Transportation is frequently cited as a barrier to health care, but rarely have researchers analyzed the problems in depth. The purpose of this study was to assess the role transportation plays in the utilization of preventive health care services among Medicaid recipients ages 0 - 20 in Texas. This preventive care is known as Early Periodic Screening and Diagnostic Testing (EPSDT), a comprehensive prevention and treatment program for Medicaid eligible children. Our computer assisted telephone interviewing based survey was administered to Medicaid recipients selected from a representative sample through a stratified sampling scheme. Binary logistic regression models were used to assess and predict factors associated with utilization of the Texas Medicaid Transportation Program (MTP) and utilization of EPSDT. We also used k-means cluster analysis to identify subgroups of Medicaid clients with particularly acute transportation barriers. Of the 1,214 Medicaid recipients interviewed, the overall odds of a Medicaid recipient being a MTP non-user was 0.94. For clients with automobile access, the probability increases to 0.98. Clients who experienced difficulties paying for gasoline decreased the overall odds to 0.86. When examining utilization of EPSDT, the overall probability of being a low utilizer was 0.59. Two factors, Spanish-speaking patients (0.21) and clients with more than one child at home (0.54) decreased the overall odds of being a low utilizer, while those with difficulty paying for gasoline increased the odds of being a low utilizer to 0.63. Increasing EPSDT utilization among the millions of Texas Medicaid recipients is an important policy objective. Because the Texas Medicaid population is large and diverse, no single approach to increasing utilization is likely to address all needs. The group concept provides a means to understand which Medicaid recipients do not access MTP services and those with low utilization rates. These groupings can be useful in targeting Medicaid clients with specific transportation difficulties. Instead of broad informational campaigns, policy makers should devise targeted strategies to promote the most appropriate types of assistance. In addition to expanding transportation options, policy makers should also examine the locations in which care is delivered, considering telemedicine, mobile health and school-based health clinics as options.

Advances in HIV care and treatment continue to prolong the lives of people diagnosed and living with HIV (PDLWH). The National HIV/AIDS Strategy mobilizes national, state, and local efforts toward ensuring equitable access to care, reducing disparities, and improving continuum of HIV care outcomes. A social/community-based factor that contributes to sub-optimal HIV outcomes for PDLWH – all of whom require regular visits to a medical facility – is access to accommodating, affordable, and acceptable HIV care providers. Employing case surveillance data to analyze relationships between social/community-based factors and HIV disease outcomes is an opportunity to identify underserved PDLWH. This analytic approach, linking individual case-level epidemiologic surveillance data with macro-level community measures, provides public health departments a more precise estimate of priority geographic zones and subpopulation clusters whereby limited public health resources can be directed for maximal impact and efficiency. This dissertation analyzed California HIV surveillance system (CHSS) data to characterize PDLWH in terms of residential census tract characteristics related to income, poverty, unemployment, vehicle access, population density, travel duration from residence to care facility, and access to care. The primary study population was 60,979 PDLWH as of 2014 who had recent, geocoded residential addresses collected in CHSS. Access to care was measured using a novel enhanced two-step floating catchment area (E2SFCA) method developed for this dissertation. We also assessed whether community characteristics, trip duration, and access to care were associated with suppressed viral load, an indicator of successful disease management. Several significant relationships were found between suppressed viral load and where people lived, how long they drove for care, and their E2SFCA-measured access to care. This analysis identifies new methods for state and local health jurisdictions to: investigate factors associated with HIV-specific health disparities, improve the capacity to direct resources for improving health outcomes for PDLWH, and enhance transmission prevention efforts.

HIV screening is recommended to destigmatize the condition, prevent partner transmission, and postpone AIDS progression. However, determinants associated with implementation of opt-out HIV screening are not well understood. The purpose of the study was to examine determinants that predicted odds of HIV screening for persons impacted by Hurricane Sandy, and how these factors differed according to demographic characteristics, geographical attributes, health-related quality of life score, access-to-care, and health insurance status. The social ecologic model provided the framework for this multilevel cross-sectional study that included New Jersey data from the Behavior Risk Factor Surveillance System. Bivariate chi-square, simple logistic regression, and adjusted multivariate and weighted logistic regression analyses were performed to estimate HIV screening odds. Findings indicated a significant odds ratio with access to care post- Hurricane Sandy and HIV screening (odds ratio = 1.74, 95% CI = 1.38-2.21). The positive social change implications may include assisting people to develop realistic plans for HIV screening, improving understanding of HIV screening determinants, and raising awareness of the risk factors related with access to medical care post-Hurricane Sandy.

Dental Caries is still considered one of the most prevalent chronic diseases that affect children in the US. Access to oral care problems could be due to the limited availability of services or unwillingness of people to seek services. As a proposed solution to those challenges, Atraumatic Restorative Technique (ART) was developed in the 1980s as an affordable, patient friendly caries management procedure that does not need extensive operator training or special skills. ART was originally developed to be conducted in field settings; however, after initial evidence of effectiveness, the World Health Organization (WHO) and the International Dental Federation (FDI) promoted the use of ART in modern clinical settings worldwide. In the US, the practice of ART is not believed to be widely used. This may be a result of little attention given to (ART) in dental education and advanced training. This dissertation is comprised of three separate studies that investigated the extent and the factors related to the didactic and clinical instruction on ART in US pre- and post-doctoral pediatric dentistry programs and the factors related to the willingness of pediatric dentists to use ART with their child patients. survey post-doctoral pediatric dentistry program directors and pre-doctoral pediatric dentistry program directors. In study III a different instrument was used to survey pediatric dentists in the US. The survey instruments were tested for content and face validity by cognitive analysis interviews and pilot testing. Using web-based survey methodology, two questionnaires were sent out in May 2010 to investigate self-reported use of ART in educational training institutes (study I and II) and in April 2011, a third questionnaire was sent to a random national sample of pediatric dentists (study III). Using a conjoint design, the third questionnaire asked pediatric dentists to rate their willingness to use ART for 9 patients' scenarios. Eighty eight percent of Pediatric Dentistry Residency programs and 66 % of pre-doctoral pediatric dentistry programs in the US provided clinical training on ART; however only 30% of post-doctoral programs and 14 % of pre-doctoral programs used ART "Very Often/ Often" as a caries management technique for their pediatric patients. Pediatric Dentistry residency programs and pre-doctoral pediatric dentistry programs used ART mainly in primary, anterior, single surface cavities and as an interim treatment. Attitudes toward ART alone and after controlling for other variables explained 35% of the level of training on ART in post- doctoral program and 23% in pre-doctoral pediatric dentistry programs. For study III, conjoint analysis showed that being very young and/or uncooperative were the most important reasons practitioners reported a higher likelihood of using ART. Although insurance coverage was the least important factor overall, not having any insurance was identified as an additional important factor in decisions to use ART. Collectively, our results suggest that that the use of ART is not widespread in the US. In addition, ART is viewed by some as a sub optimum treatment and needs to be modified to conform to the US standards of care. On the other hand, educators and pediatric dentists who had positive views of ART thought it could be a valuable treatment for very young, uncooperative children and children with no insurance.

Indiana University-Purdue University Indianapolis (IUPUI) / With an estimated 30.2 million diagnosed and undiagnosed cases among adults (and another 84 million at risk), diabetes mellitus is one of the most prevalent chronic conditions and a leading cause of mortality in the US. Diabetes self-management education and training (DSME/T) is a recognized standard of care and provides patients with the requisite knowledge and skills to properly manage the condition, improve long-term health outcomes, and reduce health care expenditures. Yet, DSME/T is greatly underutilized. Health insurance coverage that does not include benefits for DSME/T effectively imposes barriers to access for patients in need of the service. Many states have adopted laws and regulations requiring public and/or private insurers in their market to provide benefits for DSME/T; however, these requirements vary by state. It is unclear if these policies effectively improve access to DSME/T services. This dissertation seeks to rigorously assess the impact of state-mandated benefits and reimbursement provisions on access to DSME/T among adult patients with diabetes. The first analysis utilizes a unique combination of legal and programmatic data to quantify changes in the supply of DSME/T resources after the adoption of state-mandated benefits (potential access). The second analysis merges legal data with the Medical Expenditure Panel Survey (MEPS) from 2008 to 2016 to examine the impact of state mandates and reimbursement provisions on patient utilization of DSME/T (realized access). Lastly, the final analysis utilizes electronic health record data (2010-2016) from a safety net population to determine if patients’ evaluated need for DSME/T predicts the likelihood of receiving a DSME/T referral during a provider encounter (equitable access). Using novel data sources and a sophisticated policy analysis technique, this study provides a rigorous assessment of the impact of decades of state policies designed to improve access to care. / 2020-04-02

Autism spectrum disorder (ASD) is associated with a variety of physical, mental, and behavioral healthcare needs. However, parents of autistic children consistently report difficulty accessing necessary services, and no instrument has been validated to assess and quantify these barriers for autistic children. The current study aims to adapt and validate the Barriers to Care Questionnaire (BCQ), a pre-existing measure of barriers to healthcare for children with specific healthcare needs, for families of autistic children. The BCQ and theoretically related measures were collected from 242 parents (117 parents of autistic children, 125 parents of non-autistic children). Cronbach’s alpha statistics (ranging from 0.87 to 0.96 for BCQ subscales) provide evidence of reliability for the BCQ. The BCQ subscales were correlated with unmet treatment need, treatment experiences, and theoretically related variables at the child, parent, and family level, providing evidence of convergent validity. Correlations were of low magnitude with theoretically unrelated variables (parent personality and socially desirable responding), suggesting preliminary evidence of discriminant validity. Additionally, the BCQ subscales predicted a significant amount of variance in unmet need and treatment experiences over and above other predictors for autistic youth, indicating incremental validity. Parents of autistic children reported significantly more barriers to care across all subscales of the BCQ than parents of non-autistic children, and the highest average item score was on the “skills” subscale, which measures difficulties with navigating the healthcare system. Results support that the BCQ can be used among autistic youth, and suggest the critical need for family-centered supports and provider education in order to ameliorate barriers to healthcare for autistic children. / M.S. / Autism spectrum disorder (ASD) is related to many physical, mental, and behavioral healthcare needs. However, parents of autistic children state that it is often hard to receive healthcare when their child needs it. No questionnaire exists to measure barriers that make getting healthcare harder for autistic children. Our study adapted the Barriers to Care Questionnaire (BCQ) for families of autistic children. The BCQ and related questionnaires were filled out by 242 parents (117 parents of autistic children, 125 parents of non-autistic children). The BCQ reliably and consistently measured barriers to care in these groups. The BCQ subscales were associated with unmet treatment need, treatment experiences, and other related variables at the child, parent, and family level. The questionnaire was less strongly related to variables that we would not expect to be associated with barriers to care, like personality and social desirability. Also, the BCQ subscales predicted healthcare experiences even when accounting for other factors that might impact access to care. Parents of autistic children reported more barriers to care on all subscales of the BCQ than parents of non-autistic children, and the highest average item score was on the “skills” subscale, which measures difficulties with navigating the healthcare system. Results show that the BCQ can be used among autistic youth, and suggest the need for family-centered supports and provider education in order to improve barriers to healthcare for autistic children.

Background: Regular access to dental services is a well-known factor in the oral health and development of children.1 As such, the United States federal government mandates each state to include dental services for children enrolled in Medicaid through the age of 21. Despite this mandate, the utilization rate of dental services among Medicaid enrolled children has remained remarkably low.2 In July 2005, Virginia implemented a sweeping Medicaid policy reform titled “Smiles for Children,” specifically aiming to increase Medicaid pediatric dental utilization rates. The purpose of this study aims to assess the effect of this 2005 policy reform on the utilization of dental services by children enrolled in Medicaid. Objective: The purpose of this study is to examine the impact of the 2005 Virginia Smiles for Children Medicaid policy reform on the utilization of dental services among Medicaid enrolled children. Methods: This was a retrospective cohort study of children (pre-reform n=559,820, post-reform n=690,538) enrolled in Virginia Medicaid from 2002 through 2008. Descriptive statistics and repeated measures multivariate logistic regressions were used to determine the relationship between enrollment (Pre- and Post-policy reform) and the utilization of dental services (1+ Dental Visits vs. No Dental Visits). Results: Descriptive analysis of the cohort found that 34% of pre-reform children had a dental visit while 44% of post-reform children. The logistic regression models revealed that children in the post reform period were 1.39 as likely to have had a dental visit. Stratifying for enrollment length reveals that as the length of exposure time to the post-reform policy increases, the odds of having a dental visit also increase as compared to the pre-reform period: for 31-36 months of enrollment the odds increase 1.54 times. Conclusions: Medicaid policy reform can significantly improve access to dental services for children and can therefore play an important role in promoting public health.

Medicaid expansion under the Affordable Care Act (ACA) facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Tennessee’s Medicaid program experienced a dramatic Medicaid contraction when the program disenrolled approximately 170,000 nonelderly adults in 2005. Pre-ACA expansions were associated with better access to and utilization of healthcare services. However, little is known about the effect of these policy changes on improvement in health outcomes for women diagnosed with breast cancer, access to care for cancer survivors, and the effect of generosity and duration of expansion on access to care. This dissertation has three objectives. First, to assess the effects of the Tennesse’s Medicaid disenrollment on stage at diagnosis and delay in surgery for breast cancer among nonelderly women. Second, to compare access to care between cancer survivors living in non-expansion states and survivors living in expansion states. Third, to examine the effect of generosity and duration of the pre-ACA Medicaid expansions on access to and utilization of healthcare services. I use three different types of datasets: the 2002-2008 data from Tennessee Cancer Registry, the 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS), and the 2012 Medical Expenditure Panel Survey (MEPS) data. I estimate difference-in-difference models and perform multiple logistic regression models to examine the impact of these policy changes on the different measurement outcomes. While many states are expanding Medicaid eligibility under the Affordable Care Act, there has been discussion among policymakers in some states about reducing eligibility under the Affordable Care Act once full federal funding expires. This study suggests that Medicaid disenrollment leads to later stage at diagnosis for breast cancer patients, indicating negative health impacts of contractions in Medicaid coverage. Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors without access to routine care. The study informs policy makers that, relative to no expansion, moderate or generous expansion is associated with improvement in access to and utilization of healthcare services.

The focus of this research was to: 1) study the perceptions of female students attending the university Student Health Center, concerning available services, 2) learn how they describe their decisions to obtain care, and 3) identify perceived barriers to reproductive health care and contraception. This exploratory study used a mixed-methods approach that included clinic public-space observations, interviews with health care providers and staff at Student Health Services (SHS), surveys distributed to clients of the campus clinic, and in-depth interviews to contextualize emergent themes. Topics addressed included sexual health behaviors and perceptions, influence of peers and partners, the propagation of health myths, and past experiences with SHS. Gathering practitioner perspectives on student barriers to care, goals of the clinic, and perceived health needs of the student community, allowed for measurement of incongruence between student and staff, thereby adding greater context to results. SHS sought recommendations in order to improve student's use of the Sexual Health and Gynecology clinic, increase accuracy of student's sexual health knowledge, and guide future clinic operations. SHS is now working with the College of Public Health to create improvement projects based on my results, including a peer education program. Research such as this can result in greater student awareness of available services, and more productive communication between patients and provide. Implications on the larger issues of gender and the search for health care, acceptance and knowledge of STI testing, and client comfort are addressed, and provide opportunity for future work in this area.

The overwhelming social norm for pregnant women in the U.S. is to receive prenatal care from an obstetrician and to give birth in a hospital setting. However, the incidence of midwifery care and out-of-hospital birth is increasing, particularly among White, non-Hispanic women. Florida has been considered a "model" state for home birth midwifery given legislative support that mandates coverage of all types of midwifery (e.g., Certified Professional Midwives and Certified Nurse-Midwives) care in all birth settings (e.g., hospital, home, birth center) and by all forms of insurance (e.g., commercial and Medicaid). Medicaid is the payer source for nearly half of the births in the United States and in Florida. However, Florida is one of only ten states where Certified Professional Midwives, who attend the vast majority of planned home births, are actively able to receive Medicaid reimbursement for home birth care. A key question then becomes, how is the system for Medicaid-funded home birth in Florida functioning? The central aim of this research was to better understand how Medicaid impacts the practice of and access to planned home birth in Florida. This was examined through quantitative analysis of Florida birth certificates as well as through qualitative data collection and analysis that sought to describe the experiences of women who had planned home birth while on Medicaid as well as the experiences of midwives that cared for these women. Findings are presented through the lens of Critical Medical Anthropology, which helps to interpret how and why home birth is systematically supported or threatened by legislation, policy, and practice at the level of the State of Florida, the federal-state Medicaid program, and the professional organizations in the United States involved in maternity care. Key findings demonstrate that the vast majority (87%) of planned home birth in Florida is attended by Certified Professional Midwives, and that while Florida Medicaid paid for 45% of all births between 2005 and 2010, only 31% of planned home births were paid for by Medicaid. However, after controlling for multiple factors (e.g., race/ethnicity, age, parity), in fact women who completed home (vs. hospital) birth were much more likely to be self-pay (AOR 10.1) or on Medicaid (AOR 4.6) compared to private, commercial insurance. Women interviewed for this study who received Medicaid for their home births overwhelmingly appreciated the "safety net" that Medicaid provided to them and the "relief" of knowing that if a hospital transfer was necessary it would be covered. However, they nearly universally stated that they would have found a way to pay for a home birth if they had not received Medicaid. Women felt that home birth with midwives provided them the greatest chance of having a "natural" birth in the environment most likely to maintain autonomy over decisions related to their pregnancy and birth. Several women experienced significant delays in enrolling in Medicaid, and found that the only providers who would provide care during "presumptive eligibility" were Licensed, Certified Professional Midwives. Midwives appreciated the steady, reliable payments Medicaid provided, despite that these were at about 30 to 40% of their rates charged to privately insured or self-pay clients. They felt that providing care to Medicaid funded women served as a form of social justice. They strongly disliked interfacing with Medicaid HMOs. Some midwives felt that the Florida legislation supported their practice, while others felt that it constrained their practice. Medicaid coverage of planned home birth in Florida now stands at a crossroads, given that Florida Medicaid has recently transitioned to a 100% managed care program (i.e., HMOs). These HMOs act as intermediaries between Medicaid providers and their reimbursements, as well as between Medicaid providers and recipients. The new relationships between providers, patients and the HMOs have shifted from that with a state agency to that with a private, for-profit industry. It remains to be seen whether home birth providers will enroll with Medicaid HMOs in order to continue providing care to pregnant women receiving Medicaid. Key policy recommendations therefore are to monitor women's access to pregnancy Medicaid, and specifically access to services mandated under Florida statute, including home birth and midwifery care. Furthermore, the creation of an integrated maternity care system that better supports transfers of care from the home to hospital setting is needed.