reports

Managing the gap: evaluating the impact of Medicaid managed care on service use and disparities in health care access

Baltimore, MD, USA: University of Maryland (doctoral dissertation).

University of Maryland, Baltimore, MD, USA

The National Institutes of Health (NIH) define a health disparity as a “difference  in the incidence, prevalence, mortality, and burden of disease and other adverse health  conditions that exist among specific population groups” (NIH 2000). Similarly, the  Health Resources and Services Administration (HRSA) defines disparities as  “population-specific differences in the presence of disease, health outcomes, or access to  care” (HRSA 2000). As exemplified by the HRSA definition, health disparities are not  limited to a single domain. The multiple domains contained in the HRSA definition  highlight a prominent debate in disparities research represented by studies which focus on  downstream factors and those that focus on upstream factors (Schnittker and Mcleod  2005). Studies emphasizing downstream factors tend to focus more on curative  interventions at the individual level when examining disparities. The upstream approach  focuses more on the origin and prevention of disparities (McKinlay and Marceau 2000;  Schnittker and Mcleod 2005). Disparities in upstream factors such as access to basic  preventive care may result in downstream manifestations of disparate heath outcomes  (Cohen, Davis and Mikkelsen 2000; Zuvekas and Taliaferro 2003).

Recent studies have confirmed the continuing presence of disparities in access to,  and utilization of, health care services in the United States by members of racial and  ethnic minorities (Shi 1999; Smedley, Stith and Nelson 2002; Zaslavsky and Epstein  2002; Elster et al. 2003). In light of the evidence of these disparities, researchers, policymakers,  and other stakeholders have been engaged in an ongoing debate regarding the  cause and potential solutions (Nerenz 1998).

Racial and ethnic disparities in medical care may reflect a general societal  problem in that they reveal either structural or individual discrimination or racial bias in  violation of state and federal laws and may result in potentially deleterious effects on  health outcomes. Additionally, the populations that most commonly experience the  negative effects of health disparities are likely to become an ever larger proportion of the  American population. As a result of this expected population growth, the future health of  American society will be greatly influenced by the health of racial and ethnic minorities  (Williams 2002). Disparities in health have an impact on all of society as they can result  in increased worker absenteeism, decreased productivity and limitations on educational  opportunity among significant segments of society (Sullivan 2001). The presence of  health disparities within the framework of publicly financed programs such as Medicaid  raises additional concerns given that the program is publicly funded and should therefore  be held to a higher standard of equity.

The purpose of this study is to examine whether racial and ethnic minorities  experience disparate access to preventive health services in Maryland Medicaid, and if  so, the factors affecting any present disparities, and whether Maryland’s transition to  Medicaid managed care (MMC) has had an impact on any observed disparities.  Although the study of health outcomes is an important focus of disparities research, this  study will solely examine access to primary care services. Primary care services can be  viewed as gateway services that act as predictors of heath outcomes (Cohen, Davis and  Mikkelsen 2000; Zuvekas and Taliaferro 2003). Zuvekas and Taliaferro (2003:153)  argue “access problems with ambulatory care serve as a marker for more general  problems with access to health care.” Understanding and alleviating upstream disparities such as access to preventive care may aid in the mitigation of downstream disparities in  health. Access to preventive services is considered to be central to any effort to eliminate  health disparities (Cohen et al. 2000).

The fact that racial and ethnic minorities are disproportionately less affluent,  uninsured, or enrolled in Medicaid, however, could be the result of discrimination or  other structural barriers that cannot be adequately assessed in this study. Instead, this  study will consider racial and ethnic health disparities in the context of Medicaid  managed care in Maryland. Specifically, the focus of the research will be whether  socially vulnerable populations are accessing services at a level on par with the majority  white population. The study will also examine whether the managed care approach has  promoted parity.