Utilization of essential preventive health services among Asians after the implementation of the preventive services provisions of the Affordable Care Act

Changes in Health Care Access and Preventive Health Screenings by Race and Ethnicity

Importance

The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity.

Objective

To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity.

Design, Setting, and Participants

This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023.

Main Outcomes and Measures

Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines.

Results

The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage).

Conclusions and Relevance

Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.

Variation in Receipt of Cancer Screening and Immunizations by 10-year Life Expectancy among U.S. Adults aged 65 or Older in 2019

IMPORTANCE

The likelihood of benefit from a preventive intervention in an older adult depends on its time-to-benefit and the adult's life expectancy. For example, the time-to-benefit from cancer screening is >10 years, so adults with <10-year life expectancy are unlikely to benefit.

OBJECTIVE

To examine receipt of screening for breast, prostate, or colorectal cancer and receipt of immunizations by 10-year life expectancy.

DESIGN

Analysis of 2019 National Health Interview Survey.

PARTICIPANTS

8,329 non-institutionalized adults >65 years seen by a healthcare professional in the past year, representing 46.9 million US adults.

MAIN MEASURES

Proportions of breast, prostate, and colorectal cancer screenings, and immunizations, were stratified by 10-year life expectancy, estimated using a validated mortality index. We used logistic regression to examine receipt of cancer screening and immunizations by life expectancy and sociodemographic factors.

KEY RESULTS

Overall, 54.7% of participants were female, 41.4% were >75 years, and 76.4% were non-Hispanic White. Overall, 71.5% reported being current with colorectal cancer screening, including 61.4% of those with <10-year life expectancy. Among women, 67.0% reported a screening mammogram in the past 2 years, including 42.8% with <10-year life expectancy. Among men, 56.8% reported prostate specific antigen screening in the past two years, including 48.3% with <10-year life expectancy. Reported receipt of immunizations varied from 72.0% for influenza, 68.8% for pneumococcus, 57.7% for tetanus, and 42.6% for shingles vaccination. Lower life expectancy was associated with decreased likelihood of cancer screening and shingles vaccination but with increased likelihood of pneumococcal vaccination.

CONCLUSIONS

Despite the long time-to-benefit from cancer screening, in 2019 many US adults age >65 with <10-year life expectancy reported undergoing cancer screening while many did not receive immunizations with a shorter time-to-benefit. Interventions to improve individualization of preventive care based on older adults' life expectancy may improve care of older adults.

Risk Factors Amenable to Primary Prevention of Type 2 Diabetes Among Disaggregated Racial and Ethnic Subgroups in the U.S

OBJECTIVE

Race and ethnicity data disaggregated into detailed subgroups may reveal pronounced heterogeneity in diabetes risk factors. We therefore used disaggregated data to examine the prevalence of type 2 diabetes risk factors related to lifestyle behaviors and barriers to preventive care among adults in the U.S.

RESEARCH DESIGN AND METHODS

We conducted a pooled cross-sectional study of 3,437,640 adults aged ≥18 years in the U.S. without diagnosed diabetes from the Behavioral Risk Factor Surveillance System (2013-2021). For self-reported race and ethnicity, the following categories were included: Hispanic (Cuban, Mexican, Puerto Rican, Other Hispanic), non-Hispanic (NH) American Indian/Alaska Native, NH Asian (Chinese, Filipino, Indian, Japanese, Korean, Vietnamese, Other Asian), NH Black, NH Pacific Islander (Guamanian/Chamorro, Native Hawaiian, Samoan, Other Pacific Islander), NH White, NH Multiracial, NH Other. Risk factors included current smoking, hypertension, overweight or obesity, physical inactivity, being uninsured, not having a primary care doctor, health care cost concerns, and no physical exam in the past 12 months.

RESULTS

Prevalence of hypertension, lifestyle factors, and barriers to preventive care showed substantial heterogeneity among both aggregated, self-identified racial and ethnic groups and disaggregated subgroups. For example, the prevalence of overweight or obesity ranged from 50.8% (95% CI 49.1-52.5) among Chinese adults to 79.8% (73.5-84.9) among Samoan adults. Prevalence of being uninsured among Hispanic subgroups ranged from 11.4% (10.9-11.9) among Puerto Rican adults to 33.0% (32.5-33.5) among Mexican adults.

CONCLUSIONS

These findings underscore the importance of using disaggregated race and ethnicity data to accurately characterize disparities in type 2 diabetes risk factors and access to care.

Racial and ethnic disparities in cervical and breast cancer screenings by nativity and length of U.S. residence

OBJECTIVE

Previous studies of disparities in breast and cervical cancer screenings have focused on broad racial/ethnic groups or nativity status without accounting for immigration histories. Recent theoretical work argues for using intersectional approaches and examining within-group inequalities. Utilizing multiple years of National Health Interview Survey (NHIS) data, we examined between- and within-group Papanicolaou (Pap) test and mammogram screening based on nativity and length of U.S. residence for Asian and Hispanic women, along with non-Hispanic Black and White women.

DESIGN

The study samples consist of 54,900 women ages 21-64 without a hysterectomy who responded to questions about Pap test screening and 36,300 women ages 40-64 who responded to questions about mammogram screening. Asian and Hispanic women were further stratified by nativity and, for immigrants, length of time in the United States. Logistic regression analysis was used to identify significant associations with Pap test and mammogram screenings.

RESULTS

Recent Asian and Hispanic immigrants had the lowest Pap test and mammogram rates among all other groups, while Black (and White women for mammograms) women had the highest rates. After accounting for age, marital status, health insurance, education, employment status, and income, both Asian groups had lower odds, and Black and all Hispanic groups had higher odds of Pap test screening compared with White women. Similar results were observed for mammogram screening, except that long-term immigrant/U.S.-born Asian and U.S.-born Hispanic women did not have significantly different odds compared with White women. In general, the strength and direction of most sociodemographic variables were similar across groups for Pap test screening but differed for mammogram screening.

CONCLUSIONS

The between-group differences identified emphasize the disparities in screening between racial/ethnic groups while the within-group differences suggest the need to examine whether more targeted outreach efforts and prevention messages can increase screening for specific groups.

US medical student perspectives on asian american patient inclusion in medical education: a qualitative Study

BACKGROUND

Asian American (AsAm) representation is lacking in conversations surrounding cultural humility in healthcare. We aimed to investigate US medical student perspectives on AsAm patient inclusion in cultural humility training in medical education.

METHODS

This qualitative study analyzed free-text responses to an optional, open-ended question presented at the conclusion of an online survey assessing medical student experiences with and perceptions regarding AsAm patients in their medical education. This survey was distributed to a convenience sample of nine US medical schools. Medical students who completed at least one clinical rotation were eligible to participate in the survey. Qualitative analysis of free-text responses was conducted in an iterative process to generate emergent themes.

RESULTS

There was a total of 195 optional free-text responses from 688 participants (28%). Motivation to learn about AsAm population included shared identity and desire to better serve the AsAm population in their local community and future careers. Topics of interest included healthcare-related cultural preferences, healthcare delivery strategies, and health disparities for the AsAm population and other minority patients. Students reported that they drew on personal experiences and some pre-clinical or clinical exposures to learn about AsAm patients. Respondents cited the lack of exposure in the medical school curriculum and clinical experiences as the main challenge to learning about AsAm health and provided suggestions for the delivery of this education in their pre-clinical and clinical education. Respondents emphasized that AsAms are treated as a monolith in medical education and healthcare, despite their heterogeneity.

CONCLUSIONS

Medical students identified a need and interest for greater inclusion of AsAm topics in medical education on cultural humility and minority health.

Trends in Differences Across Subgroups of Adults in Preventive Services Utilization

BACKGROUND

There were large differences across subgroups of adults in preventive services utilization before 2010. The Affordable Care Act had numerous provisions aimed at increasing utilization as well as at reducing disparities.

OBJECTIVE

This study examines whether preventive services utilization changed over time, across subgroups of adults defined by race/ethnicity, insurance coverage, poverty status, Census region, and urbanicity.

METHODS

Data from the Medical Expenditure Panel Survey Household Component are used to examine service utilization before the passage of the Affordable Care Act (2008/2009), after the implementation of the preventive services mandate and the dependent coverage provision (2012/2013), and after Medicaid expansions (2015/2016). Four preventive services are examined for adults aged 19-64-general checkups, blood cholesterol screening, mammograms, and colorectal cancer screening. Multivariate logistic regression models are used to predict preventive services utilization of adult subgroups in each time period, and to examine how differences across subgroups changed between 2008/2009 and 2015/2016.

RESULTS

There were modest increases in utilization between 2008/2009 and 2015/2016 for blood cholesterol and colorectal cancer screenings. For 3 of 4 preventive services, differences between the Northeast and the Midwest regions narrowed. However, large gaps in utilization across income groups and between those with and without coverage persisted. Disparities across racial/ethnic groups in general checkups persisted over time as well.

CONCLUSION

While some differences have narrowed, large gaps in preventive service utilization across population subgroups remain.

Inequities in Access to Care and Health Care Spending for Asian Americans With Cancer

BACKGROUND

Asian Americans have lower cancer screening rates than non-Latino "Whites," suggesting inequities in cancer prevention among Asian Americans. Little is known about inequities in cancer treatment between Whites and Asian Americans with cancer.

METHODS

Using the 2002-2017 Medical Expenditure Panel Survey, we examined inequities in access to care and health care spending between Whites and Asian Americans with and without cancer. Our outcomes included 3 measures of access to care and 3 measures of health care spending. We used multivariable regressions while adjusting for predisposing, enabling, and need factors and estimated the mean adjusted values of the outcomes for each group. We then examined the differences in these adjusted mean outcomes among Asian Americans relative to Whites.

RESULTS

We observed evidence of inequities that Asian Americans without cancer experienced limited access to care due to a lack of a usual source of care. The likelihood of having a usual source of care was lower among Asian Americans without cancer than Whites without cancer. Inequities were not observed among Asian Americans with cancer. Compared with Whites with cancer, Asian Americans with cancer had similar or better levels of access to care. No or marginal differences in health care spending were detected between Whites and Asian Americans with cancer. These findings were consistent in both nonelderly and elderly groups.

CONCLUSION

While Asian Americans without cancer have unmet medical needs due to limited access to care, access to care and spending are relatively equitable between Whites and Asian Americans with cancer.

Racial and ethnic patterns and differences in health care expenditures among Medicare beneficiaries with and without cognitive deficits or Alzheimer's disease and related dementias

BACKGROUND

Numerous studies have documented racial and ethnic differences in the prevalence and incidence of Alzheimer's disease and related dementias (ADRD). Less is known, however, about racial and ethnic differences in health care expenditures among older adults at risk for ADRD (cognitive deficits without ADRD) or with ADRD. In particular, there is limited evidence that racial and ethnic differences in health care expenditures change over the trajectory of ADRD or differ by types of service.

METHODS

We examined racial and ethnic patterns and differences in health care expenditures (total health care expenditures, out-of-pocket expenditures, and six service-specific expenditures) among Medicare beneficiaries without cognitive deficits, those with cognitive deficits without ADRD, and those with ADRD. Using the 1996-2017 Medical Expenditure Panel Survey, we performed multivariable regression models to estimate expenditure differences among racial and ethnic groups without cognitive deficits, those with cognitive deficits without ADRD, and those with ADRD. Models accounted for survey weights and adjusted for various demographic, socioeconomic, and health characteristics.

RESULTS

Black, Asians, and Latinos without cognitive deficits had lower total health care expenditures than whites without cognitive deficits ($10,236, $9497, $9597, and $11,541, respectively). There were no racial and ethnic differences in total health care expenditures among those with cognitive deficits without ADRD and those with ADRD. Across all three groups, however, Blacks, Asians, and Latinos consistently had lower out-of-pocket expenditures than whites (except for Asians with cognitive deficits without ADRD). Furthermore, service-specific health care expenditures varied by racial and ethnic groups.

CONCLUSIONS

Our study did not find significant racial and ethnic differences in total health care expenditures among Medicare beneficiaries with cognitive deficits and/or ADRD. However, we documented significant differences in out-of-pocket expenditures and service-specific expenditures. We speculated that the differences may be attributable to racial and ethnic differences in access to care and/or preferences based on family structure and cultural/economic factors. Particularly, heterogeneous patterns of service-specific expenditures by racial and ethnic groups underscore the importance of future research in identifying determinants leading to variations in service-specific expenditures among racial and ethnic groups.

The Importance of Health Insurance in Addressing Asian American Disparities in Utilization of Clinical Preventive Services: 12-Year Pooled Data from California

Purpose: Previous research has shown that Asian Americans are less likely to receive recommended clinical preventive services especially for cancer compared with non-Hispanic whites. Health insurance expansion has been recommended as a way to increase use of these preventive services. This study examines the extent to which utilization of preventive services by Asians overall and by ethnicity compared with non-Hispanic whites is moderated by health insurance. Methods: Data from the California Health Interview Survey (CHIS) was used to examine preventive service utilization among non-Hispanic whites, Asians, and Asian subgroups 50-64 years of age by insurance status. Six waves of CHIS data from 2001 to 2011 were combined to allow analysis of Asian subgroups. Logistic regression models were run to predict the effect of insurance on receipt of mammography, colorectal cancer (CRC) screening, and flu shots among Asians overall and by ethnicity compared with whites. Results: Privately insured Asians reported significantly lower adjusted rates of mammography (83.1% vs. 87.6%) and CRC screening (54.7% vs. 59.4%), and higher rates of influenza vaccination (48.7% vs. 38.5%) than privately insured non-Hispanic whites. Adjusted rates of cancer screening were lower among Koreans and Chinese for mammography, and lower among Filipinos for CRC screening. Conclusion: This study highlights the limitations of providing insurance coverage as a strategy to eliminate disparities for cancer screening among Asians without addressing cultural factors.

Insurance Coverage and Health Care Utilization Among Asian Youth Before and After the Affordable Care Act

OBJECTIVE

We examined changes in insurance coverage and health care utilization associated with the Affordable Care Act (ACA) among subgroups of Asian youth relative to non-Latino white youth.

METHODS

Data were from the 2010 to 2017 American Community Survey and National Health Interview Survey. Difference-in-difference models were used to examine changes in insurance coverage and health care utilization associated with the ACA among subgroups of Asian youth relative to white youth and subgroups of Asian youth in households below 200% of the federal poverty level relative to comparable white youth.

RESULTS

Since the implementation of the ACA, insurance coverage increased among all Asian subgroups and white youth. The magnitude of the increase in insurance coverage was larger among Asian subgroups than white youth. More pronounced increases were found among almost all Asian subgroups in households below 200% federal poverty level. Changes in health care utilization were limited and varied by subgroup. Increases in well-child visits were observed only among Chinese and "other" Asian youth.

CONCLUSIONS

Insurance coverage increased among Asian youth after the implementation of the ACA. Improvements in health care utilization were limited and differed by subgroups. Programs to improve health care utilization should be tailored to Asian youth according to subgroup.