Considering the neighborhood context: The relationship between food and housing insecurity and healthcare use among Virginia Medicaid expansion members

December 9, 2024 by Drew Necci

For a new article published by Health Services Research, several VCU Department of Health Policy faculty members, students, and alums collaborated with other faculty from the VCU School Of Public Health and several officials from the Virginia Department of Medical Assistance Services (DMAS) to examine the relationships between healthcare use and food and housing insecurity among Virginia Medicaid members who were initially covered as part of the 2019 expansion of Virginia Medicaid services to additional adults living in poverty. Article authors include several Department of Health Policy members, including alum Hannah Shadowen, Ph.D. candidate Sarah Marks, assistant professor Anika Hines, professor and interim chair Peter Cunningham, and professor Andrew Barnes; along with Department of Biostatistics professor Roy Sabo, School of Family Medicine professor Alexander Krist, and Virginia DMAS officials Olufemi Obembe, Andrew Mitchell, and Chethan Bachireddy. In the article, they explain that food insecurity is associated with less primary care and more emergency department use, but this relationship differs depending on the neighborhood in which members live. They found that efforts to coordinate medical and social service benefits, and to consider local context, may increase access to necessary care.

1 INTRODUCTION

Medicaid expansion provides insurance for low-income individuals with minimal or no premiums or co-pays.¹ Medicaid expansion is associated with decreased healthcare costs for families, changes in healthcare utilization, and improvements in health-related social needs (HRSN).^2–4 More specifically, low-income families living in Medicaid expanded states were 11% less likely to have any out-of-pocket spending.² Further, Medicaid expansion enrollment has been associated with reductions in difficulty paying medical bills.^3, 5 Consequently, Medicaid expansion is associated with changes in healthcare utilization and HRSN. Medicaid expansion is associated with increases in primary care utilization and decreases in emergency department (ED) utilization for ambulatory sensitive conditions.^6–8 While Medicaid expansion’s association with healthcare affordability, access, and social needs have each been studied separately, the relationship between HRSN and healthcare utilization in Medicaid expansion members is unclear.⁹

Previous studies show that individuals make trade-offs between paying for HRSN and health care.^10, 11 Individuals experiencing HRSNs use less preventive or routine health care,^12–14 experience greater delays in doctor’s visits,^12, 14 forgo routine check-ups, and lack a usual source of care compared with their food or housing secure counterparts.¹³ Additionally, food insecurity is significantly associated with frequent ED visits among adults.^15, 16 Together, this suggests that households are constrained by household resources, including time, financial resources, and mental energy.¹⁷ Therefore, individuals experiencing HRSN may not have the mental, financial, or time resources to use any health care or may not use primary care for nonurgent issues and instead opt for emergency room care that is often lower barrier and always available. However, these studies often focus on populations with heterogenous insurance coverage, making it unclear how individuals with Medicaid expansion coverage, that requires no or very limited co-pays or premiums for the individual, may navigate these competing needs.

The trade-off between competing needs may be different for individuals with Medicaid expansion coverage. Evidence suggests individuals with HRSN have higher rates of chronic disease and thus have an increased need for primary care.^18–20 However, Medicaid may not address previously described barriers to accessing primary care for individuals experiencing HRSN in samples with heterogenous insurance coverage. For example, lack of paid sick leave is more common among individuals facing food insecurity and is not ameliorated by Medicaid coverage, making it a potential barrier to care for individuals enrolled in Medicaid.²¹ The relationship between food and housing insecurity and healthcare utilization in Medicaid expansion populations is unclear.

Importantly, access to food, housing, and health care occurs within the larger community context shaped by rurality and segregation. For example, the supply of primary care providers (PCPs) per capita is lower in rural areas than that in urban areas leading to increases in travel barriers for rural individuals.^22–25 Due to these difficulties in accessing care, individuals experiencing HRSN in rural areas may not use primary care as frequently as individuals experiencing HRSN in urban areas. Similarly, residential segregation, defined as the historic, intentional physical separation of races by enforced residence in certain areas,²⁶ has led to fewer healthcare providers in predominately Black communities leading to systematically differential opportunities by neighborhoods.^27, 28 Likewise, in a systemically racist society, access to secure sources of food and stable housing differ by neighborhood racial composition by design.^29–33 Thus, residents in predominately Black neighborhoods may have greater barriers to primary care that are amplified if individuals are also experiencing food and housing insecurity.

This study aimed to understand relationships between food and housing insecurity and the use of primary and emergency department care among Medicaid expansion members. To do this, we used a sample of newly enrolled Virginia Medicaid expansion members to understand if there was an association between experiencing food and housing insecurity at the time of enrollment and healthcare use in the subsequent year of enrollment. Further, we assessed if this relationship was moderated by community-level rurality and residential segregation. We hypothesized that individuals experiencing HRSN at enrollment would have reduced primary care use and increased ED use compared with individuals not experiencing these HRSN. We further hypothesized that members with HRSN would use less primary care and more ED care after enrollment compared to members without HRSN if they lived in rural or predominately Black or low-income neighborhoods compared with urban or predominately White neighborhoods.

Read the full article here. Top Photo by By Martin Kraft, CC BY-SA 3.0, via Wikimedia