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Abstract BackgroundThere are racial differences in COVID-19 vaccination rates, but social factors, such as lack of health insurance or food insecurity, may explain some of the racial disparities.ObjectiveTo assess social factors, including insurance coverage, that may affect COVID-19 vaccination as of June–July 2021 and vaccine hesitancy among those not yet vaccinated, and how these may affect racial equity in vaccinations.DesignCross-sectional analysis of nationally representative survey data.ParticipantsAdults 18 to 64 participating in the Census Bureau’s Household Pulse Survey for June 23 to July 5, 2021.Main MeasuresVaccination: receipt of at least one dose of a COVID-19 vaccine. Vaccine hesitancy: among those not yet vaccinated, intent to definitely or probably not get vaccinated.Key ResultsIn unadjusted analyses, black adults were less likely to be vaccinated than other respondents, but, after social factors were included, including health insurance status, food sufficiency, income and education, and state-level political preferences, differences between black and white adults were no longer significant and Hispanics were more likely to be vaccinated (OR = 1.87, p < .001). Among those not yet vaccinated, black and Hispanic adults were vaccine hesitant than white adults (ORs = .37 and .45, respectively, both p < .001) and insurance status and food insufficiency were not significantly associated with vaccine hesitancy. The percent of state voters for former President Trump in 2020 was significantly associated with lower vaccination rates and with increased vaccine hesitancy.DiscussionThe results indicate that much of the gap in COVID vaccination rates for minority adults are due to social barriers, rather than differences in racial attitudes. Unvaccinated minority adults expressed less vaccine hesitancy than white adults. Social barriers like food insecurity and insurance coverage could have deterred prompt COVID-19 vaccinations. Reducing these problems might help increase vaccination rates.

Medicaid enrollees are about twice as likely as the general US population to smoke tobacco: 32 percent of people in the program identify themselves as smokers. This article provides the first data about the effectiveness of state Medicaid programs in promoting smoking cessation. Our analysis of Medicaid enrollees' use of cessation medications found that about 10 percent of current smokers received cessation medications in 2013. Every state Medicaid program covers cessation benefits, but the use of these medications varies widely, with the rate in Minnesota being thirty times higher than that in Texas. Most states could increase their efforts to help smokers quit, working with public health agencies, managed care plans, and others. In 2013 Medicaid spent $103 million on cessation medications-less than 0.25 percent of the estimated cost to Medicaid of smoking-related diseases. Additionally, states that have not expanded Medicaid eligibility in the wake of the Affordable Care Act have higher smoking prevalence and lower utilization rates of cessation medication, compared to expansion states. Given these factors, nonexpansion states will have a greater public health burden related to smoking. Medicaid and public health agencies should work together to make smoking cessation a priority for Medicaid beneficiaries.

Medicaid and the Supplemental Nutrition Assistance Program were developed during the Civil Rights era to help poor people and reduce racial and ethnic differences in health care access and food security. Although the two programs have succeeded in narrowing health and nutrition disparities, certain policies hinder goals of racial and ethnic equity, even though they do not explicitly mention race or ethnicity. These policies, including administrative policies (such as work requirements) and more basic decisions about whether to cover immigrants or expand Medicaid, can create barriers that promote racial and ethnic disparities, contrary to the programs' underlying goals.

The lack of racial and ethnic concordance between patients and their physicians may contribute to American health disparities. To examine the level of racial and ethnic concordance for patients and primary care clinicians and its association with measures of patient experience. Multivariate cross-sectional analysis of nationally representative data. Adults 18 to 64 in the 2019 Medical Expenditure Panel Survey who had at least one medical visit in the past year. Key independent variables include having a racially/ethnically concordant primary care clinician, lacking a usual source of care, and having a usual source that is a place rather than a person. Outcomes include overall satisfaction with health care, number of medical visits, having enough time in care, ease of understanding the clinician, and receiving respect. The comparison between the actual level of concordance with an expected distribution if all patients had the same probability of having a clinician of a given race or type indicates that Black, Latino, and Asian patients are three or more times as likely to have a concordant clinician than expected, suggesting a strong preference for clinicians of the same race or ethnicity. Racial or ethnic concordance has a modest positive association with overall health care satisfaction and respect but is not significantly associated with the number of medical visits or other outcomes. Poor health status, being uninsured, and lacking a usual source of care are more strongly associated with patient experience. Efforts to increase the diversity of the primary care workforce could increase racial/ethnic concordance but may have only modest effects on patients' experience of care. Policies like lowering the number of uninsured or increasing those with a usual source of care may be more salient in improving experience of care.

Research amply documents that language barriers impede access to health care, compromise quality of care, and increase the risk of adverse health outcomes among patients with limited English proficiency. Federal civil rights policy obligates health care providers to supply language services, but wide gaps persist because insurers typically do not pay for interpreters, among other reasons. Health care financing policies should reinforce existing medical research and legal policies: Payers, including Medicaid, Medicare, and private insurers, should develop mechanisms to pay for interpretation services for patients who speak limited English. [PUBLICATION ABSTRACT]

A high proportion of low-income people insured by the Medicaid program smoke. Earlier research concerning a comprehensive tobacco cessation program implemented by the state of Massachusetts indicated that it was successful in reducing smoking prevalence and those who received tobacco cessation benefits had lower rates of in-patient admissions for cardiovascular conditions, including acute myocardial infarction, coronary atherosclerosis and non-specific chest pain. This study estimates the costs of the tobacco cessation benefit and the short-term Medicaid savings attributable to the aversion of inpatient hospitalization for cardiovascular conditions. A cost-benefit analysis approach was used to estimate the program's return on investment. Administrative data were used to compute annual cost per participant. Data from the 2002-2008 Medical Expenditure Panel Survey and from the Behavioral Risk Factor Surveillance Surveys were used to estimate the costs of hospital inpatient admissions by Medicaid smokers. These were combined with earlier estimates of the rate of reduction in cardiovascular hospital admissions attributable to the tobacco cessation program to calculate the return on investment. Administrative data indicated that program costs including pharmacotherapy, counseling and outreach costs about $183 per program participant (2010 $). We estimated inpatient savings per participant of $571 (range $549 to $583). Every $1 in program costs was associated with $3.12 (range $3.00 to $3.25) in medical savings, for a $2.12 (range $2.00 to $2.25) return on investment to the Medicaid program for every dollar spent. These results suggest that an investment in comprehensive tobacco cessation services may result in substantial savings for Medicaid programs. Further federal and state policy actions to promote and cover comprehensive tobacco cessation services in Medicaid may be a cost-effective approach to improve health outcomes for low-income populations.

Smoking rates for Medicaid beneficiaries have remained flat in recent years. Medicaid may support smokers in quitting by covering a broad array of tobacco cessation services without barriers such as copays. This study examines the impact of increasing generosity in Medicaid tobacco cessation coverage policies on smoking and cessation behaviors. We used 2010 and 2015 National Health Interview Survey data merged with information on state tobacco, Medicaid cessation, and Medicaid eligibility policies to estimate state fixed effects models of cessation medication use, counseling use, quit attempts, and current smoking. Smokers living in states that cover cessation medications but not counseling services were less likely to use counseling. Smokers were more likely to report having tried to quit in states with higher rates of use of cessation medications among Medicaid beneficiaries. We found no impact of Medicaid policies on use of cessation medications. States that impose copays had higher rates of smoking, while those that require counseling as a condition of receiving medication had lower rates of smoking. Additionally, we found that expanding Medicaid eligibility under the Affordable Care Act is associated with decreased smoking prevalence among Medicaid beneficiaries. Covering cessation counseling may encourage smokers that want to quit to use this service. Promoting the use of cessation medications may improve the likelihood that smokers try to quit. Medicaid coverage of cessation services is an important but incomplete strategy in addressing smoking among low-income populations. States may be able to improve utilization of cessation counseling by providing Medicaid reimbursement for this service. Encouraging utilization of tobacco cessation medications may help more smokers quit. States should consider how to promote effective cessation methods among clinicians and patients.

The article by Muchomba and Kaushal in this issue of AJPH (p. 1106) describes how states' Medicaid expansions led to a reduction in Supplemental Security Income (SSI) payments for nonelderly disabled adults, saving the federal government more than $600 million. The use of SSI fell more for noncitizen immigrants (12%) than for citizens (2%). The authors used difference-in-difference methods to compare results in Medicaid expansion versus nonexpansion states. Using two data sources, they found consistent results, providing strong evidence that Medicaid expansions reduced SSI participation more for noncitizen immigrants than for citizens. Those who get SSI are usually automatically enrolled in Medicaid. But rigid SSI income and asset eligibility criteria have meant that some disabled adults could be discouraged from working and earning more, because going over the SSI limits (and losing SSI assistance) would trigger the loss of health insurance, which is essential for those with disabilities. The Affordable Care Act allowed states to raise Medicaid income eligibility above SSI levels and eliminated asset tests, so adults with disabilities could keep their health insurance even if they earned more than SSI allows. Previous research has shown how Medicaid expansions improve work incentives and increase employment of disabled SSI recipients.