Dissertations and Theses
Date of Degree
6-3-2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy (Ph.D.)
Department
Community Health and Social Sciences
Advisor(s)
Mustafa Hussein
Committee Members
Onur Baser
Elliott Fisher
Ellesse-Roselee Akré
Neil Calman
Subject Categories
Public Health
Keywords
Medicaid; Racial Inequities; Ambulatory Care
Abstract
Regular preventive care in ambulatory care settings is associated with improved outcomes. However, past research finds that Medicaid beneficiaries of racialized groups, specifically identifying as Black or Hispanic, are more likely to receive care within safety-net care settings (hospital outpatient clinics, community health centers, and emergency departments) with worse outcomes compared to their White non-Hispanic counterparts. While there are various and complex factors that influence where patients receive outpatient care, understanding the extent to which different racial groups utilize different care settings has important health equity implications. Further controlling for known factors such as sociodemographics, neighborhood characteristics, and prior health needs further isolates the residual effects of structural racism that continue to operate within healthcare systems and perpetuate inequities for racialized groups.
This dissertation uses Medicaid TAF claims data to first assess the extent to which beneficiary racial identity (n=579,435) is associated with regular ambulatory care setting using linear probability models for beneficiaries across year. We build on these findings, using causal mediation analysis to assess the extent to which racial disparities in care settings translate into disparities in outcomes (having a Hemoglobin A1c, having an Eye Examination, All-Cause and Diabetes-Related Inpatient Admissions, and All-Cause and Diabetes-Related Emergency Department Visits) (n=542,850). Finally, we evaluate the extent of race-based sorting into specific ambulatory care settings following an inpatient admission (n=51,614) using linear probability models with fixed effect for hospital facility and month of inpatient admission.
We find racial disparities in the care settings beneficiaries use, with Black non-Hispanic and Hispanic individuals more likely to receive services at safety-net ambulatory care settings (by 19 and 14 percentage points, respectively). Mediation analysis shows that racial disparities in care settings have a small indirect effect, either enhancing or mitigating, the total racial disparity across six outcomes and racial groups. Community health centers consistently mitigate the total racial disparity across outcomes for Black NH and Hispanic beneficiaries. Finally, we find that Black NH and Hispanic beneficiaries continue to be more likely to visit a safety-net facility following an inpatient admission (3.6 and 2.6 percentage points, respectively) compared to White NH counterparts, after controlling for severity of index admissions, pre-admission regular ambulatory care settings, and other individual- and community-level drivers.
To our knowledge, this is the first study to use TAF claims to corroborate and provide nuance about findings in the literature linking race, care settings, and outcomes. Our findings support existing research showing racial disparities in where Medicaid beneficiaries receive ambulatory care. These patterns are consistent with a landscape in which higher-income, less Medicaid-dependent neighborhoods have more physician organizations and individual practices, while low-income, Medicaid-dense neighborhoods may utilize more on under-resourced safety-net facilities and are more dependent on Medicaid funding. This study contextualizes racial inequities within ambulatory care settings, which are influenced by structural factors and driven by historical disinvestments.
Recommended Citation
Chiofalo, Jacqueline, "Racial disparities in ambulatory care settings and outcomes: evidence among Medicaid beneficiaries with diabetes in three urban areas" (2026). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/129
