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How Can the Health Care System Be Made More Equitable?

What Are the Nature and Magnitude of Disparities in Access and Outcomes?

Profound disparities in health and socioeconomic status often occur along racial or ethnic lines. The Patient Protection and Affordable Care Act aims to address these disparities and strengthen our health care system for all Americans. Mathematica has worked to create accurate ways to measure and document disparities and looked at differences in utilization of services and in health outcomes. Our work ranges from studies of broad-based changes in health systems, physician practice patterns, and insurance coverage to evaluations of specific health programs, such as mammography, prostate cancer screening, nutrition, and chronic disease management programs and their effectiveness for specific racial or ethnic groups. Related publications include:

"Beyond Affordability: The Impact of Nonfinancial Barriers on Access for Uninsured Adults in Three Diverse Communities." (Journal of Community Health, June 2010). To shed light on the multidimensional issue of health care access, this study identifies nonfinancial barriers to health care uninsured low-income adults in three diverse communities face.
"Racial Disparities in Hospitalizations for Ambulatory Care-Sensitive Conditions."(American Journal of Preventive Medicine, April 2010). This study identified differences in hospitalization rates for elderly African Americans and whites in Maryland for eight ambulatory care-sensitive conditions and estimated excess costs associated with these disparities.
"Differences in Prevalence, Treatment, and Outcomes of Asthma Among a Diverse Population of Children With Equal Access to Care: Findings From a Study in the Military Health System."(Archives of Pediatric and Adolescent Medicine, June 2010). The authors analyzed data from 822,900 children age 2 through 17 who were continuously enrolled throughout 2007 in TRICARE Prime, a Department of Defense health maintenance organization-type plan. Asthma prevalence, treatment patterns and outcomes were assessed among children age 2 to 4, 5 to 10 and 11 to 17.
"Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care for U.S. Health Center Patients Compared with Non-Health Center Patients."(Journal of Ambulatory Care Management, October/December 2009). This study compares racial/ethnic and socioeconomic disparities in access to care and quality of care for U.S. health center patients and non-health center patients.
"Measuring Racial and Ethnic Disparities in Health Care: Efforts to Improve Data Collection" (May 2009). This policy brief examines recent federal and state activities aimed at strengthening the collection of health-related data on race, ethnicity, and primary language. It highlights three states—California, Massachusetts, and New Jersey—that implemented laws or regulations guiding data collection activities by hospitals, health plans, and government agencies.
"Reducing Racial and Ethnic Disparities in Health Care: Partnerships Between Employers and Health Plans." (July 2009). This policy brief draws on interviews with large employers, health plan representatives, government officials, and national experts to assess health plan/employer partnerships addressing disparities. The brief also looks at barriers that prevent partnerships from forming and discusses strategies to encourage increased involvement of employers.
"Differences in Hospitalizations for Ambulatory Care Sensitive Conditions Among Maryland Medicare Beneficiaries 2006" (December 2008). Analyzes Maryland Medicare claims data showing that significant differences in rates of ACSC-related hospitalizations by race and gender were only partially explained by disease burden or socioeconomic and geographic factors.
"Evidence of Trends, Risk Factors, and Intervention Strategies" (A Report from the Healthy Start National Evaluation 2006: Racial and Ethnic Disparities in Infant Mortality, June 2008). Provides an evidence base to support Healthy Start’s targeted interventions to reduce disparities.
"Racial Disparities in Prescription Drug Use Among Dually Eligible Beneficiaries" (Health Care Financing Review, winter 2003-2004). Compares the difference in Medicaid pharmacy use between black and white dually eligible Medicare beneficiaries.

How Can Public Policy Address Disparities in Access and Outcomes?

Government agencies and foundations have taken the initiative to address disparities in access and health outcomes. We have helped to evaluate some of those initiatives and provide guidance about potentially effective future strategies. Related publications include:

"Availability of Data to Measure Disparities in Leading Health Indicators at the State and Local Levels" (Journal of Public Health Management Practice, November 2008). This article analyzes the availability of state and local data to support elimination of health disparities and concludes that some relevant state data exist, major gaps remain, local estimates are limited, and some states make better use of data than others.
"State Efforts to Address the Healthy People 2010 Goal to Eliminate Health Disparities: Two Case Studies
" (September 2008). Examines North Carolina and Washington, two states that are making notable use of data to address disparities.
"Lessons from Local Access Initiatives: Contributions and Challenges" (August 2007). Looks at community initiatives to improve access for low-income, nonelderly adults, a group likely to be uninsured.
"Evaluation of a Learning Collaborative’s Process and Effectiveness to Reduce Health Care Disparities Among Minority Population" (December 2006). Uses social network analysis to study the relationships among organizations participating in a large-scale, public-private collaboration among major health plans to reduce racial and ethnic disparities in health care.
"How Seniors Learn" (2003). The learning capacity of older adults has direct, practical implications for professionals trying to educate older people and their families about health care services and benefits, especially in Medicare. This brief discusses how older people learn, explores research from the field of cognitive aging, and offers tips for adapting educational materials to build on clients' cognitive strengths and compensate for some of the losses that can occur with aging.
"Developing Culturally Appropriate Medicare Education Materials" (2001). Cultural differences are some of the most subtle, yet critical, factors affecting how people with Medicare understand their benefits, rights, and choices. This brief explores the lessons learned from an effort to develop and test Medicare education materials suitable for audiences of varying cultural backgrounds, noting that more than translation is needed for materials to be effective.

How Do We Assess Needs of Special Populations and Design Appropriate Programs?

Reaching vulnerable groups is one of our nation's biggest challenges. Vulnerable groups may need intensive or specialized services, or they may face difficulties in accessing services. Mathematica has worked with many special populations to assess their needs and help design effective programs. Related publications include:

"The Effects of State Policy Decisions on the Employment and Earnings of Medicaid Buy-In Participants in 2006." (Journal of Disability Policy Studies, December 2009). This article examines the Medicaid Buy-In program, so named because workers with disabilities “buy into” Medicaid coverage with monthly premiums. In 2006, over 97,000 individuals were enrolled in 32 state Buy-In programs.
"State Variation in Out-of-Home Medicaid Mental Health Services for Children and Youth: An Examination of Residential Treatment and Inpatient Hospital Services" (Administration and Policy in Mental Health and Mental Health Services Research, August 2009). Using Medicaid data from 2003, this article describes the demographics and diagnoses of youth under 22 receiving mental health services in general and psychiatric hospitals, psychiatric residential treatment facilities, and other residential treatment settings.
"Implementation of Mental Health Parity: Lessons from California." (Psychiatric Services, December 2009). This article reviews the experiences of state health plans, providers, and consumers between 2000 and 2005 in implementing parity and discusses implications for the 2008 federal parity law.
"Participants in the Medicaid Buy-In Program, 2000-2004: Characteristics, Earnings, and Medical Expenditures" (Journal of Disability Policy Studies, September 2008). Describes enrollment, expenditures, and earnings for Medicaid Buy-In participants in 27 states between 2000 and 2004. Click here for other research related to the Medicaid Buy-In program.
"Do We Know If Medicare Advantage Special Needs Plans Are Special?" (January 2008). This report describes the history of special needs plans, how they fit into the larger Medicare Advantage marketplace, and how to assess whether plans are performing differently from other Medicare Advantage plans.
"Receiving Advice About Child Mental Health From a Primary Care Provider: African American and Hispanic Parent Attitudes" (Medical Care, November 2007). Investigates parent attitudes associated with receiving advice about child mental health in primary care and whether attitudes differed according to race and ethnicity.
More than Ramps: Improving Health Care Quality for People with Disabilities (New York: Oxford University Press, 2006). Discusses health insurance and social policies affecting people with disabilities, describes challenges people with disabilities face when accessing health care, and suggests ways for successfully overcoming challenges.