BACKGROUND: While Medicaid is an important source of insurance coverage for persons with disabilities, barriers remain to accessing care for this population. OBJECTIVES: This study addresses 3 research questions: (1) do adults with disabilities experience greater unmet need/delayed care?; (2) do barriers related to cost, providers, or structure vary by disability status?; and (3) do barriers mediate the relationship between disability and access to care? RESEARCH DESIGN: Data were obtained from a 2008 stratified random sample of Minnesota Health Care Program's nonelderly adult enrollees (n=1880). The survey was administered by mail, with a telephone follow-up for nonresponders. MEASURES: Disability is defined by self-report. Access to care is measured by reported delayed and unmet need for medical care within the past year. Respondents were asked about their experiences with a variety of cost-related, provider-related, and structural barriers to care. RESULTS: Respondents with a disability were more likely to experience delayed (40%) and unmet need (23%) for medical care than persons without disabilities (24% and 10%, respectively). Persons with disabilities also reported multiple barriers to health care, especially structural barriers, such as making a timely appointment and accessing transportation (74% vs. 59%). The greater likelihood of facing a structural barrier partially explained increased risk of delayed or unmet care among adults with disabilities. CONCLUSIONS: Disparities in access to health care based on disability status remain even for persons who have insurance. These disparities deserve further research and policy attention to better address the particular needs of this population.

PURPOSE: Little is known about mental health disorders (MHDs) and their associated health care expenditures for the dual eligible elders across long-term care (LTC) settings. We estimated the 12-month diagnosed prevalence of MHDs among dual eligible older adults in LTC and non-LTC settings and calculated the average incremental effect of MHDs on medical care, LTC, and prescription drug expenditures across LTC settings. METHODS: Participants were fee-for-service dual eligible elderly beneficiaries from 7 states. We obtained their 2005 Medicare and Medicaid claims data and LTC program participation data from federal and state governments. We grouped beneficiaries into non-LTC, community LTC, and institutional LTC groups and identified enrollees with any of 5 MHDs (anxiety, bipolar, major depression, mild depression, and schizophrenia) using the International Classification of Diseases Ninth Revision codes associated with Medicare and Medicaid claims. We obtained medical care, LTC, and prescription drug expenditures from related claims. RESULTS: Thirteen percent of all dual eligible elderly beneficiaries had at least 1 MHD diagnosis in 2005. Beneficiaries in non-LTC group had the lowest 12-month prevalence rates but highest percentage increase in health care expenditures associated with MHDs. Institutional LTC residents had the highest prevalence rates but lowest percentage increase in expenditures. LTC expenditures were less affected by MHDs than medical and prescription drug expenditures. IMPLICATIONS: MHDs are prevalent among dual eligible older persons and are costly to the health care system. Policy makers need to focus on better MHD diagnosis among community-living elders and better understanding in treatment of MHDs in LTC settings.

BACKGROUND: Dual eligible Medicare and Medicaid beneficiaries consume disproportionate shares of both programs. OBJECTIVES: To compare Medicare and Medicaid expenditures of elderly dual eligible beneficiaries with non-dual eligible beneficiaries based on their long-term care (LTC) use. RESEARCH DESIGN: Secondary analysis of linked MAX and Medicare data in seven states. SUBJECTS: Dual eligible adults (65+) receiving LTC in institutions, in the community, or not at all; and Medicare non-dual eligibles. MEASURES: Medicaid acute medical and LTC expenditures per beneficiary year, Medicare expenditures. RESULTS: Among dual eligibles and non-dual eligibles, the average number of diseases and case mix scores are higher for LTC users. Adjusting for case mix virtually eliminates the difference for medical costs, but not for LTC expenditures. Adjusting for LTC status reduces the difference in LTC costs, but increases the difference in medical costs. CONCLUSIONS: Efforts to control costs for dual eligibles should target those in LTC while better coordinating medical and LTC expenditures.

OBJECTIVE: Drawing from cumulative inequality theory, the authors examine the relationship between perceived work trajectories and mortality risk among Black and White women over 36 years. METHOD: Panel data from the National Longitudinal Survey of Mature Women (1967-2003) are used to evaluate how objective and subjective elements of work shape mortality risk for Black and White women born between 1923 and 1937. RESULTS: Estimates from Cox proportional hazards models reveal that Black working women manifest higher mortality risk than White working women even after accounting for occupation, personal income, and household wealth. Perceived work trajectories were also associated with mortality risk for Black women but not for White women. DISCUSSION: The findings reveal the imprint of women's work life on mortality, especially for Black women, and illustrate the importance of considering personal meanings associated with objective work characteristics.

OBJECTIVE: Drawing from cumulative inequality theory, this research examines how accumulated financial strain affects women's self-rated health in middle and later life. METHOD: Using data from the National Longitudinal Survey of Mature Women (1967-2003), we employ random-coefficient growth curve models to examine whether recurring financial strain influences women's health, above and beyond several measures of objective social status. Predicted probabilities of poor health were estimated by the frequency of financial strain. RESULTS: Financial strain is associated with rapid declines in women's health during middle and later life, especially for those women who reported recurrent strain. Changes in household income and household wealth were also associated with women's health but did not eliminate the effects due to accumulated financial strain. DISCUSSION: Accumulated financial strain has long-term effects on women's health during middle and later life. The findings demonstrate the importance of measuring life course exposure to stressors in studies of health trajectories.

In 2011, about 25 percent of the Medicare fee-for-service population had diabetes. Among Medicare beneficiaries with diabetes, approximately 14 percent had type 1, 85 percent had type 2 but did not use insulin, and less than 1 percent had type 2 diabetes and used insulin to manage their condition. Between 2007 and 2011, beneficiaries with type 2 diabetes who used insulin had the highest burden of comorbidity, hospitalization rates, and allowed payment, followed by those with type 1 diabetes. Most beneficiaries with diabetes had evaluation and management visits. Most also received needed preventive care, including HbA1c and LDL testing, and about half received an annual flu shot and eye exam. However, beneficiaries with type 2 diabetes using insulin had the lowest rates of receipt of preventive care. Most beneficiaries with diabetes visited both primary care and specialty providers. The number of providers with whom they had contact is high, indicating potential fragmentation in both primary and specialty care.

Nursing homes (NH) and other institutional-based long-term care settings are not considered an appropriate place for the care of those with serious mental illness, absent other medical conditions or functional impairment that warrants skilled care. Despite policy and regulatory efforts intended to curb the unnecessary placement of people with serious mental illness (SMI) in these settings, the number of adults with SMI who receive care in NHs has continued to rise. Through a scoping review, we sought to summarize the available literature describing NH care for adults with SMI from 2000 to 2020. We found that SMI was operationalized and measured using a variety of methods and diagnoses. Most articles focused on a national sample, with the main unit of analysis being at the NH resident-level and based on analysis of secondary data sets. Understanding current evidence about the use of NHs by older adults with SMI is important to policy and practice, especially as we continue to grapple as a nation with how to provide quality care for older adults with SMI.

Transforming nursing homes (NHs) from restrictive institutions to person-centered homes, referred to as NH culture change, is complex and multifaceted. This study, based on a survey of administrators in Minnesota NHs (n ¼ 102), tested the domain-specific relationships of culture change practices with resident quality of life (QOL) and family satisfaction, and examined the moderating effect of small-home or household models on these relationships. The findings revealed that culture change operationalized through physical environment transformation, staff empowerment, staff leadership, and end-of-life care was positively associated with at least one domain of resident QOL and family satisfaction, while staff empowerment had the most extensive effects. Implementing small-home and household models had a buffering effect on the positive relationships between staff empowerment and the outcomes. The findings provide meaningful implications for designing and implementing NH culture change practices that best benefit residents' QOL and improve family satisfaction.

Whole-person care is a new paradigm for serious illness, but few programs have been robustly studied. We sought to test the effect of LifeCourse (LC), a person-centered program for patients living with serious illness, on health-care utilization, care experience, and quality of life, employing a quasi-experimental design with a Usual Care (UC) comparison group. The study was conducted 2012 to 2017 at an upper-Midwest not-for-profit health-care system with outcomes measured every 3 months until the end of life. Enrolled patients (N ¼ 903) were estimated to be within 3 years of end of life and diagnosed with 1þ serious illness. Exclusion criteria included hospice enrollment at time of screening or active dying. Community health workers (CHWs) delivered standardized monthly 1-hour home visits based on palliative care guidelines and motivational interviewing to promote patients' physical, psychosocial, and financial well-being. Primary outcomes included health-care utilization and patient-and caregiver-experience and quality of life. Patients were elderly (LC 74, UC 78 years) and primarily non-Hispanic, white, living at home with cardiovascular disease as the primary diagnosis (LC 69%, UC 57%). A higher proportion of LC patients completed advance directives (N ¼ 173, 38%) than UC patients (N ¼ 66, 15%; P < .001). LifeCourse patients who died spent more days in hospice (88 + 191 days) compared to UC patients (44 + 71 days; P ¼ .018). LifeCourse patients reported greater improvements than UC in communication as part of the care experience (P ¼ .016). Implementation of person-centered programs delivered by CHWs is feasible; inexpensive upstream expansion of palliative care models can yield benefits for patients and caregivers. Trial Registration: Trial NCT01746446 was registered on November 27, 2012 at ClinicalTrials.gov.