Health care use among limited english proficiency enrollees with chronic conditions: Findings from California's low income health program

Background: The Low Income Health Program (LIHP) is a county-operated Medicaid Waiver demonstration program which expands coverage to eligible low income adults effective July 1, 2011 through December 31, 2013. Under the Affordable Care Act (ACA), LIHP enrollees will transition to California's Medi-Cal Program or Health Benefit Exchange. The delivery of care to those with chronic conditions and Limited English Proficiency (LEP) can be more challenging and would require culturally competent care coordination. The safety net providers participating in the LIHP program deliver such services.

Methods: We used claims and enrollment data from 12 participating counties and a consortium of 35 rural counties. Over 500,000 individuals enrolled in LIHP during the first program year were included in the analysis. Preference for communication in a language other than English was used as a proxy for LEP status. Chronic conditions included diabetes, asthma and chronic obstructive pulmonary disease, cardiovascular disease and congestive heart failure, dyslipidemia, and hypertension. LEP, sex, age, federal poverty level, county and a chronic condition indicator were predictors of inpatient, emergency room (ER), and outpatient evaluation and management (E&M) utilization using logistic regression models.

Results: Compared to non-LEP enrollees, LEP enrollees were more likely to be female, over the age of 55, and have a diagnosis of diabetes, dyslipidemia, or hypertension. Over 30% of LIHP enrollees with a chronic condition were LEP, with 70% of LEP enrollees preferring Spanish, 23% preferring Asian American languages, and 7% preferring another language. Those with chronic conditions had higher rates of E&M, ER, and inpatient visits. However, those with LEP and chronic conditions had a significantly higher likelihood of E&M visits (OR=1.5) than non- LEP (OR=1.1), after controlling for potential confounders. In contrast, those with LEP and chronic conditions had a lower likelihood of ER (0.6 vs. 0.7) and inpatient (0.6 vs. 0.7) visits.

Conclusions: Higher E&M use and lower use of ER and inpatient care among chronically ill and LEP LIHP enrollees may be due to better culturally competent primary care visits which in turn contributed to lower use of more costly emergency and inpatient services. The effectiveness of care delivery under the Medicaid expansion and Health Benefit Exchange programs may be improved with additional effort to improve delivery of culturally concordant care management.