Nancy A. Miller

Adult Tobacco Use Levels After Intensive Tobacco Control Measures: New York City, 2002–2003

OBJECTIVES We sought to determine the impact of comprehensive tobacco control measures in New York City. METHODS In 2002, New York City implemented a tobacco control strategy of (1) increased cigarette excise taxes; (2) legal action that made virtually all work-places, including bars and restaurants, smoke free; (3) increased cessation services, including a large-scale free nicotine-patch program; (4) education; and (5) evaluation. The health department also began annual surveys on a broad array of health measures, including smoking. RESULTS From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, approximately 140000 fewer smokers). Smoking declined among all age groups, race/ethnicities, and education levels; in both genders; among both US-born and foreign-born persons; and in all 5 boroughs. Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third. CONCLUSIONS Concerted local action can sharply reduce smoking prevalence. However, further progress will require national action, particularly to increase cigarette taxes, reduce cigarette tax evasion, expand education and cessation services, and limit tobacco marketing.

Female Clients in Substance Abuse Treatment

This paper reviews recent research on sex differences in the nature of alcohol and drug problems, use of treatment services, and the role of treatment and extratreatment factors in influencing these problems. Although patterns of use are different for men and women, responses to traditional treatment programs have not been different. Research suggests that programs providing ancillary services designed to meet the particular needs of women, such as child care, and those involving other family members and significant others hold the greatest promise for women with drug and alcohol problems.

S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.

ocial Health Maintenance Organizations (SMMOs) are S milestones in the quest for improved and better integrated systems of acute care and long-term care (LTC). As part of a long-lived demonstration program implemented at four sites in the mid 1980s, S/HMO leaders were involved heavily in fashioning technology for LTC in managed care. In 1991, while the evaluation of SMMOs was still in progress, Congress reaffirmed its enthusiasm to continue S/HMOs and stipulated that new S/HMOs be created. In January 1995, the Health Care Financing Administration (HCFA) awarded planning grants to six prospective second generation S/HMOS.~ These projects are now engaged in developing their plans, including their benefit structures and rates. Like their predecessors, the second generation S/HMOs are intended to demonstrate the integration of acute care and LTC within a capitated managed-care framework. The second generation differs from the first, however, in several key respects: ( 1 ) Rather than controlling for adverse selection by proportional enrollment at various impairment levels, they will establish reimbursement rates based on the individual members impairment and illness profile at time of enrollment and annually thereafter. An enrollees reimbursement rate will not change during each year if an enrollees status changes (as occurred with S/HMO I); rather, the rate will apply for the full enrollment year. (2 ) They have committed to clinical as well as financial integration. Building upon the experience of the first SMMOs, they are planning state-ofthe-art geriatric health care programs, which will apply, as appropriate, to all enrollees, not just those who use LTC. (3) The projects are committed to coordinating the acute care with a set of flexible, user-friendly, efficient LTC services. (4) Sites plan a special emphasis on serving underrepresented groups, including rural, Medicaid, and minority populations.

Do medical students know enough about smoking to help their future patients? Assessment of New York City fourth-year medical students' knowledge of tobacco cessation and treatment for nicotine addiction.

Purpose Practicing physicians underutilize U.S. Department of Health and Human Services evidence-based approaches to nicotine addiction and treatment. Few studies have assessed medical student knowledge in this area. This study examined New York City fourth-year medical students’ knowledge of tobacco cessation and treatment of nicotine addiction. Method The authors conducted a Web-based survey, comprising 27 closed- and open-ended questions, of six of seven New York City medical schools in the spring of 2004. They drew questions from international, national, and local surveys on tobacco and health, U.S. Department of Health and Human Services tobacco treatment guidelines, and prior studies. Primary outcome measures were knowledge of the epidemiology of smoking, benefits of cessation and treatment of nicotine addiction, clinical cessation practices, and students’ use of tobacco and intentions to stop smoking. Results Of 943 fourth-year medical students, 469 (50%) completed an online survey. Students had good knowledge of the epidemiology of smoking, including its prevalence and health effects, with most responding correctly to relevant questions (mean correct response 79%; SD = 9.4). Students demonstrated a fair understanding of the benefits of cessation (mean correct response, 67%; SD = 19.2) and treatment of nicotine addiction (mean correct response, 61%; SD = 13.2). Three hundred students (64%) rated their own preparation to assist patients to quit as less than adequate. Conclusions Fourth-year medical students at the participating schools in New York City understood the harms of smoking but needed more information on the benefits of stopping smoking and treatment of nicotine addiction.

Use of Medicaid 1915(c) Home- and Community-Based Care Waivers to Reconfigure State Long-Term Care Systems:

Since Congressional authorization in 1981, Medicaid 1915(c) home- and community-based care waivers have influenced states’ efforts to transform their long-term care systems. In 1997, every state participated in the 1915(c) waiver program, while waiver expenditures, at

The Relation Between Health Insurance and Health Care Disparities Among Adults With Disabilities

8.1 billion, represented 59.6 percent of all Medicaid community-based care expenditures. To explore state-level factors that appear related to these expenditures, the authors turn to a body of work on Medicaid resource allocation. They compare the influence of five factors—sociodemographic, supply, economic, programmatic, and political environment—on states’ allocations to long-term care expenditures and 1915(c) waiver expenditures. The state economic environment was an important influence on total, as well as waiver expenditures. State regulation of long-term care supply demonstrated the most substantive relationship, increasing the share of dollars supporting 1915(c) waivers from 11.6 to 20.0 over the study period, all else equal.

State Policy Choices and Medicaid Long-Term Care Expenditures

OBJECTIVES We examined disparities among US adults with disabilities and the degree to which health insurance attenuates disparities by race, ethnicity, and socioeconomic status (SES). METHODS We pooled data from the 2001-2007 Medical Expenditure Panel Survey on individuals with disabilities aged 18 to 64 years. We modeled measures of access and use as functions of predisposing, enabling, need, and contextual factors. We then included health insurance and examined the extent to which it reduced observed differences by race, ethnicity, and SES. RESULTS We found evidence of disparities in access and use among adults with disabilities. Adjusting for health insurance reduced these disparities most consistently for emergency department use. Uninsured individuals experienced substantially poorer access across most measures, including reporting a usual source of care and experiencing delays in or being unable to obtain care. CONCLUSIONS Although health insurance is an important enabling resource among adults with disabilities, its effect on reducing differences by race, ethnicity, and SES on health care access and use was limited. Research exploring the effects of factors such as patient-provider interactions is warranted.

Relations Among Home- and Community-Based Services Investment and Nursing Home Rates of Use for Working-Age and Older Adults: A State-Level Analysis

State long-term care policies are directed toward a variety of goals. Concerns with expenditure control are primary. Certain states are also seeking to increase the availability of community-based care. A more balanced system would assist consumers in attaining valued goals, while being consonant with federal policy initiatives and legal rulings. The authors examine the relationship between state policies and Medicaid long-term care expenditures. These relationships are tested by multiple regression analysis, using a random effects model for 1991 through 1997. Prospective payment may moderate nursing facility expenditure growth and total long-term care expenditures. Institutional supply constraints demonstrated a positive relationship to both forms of community-based care expenditures. The authors found no evidence of Medicare maximization as a policy to constrain Medicaid expenditure growth. Finally, the authors note the importance of additional work in exploring the dynamics between state long-term care policies and expenditures for individuals with differing disabilities.

Developing personal care programs: national trends and interstate variation, 1992-2002.

OBJECTIVES I examined state-level rates of nursing home use for the period from 2000 to 2007. METHODS I used multivariate fixed-effects models to examine associations between state sociodemographic, economic, supply, and programmatic characteristics and rates of use. RESULTS Nursing home use declined among older adults (aged ≥65 years) in more than two thirds of states and the District of Columbia but increased among older working-age adults (aged 31-64 years) in all but 2 states. State characteristics associated with these trends differed by age group. Although relatively greater state investment in Medicaid home- and community-based services coupled with reduced nursing home capacity was associated with reduced rates of nursing home care for adults aged 65 years and older, neither characteristic was associated with use among older working-age adults. Their use was associated with state sociodemographic characteristics, as well as chronic disease prevalence. CONCLUSIONS Policy efforts to expand home- and community-based services and to reduce nursing facility capacity appear warranted. To more fully extend the Supreme Courts Olmstead decisions promise to older working-age adults, additional efforts to understand factors driving their increasing use are required.

Miller et al. Respond

This paper examines the development of programs delivering personal care to the elderly and disabled. First, we report the latest national participant and expenditure trend data for the three main personal care programs: the Medicaid Personal Care Services (PCS) benefit, Medicaid 1915(c) waivers, and the Older Americans Act Title III. Second, to examine interstate variation revealed in the trend analysis, we present three time-series regression models of personal care development (expenditures, participants, and existence of PCS benefit) that control for state socioeconomic, political, policy, and provider characteristics. Positive predictors of personal care development include: percentages of population aged 85 and older, and nonwhite; per capita income; and liberal state politics. Negative predictors of personal care development include rates of Medicare home health users and hospital beds.