Health Care Disparities in Maryland in the "Contract with America" Era

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In the early 1990s, the Medicaid budget expanded dramatically. In response, federal and state policymakers implemented changes to curb patient demand. Taken together, these policies may have impeded low-income health care access in Maryland more effectively and less equitably than anticipated.

Research question: Did access-affecting policy changes in the mid-1990s alter Maryland's low-income health care market differently for different racial and ethnic groups?

Following extensive document and literature reviews, semi-structured interviews were conducted with stakeholders and experts in Maryland's low-income health care market. A content analysis of interview transcripts was performed. HCUP SID hospital discharge data from Maryland and New Jersey was then used to test for treatment delay. A quasi-temporal measure was devised using patient-level racial/ethnic differences in incidences of appendicitis, appendiceal perforation, and prolongation of hospital stay following appendicitis with and without perforation.

Qualitative analysis indicated that implementation of policy changes initially widened gaps in Maryland's health care safety net. This continued to hamper access to care disproportionately for homeless persons and immigrants. HCUP data indicated that Maryland's black appendicitis patients in 1996 were more likely (by 6 percentage points, p<0.05) than their white counterparts to suffer appendiceal perforation. In 2003, black patients no longer showed higher incidence; similar trends emerged for Hispanics and other groups. However, hospitalizations for black appendicitis patients increased from 0.58 days longer than their white counterparts (p<0.01) in 1996 to 0.65 days longer (p<0.01) in 2003. Most notably, insurance status disparities revealed that, in 1996, Maryland's uninsured were more likely than the privately-insured to experience perforation (by 2.3 percentage points). By 2003, Maryland's uninsured were 6.7 percentage points (p<.01) more likely than the privately-insured to suffer perforation. Hospitalizations for uninsured appendicitis patients were accordingly longer than for privately-insured patients, although length of stay data failed to achieve statistical significance in both years.

This research suggests demand was decreased largely by impeding access, disproportionately to the disadvantage of racial/ethnic minorities, the homeless, and immigrants. Data confirm that access declined for the uninsured. As this population continues to grow, insufficient access to care for the uninsured will remain an urgent problem.