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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.

Immigrant children in the US have very limited health insurance coverage and health care access. Immigration status is not static: Census data show that the majority of census respondents who enter as noncitizen children eventually become citizens. Eligibility restrictions that prevent noncitizen children from being publicly insured can contribute to their experiencing poorer health and higher medical costs in their adult lives. We isolate the impact of lack of citizenship from socioeconomic factors by comparing citizen and noncitizen siblings living in mixed-status families, using fixed-effects models to net out socioeconomic factors shared within families. Lacking citizenship increased a child's risk of being uninsured and lowered by 26 percentage points the chances that they would have Medicaid or Children's Health Insurance Program coverage. Noncitizen children had significantly more delays in needed medical care because of cost, primarily mediated by the lack of insurance coverage. The US should reexamine policies that exclude noncitizen children from public health insurance programs.

Community health centers are a vital part of the primary and behavioral health care systems in rural areas. We compared behavioral health care staffing and services in rural and urban centers. In the period 2013-17 the overall staff-to-patient ratio in behavioral health rose by 66 percent in rural centers, faster than growth in urban centers (49 percent). Growth in both settings was mostly driven by clinical social workers and other licensed mental health providers; staffing by psychiatrists and psychologists changed only slightly. In rural centers the average adjusted increase in annual visits per additional behavioral health staff member was 411 for substance use disorders, slightly higher than at urban centers. Additional annual visits per additional staff member in rural centers were 539 for depression, 466 for anxiety, and 300 for other mental disorders, similar to the numbers in urban centers. Behavioral health staff currently participating in the National Health Service Corps (NHSC) contributed more to visits for depression and anxiety in rural centers, compared to both their urban counterparts and non-NHSC staff in rural centers. Enhancing behavioral health staffing in rural community health centers could help reduce the urban-rural gap in the availability of behavioral health services, but still more could be done.

Through the expansion of Medicaid eligibility and increases in core federal grant funding, the Affordable Care Act (ACA) sought to increase the capacity of community health centers to provide primary care to low-income populations. We examined the effects of the ACA Medicaid expansion and changes in federal grant levels on the centers' numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015. In the period after expansion (2014-15), health centers in expansion states had a 5 percent higher total patient volume, larger shares of Medicaid patients, smaller shares of uninsured patients, and increases in overall visits and mental health visits, compared to centers in nonexpansion states. Increases in federal grant funding levels were associated with increases in numbers of patients and of overall, medical, and preventive service visits. If federal grant levels are not sustained after 2017, there could be marked reductions in health center capacity in both expansion and nonexpansion states., (Project HOPE—The People-to-People Health Foundation, Inc.)

Pay for success (PFS) is a type of social impact investing that uses private capital to finance proven prevention programs that help a government reduce public expenditures or achieve greater value. We conducted an analysis of the first eleven PFS projects in the United States to investigate the potential of PFS as a strategy for financing and disseminating interventions aimed at improving population health and health equity. The PFS approach has significant potential for bringing private-sector resources to interventions regarding social determinants of health. Nonetheless, a number of challenges remain, including structuring PFS initiatives so that optimal prevention benefits can be achieved and ensuring that PFS interventions and evaluation designs are based on rigorous research principles. In addition, increased policy attention regarding key PFS payout issues is needed, including the "wrong pockets" problem and legal barriers to using federal Medicaid funds as an investor payout source., (Project HOPE—The People-to-People Health Foundation, Inc.)

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., (Project HOPE—The People-to-People Health Foundation, Inc.)

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served., (Project HOPE—The People-to-People Health Foundation, Inc.)

The Affordable Care Act increases US investment in Medicaid and community health centers, yet many people believe that care in such safety-net programs is substandard. Using data from more than 31,000 visits to primary care physicians in the period 2006-10, we examined whether the length or content of a visit was different for safety-net patients-those insured by Medicaid, those who are uninsured, and those seen in a community health center-compared to patients with private insurance. We found no significant differences in the average length of a primary care visit or in the likelihood of a patient's receiving preventive health counseling. Medicaid patients received more diagnostic and treatment services, and uninsured patients received fewer services, compared to privately insured patients, but the differences were small. This analysis indicates that length and content of primary care visits are comparable for safety-net and other patients. The main factors that contribute to differences in visit length and content are patients' health needs and the type of visit involved.

A key method of stabilizing Medicaid coverage is to provide beneficiaries with twelve months of continuous eligibility. Following the passage of the Children's Health Insurance Program Reauthorization Act in 2009, seven states adopted the continuous-eligibility option for children. That policy change led to a 1.8-percentage-point increase in the average length of child enrollment during fiscal year 2010 and increased annual costs for children by about 2.2 percent. The Medicaid and CHIP Payment and Access Commission has recommended offering states the option of giving adults twelve-month continuous eligibility for Medicaid. Our findings suggest that continuous eligibility could promote more stable coverage for adults enrolled in Medicaid at a modest cost.

Our analyses of federal survey data show that more than four in five office-based physicians could qualify for new federal incentive payments to encourage the adoption and "meaningful use" of electronic health records, based on the numbers of Medicare or Medicaid patients they see. The incentives are thus likely to accelerate the spread of electronic health records. However, our analyses also indicate that eligibility for the incentives is likely to vary by specialty: 90.6 percent of physicians working in general or family practice or internal medicine could qualify for incentives, but fewer than two-thirds of pediatricians, obstetrician-gynecologists, and psychiatrists may qualify. Eligibility and use will also vary by factors such as size and type of practice; physicians in solo practice are much less likely to use electronic health records than physicians in other practice settings. We suggest actions that policy makers can take to lessen disparities and increase the adoption and meaningful use of electronic health records.

Federal and state governments must soon begin planning and developing systems to implement the expansion of Medicaid for low-income adults, as prescribed in the Patient Protection and Affordable Care Act of 2010. States will have to establish enrollment and coordination procedures, determine benefit packages, and update arrangements with providers. Federal estimates indicate that states will bear relatively little of the new cost, but some states disagree. State planning efforts will be challenged by current budget shortfalls and, in many states, political opposition. Paradoxically, many of the states opposing expansions are those whose Medicaid-eligible patient populations have the most to gain from health reform.

Some proposals to expand health insurance coverage for people with low incomes are based on expansions of public programs, such as Medicaid or the State Children's Health Insurance Program (SCHIP), while others rely on the use of tax subsidies for individuals to purchase private insurance. Analyses of data from the 2005 Medical Expenditure Panel Survey indicate that total medical spending is much lower when coverage is provided by Medicaid or SCHIP than it is when coverage is provided by private insurance. Public insurance is particularly advantageous from the consumer's perspective because associated out-of-pocket spending is far lower.

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.

Recent policy changes have limited immigrants' access to insurance and to health care. Fewer noncitizen immigrants and their children (even U.S.-born) have Medicaid or job-based insurance, and many more are uninsured than is the case with native citizens or children of citizens. Noncitizens and their children also have worse access to both regular ambulatory and emergency care, even when insured. Immigration status is an important component of racial and ethnic disparities in insurance coverage and access to care.

Welfare reform and changes in immigrants' eligibility may lead to significant reductions in Medicaid caseloads, even though many states are expanding Medicaid eligibility rules to accommodate changes under the new welfare programs. In 1996, for the first time in almost a decade, Medicaid participation of adults and children fell about 2 percent, and further reductions seem likely in 1997. The gradual restrictions on new immigrants also will affect future caseloads. Although new initiatives such as the State Children's Health Insurance Program (CHIP) should expand health coverage for children, the welfare reform and immigration changes will disproportionately lead to loss of insurance among adults.

With the demise of health care reform at the national level, much of the attention has shifted to state-level efforts. Recently, several states have begun looking to the Medicaid program as a way to solve their health care problems. A principal way in which states are implementing health care reform is through the Section 1115 research and demonstration Medicaid waiver program. The 1115 waiver authority provides states considerable flexibility to restructure their Medicaid programs to offer health care to new populations and thus has great potential for covering large segments of the uninsured population. While it shows great promise, however, there are many obstacles states must overcome both in implementing and in maintaining an 1115 program.