Author(s): Jason Semprini, University of Iowa, College of Public Health; Abinasir K. Ali, University of Iowa, College of Public Health; and Gabriel A. Benavidez, Department of Epidemiology and Biostatistics, University of South Carolina 

Article Type: Peer-reviewed journal 

While there has been ample research on the effect of Medicaid expansion on reducing individual-level racial and ethnic disparities in health insurance coverage, authors here attempt to fill the gap in research on how Medicaid expansion is affected by root causes of health inequities, such structural racism, as measured by the historically racist policy of residential redlining. The federal government’s rating system for mortgage investments, which benefited white, upper middle-class families and penalized minoritized communities and the working-class, has had lasting effects even after it was outlawed in the late 1960s. These effects include substantial wealth gaps, under-resourced communities, and poorer health outcomes. The authors use data from national surveys and a difference-in-differences design to explore how exposure to historical redlining may have influenced the effect of Medicaid expansion on population-level insurance rates for non-Hispanic Black, non-Hispanic White, and Hispanic nonelderly adults. When comparing uninsurance rates in Medicaid expansion and non-expansion states before and after the passage of the Affordable Care Act, authors found that Medicaid expansion had the greatest impact on lowering uninsurance rates in areas with the highest level of historic redlining. Even though no statistically significant differences were observed by race and ethnicity within each redline category, authors conclude that “Medicaid expansion may have helped to reduce some of the negative consequences of structural racism…” and emphasize the importance of studying contextual factors when evaluating health programs and policies. 

Author(s): Shilpa Londhe, Department of Health Policy and Management, Yale School of Public Health; Grant Ritter, Heller School for Social Policy and Management, Brandeis University, Mark Schlesinger, Department of Health Policy and Management, Yale School of Public Health 

Article Type: Peer-reviewed journal 

This article studies the relationship between county Medicaid enrollment and food insecurity in over 350 counties. The authors acknowledge that food insecurity prevalence ranges widely across the country, from as low as 4 percent up to 39 percent in some states. The authors observe that counties who expanded their Medicaid program in 2012 had significantly reduced food insecurity compared to their baseline year of 2009, and compared to counties that expanded later in calendar year 2014. While the authors acknowledge that food insecurity and lack of insurance coverage are likely related, they conclude that Medicaid likely offers greater financial security overall, which alludes to many improvements for low-income families, with overcoming food insecurity being one positive of many likely effects.  

Author(s): Sarah Bowen, Professor of Sociology at North Carolina State University; Sinikka Elliot, Associate Professor of Sociology at the University of British Columbia; Annie Hardison-Moody, Associate Professor of Agricultural and Human Sciences at North Carolina State University 

Article Type: Peer-reviewed journal 

This article, written by scholars in the US and Canada and funded by the US Department of Agriculture, provides a detailed overview of the patterns of food insecurity in the recent past. These patterns of food insecurity include that it is associated with lower income households, mostly cyclical as opposed to chronic, more prevalent in households with children and in households headed by women, and households headed by people of color and people with disabilities. Food insecurity also has negative effects on physical and mental health as well as academic performance and risk of hospitalization among children. Authors summarize evidence on the association between food insecurity and poverty, other forms of hardship, housing insecurity, and neighborhood support systems, but argue that there is a more fundamental cause for food insecurity: racism and persistent unequal access for people of color to opportunities and resources. To combat food insecurity, structural change is needed. While the article does not go into detail about specific recommendations for the Medicaid program, it references advocating for Medicaid expansion and against “...punitive and stringent policies that disproportionately harm people of color…,” which can be the price for access to assistance.

Author(s): Sana Charania, George Washington University’s School of Public Health in Washington, DC 

Article Type: Peer-reviewed policy reform brief 

This peer-reviewed policy reform brief includes a list of strategies that state Medicaid programs can pursue with providers to alleviate health care stressors of those experiencing homelessness. The author remarks that in 2020, over half a million people experience homelessness on any given night in the United States. According to survey data from a decade earlier, about a quarter of “…sheltered persons experiencing homelessness had a severe mental illness and 35 percent had problems with substance use”. The author states that there is a need for better supportive housing options and discusses studies in several states that showed providing permanent housing and needed services (such as behavioral health care) to individuals who were previously homeless led to decreased inpatient or emergency department visits and lower health care costs. The author emphasizes that it is not entirely on state Medicaid programs to reach those experiencing homelessness; clinicians and hospitals have a role to play in resolving biases about this very stigmatized group of people and assessing the basic needs of their patients. The author does highlight the importance of Medicaid expansion under the ACA – citing the improved health conditions of those experiencing homelessness and an increase in coverage in expansion states.

Author(s): Julia M. Dennett, Yale University School of Public Health, New Haven, CT; Katherine Baicker, University of Chicago Harris School of Public Policy, Chicago, IL and the National Bureau of Economic Research, Cambridge, MA.

Article Type: Peer-reviewed journal 

This article is an analysis of whether key neighborhood characteristics, such as “socioeconomic deprivation (which is a score that reflects neighborhood ethnicity, education, employment, poverty, and housing/crowding), food access, park access and green space, attributes that promote active living, and land use” influence the effect of health insurance coverage on health outcomes. Using data collected in 2009 and 2010 about participants in the Oregon Health Insurance living in the Portland area, some of whom had access to Medicaid coverage and some of whom did not, authors found neighborhood characteristics played only a limited role in moderating the impacts of coverage on select health outcomes. The study’s null findings imply that Medicaid expansion benefited many across the board, regardless of neighborhood. Also implied is that the relationship between coverage and neighborhood characteristics and health outcomes is complex. Authors note several study limitations, including other factors to consider in the definition of neighborhood characteristics and their inability to conduct subgroup analyses. They also call for future research to inform policy.

Author(s): Lacee Satcher, Professor of Sociology and Environmental Studies at Boston College 

Article Type: Peer-reviewed journal 

This peer-reviewed article summarizes research examining the relationship between resource scarcity (measured in terms of multiply-deserted areas (MDAs)) and health. The author goes on to discuss how this relationship varies according to race and class composition of urban neighborhoods in the South and its implications for public programs, including Medicaid. MDAs were constructed based on three types of resource deserts: food, green spaces, and pharmacy deserts. Health outcomes examined included adults with diabetes, obesity, asthma, and no leisure-time physical activity. Results show that, compared to less resource-scarce areas, MDAs are associated with higher disease prevalence as well as higher rates of inactivity. Co-occurring resource scarcity has more influence on outcomes and activity levels than single-resource scarcity resulting in greater stress and negative impacts on health. “While there have been efforts to increase food access or greenspace for low-income, predominantly Black neighborhoods via farmer’s markets and community gardens, understanding that these neighborhoods are experiencing compounded, co-occurring resource scarcity calls for a more comprehensive policy intervention or community initiative that increases access to healthy foods, greenspace, and prescription medicines.” The author explains further that, “reducing disparities in prescription access and adherence via expansion of Medicare Part D and Medicaid are important, but study findings suggest that policy efforts to reduce disparities should also increase spatial access to pharmacies.”

Author(s): Yaguang Wei, Xinye Qiu, Mahdieh Danesh Yazdi, Longxiang Li, Adjani A. Peralta,  Cuicui Wang, Petros Koutrakis, Antonella Zanobetti, are all from the Department of Environmental Health at Harvard T.H. Chan School of Public Health; Matthew Benjamin Sabath Francesca Dominici are from the Department of Biostatistics at Harvard T.H. Chan School of Public Health; Kanhua Yin is from the Department of Epidemiology at Harvard T.H. Chan School of Public Health; and Joel D. Schwartz is associated with both the Department of Environmental Health at Harvard T.H. Chan School of Public Health as well as the Department of Surgery, Massachusetts General Hospital, Harvard Medical School. 

Article Type: Peer-reviewed journal

This peer reviewed study analyzes inpatient claims of Medicaid beneficiaries from 2000 to 2012 by zip code in order to determine the effect of three common air pollutants (nitrogen dioxide, ozone pollution, and particulate matter) on asthma hospitalizations. The researchers found a positive relationship between short-term exposures and increased risk of asthma hospitalization for those with one asthma admission during the study period, but air pollutants appeared to be less of a factor for those with multiple asthma admissions during the study period. A community-level analysis found higher risk of asthma hospitalization for people living in low population density zip codes, people with higher average BMI, and people living a longer distance to the nearest hospital. There were no significant differences in risk of asthma hospitalizations by race or ethnicity. These results emphasize the importance of both individual and contextual factors in assessing the quality of health care for the Medicaid population, where the impact of air pollutant exposures on asthma susceptibility differed by severity and place characteristics.   

Author(s): Christy Mallory and Will Tentindo, Williams Institute at University of California - Los Angeles

Article Type: Report 

This report highlights key factors related to Medicaid coverage of gender affirming care. Emphasis is placed on the sheer number of individuals who identify as transgender or gender non-conforming that are covered by Medicaid – about one fourth of those who identify as transgender or gender non-conforming in the United States rely on Medicaid for their gender affirming care. Underlying factors contributing to inequities for this group include unclear language about what services are covered, and/or gender affirming care services are not covered at all in their state. Authors urge all states to fully expand their Medicaid program under the Affordable Care Act. 

Author(s): Robin J. Kempf, Assistant Professor in the College of Public Service at the University of Colorado - Colorado Springs; Nicole M. Elias, Associate Professor in the Department of Public Management at John Jay College of Criminal Justice, City University of New York; Alonso J. Rubin-DeSimone, John Jay College of Criminal Justice, City University of New York

Article Type: Peer-reviewed journal 

This peer reviewed journal article describes how transgender and gender non-binary individuals have been marginalized historically in U.S. society, including in terms of institutional or informal “erasure” as well as through isolation and “hypervisibility.” In health care, this discrimination translates into lack of access to qualified professionals and lack of coverage for a continuum of needed services. Authors chose to review state Medicaid program coverage policies to identify opportunities to build equity for all U.S. residents and noted that discrimination of individuals identifying as non-cisnormative gender can be compounded by the intersectionality of race, sexual orientation, socioeconomic status, and geographical location. They assessed comprehensiveness of state Medicaid coverage in accordance with the World Professional Association for Transgender Health (WPATH) standards. Authors found that the five states in their sample varied widely in terms of health coverage to transgender and gender non-binary Medicaid beneficiaries, however, there were stand out states in terms of the continuum of services offered as well as opportunities for improvement. Authors recommend removal of barriers to needed care such as prior authorization requirements as well as additional training for providers and individuals making coverage determinations.

Author(s): Nance Yuan, Cedars-Sinai Transgender Surgery and Health Program, and member of the Urology and Plastic Surgery Divisions at Cedars-Sinai Medical Center; Theodore Chung, David Geffen School of Medicine, University of California, Los Angeles; Alma Jimenez-Eichelberger and Caitlin Sioni, Cedars-Sinai Transgender Surgery and Health Program and the Division of Urology at Cedars-Sinai Medical Center; Edward C. Ray, Division of Plastic Surgery, Cedars-Sinai Medical Center; Maurice M. Garcia, Departments of Urology and Anatomy, University of California, San Francisco 

Article Type: Peer-reviewed journal 

This peer reviewed article investigates and discusses insurance requirements for referral letters from mental health providers prior to genital gender affirming surgeries for trans and non-binary individuals. In this study, half of the participants had federally funded insurance, such as Medicaid. Most plans, both public and private, required at least two referral letters at every stage of surgery (there may be four to five stages depending on the operation). Authors state that it took office staff, “an average of 2.5 hours per patient, per surgery, dedicated to coordinating submission of updated referral letters”. Some participants had to cancel or reschedule an operation due to lack of coordination of care, and/or administration not receiving referral letters. This resulted in patients being forced to pay for surgeries out-of-pocket instead of using insurance coverage. The authors discuss how multiple letters for each stage of a surgery is unnecessary, when no participant was deemed mentally unfit for any previously performed procedure. Authors state that requiring updated letters for each year was also a point of stress for participants as these administrative burdens were “costly and burdensome” to patients and providers alike. The authors urge organizations such as the World Professional Association for Transgender Health (WPATH) to revisit their recommendations for referral letter requirements to alleviate the burdens on both administrators and patients alike.

Author(s): Samuel Mann, Christopher S. Carpenter, Benjamin Harrell, and Cameron Deal are all from the Department of Economics, LGBTQ+ Policy Lab, Vanderbilt University, Nashville, Tennessee; Gilbert Gonzales is also a member of the Department of Medicine, Health & Society, and Department of Health Policy at Vanderbilt University. 

Article type: Peer-reviewed journal 

This peer reviewed journal article analyzes how Medicaid expansion influenced health insurance coverage for individuals in same-sex partnerships. Using data from the American Community Survey, authors found that there was a significant increase in coverage between 2009 and 2018 for low-income adults who were in a same-sex relationship, especially for women. The authors attribute this to a much higher prevalence of children being in households of women same-sex couples compared to men. The authors also state that sexual minority women may have stronger social ties that reduce stigma surrounding Medicaid or public options compared to sexual minority men. This research has implications that are important for policymaking and underlying factors of inequity within Medicaid in terms of barriers to seeking health insurance coverage and accessibility of services for those individuals in same-sex partnerships.