Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

Christopher, Andrea S.; McCormick, Danny; Woolhandler, Steffie; Himmelstein, David U.; Bor, David H.; Wilper, Andrew P.

doi:10.2105/ajph.2015.302925

Cited by 66 publications

(45 citation statements)

References 27 publications

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“…Comparisons of Medicaid enrollees to low-income uninsured persons have found greater awareness and control of chronic diseases, while many studies show delayed diagnosis and worse management of chronic diseases for the uninsured. [17][18][19] Like other studies, 20,21 PCPs reported an increase in new patients, including some who had not sought primary care in many years. They reported hiring clinicians and staff, changing workflow for new patients, colocating mental health care in primary care, and hiring or consulting with care coordinators, case managers, and community health workers.…”

Section: Discussionmentioning

confidence: 66%

Primary Care Clinicians’ Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study

et al. 2018

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Section: Discussionmentioning

confidence: 66%

Primary Care Clinicians’ Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study

et al. 2018

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“…This finding of an increase in the diagnosis of late‐stage breast cancer is supported by results from prior studies that demonstrated that Medicaid disenrollment leads to reduced access to a usual source of outpatient care and increases in emergency room visits . Low‐income women who lose Medicaid coverage are likely to remain uninsured; therefore, they will have limited access to screening mammograms and may not seek care promptly when they experience symptoms of breast cancer .…”

mentioning

confidence: 56%

Delays in breast cancer diagnosis after a state policy limiting Medicaid enrollment

Subramanian

Keating

2017

Cancer

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There currently is great interest in understanding the benefits and harms associated with Medicaid expansions and contractions. The Patient Protection and Affordable Care Act expanded eligibility for Medicaid to individuals and families with incomes up to 138% of the federal poverty level (FPL), although the Supreme Court later made this Medicaid expansion voluntary (to date, 31 states and the District of Columbia have expanded their Medicaid programs). More recently, the American Health Care Act considered by Congress in early 2017 sought to limit Medicaid enrollment substantially. Currently, to the best of our knowledge, relatively few data are available regarding the health implications of federal and state policies that contract Medicaid benefits.In this issue of Cancer, Tarazi et al 1 investigated the effects of a state policy that substantially limited Medicaid enrollment on the timeliness of breast cancer diagnosis. In 2005, Tennessee, which previously had provided coverage to individuals with incomes up to 400% of the FPL, adopted reduced income threshold levels consistent with traditional Medicaid coverage, resulting in the abrupt disenrollment of approximately 170,000 low-income beneficiaries. 2 The authors used this natural experiment to conduct a difference-in-difference analysis that compared late-stage diagnosis (cancers detected at a regional or distant stage) before and after the Tennessee policy change for women living in low-income areas (who were more likely to be affected by the change) versus those living in high-income areas. They observed a statistically significant increase of 3.3 percentage points in the percentage of women diagnosed with late-stage cancers after the policy change among women living in low-income versus high-income areas.This finding of an increase in the diagnosis of late-stage breast cancer is supported by results from prior studies that demonstrated that Medicaid disenrollment leads to reduced access to a usual source of outpatient care and increases in emergency room visits. 3-5 Low-income women who lose Medicaid coverage are likely to remain uninsured; therefore, they will have limited access to screening mammograms and may not seek care promptly when they experience symptoms of breast cancer. 6 Some women in Tennessee who lost their Medicaid coverage were eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides free mammograms to uninsured and underinsured women who have incomes <250% of the FPL. However, the NBCCEDP generally reaches a minority of eligible women, 7 and women with incomes >250% of the FPL who were no longer covered by Medicaid would not have been eligible for the NBCCEDP. Although only a subset of women who lost Medicaid coverage would have benefitted from the NBCCEDP, without this program, the rate of late-stage diagnoses among low-income women would likely have been higher.Avoiding delays in the diagnosis of breast cancer is of crucial importance because of the higher cancer mortality and increased fin...

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“…When using EHR data for surveillance, we unintentionally condition on patients being ill for inclusion into the study. The exception to this are records that capture preventive care interactions, yet these too are subject to selection bias because factors such as education, health insurance coverage, and transportation might influence who uses these primary care services 11,12 .…”

Section: Selection Biasmentioning

confidence: 99%

Addressing Bias in Electronic Health Record-based Surveillance of Cardiovascular Disease Risk: Finding the Signal Through the Noise

et al. 2017

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PURPOSE OF REVIEW: Use of the electronic health record (EHR) for CVD surveillance is increasingly common. However, these data can introduce systematic error that influences the internal and external validity of study findings. We reviewed recent literature on EHR-based studies of CVD risk to summarize the most common types of bias that arise. Subsequently, we recommend strategies informed by work from others as well as our own to reduce the impact of these biases in future research. RECENT FINDINGS: Systematic error, or bias, is a concern in all observational research including EHR-based studies of CVD risk surveillance. Patients captured in an EHR system may not be representative of the general population, due to issues such as informed presence bias, perceptions about the healthcare system that influence entry, and access to health services. Further, the EHR may contain inaccurate information or be missing key data points of interest due to loss to follow-up or over-diagnosis bias. Several strategies, including implementation of unique patient identifiers, adoption of standardized rules for inclusion/exclusion criteria, statistical procedures for data harmonization and analysis, and incorporation of patient-reported data have been used to reduce the impact of these biases. SUMMARY: EHR data provide an opportunity to monitor and characterize CVD risk in populations. However, understanding the biases that arise from EHR datasets is instrumental in planning epidemiological studies and interpreting study findings. Strategies to reduce the impact of bias in the context of EHR data can increase the quality and utility of these data.

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Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

Abstract: Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

Cited by 66 publications

References 27 publications

Primary Care Clinicians’ Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study

Primary Care Clinicians’ Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study

Delays in breast cancer diagnosis after a state policy limiting Medicaid enrollment

Addressing Bias in Electronic Health Record-based Surveillance of Cardiovascular Disease Risk: Finding the Signal Through the Noise

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