Search tips
Search criteria

Results 1-25 (340267)

Clipboard (0)

Related Articles

1.  Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt 
Western Journal of Medicine  1980;132(6):550-561.
California's Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.
Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.
The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.
PMCID: PMC1272170  PMID: 6996334
2.  Pediatrician Participation in Medicaid—Findings of a Five-Year-Follow-up Study in California and Elsewhere 
Western Journal of Medicine  1986;145(4):546-550.
Medi-Cal—California's Medicaid program—underwent significant changes during the period 1978 through 1983. Most notable were the imposition of new copayments, reductions in physician reimbursement and selective contracting for hospital services. The state-funded medically indigent program was transferred to the counties and the state began to experiment with bulk purchasing of drugs and supplies, a lock-in for overutilizers and primary care case management.
How have these changes affected primary care providers' participation in Medi-Cal? Surveys of California pediatricians in 1978 and 1983 suggest that while most continue to participate, the level of limited participation in Medi-Cal increased from 23% to 51%. Most pediatricians express discontent with the level of Medicaid payments and there is a growing sentiment that Medicaid regulations interfere with the provision of high quality medical care. Future Medi-Cal policy developments, such as contracting for physician services, should be structured in ways that maximize participation of primary care providers in the program.
PMCID: PMC1307011  PMID: 3538665
3.  Does “Mainstreaming” Guarantee Access to Care for Medicaid Recipients with Asthma? 
Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated.
Cross-sectional survey.
A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group.
We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction.
Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.
PMCID: PMC1495233  PMID: 11520386
Medicaid; Medicare; asthma; access to care; primary care
4.  Enrolling in Medicaid Through the National School Lunch Program: Outcome of a Pilot Project in California Schools 
Public Health Reports  2007;122(4):452-460.
California has several health insurance programs for children. However, the system for enrolling into these programs is complex and difficult to manage for many families. Express Lane Eligibility is designed to streamline the Medicaid (called Medi-Cal in California) enrollment process by linking it to the National School Lunch Program. If a child is eligible for free lunch and the parents consent, the program provides two months of presumptive eligibility for Medi-Cal and a simplified application process for continuation in Medi-Cal. For those who are ineligible, it provides a referral to other programs.
An evaluation of Express Lane shows that while many children were presumptively enrolled, nearly half of the applicants were already enrolled in Medi-Cal. Many Express Enrolled children failed to complete the full Medi-Cal enrollment process. Few were referred to the State Children's Health Insurance Program or county programs. Express Lane is less useful as a broad screening strategy, but can be one of many tools that communities use to enroll children in health insurance.
PMCID: PMC1888518  PMID: 17639647
5.  A comparison of capitated and fee-for-service Medicaid reimbursement methods on pregnancy outcomes. 
Health Services Research  1998;33(1):55-73.
OBJECTIVE: To determine if the payment method influenced the likelihood of selected obstetrical process measures and pregnancy outcome indicators among Medicaid women. DATA SOURCE/STUDY SETTING: Data from the live birth certificates computer file for 1993 from the State of California. The computer files contain information about the demographic characteristics of the mother, her medical conditions prior to delivery, medical problems during labor and delivery, delivery method, newborn and maternal outcomes, and expected principal source of payment for prenatal care and for hospital delivery. STUDY DESIGN: The study sample consisted of singleton live births to women in the California Medi-Cal program residing in one of two counties in which a mixed-model managed care plan was the method of reimbursement or in one of three counties in which fee-for-service was the payment method. The study and control counties were matched in terms of geographic proximity and sociodemographics. PRINCIPAL FINDINGS: Among Medi-Cal women, the likelihood of low birth weight (LBW) was lower in the capitated payment group than in the fee-for-service payment group even when controlling for maternal and newborn characteristics and adequacy of prenatal care. There was no difference in either the adequacy of prenatal care, the cesarean birth rate, or the likelihood of adverse pregnancy outcomes other than LBW between the two payer groups. CONCLUSIONS: Results of this "natural experiment" suggest that enrollment of pregnant Medi-Cal beneficiaries in capitated healthcare services through a primary care case management system in a county-organized health system/health insuring organization can have a beneficial effect on low birth weight and provide care comparable to a fee-for-service system.
PMCID: PMC1070246  PMID: 9566177
6.  Capitation in California—An Analysis of At-Risk Financing of Medicaid Services 
Western Journal of Medicine  1986;145(2):258-262.
Recent legislative changes have fostered the growth of a highly competitive health care market in California. In addition to selective hospital contracting for Medicaid (Medi-Cal) services, the California Medical Assistance Commission is attempting to initiate pilot projects to capitate Medi-Cal beneficiaries in selected geographic areas throughout the state. Selective contracting with county capitated organized health systems is also underway in Santa Barbara County, with plans for other counties on the drawing boards. This paper describes these capitated programs as well as addressing problems that may arise in this transition from a fee-for-service to a capitated Medi-Cal system. Specifically considered are issues related to underutilization, quality of care, implementation, eligibility and effects on existing patterns of care.
PMCID: PMC1306907  PMID: 3532566
7.  Effect of insurance coverage on the relationship between asthma hospitalizations and exposure to air pollution. 
Public Health Reports  1999;114(2):135-148.
OBJECTIVE: Based on the assumption that people without health insurance have limited access to the primary care services needed to prevent unnecessary hospitalizations for asthma, the authors hypothesized that insurance is a factor in the strength of the association between hospital admissions for asthma and exposure to air pollution. They tested this hypothesis with 1991-1994 data from central Los Angeles. METHODS: The authors analyzed the effect of insurance status on the association between asthma-related hospital admissions and exposure to atmospheric particulates (PM10) and ozone (O3) using hospital discharge and air quality data for 1991-1994 for central Los Angeles. They used regression techniques with weighted moving averages (simulating distributed lag structures) to measure the effects of exposure on overall hospital admissions, admissions of uninsured patients, admissions for which MediCal (California Medicaid) was the primary payer, and admissions for which the primary payer was another government or private health insurance program. RESULTS: No associations were found between asthma admissions and O3 exposure. An estimated increase from 1991 to 1994 of 50 micrograms per cubic meter in PM10 concentrations averaged over eight days was associated with an increase of 21.0% in the number of asthma admissions. An even stronger increase--27.4%--was noted among MediCal asthma admissions. CONCLUSIONS: The authors conclude that low family income, as indicated by MediCal coverage, is a better predictor of asthma exacerbations associated with air pollution than lack of insurance and, by implication, a better predictor of insufficient access to primary care.
PMCID: PMC1308453  PMID: 10199716
8.  Medi-Cal Hospital Contracting—Did It Achieve Its Legislative Objectives? 
Western Journal of Medicine  1985;143(1):118-124.
The 1982 Medi-Cal reforms and reductions established selective contracting with hospitals for inpatient care of Medi-Cal beneficiaries. The legislation established a special negotiator and criteria to be used in selecting contract hospitals. We report the findings of a study that analyzed the characteristics of contract and noncontract hospitals in Los Angeles County to assess how well these criteria were reflected in the outcome of the contracting process. We examine issues of beneficiary access to general inpatient care and to specialized services, the efficiency of contract hospitals compared with noncontract ones and quality-related issues.
PMCID: PMC1306262  PMID: 3898595
9.  The long-term effects of Medicaid managed care on obstetrics care in three California counties. 
Health Services Research  2001;36(4):751-771.
OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.
PMCID: PMC1089255  PMID: 11508638
10.  The Impact of Health Insurance Policy Changes on Californians with Severe Chronic Disease 
Two recent changes in health policy will likely negatively impact state budgets and the health of low-income Californians with chronic disease. The new cost-sharing for medical visits, pharmaceuticals, and inpatient stays in California's Medcaid program (Medi-Cal) and the exclusion of the undocumented and individuals who have been legal residents for less than five years from the insurance expansions that The Patient Protection and Affordable Care Act of 2010 provides will reduce medical care utilization and may raise, rather than lower, state costs. Based on historical Medi-Cal utilization patterns, people living with HIV (PLWH) would average $514 in cost-sharing fees annually. The undocumented may lose coverage entirely and face even higher costs. The charges are high relative to the low incomes of both Medi-Cal recipients and the undocumented and are likely to discourage relatively inexpensive, but productive, medical care. Increasing patient costs harms patient health, harms public health, and increases state spending on medical care.
PMCID: PMC3828734  PMID: 24244803
Affordable Care Act; health policy; Medicare; Medicaid; health insurance
11.  Patterns of Antibacterial Use and Impact of Age, Race-Ethnicity, and Geographic Region on Antibacterial Use in an Outpatient Medicaid Cohort 
Pharmacotherapy  2014;34(7):677-685.
To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors—age, race-ethnicity, state county, and population density—on those patterns.
Retrospective analysis of administrative claims data.
Medi-Cal fee-for-service system claims database.
All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim.
Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial-ethnic and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = –0.971, p = 0.0012; τ-b = –1.00, p = 0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ2 (2) = 320,000, p < 0.001); among racial-ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ2 (5) = 197,000, p < 0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1–28.2%) to 32.7% (95% CI 32.6–32.8%) over the study period. Senior age groups and Caucasians received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5–54.3%] and 36.6% [95% CI 36.6–36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = –0.432, p = 0.0018) and broad-spectrum antibacterial prescribing (ρ = –0.359, p < 0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent.
Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial-ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.
PMCID: PMC4082730  PMID: 24753176
Antibiotic management; Medicaid; Epidemiology; Infectious disease; Community practice
12.  Measuring the Impact of Outreach and Enrollment Strategies for Public Health Insurance in California 
Health Services Research  2011;46(1p2):319-335.
Objective and Study Setting
To evaluate the effectiveness of different approaches to outreach on public health insurance enrollment in 25 California counties with a Children's Health Initiative.
Data Source
Administrative enrollment databases.
Study Design
The use of eight enrollment strategies were identified in each quarter from 2001 to 2007 for each of 25 counties (county quarter). Strategies were categorized as either technology or nontechnology. New enrollments were obtained for Medi-Cal, Healthy Families, and Healthy Kids. Bivariate and multivariate analyses assessed the link between each strategy and new enrollments rates of children.
Data Collection
Methods Surveys of key informants determined whether a specific outreach strategy was used in each quarter. These were linked to new enrollments in each county quarter.
Principal Findings
Between 2001 and 2007, enrollment grew in all three children's health programs. We controlled for the effects of counties, seasons, and county-specific child poverty rates. There was an increase in enrollment rates of 11 percent in periods when technology-based systems were in use compared with when these approaches were inactive. Non-technology-based approaches, including school-linked approaches, yielded a 12 percent increase in new enrollments rates. Deploying seven to eight strategies yielded 54 percent more new enrollments per 10,000 children compared with periods with none of the specific strategies.
Conclusions and Implications
National health care reform provides new opportunities to expand coverage to millions of Americans. An investment in technology-based enrollment systems will maximize new enrollments, particularly into Medicaid; nontechnological approaches may help identify harder-to-reach populations. Moreover, incorporating several strategies, whether phased in or implemented simultaneously, will enhance enrollments.
PMCID: PMC3037785  PMID: 21054378
Outreach; health insurance; health care reform; Medicaid; Medi-Cal; CHIP; Healthy Kids; enrollment
13.  A community-based collaboration to assess and improve medical insurance status and access to health care of Latino children. 
Public Health Reports  2001;116(6):575-584.
OBJECTIVES: Despite eligibility for subsidized insurance, low-income Latino children are at high risk of being medically uninsured. The authors sought to understand and improve access to medical insurance for Latino children living in a California community of predominantly low-income immigrant families. METHODS: During the summer of 1999, trained women from the community conducted interviews in Spanish with 252 randomly selected mothers of 464 children younger than age 19. Mothers provided information about family demographics, children's medical insurance, health care access, and experiences obtaining and maintaining children's insurance. RESULTS: Most children (83.3%) were eligible for subsidized medical insurance (48.4% Medi-Cal eligible; 35.0% Healthy Families eligible). Twenty-eight percent of eligible children were not enrolled. Non-enrolled eligible children were older (median age 7) than enrolled children (median age 4) and more likely to be born outside the U.S. (22.2%) than enrolled children (4.8%). Among children ages 3-18, those not enrolled were less likely to have visited a doctor in the past 12 months (58% compared to 78.7%) and less likely to have a usual source of care (96.3% compared to 99.5%). Mothers of non-enrolled children were more likely than mothers of enrolled children to have less than seven years of education (47.8% compared to 36.4%). Families with non-enrolled children were more likely to report out-of-pocket medical expenses (84.1% compared to 53%). Families with non-enrolled children were more likely to report barriers to the enrollment process, such as problems providing required documents (39.7% compared to 15.1%), problems understanding Spanish forms (19.4% compared to 8.9%), and confusing paperwork (39.7% compared to 24.7%). Most mothers (75.9%) reported that community organizations provided very useful help with children's insurance enrollment. Almost half (48.6%) preferred to receive enrollment assistance from community organizations. Only 43.3% of mothers had heard of the Healthy Families program. CONCLUSIONS: To reach the majority of uninsured Latino children, community-based outreach and insurance application assistance are crucial. Most important, the process of applying for and maintaining coverage in Medi-Cal or Healthy Families must be simplified.
PMCID: PMC1497393  PMID: 12196617
14.  Pediatric hospital admissions for measles. Lessons from the 1990 epidemic. 
Western Journal of Medicine  1996;165(1-2):20-25.
To examine the descriptive epidemiology of serious measles complications and associated hospital costs during a major epidemic, we used California population-based hospital discharge data to identify hospital admissions for measles during 1986 through 1990 (ICD-9 code 055, n = 4,201). We examined 5-year trends and, for 1990 pediatric epidemic cases (n = 2,234), sociodemographic and hospital admission financial data. Hospital admission rates for measles rose significantly between 1986 and 1990. During the 1990 epidemic, preschool children aged 1 to 5 years, Medi-Cal (California's Medicaid) beneficiaries, Hispanics, and those living in urban counties accounted for most hospital admissions. Young infants and residents of southern California and the San Joaquin Valley had the highest risks. Medi-Cal beneficiaries and Asian children were at an increased risk for death during the hospital stay. The average hospital admission cost was $8,201, and the average length of hospital stay was 4.6 days. Hospital costs amounted to $18 million, two thirds of which was paid for by Medi-Cal. Measles is a serious disease that can result in severe complications requiring lengthy and costly hospital stays. We must remain alert to its continuing threat, complications, and resulting financial burdens.
PMCID: PMC1307536  PMID: 8855680
15.  Determinants of Children's Participation in California's Medicaid and SCHIP Programs 
Health Services Research  2007;42(2):847-866.
To develop a comprehensive predictive model of eligible children's enrollment in California's Medicaid (Medi-Cal [MC]) and State Children's Health Insurance Program (SCHIP; Healthy Families [HF]) programs.
Data Sources/Study Setting
2001 California Health Interview Survey data, data on outstationed eligibility workers (OEWs), and administrative data from state agencies and local health insurance expansion programs for fiscal year 2000–2001.
Study Design
The study examined the effects of multiple family-level factors and contextual county-level factors on children's enrollment in Medicaid and SCHIP.
Data Collection/Extraction Methods
Simple logistical regression analyses were conducted with sampling weights. Hierarchical logistic regressions were run to control for clustering.
Principal Findings
Participation in MC and HF programs is determined by a combination of family-level predisposing, perceived need, and enabling/disabling factors, and county-level enabling/disabling factors. The strongest predictors of MC enrollment were family-level immigration status, ethnicity, and income, and the presence of a county-level “expansion program”; and the county-level ratio of OEWs to eligible children. Important HF enrollment predictors included family-level ethnicity, age, number of hours a parent worked, and urban residence; and county-level population size and outreach and media expenditure.
MC and HF outreach/enrollment efforts should target poorer and immigrant families (especially Latinos), older children, and children living in larger and urban counties. To reach uninsured eligible children, it is important to further simplify the application process and fund selected outreach efforts. Local health insurance expansion programs increase children's enrollment in MC.
PMCID: PMC1955353  PMID: 17362221
Medicaid; SCHIP; eligibility; outreach; enrollment
16.  Use of Postpartum Care: Predictors and Barriers 
Journal of Pregnancy  2014;2014:530769.
This study aimed to identify actual and perceived barriers to postpartum care among a probability sample of women who gave birth in Los Angeles County, California in 2007. Survey data from the 2007 Los Angeles Mommy and Baby (LAMB) study (N = 4,075) were used to identify predictors and barriers to postpartum care use. The LAMB study was a cross-sectional, population-based study that examined maternal and child health outcomes during the preconception, prenatal, and postpartum periods. Multivariable analyses identified low income, being separated/divorced and never married, trying hard to get pregnant or trying to prevent pregnancy, Medi-Cal insurance holders, and lack of prenatal care to be risk factors of postpartum care nonuse, while Hispanic ethnicity was protective. The most commonly reported barriers to postpartum care use were feeling fine, being too busy with the baby, having other things going on, and a lack of need. Findings from this study can inform the development of interventions targeting subgroups at risk for not obtaining postpartum care. Community education and improved access to care can further increase the acceptability of postpartum visits and contribute to improvements in women's health. Postpartum care can serve as a gateway to engage underserved populations in the continuum of women's health care.
PMCID: PMC3945081  PMID: 24693433
17.  Informing public policy toward binational health insurance: Empirical evidence from California 
Salud publica de Mexico  2013;55(0 4):S468-S476.
To estimate reimbursement rate differences between Mexico and US based physicians reimbursed by a binational health insurance (BHI) plan and US payers, respectively; and show the relationship between plan benefit designs and health care utilization in Mexico.
Materials and methods
Data include 33 841 and 53 909 HMO enrollees in California from Sistemas Médicos Nacionales (SIMNSA) and Salud con Health Net, respectively. We use descriptive statistical methods.
SIMNSA’s physician reimbursement rates averaged 50.7% (95% CI: 34.5%–67.0%) of Medi-Cal’s, 28.3% (95% CI: 19.6%–37.0%) of Medicare’s, and 22% of US private plans’. Each year, 99.4% of SIMNSA enrollees but only 0.1% of Salud con Health Net enrollees obtained care in Mexico.
SIMNSA only covers emergency and urgent care in the US, while Salud con Health Net covers comprehensive care with higher patient cost sharing than in Mexico. To realize potential savings, plans need strong incentives to increase utilization in Mexico.
PMCID: PMC4412842  PMID: 25153186
binational health insurance; US-Mexico border; emigrants and immigrants; health care costs; cross-border health care utilization; medically uninsured
18.  Nurse Practitioner and Physician's Assistant Clinics in Rural California 
Western Journal of Medicine  1980;132(2):171-178.
The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP's) or physician's assistants (PA's). All of these have physician supervision and support. NP's and PA's have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.
NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician's assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California's Medicaid program).
Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician's assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP's and PA's will serve an even greater role in rural areas.
PMCID: PMC1272011  PMID: 6104383
19.  Children of working low-income families in California: does parental work benefit children's insurance status, access, and utilization of primary health care? 
Health Services Research  2000;35(2):417-441.
OBJECTIVE: To examine financial and nonfinancial access to care and utilization of primary health care services among children of working low-income families earning below 200 percent of the federal poverty level in California, and to compare them to children in nonworking low-income families and in families earning over 200 percent of poverty. DATA SOURCES/STUDY SETTING: The 1994 National Health Interview survey weighted to reflect population estimates for California. STUDY DESIGN: This cross-sectional study of 3,831 children under age 19 focuses on financial access, that is, the prevalence and continuity of health insurance coverage; structural access, including the presence of a usual source of care, the predominant care source, its responsiveness to patient's needs, and any indications of delayed or missed care; and utilization of health care measured by the presence of an outpatient doctor's visit and the mean number of visits relative to child health status. DATA COLLECTION: The study uses secondary analysis. FINDINGS: Compared to children of nonworking low-income parents and to nonpoor children, children of working low-income parents were more likely to be uninsured (32.1 percent versus 15.6 percent and 10.3 percent, p = .0001) and to experience disruptions in insurance coverage (p = .0009). These differences persisted after controlling for other covariates in multivariate analyses. Children of working low-income parents did not differ significantly from children of nonworking low-income parents on measures of structural access or utilization, after adjusting for other covariates. However, they differed significantly from nonpoor children on structural access and utilization, and these differences mostly persisted after adjusting for other covariates (odds ratios from 1.5 to 2.9). Similar patterns were observed when children of full-time, year-round working parents with low earnings were compared with the two reference populations. CONCLUSION: Children in working low-income families in California have some of the worst access problems. Even full attachment to the workforce does not guarantee health insurance benefits, access to care, or improved health care use for children of low-income parents. These children are not better off than other low-income children of nonworking parents and are much worse off than nonpoor children. Expansion of health insurance coverage through Healthy Families and Medi-Cal, and attention to nonfinancial barriers to care for working low-income families may help to reduce these disparities.
PMCID: PMC1089127  PMID: 10857470
20.  Predictors of California nursing facilities' acceptance of people with HIV/AIDS. 
Health Services Research  1998;32(6):867-880.
OBJECTIVE: To examine factors that might predict the provision of HIV/AIDS care among California nursing facilities (NFs) in 1990. STUDY DESIGN: Logistic regression to examine the probability that a NF had admitted a person with AIDS/HIV (PWA/H). Independent variables of key interest included whether the facility was hospital-based; whether it sustained a financial loss in FY 1990; whether it had a hospice; the percentage of its residents on Medicare; the percentage of its residents on MediCal; the number of PWA/Hs per elderly in the county where the facility was located; the ratio of home-based hospices to elderly in the county; and the ratio of NF beds to elderly in the county. DATA COLLECTION METHODS: Data on all California NFs, obtained from the Office of Statewide Health Planning and Development (OSHPD), were merged with state data on the cumulative incidence of AIDS cases by county; U.S. census data on the number of elderly by county; and home-based hospice data from the 1990 Case Management Resource Guide for California. PRINCIPAL FINDINGS: Of the 902 facilities examined, 7.65 percent served AIDS residents. The financial loss variable was not significant. The community-based hospice variable was significant and negative. All other key variables were significant and positive. CONCLUSIONS: This study (1) suggests that NFs respond to external pressures to provide AIDS care even in the absence of financial incentives or a positive financial margin; (2) supports concerns that competition may exist between the elderly and PWA/H for NF beds; (3) shows that NFs are less likely to provide care if substitute services are available; and (4) demonstrates that facilities capable of providing a higher level of clinical and psychosocial care may be particularly willing, perhaps able, to provide AIDS care.
PMCID: PMC1070238  PMID: 9460491
21.  Low-birth-weight rate reduced by the obstetrical access project 
Health Care Financing Review  1987;8(3):83-86.
Obstetrical (OB) access was a Medicaid pilot project that operated in 13 California counties from July 1979 through June 1982. The project goals were to both improve access to care in underserved areas and improve pregnancy outcomes by providing enhanced prenatal care, including psychosocial, health education, and nutrition services. The project registered 6,774 women. The findings were: 87 percent of the registrants started prenatal care during the first or second trimester; 84 percent of the registrants completed care in the project; OB access mothers had a low-birth-weight rate of 4.7 percent, compared with 7.0 percent for a matched control group, suggesting a 33-percent reduction in low birth weight through the project; and the benefit-cost ratio of this program was about 2 to 1 for the short run because of savings in neonatal intensive care services. The State of California approved legislation in 1984 authorizing the project's scope of services for Medi-Cal recipients on a statewide basis.
PMCID: PMC4192843  PMID: 10312118
22.  Do Experiences Consistent With a Medical-Home Model Improve Diabetes Care Measures Reported by Adult Medicaid Patients? 
Diabetes Care  2014;37(9):2565-2571.
The patient-centered medical home has gained much traction. Little is known about the relationship between the model and specific health care processes for chronic diseases such as diabetes. This study assesses the impact of features of a medical home on diabetes care.
A cross-sectional survey of 540 patients with Medicaid (Medi-Cal) health insurance and type 2 diabetes in Los Angeles County was performed. The Primary Care Assessment Tools was used to measure seven features of medical-home performance.
The response rate of the patient survey was 68.9%. Patient-reported medical-home performance averaged a score of 2.85 ± 0.29 (on a 1–4 scale, with 4 equaling the best care). Patients who received more timely and thorough diabetes care reported higher medical-home performance in every feature except for the comprehensiveness-services available. For example, the first-contact access feature score was higher among patients who had an HbA1c test in the past 6 months versus those who did not (2.38 vs. 2.25; P < 0.05). Before and after adjusting for sociodemographics and health status, total medical-home performance was positively associated with each diabetes care measure. A 1-point increase in total medical-home score was associated with 4.53 higher odds of an HbA1c test in the past 6 months and 1.88 higher odds of an eye exam in the past year.
Features consistent with higher medical-home performance are associated with improvements in patient-reported diabetes care process measures, even in this low socioeconomic status setting. The patient-centered medical-home model may help in caring for people with type 2 diabetes.
PMCID: PMC4140163  PMID: 24947789
23.  Health and Oral Health Care Needs and Health Care-Seeking Behavior Among Homeless Injection Drug Users in San Francisco 
Few existing studies have examined health and oral health needs and treatment-seeking behavior among the homeless and injection drug users (IDUs). This paper describes the prevalence and correlates of health and oral health care needs and treatment-seeking behaviors in homeless IDUs recruited in San Francisco, California, from 2003 to 2005 (N = 340). We examined sociodemographic characteristics, drug use patterns, HIV status via oral fluid testing, physical health using the Short Form 12 Physical Component Score, self-reported needs for physical and oral health care, and the self-reported frequency of seeking medical and oral health care. The sample had a lower health status as compared to the general population and reported a frequent need for physical and oral health care. In bivariate analysis, being in methadone treatment was associated with care-seeking behavior. In addition, being enrolled in Medi-Cal, California’s state Medicaid program, was associated with greater odds of seeking physical and oral health care. Methamphetamine use was not associated with higher odds of needing oral health care as compared to people who reported using other illicit drugs. Homeless IDUs in San Francisco have a large burden of unmet health and oral health needs. Recent cuts in Medi-Cal’s adult dental coverage may result in a greater burden of oral health care which will need to be provided by emergency departments and neighborhood dental clinics.
PMCID: PMC3005094  PMID: 20945108
IDU; Homeless; Health Care; Oral Health; Methamphetamine; Dental Care
24.  Shaking Up the Dental Safety-net: Elimination of Optional Adult Dental Medicaid Benefits in California 
In July 2009, California eliminated funding for most adult non-emergency Medicaid dental benefits (Denti-Cal). This paper presents the findings from a qualitative assessment of the impacts of the Denti-Cal cuts on California's oral health safety-net. Interviews were conducted with dental safety-net providers throughout the state, including public health departments, community health centers, dental schools, Native American health clinics, and private providers, and were coded thematically using Atlas.ti. Safety-net providers reported decreased utilization by Denti-Cal-eligible adults, who now primarily seek emergency dental services, and reported shifting to focus on pediatric and privately-insured patients. Significant changes were reported in safety-net clinic finances, operations, and ability to refer. The impact of the Denti-Cal cuts has been distributed unevenly across the safety-net, with private providers and County Health Departments bearing the highest burden.
PMCID: PMC4175711  PMID: 24583494
Medicaid; dental clinics; vulnerable populations; oral health; dental public health; access to care
25.  Psychiatric admissions of low-income women following abortion and childbirth 
Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.
We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.
Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.
Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.
PMCID: PMC154179  PMID: 12743066

Results 1-25 (340267)