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JAMA Health Forum Apr 2024Policy changes and the COVID-19 pandemic affected health coverage rates, and the "unwinding" of Medicaid's continuous coverage provision in 2023 and 2024 may cause...
IMPORTANCE
Policy changes and the COVID-19 pandemic affected health coverage rates, and the "unwinding" of Medicaid's continuous coverage provision in 2023 and 2024 may cause widespread coverage loss. Recent coverage patterns in national survey and administrative data can inform these issues.
OBJECTIVE
To assess national and state changes in survey-based Medicaid, private insurance, and uninsured rates between 2019 and 2022, as well as how these changes compare with administrative Medicaid enrollment totals.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study analyzes nationally representative survey data for all US residents in the American Community Survey (ACS) from 2019 to 2022 compared with administrative data on Medicaid and the Children's Health Insurance Program from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted between June 2023 and January 2024.
EXPOSURES
The COVID-19 pandemic, the Medicaid continuous coverage provision, and policy efforts to increase Marketplace coverage.
MAIN OUTCOMES AND MEASURES
Medicaid coverage (self-reported [ACS] and administratively recorded [CMS]), survey-reported uninsured, Medicare, and private insurance status.
RESULTS
A nationally representative sample consisted of 12 506 584 US residents of all ages (survey-weighted 59.7% aged 19-64 years and 50.6% female). CMS statistics showed an increase in Medicaid coverage of 5.2 percentage points as a share of the population from 2019 to 2022. However, changes in the uninsured rate and survey-reported Medicaid were smaller: -1.2 (95% CI, -1.3 to -1.2) percentage points and 1.3 (95% CI, 1.2-1.4) percentage points, respectively. There was a 3.9 percentage point increase in the ACS's "undercount" of Medicaid enrollment, compared with CMS data, from 2019 to 2022. This undercount was larger among children than adults but smaller in states that recently expanded Medicaid. Rates of additional forms of coverage (such as private insurance) among those in Medicaid also grew during this time.
CONCLUSION AND RELEVANCE
In this cross-sectional study, the uninsured rate declined considerably from 2019 to 2022 but was just one-fourth as large as the growth in administrative Medicaid enrollment under the pandemic continuous coverage provision. Survey-based Medicaid growth was far smaller than administrative growth. This suggests that many people who remained enrolled in Medicaid during the pandemic did not realize that their coverage had continued. These findings have implications for projecting uninsured changes during unwinding, as well as the effect of continuous coverage policies on continuity of care.
Topics: Adult; Child; Humans; Aged; Female; United States; Male; Medicaid; Cross-Sectional Studies; Pandemics; Medicare; Surveys and Questionnaires; COVID-19
PubMed: 38578627
DOI: 10.1001/jamahealthforum.2024.0430 -
American Journal of Perinatology May 2024Hypertensive disorders of pregnancy (HDP) contribute significantly to the development of severe maternal morbidities (SMM), particularly among low-income women. The...
OBJECTIVE
Hypertensive disorders of pregnancy (HDP) contribute significantly to the development of severe maternal morbidities (SMM), particularly among low-income women. The purpose of the study was to explore the relationship between maternal characteristics and SMM, and to investigate if differences in SMM exist among patients with HDP diagnosis.
STUDY DESIGN
This study utilized 2017 Alabama Medicaid administrative claims. SMM diagnoses were captured using the Centers for Disease Control and Prevention's classification by International Classification of Diseases codes. Maternal characteristics and frequencies were compared using Chi-square and Cramer's V statistics. Logistic regression analyses were conducted to examine multivariable relationships between maternal characteristics and SMM among patients with HDP diagnosis. Odds ratios and 95% confidence intervals (CIs) were used to estimate risk.
RESULTS
A higher proportion of patients experiencing SMM were >34 years old, Black, Medicaid for Low-Income Families eligible, lived in a county with greater Medicaid enrollment, and entered prenatal care (PNC) in the first trimester compared with those without SMM. Almost half of patients (46.2%) with SMM had a HDP diagnosis. After controlling for maternal characteristics, HDP, maternal age, county Medicaid enrollment, and trimester PNC entry were not associated with SMM risk. However, Black patients with HDP were at increased risk for SMM compared with White patients with HDP when other factors were taken into account (adjusted odds ratio [aOR] = 1.37, 95% CI: 1.11-1.69). Patients with HDP and SMM were more likely to have a prenatal hospitalization (aOR = 1.45, 95% CI: 1.20-1.76), emergency visit (aOR = 1.30, 95% CI: 1.07-1.57), and postpartum cardiovascular prescription (aOR = 2.43, 95% CI: 1.95-3.04).
CONCLUSION
Rates of SMM differed by age, race, Medicaid income eligibility, and county Medicaid enrollment but were highest among patients with clinical comorbidities, especially HDP. However, among patients with HDP, Black patients had an elevated risk of severe morbidity even after controlling for other characteristics.
KEY POINTS
· Patients with SMM were more likely to have a HDP diagnosis.. · Among those with HDP, Black patients had elevated risk of SMM.. · Differences in care delivery did not explain SMM disparities..
Topics: Humans; Female; Pregnancy; Adult; Medicaid; Poverty; United States; Hypertension, Pregnancy-Induced; Alabama; Young Adult; Logistic Models; Prenatal Care; Black or African American; Retrospective Studies; Risk Factors; Maternal Age; Odds Ratio
PubMed: 35977711
DOI: 10.1055/a-1925-9972 -
JAMA Health Forum Jun 2024States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic...
IMPORTANCE
States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care.
OBJECTIVE
To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states.
DESIGN, SETTING, AND PARTICIPANTS
This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level.
EXPOSURE
Medicaid enrollment at any point since March 2020, when continuous coverage began.
MAIN OUTCOMES AND MEASURES
Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment.
RESULTS
The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care.
CONCLUSIONS AND RELEVANCE
The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.
Topics: Humans; Medicaid; United States; Health Services Accessibility; Adult; Female; Male; Insurance Coverage; Middle Aged; COVID-19; Poverty; Young Adult; Arkansas
PubMed: 38943683
DOI: 10.1001/jamahealthforum.2024.2193 -
Medicaid Costs and Utilization of Collaborative Versus Colocation Care for Patients With Depression.Psychiatric Services (Washington, D.C.) Nov 2023The authors examined cost and utilization metrics for racially diverse Medicaid primary care patients with depression receiving care through either a collaborative care...
OBJECTIVE
The authors examined cost and utilization metrics for racially diverse Medicaid primary care patients with depression receiving care through either a collaborative care model (CoCM) of integration or the standard colocation model.
METHODS
Data from a retrospective cohort of Medicaid patients screening positive for clinically significant depression during January 2016-December 2017 were analyzed to assess health care costs and selected utilization measures. Seven primary care clinics providing CoCM were compared with 16 clinics providing colocated behavioral health care. Data for the first year and second year after a patient received an initial Patient Health Questionnaire-9 score ≥10 were analyzed.
RESULTS
In the first year, compared with patients receiving colocated care (N=3,061), CoCM patients (N=4,315) had significantly lower odds of emergency department (ED) visits (OR=0.95) and medical specialty office visits (OR=0.92), with slightly higher odds of primary care provider (PCP) visits (OR=1.03) and behavioral health office visits (OR=1.03). In year 2, CoCM patients (N=2,623) had significantly lower odds of inpatient medical admissions (OR=0.87), ED visits (OR=0.84), medical specialty office visits (OR=0.89), and PCP visits (OR=0.94) than the colocated care patients (N=1,838). The two groups did not significantly differ in total cost in both years.
CONCLUSIONS
Access to CoCM treatment in primary care for racially diverse Medicaid patients with depression was associated with more positive health care utilization outcomes than for those accessing colocated treatment. As organizations continue to seek opportunities to integrate behavioral health care into primary care, consideration of health care costs and utilization may be helpful in the selection and implementation of integration models.
Topics: United States; Humans; Retrospective Studies; Medicaid; Depression; Health Care Costs; Patient Acceptance of Health Care; Emergency Service, Hospital
PubMed: 37221885
DOI: 10.1176/appi.ps.20220604 -
JAMA Network Open Dec 2023State Medicaid programs have recently implemented several policies to improve access to health care during the postpartum period. Understanding whether these policies...
IMPORTANCE
State Medicaid programs have recently implemented several policies to improve access to health care during the postpartum period. Understanding whether these policies are succeeding will require accurate measurement of postpartum visit use over time and across states; however, current estimates of use vary substantially between data sources.
OBJECTIVES
To examine disagreement between postpartum visit use reported in the Pregnancy Risk Assessment Monitoring System (PRAMS) and Medicaid claims and assess whether insurance transitions from Medicaid at the time of childbirth to other insurance types after delivery are associated with the degree of disagreement.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study was conducted among individuals in South Carolina after delivery who had completed a PRAMS survey and for whom Medicaid was the payer of their delivery care. PRAMS responses from 2017 to 2020 were linked to inpatient, outpatient, and physician Medicaid claims; survey-weighted logistic regression models were then used to examine the association between postpartum insurance transitions and data source disagreement. Data were analyzed from February through October 2023.
EXPOSURE
Insurance transition type: continuous Medicaid, Medicaid to private insurance, Medicaid to no insurance, and Emergency Medicaid to no insurance.
MAIN OUTCOME AND MEASURE
Data source disagreement due to reporting a postpartum visit in PRAMS without a Medicaid claim for a visit or having a Medicaid claim for a visit without reporting a postpartum visit in PRAMS.
RESULTS
Among 836 PRAMS respondents enrolled in Medicaid at delivery (663 aged 20-34 years [82.9%]), a mean of 85.7% (95% CI, 82.1%-88.7%) reported a postpartum visit in PRAMS and a mean of 61.6% (95% CI, 56.9%-66.0%) had a Medicaid claim for a postpartum visit. Overall, 253 respondents (30.3%; 95% CI, 26.1%-34.7%) had data source disagreement: 230 individuals (27.2%; 95% CI, 23.2%-31.5%) had a visit in PRAMS without a Medicaid claim, and 23 individuals (3.1%; 95% CI, 1.8%-5.2%) had a Medicaid claim without a visit in PRAMS. Compared with individuals continuously enrolled in Medicaid, those who transitioned to private insurance after delivery and those who were uninsured after delivery and had Emergency Medicaid at delivery had an increase in the probability of data source agreement of 15.8 percentage points (95% CI, 2.6-29.1 percentage points) and 37.2 percentage points (95% CI, 19.6-54.8 percentage points), respectively.
CONCLUSIONS AND RELEVANCE
This study's findings suggest that Medicaid claims may undercount postpartum visits among people who lose Medicaid or switch to private insurance after childbirth. Accounting for these insurance transitions may be associated with better claims-based estimates of postpartum care.
Topics: United States; Female; Pregnancy; Humans; Self Report; Cross-Sectional Studies; Medicaid; Postpartum Period; Parturition
PubMed: 38150253
DOI: 10.1001/jamanetworkopen.2023.49457 -
JAMA Health Forum Dec 2023Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little...
IMPORTANCE
Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change.
OBJECTIVE
To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023.
MAIN OUTCOMES AND MEASURES
Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures.
RESULTS
This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care.
CONCLUSIONS AND RELEVANCE
The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.
Topics: United States; Humans; Female; Medicaid; Cohort Studies; Health Services; Managed Care Programs
PubMed: 38153809
DOI: 10.1001/jamahealthforum.2023.4593 -
Health Economics Oct 2023In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal...
In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre-conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference-in-difference models in conjunction with event studies. Data come from individual-level birth certificates and state-level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre-pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery.
Topics: Pregnancy; Female; United States; Humans; Medicaid; Patient Protection and Affordable Care Act; Insurance Coverage; Health Services Accessibility; Maternal Health; Insurance, Health
PubMed: 37417880
DOI: 10.1002/hec.4724 -
JAMA Network Open Jan 2024A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time.
IMPORTANCE
A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time.
OBJECTIVES
To quantify rates of outpatient pediatric medical subspecialty use.
DESIGN, SETTING, AND PARTICIPANTS
This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS.
EXPOSURE
Calendar year and type of medical subspecialty.
MAIN OUTCOMES AND MEASURES
Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings.
RESULTS
Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]).
CONCLUSIONS AND RELEVANCE
The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.
Topics: Male; Female; United States; Humans; Child; Outpatients; Cross-Sectional Studies; Medicaid; Health Services Research; Academic Medical Centers
PubMed: 38175643
DOI: 10.1001/jamanetworkopen.2023.50379 -
Dental Clinics of North America Jan 2024The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate... (Review)
Review
The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate attention, and mortality and morbidity rates. Historically, OMS specialists have made significant contributions to modern anesthesia; however, recent changes in Centers for Medicare and Medicaid Services have led to increased scrutiny of the OMS anesthesia model. Proponents argue that the model is safe and effective, thanks to well-trained Dental Anesthesia Assistants and OMS surgeons' extensive experience in dental anesthesia cases.
Topics: Aged; Humans; United States; Medicare; Surgery, Oral; Anesthesia; Medicaid; Patient Safety
PubMed: 37951639
DOI: 10.1016/j.cden.2023.07.006 -
JAMA Health Forum Oct 2023Federal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between...
IMPORTANCE
Federal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements.
OBJECTIVE
To identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums.
DESIGN, SETTING, AND PARTICIPANT
A cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023.
MAIN OUTCOMES AND MEASURES
Agreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an internet panel to recruit residents aged 18 years or older. Findings were weighted to reflect state demographics. Of 39 110 landlines called, 209 reached an eligible person (of whom 150 participated), 8654 were of unknown eligibility, and 30 247 were ineligible. Of 55 305 cell phone lines called, 617 reached an eligible person (of whom 451 participated), 29 951 were of unknown eligibility, and 24 737 were ineligible. Internet recruitment (602 participants) used a panel of adult Kentucky residents maintained by an external data collector.
RESULTS
Percentages were weighted to resemble the adult population of Kentucky residents. Of the participants in the study, 52% (95% CI, 48%-55%) were women, 80% (95% CI, 77%-82%) were younger than 65 years, 41% (95% CI, 38%-45%) were enrolled in Medicaid, 36% (95% CI, 32%-39%) were Republican voters, 32% (95% CI, 29%-36%) were Democratic voters, 14% (95% CI, 11%-16%) were members of racial and ethnic minority groups (including but not limited to American Indian or Alaska Native, Asian, Black, Hispanic or Latinx, and Native Hawaiian or Pacific Islander), and 48% (95% CI, 44%-52%) were employed. Most participants supported work requirements generally (69% [95% CI, 66%-72%]) but did not support terminating benefits due to noncompliance (43% [95% CI, 39%-46%]) or requiring quotas of 20 or more hours per week (34% [95% CI, 31%-38%]). Support for monthly premiums (34% [95% CI, 31%-38%]) and exclusion penalties for premium nonpayment (22% [95% CI, 19%-25%]) was limited. Medicaid enrollees were significantly less supportive of these policies than nonenrollees. For instance, regarding work requirements, agreement was lower (64% [95% CI, 59%-69%] vs 72% [95% CI, 68%-77%]) and disagreement higher (26% [95% CI, 21%-31%] vs 20% [95% CI, 16%-24%]) among current Medicaid enrollees compared with nonenrollees (P = .04). Among Medicaid enrollees, some beliefs about work requirements varied significantly by employment status but not by political affiliation. Among nonenrollees, beliefs about work requirements, premiums, and Medicaid varied significantly by political affiliation but not by employment.
CONCLUSIONS AND RELEVANCE
This study suggests that even when public constituencies express general support for Medicaid work requirements or premiums, they may oppose central design features, such as quotas and termination of benefits. Program participants may also hold significantly different beliefs than nonparticipants, which should be understood before policies are changed.
Topics: Adult; Female; Humans; Male; Cross-Sectional Studies; Ethnicity; Kentucky; Medicaid; Minority Groups; United States; Middle Aged; Aged
PubMed: 37862033
DOI: 10.1001/jamahealthforum.2023.3656