreased for pharmacy (−2.2 percent, p<.001; −10.5 percent, p<.001) but increased for inpatient (+27.3 percent, p<.001; +20.1 percent, p=.03) and hospital outpatient services (+13.5 percent, p<.001; +19.7 percent, p<.001). Ambulatory professional (−7.7 percent, p<.001) and emergency department (−7.9 percent, p=.03) use decreased, yet expenditures remained unchanged (−1.5 percent, p=.75; −2.0 percent, p=.68, respectively) as expenditures per service user rose (+6.6 percent, p=.13; +7.9 percent, p=.03, respectively). Conclusions. In the Oregon Medicaid program applying copayments shifted treatment patterns but did not provide expected savings. Policy makers should use caution in applying copayments to low‐income Medicaid beneficiaries.

Introduction It is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S, primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon’s 2008 randomized Medicaid expansion (“Oregon Experiment”) on receipt of 12 preventive care services in community health centers using electronic health record data. Methods Demographic data from adult (aged 19–64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008–2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012–2014; analysis performed in 2014–2015). Results Intent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for eight of 12 assessed preventive services. In intent-to-treat[MM1] analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography). Conclusions Rates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations.

IMPORTANCE In the United States, health insurance is not universal. Observational studies show an association between uninsured parents and children. This association persisted even after expansions in child-only public health insurance. Oregon’s randomized Medicaid expansion for adults, known as the Oregon Experiment, created a rare opportunity to assess causality between parent and child coverage. OBJECTIVE To estimate the effect on a child’s health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage. DESIGN, SETTING, AND PARTICIPANTS Oregon Experiment randomized natural experiment assessing the results of Oregon’s 2008 Medicaid expansion. We used generalized estimating equation models to examine the longitudinal effect of a parent randomly selected to apply for Medicaid on their child’s Medicaid or Children’s Health Insurance Program (CHIP) coverage (intent-to-treat analyses). We used per-protocol analyses to understand the impact on children’s coverage when a parent was randomly selected to apply for and obtained Medicaid. Participants included 14 409 children aged 2 to 18 years whose parents participated in the Oregon Experiment. EXPOSURES For intent-to-treat analyses, the date a parent was selected to apply for Medicaid was considered the date the child was exposed to the intervention. In per-protocol analyses, exposure was defined as whether a selected parent obtained Medicaid. MAIN OUTCOMES AND MEASURES Children’s Medicaid or CHIP coverage, assessed monthly and in 6-month intervals relative to their parent’s selection date. RESULTS In the immediate period after selection, children whose parents were selected to apply significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a nonsignificant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected (adjusted odds ratio [AOR] = 1.18; 95% CI, 1.10–1.27). The effect remained significant during months 7 to 12 (AOR = 1.11; 95% CI, 1.03–1.19); months 13 to 18 showed a positive but not significant effect (AOR = 1.07; 95% CI, 0.99–1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage (AOR = 2.37; 95% CI, 2.14–2.64). CONCLUSIONS AND RELEVANCE Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents’ access to Medicaid coverage and their children’s coverage.