Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act

Socioeconomic/health-related factors associated with HPV vaccination initiation/completion among females of paediatric age: A systematic review with meta-analysis

Objectives

To systematically identify, appraise, and summarise published evidence on individual socioeconomic and health-related factors associated with human papillomavirus (HPV) vaccination initiation and completion among females of paediatric age.

Study design

A global systematic review with meta-analysis (PROSPERO: CRD42023445721).

Methods

We performed a literature search in December 2022 and supplemented the search on August 1, 2023. Appropriate data were pooled using an inverse variance, random-effects model and the results were expressed as odds ratios, with 95 % confidence intervals. A statistically significant point pooled increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥70 % was very strongly associated.

Results

We included 83 cross-sectional studies. Among several significantly associated factors, being an older girl: 1.67 (1.44-1.93), having health insurance: 1.41 (1.16-1.72), and being in a public school: 1.54 (1.05-2.26) strongly increased the odds of vaccination initiation, and nativity in the country of study: 1.82 (1.33-2.50), use of contraception: 2.00 (1.16-3.46), receipt of influenza vaccination: 1.75 (1.54-2.00) and having visited a healthcare provider: 1.85 (1.51-2.28) in the preceding year very strongly increased the odds of vaccination initiation. Likewise, being an older girl: 1.36 (1.23-1.49) and having visited a healthcare provider in the preceding year: 1.46 (1.05-2.04) strongly increased the odds of vaccination series completion, and school-based vaccination: 3.08 (1.05-9.07), having health insurance: 1.72 (1.27-2.33), and receipt of influenza vaccination in the preceding year: 1.72 (1.62-1.83) very strongly increased the odds of vaccination series completion. We made similar observations when the studies were limited to the United States.

Conclusions

Several individual socioeconomic/health-related factors may determine initiating and completing the HPV vaccination series among paediatric females. These factors provide insights that may be key to identifying girls at increased risk of not being vaccinated and may aid targeted public health messaging.

Closing Gaps or Holding Steady? The Affordable Care Act, Medicaid Expansion, and Racial Disparities in Coverage, 2010-2021

CONTEXT

Medicaid expansion under the Affordable Care Act (ACA) produced major gains in coverage. However, findings on racial and ethnic disparities are mixed and may depend on how disparities are measured. This study examines absolute and relative changes in uninsurance from 2010 to 2021 by race and ethnicity, stratified by Medicaid expansion status.

METHODS

The sample included all respondents younger than age 65 (N = 30,339,104) from the American Community Survey, 2010-21. Absolute and relative differences in uninsurance, compared to white Non-Hispanic individuals, were calculated for individuals who were Hispanic; Black; Asian American, Pacific Islander, and Native Hawaiian (AANHPI); American Indian and Alaska Native (AIAN); and multiracial. States were stratified into ever-expanded versus nonexpansion status.

FINDINGS

After the ACA, three patterns of coverage disparities emerge. For Hispanic and Black individuals, relative to white individuals, absolute disparities in uninsurance declined, but relative disparities were largely unchanged in both expansion and nonexpansion states. For AANHPI individuals, disparities were eliminated entirely in both expansion and nonexpansion states. For AIAN individuals, disparities declined in absolute terms but grew in relative terms, particularly in expansion states.

CONCLUSIONS

All groups experienced coverage gains after the ACA, but changes in disparities were heterogeneous. Focused interventions are needed to improve coverage rates for Black, Hispanic, and AIAN individuals.

The American Rescue Plan Act and Access to Health Care for Latinos According to Citizenship Status

OBJECTIVE

We studied patterns in health care access between Latino and non-Latino White adults according to citizenship status before and after the American Rescue Plan Act (ARPA) of 2021 was enacted to determine whether inequities changed.

METHODS

This study used 2019-2022 National Health Survey Interview data. Differences in predicted probabilities from logistic regression models were used to estimate changes in health care access outcomes (any insurance coverage, private insurance coverage, delaying care due to cost, and having a usual source of care) among Latino citizens, Latino noncitizens, and non-Latino White citizens in periods before and after ARPA's enactment (2019-2020 vs 2021-2022).

RESULTS

Adjusted models observed that inequities in health care access did not change between Latino and non-Latino White citizens from the 2019-2020 period to the 2021-2022 period. Moreover, the health insurance gap widened by 5.8 percentage points between Latino noncitizens and non-Latino White citizens ( P < 0.01) and by 5.2 percentage points between Latino noncitizens and Latino citizens ( P < 0.05) from the 2019-2020 period to the 2021-2022 period. The private insurance coverage gap widened by 6.8 percentage points between Latino noncitizens and non-Latino White citizens ( P < 0.01) and by 6.9 percentage points between Latino noncitizens and Latino citizens ( P < 0.01) from the 2019-2020 period to the 2021-2022 period.

CONCLUSION

ARPA may have helped increase White citizens' insurance coverage, but this benefit did not extend to Latinos, regardless of citizenship status. Developing more inclusive health policies that do not have restrictions based on citizenship and legal authorization status is an important step toward reducing health care inequities.

Implications of the initial Braidwood v. Becerra ruling for colorectal cancer outcomes: a modeling study

The Affordable Care Act (ACA) eliminated patient cost-sharing for United States Preventive Service Task Force (USPSTF) recommended services. However, if the US Court of Appeals for the Fifth Circuit fully upheld a US District Court ruling in Braidwood Management v. Becerra, 666 F. Supp. 3d 613 (N.D. Tex 2023), cost-sharing for USPSTF recommendations made after ACA passage would have been reinstated for more than 150 million people. The case would have reinstated cost-sharing for colorectal cancer (CRC) screening for ages 45-49 years and for polyp removal during (diagnostic) colonoscopy across all ages. Using the MISCAN-Colon model, we simulated the potential impact on CRC outcomes, assuming early-onset CRC trends and lower screening participation. An 8-percentage-point decline in screening participation could increase CRC incidence by 5.1% and CRC mortality by 9.1%, with slightly lower costs due to increased cost-sharing. Larger decreases in screening participation can result in higher costs from increased incidence and delayed diagnoses.

Do Patients of Different Levels of Affluence Receive Different Care for Pediatric Osteosarcomas? One Institution's Experience

BACKGROUND

The published reports examining socioeconomic factors and their relationship to osteosarcoma presentation and treatment suggest an association between lower socioeconomic status and a worse response to chemotherapy and lower survivorship. However, the driving factors behind these disparities are unclear. The Child Opportunity Index was developed by diversitydatakids.org ( https://www.diversitydatakids.org/ ) in 2014 to cumulatively quantify social determinants of health in an index specifically tailored toward a pediatric population and organized by census tract. The Childhood Opportunity Index can be used to explore the relationship between a patient's socioeconomic background and disparities in osteosarcoma presentation, treatment, and outcomes.

QUESTION/PURPOSES

Are differences in a child's Childhood Opportunity Index score associated with differences in (1) time from symptom onset to first office visit for osteosarcoma, (2) timing of chemotherapy or timing and type of surgical resection, or (3) initial disease severity, development of metastatic disease, or overall survival?

METHODS

A retrospective therapeutic study was conducted using data drawn from the institutional records of a large pediatric tertiary cancer center located in the Mid-Atlantic region of the United States from the years 2006 to 2022. Our main site is in an urban setting, with ample access to public transit. Patients were excluded from analysis if they were seeking a second opinion or our institution was not the main point of orthopaedic care (20% [45 of 223]). Of the remaining patients, those with incomplete electronic medical records (24% [43 of 178]), resided in an international country (5% [9 of 178]), presented after relapse (4% [8 of 178]), or lacked 2 years of follow-up at our institution (3% [5 of 178]) were excluded as well. A total of 113 pediatric patients (children younger than 18 years) met the inclusion criteria. The Child Opportunity Index is a composite index derived from three domains (education, health and environment, and social and economic) and 29 indicators within the domains that serve to capture the cumulative effect of disparities on child well-being. National Childhood Opportunity scores were collected and scored from 1 to 100. Each score represents an equal proportion of the US population of children 18 years of age or younger. A higher number indicates higher levels of socioeconomic opportunity. The overall Childhood Opportunity Index score was then broken down into three groups representative of the child's relative socioeconomic opportunity: lowest tertile for scores < 34, middle tertile for scores between 34 and 66, and highest tertile for scores > 66. Means, ranges, medians, IQRs, and percentages were used to describe the study sample. Data analysis was conducted across the three groups (lowest tertile, middle, and highest), assessing differences in time to presentation, treatment variations, disease severity, and overall survivorship. Chi-square and Fisher exact tests were applied to compare categorical variables. Mann-Whitney U tests compared continuous data. Kaplan-Meier survival analysis, stratified by Childhood Opportunity Index tertile, was performed for a 5-year period to evaluate the development of metastatic disease and overall survivorship. A log-rank test was applied to evaluate statistical significance. Due to the small sample size, we were unable to control potential confounders such as race and insurance. However, the three domains (education, health and environment, and social and economic) encapsulated by the Childhood Opportunity Index data indirectly account for disparities related to race and insurance status.

RESULTS

There was no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles for the interval between symptom onset and first office visit (mean ± SD lowest tertile 77 ± 67 days [95% confidence interval (CI) 60 to 94], middle tertile 69 ± 94 days [95% CI 50 to 89], and highest tertile 56 ± 58 days [95% CI 41 to 71]; p = 0.3). Similarly, we found no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles and the time elapsed from the first office visit to the first chemotherapy session (lowest tertile 19 ± 12 days [95% CI 12 to 26], middle 19 ± 14 days [95% CI 11 to 26], and highest 15 ± 9.7 days [95% CI 8.4 to 21]; p = 0.31), the time to surgical resection (lowest tertile 99 ± 35 days [95% CI 87 to 111], middle 88 ± 28 days [95% CI 77 to 99], and highest 102 ± 64 days [95% CI 86 to 118]; p = 0.24), or the type of surgical resection (limb-sparing versus amputation: 84% [21 of 25] in lowest tertile, 83% [24 of 29] in the middle tertile, and 81% [48 of 59] in the highest tertile received limb-sparing surgery; p = 0.52). Finally, we found no differences in terms of disease-free survival at 5 years (lowest tertile 27% [95% CI 7.8% to 43%], middle 44% [95% CI 23% to 59%], and highest 56% [95% CI 40% to 67%]; p = 0.22), overall survival (lowest 74% [95% CI 58% to 95%], middle 82% [95% CI 68% to 98%], and highest 64% [95% CI 52% to 78%]; p = 0.27), or in terms of survivorship of the cohort, excluding patients who presented with metastatic disease (lowest 84% [95% CI 68% to 100%], middle 91% [95% CI 80% to 100%], and highest 68% [95% CI 55% to 83%]; p = 0.10).

CONCLUSION

In our single-center retrospective study of 113 children who presented with osteosarcoma, we did not find an association between a patient's national socioeconomic opportunity and their time to presentation, chemotherapy treatment, time to and type of surgical resection, or disease-free and overall survival. Prior work has shown an association between socioeconomic background and disparities in osteosarcoma treatment. It is possible that these findings will be similar to those from other hospitals and geographic areas, but based on our findings, we believe that proximity to providers, access to public transit, and regional insurance policies may help diminish these disparities. Future multicenter studies are needed to further explore the role that regional variations and the aforementioned factors may play in osteosarcoma treatment to help inform the direction of public policy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Hepatitis B vaccination initiation and vaccination series completion: An in-depth systematic evidence review, with meta-analysis of associations with individual socioeconomic and health-related factors

BACKGROUND

Associations between hepatitis B vaccination and individual socioeconomic/health-related factors have not been summarised.

METHODS

We conducted a systematic review with meta-analysis (PROSPERO: CRD42023445721) wherein we grouped study populations into a paediatric population (<18-year-olds), community-dwelling adults (≥18-year-olds of average risk), persons at a higher risk of exposure, and persons with a chronic condition(s). We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model, with the pooled results expressed as odds ratios and associated 95% confidence intervals.

RESULTS

We included 83 cross-sectional studies. Thirty-nine studies reported on vaccination initiation, and 51 reported on vaccination series completion. In the paediatric population, being a child of an Asian versus White mother increased the odds of vaccination initiation, whereas a low versus high mother's socioeconomic status and birth in a health facility versus home birth increased the odds of vaccination series completion. In community-dwelling adults, there were increased odds of vaccination initiation with being younger, a White versus Black/Hispanic person, a health professional, higher education, HIV/hepatitis B screening, influenza vaccination in the past year, health insurance, and health care utilisation. There were increased odds of vaccination series completion with factors like initiation. In persons at a higher risk of exposure, older age, higher education, HIV/hepatitis B screening, influenza vaccination in the past year, being married/cohabiting, and training on infection increased the odds of vaccination initiation. In contrast, drug use, HIV/hepatitis B screening, being married/cohabiting, being female, being a current/former smoker, and having more health worker experience increased the odds of vaccination series completion. In persons with chronic condition(s), younger age was associated with increased odds of vaccination initiation, whereas higher education and being a health professional increased the odds of vaccination series completion.

CONCLUSIONS

Several individual socioeconomic and health-related factors may influence hepatitis B vaccination, particularly in community-dwelling adults and persons at higher risk of exposure. Our findings may inform targeted messaging to optimise hepatitis B vaccination.

Healthcare access barriers and utilization among the Arab Bedouin population in Israel: a cross-sectional study

BACKGROUND

The Arab Bedouin Muslim minority in Israel, is one of the country's most vulnerable groups. They are residents of the Israeli geographical and social periphery. Bedouin's healthcare service utilization is shaped by its sociocultural and environmental characteristics. This study explores healthcare access barriers and utilization patterns among the Arab Bedouin population, focusing on two types of legal status locality: a legally recognized Bedouin town and the surrounding unrecognized villages.

METHODS

We conducted a cross-sectional study among Arab Bedouin adults (N = 246) residing in a Bedouin recognized town and unrecognized villages. Using an anonymous, self-administered questionnaire in Arabic. We collected information about healthcare visits, types of services accessed, access barriers and the factors influencing healthcare-seeking behavior. Multivariate linear regression was conducted to examine the predictors of healthcare services utilization.

RESULTS

Of the 246 participants, 60% resided in a recognized Bedouin town and 40% resided in unrecognized villages. Most participants were female (61%) and the mean age was 37.8 ± 13.9 years. The findings showed that barriers to seeking care differed based on the residence town's legal status. While residents of unrecognized villages face significant physical access barriers, they also show a notable reliance on cross-border healthcare providers, particularly in the Palestinian Authority. Chronic medical conditions (B = 1.147, p < 0.001), gender (B = -0.459, p < 0.01), and parental status (B = 0.667, p = 0.001) have been identified as strong predictors of healthcare service utilization.

CONCLUSION

This study offers new insights regarding the complexity of healthcare access and utilization in the Arab Bedouin population in Israel, emphasizing that barriers are not only structural but also deeply intertwined with cultural and linguistic factors. The study highlights the universal message of addressing both physical and systemic barriers to healthcare access, ensuring that healthcare services are culturally and linguistically tailored to the specific needs of marginalized populations locally and globally. These findings provide actionable insights for policymakers emphasizing the need to improve health equity by addressing the access barriers faced by the Arab Bedouin population, including structural, cultural, and linguistic challenges, and ensuring targeted interventions for marginalized communities both locally and globally.

Racial Disparities in Hospitalization Rates During Long-Term Follow-Up After Deceased-Donor Kidney Transplantation

OBJECTIVE

To compare hospitalization rates between African American (AA) and European American (EA) deceased-donor (DD) kidney transplant (KT) recipients during over a10-year period.

METHOD

Data from the Scientific Registry of Transplant Recipients and social determinants of health (SDoH), measured by the Social Deprivation Index, were used. Hospitalization rates were estimated for kidney recipients from AA and EA DDs who had one kidney transplanted into an AA and one into an EA, leading to four donor/recipient pairs (DRPs): AA/AA, AA/EA, EA/AA, and EA/EA. Poisson-Gamma models were fitted to assess post-transplant hospitalizations.

RESULT

Unadjusted hospitalization rates (95% confidence interval) were higher among all DRP involving AA, 131.1 (122.5, 140.3), 134.8 (126.3, 143.8), and 102.4 (98.9, 106.0) for AA/AA, AA/EA, and EA/AA, respectively, compared to 97.1 (93.7, 100.6) per 1000 post-transplant person-years for EA/EA pairs. Multivariable analysis showed u-shaped relationships across SDoH levels within each DRP, but findings varied depending on recipients' race, i.e., AA recipients in areas with the worst SDoH had higher hospitalization rates. However, EA recipients in areas with the best SDoH had higher hospitalization rates than their counterparts.

CONCLUSIONS

Relationship between healthcare utilization and SDoH depends on DRP, with higher hospitalization rates among AA recipients living in areas with the worst SDoH and among EA recipients in areas with the best SDoH profiles. SDoH plays an important role in driving disparities in hospitalizations after kidney transplantation.

Exploring social determinants of healthcare and cognition levels among diverse older adults

BACKGROUND

The purpose was to investigate the impact of social determinants of health on healthcare utilization among older adults in two cognition groups: normal and dementia/impaired cognition.

METHODS

We used cross-sectional data from the Health and Retirement Study (N = 16,339) to assess healthcare utilization: hospital stay, nursing home stay, hospice care, and doctor visits. The respondents were classified into two cognition groups using the Langa-Weir approach.

RESULTS

A cohort comparison between normal (mean age = 66.1) and dementia/impaired cognition (mean age = 71.9) groups revealed dementia/impaired group included more individuals from racial and ethnic minorities (42.7 % Black/Other, 20.8 % Hispanic) compared to the normal cognition (24.7 % Black/Other, 12.1 % Hispanic). They experienced longer hospital, nursing home, and hospice stays and varied doctor visit frequencies. These differences were influenced by race, age, marital status, education, and rurality.

CONCLUSION

Social determinants of health play an important role in predicting disparities in healthcare utilization among older adults across cognition levels.

Does Trust Mediate the Relationship Between Experiences of Discrimination and Health Care Access and Utilization Among Minoritized Canadians During COVID-19 Pandemic?

OBJECTIVES

We sought to determine if trust in government institutions mediate the relationship between experiences of discrimination and health care utilization during the COVID-19 pandemic.

METHODS

We used data from Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination. We used generalized linear latent and mixed models (Gllamm) with a binomial and logit link function as well as generalized structural equation modeling (GSEM) to determine if reported discrimination and trust were associated with difficulties in accessing health services, health care, and the likelihood of experiencing negative health impacts. We also examined if trust mediated the relationship between experiences of discrimination and these health outcomes. Our analytical sample consisted of 2568 individuals who self-identified as belonging to a visible minority group.

RESULTS

The multivariate results indicate that experiences of discrimination during COVID-19 were associated with higher odds of reporting difficulties in accessing general health services (OR = 1.99, p ≤ 0.01), receiving care (OR = 1.65, p ≤ 0.01), and higher likelihood of reporting negative health impacts (OR = 1.68, p ≤ 0.01). Our mediation analysis indicated that trust in public institutions explained a substantial portion of the association between reported discrimination and all the health outcomes, although the effects of experiencing discrimination remain significant and robust.

CONCLUSION

The findings show that building and maintaining trust is important and critical in a pandemic recovery world to build back better.

Racial and ethnic composition of peer recovery community members and barriers to acquiring funding for organizations in the ecosystem of recovery

INTRODUCTION

Organizations in the "ecosystem of recovery"-most often non-profits led and staffed by individuals with lived substance use disorder (SUD) experience-offer peer services, group counseling, and a wide variety of programs to help those struggling with SUD. The efforts of such organizations are effective in transitioning those suffering from SUD into long-term recovery. Despite well-established evidence depicting inequitable access to SUD treatment between BIPOC and non-Hispanic White Americans, there has been no empirical undertaking of whether organizations in the ecosystem of recovery face barriers to fund their operations based on the racial and ethnic composition of their community members.

METHODS

In this 2022 needs assessment, "Optimizing Recovery Funding," we combined the results of quantitative and qualitative data for a mixed methods analytic approach. The study employs bivariate descriptive statistics and inferences along with thematic analyses. From an initial list of 537 organizations across U.S. states and territories, 145 leaders of these organizations comprise our survey analytic sample. A total of 85 leaders participated in one of 16 focus groups, with 10 based on geography and 6 based on population identity. This needs assessment produced comprehensive data on the operations of organizations in the ecosystem of recovery.

RESULTS

A lack of training and existing organizational funding, as well as non-inclusive language in funding requests for proposals contributed to some organizations' decisions not to pursue certain grants and funding mechanisms. There were no statistical differences in applying for, nor success in receiving, federal and state funding between organizations serving predominantly BIPOC community members and those serving mostly non-Hispanic White community members. However, there were key instances of-at times inexplicable-inequity in funding outcomes.

CONCLUSIONS

All leaders of organizations in the ecosystem of recovery who participated in the needs assessment made it clear that there are fundamental issues to accessing peer recovery operational and programmatic funding. Innovative strategies for developing inclusive and culturally responsive funding approaches that prioritize organizations predominantly serving historically marginalized communities are needed.

Assessing Between- and Within-Hospital Differences in Patient Safety Between Medicaid and Privately Insured Hospital Patients

OBJECTIVES

The aims of the study are to investigate differences in rates of adverse safety events between nonelderly adult patients with Medicaid and those with private insurance and to assess whether differences are driven by differences in access to quality hospitals or differences in the quality of care delivered within hospitals.

DATA SOURCE

Inpatient records from 26 states in 2017 were collected from the Agency for Health Care Research and Quality's Hospital Cost and Utilization Project.

STUDY DESIGN

This study measures differences in 11 patient safety indicators between patients with Medicaid coverage and patients with private insurance coverage. I use regression analysis to investigate differences in adverse safety events within hospitals. I further establish hospital-level quality based on overall rates of adverse safety events and use regression analysis to evaluate the difference in the probability of admission to high-quality hospitals.

DATA COLLECTION/EXTRACTION

This study uses hospital discharge data that is restricted to adults ages 19-64 with Medicaid or private coverage.

PRINCIPAL FINDINGS

Relative to privately insured patients, Medicaid patients had significantly higher rates of adverse safety events on 8 of 11 patient safety indicators, including on 6 of 7 surgery-related patient safety indicators. Medicaid patients experience respiratory failure and sepsis infections at rates that are 2.9 and 2.5 cases per 1000 greater than rates experienced by privately insured patients. After adjusting for demographic characteristics, patient diagnostic classifications and comorbidities, and geographic factors, 6 of 11 differences in patient safety indicators remained large and statistically significant. These differences were unchanged when further including hospital indicators, indicating that Medicaid and privately insured patients receive different quality of care within hospitals. There is little association between overall hospital quality and differences in the probability of admission between Medicaid and privately covered patients.

CONCLUSIONS

Medicaid patients received lower quality of care, based on patient safety metrics, relative to privately insured patients within the same hospitals. Reducing payer disparities in adverse safety events requires reforming staffing and treatment patterns for Medicaid and privately insured patients within hospitals.

STUDY DATE AND LOCATION

Analysis for this study was conducted in 2023 at the Urban Institute and at Loyola University Chicago.

Racial and ethnic disparities in treatment refusal for head and neck cutaneous malignancies

Racial and ethnic minorities with skin cancer experience disproportionately worse prognoses and adverse outcomes compared to non-Hispanic, White patients. We analyzed patients diagnosed with any cutaneous malignancies of the head and neck between 2010 to 2021 using the data from the National Cancer Database to quantify disparities. The primary outcome variable was treatment refusal, and secondary variables included days from diagnosis to treatment, tumor depth, and mortality. Among the 151,733 patients analyzed, most were non-Hispanic White (99%) and male (71%). Black patients had the greatest odds of treatment refusal (4.166, 95% CI: 2.054-8.452, p < 0.001) across all cutaneous malignancies of the head and neck. Black and Hispanic patients also had increased times from diagnosis to treatment (p < 0.001). Black patients had higher odds of 90-day mortality compared to non-Hispanic White patients (p < 0.001). This coincided with greater tumor depth in Black and Hispanic patients compared to that of non-Hispanic White patients (p < 0.001). Black patients were more likely to refuse treatment for head and neck cutaneous malignancies. Moreover, Black and Hispanic patients experienced more treatment delays. These findings may relate to the increased 90-day mortality among Black patients and increased tumor depth in Black and Hispanic patients. Further investigation into the quality of life and functional impairment is warranted alongside interventions to reduce these disparities.

Healthcare Expenditures Among Older Immigrants in the United States With Alzheimer's Disease and Related Dementias: Population-Based Study Between 2007 and 2020

OBJECTIVES

Using nationally representative data sets, this study examined differences in healthcare expenditures between U.S.-born and foreign-born individuals aged 65 and above by the presence of Alzheimer's disease and related dementias (ADRD) and cognitive limitations (CL). This study further examined whether healthcare expenditures among foreign-born individuals vary by their duration of residence in the United States.

METHODS

The study used the 2007-2020 Medical Expenditure Panel Survey and employed generalized linear regression models to estimate differences in healthcare expenditures between U.S.-born and foreign-born older adults with ADRD, CL, and without ADRD or CL. Survey weights were applied to all estimates.

RESULTS

Our study identified significant differences in healthcare expenditures among older adults by the presence of ADRD/CL and immigrant status. Having ADRD/CL had a more pronounced impact on high healthcare expenditures among foreign-born older adults than U.S.-born adults with ADRD/CL, thereby diminishing the difference in healthcare expenditures by U.S. nativity status for the older adults with ADRD or CL. In the analysis further distinguishing immigrants by their duration of residence, lower healthcare expenditures were primarily observed among foreign-born individuals with ADRD or CL who had lived in the United States for less than 10 years.

DISCUSSION

Our results suggest potential shifts in costs resulting from delayed access to, and diagnosis or treatment of ADRD at a younger age, leading to increased healthcare needs and expenses among U.S. foreign-born older adults.

Community Health Center Penetration and Kidney Care Outcomes among Low-Income, Nonelderly Adults with Kidney Failure

Key Points

Populations who experience health disparities often rely on community health centers (CHCs) for ambulatory care. Among low-income populations, higher CHC penetration is associated with greater preparedness for, and better outcomes after, kidney failure onset. Our study suggests that CHCs provide essential ambulatory care for nonelderly adults who experience kidney health disparities.

Background

In the United States, historically minoritized populations experience disproportionately high incidence of progressive kidney disease but are often unprepared for kidney failure. Owing to limited options for health care, many minoritized patients with kidney disease rely on community health centers (CHCs) for affordable ambulatory care.

Methods

We conducted a retrospective cohort study of 139,275 adults aged 18–64 years who were enrolled in Medicaid or uninsured at the time of ESKD onset during 2016–2020. We examined whether CHC penetration of the state-level low-income population was associated with ESKD incidence, process measures reflective of pre-ESKD care quality, and survival and kidney transplant waitlisting 1 year after ESKD onset. We obtained population characteristics of the 1370 Health Resources and Services Administration CHCs and 50 states (and DC) for the same period.

Results

Mean CHC penetration among low-income residents (percentage of low-income residents who were CHC patients in each state) was 36% (SD, 19%). The Northeast (census region) had the highest proportion of states with high CHC penetration, and the South had the highest proportion of states with low CHC penetration. The prevalence of diabetes mellitus, high BP, and obesity were lower in states with high versus low CHC penetration. There were no significant differences in age- and sex-standardized ESKD incidence according to CHC penetration. In individual-level analyses, higher CHC penetration was significantly associated with a higher likelihood of prolonged nephrology care (adjusted odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03 to 1.05]), arteriovenous fistula or graft usage at hemodialysis initiation (OR, 1.11 [95% CI, 1.09 to 1.12]), home dialysis usage (OR, 1.04 [95% CI, 1.02 to 1.05]), and 1-year kidney transplant waitlisting (OR, 1.19 [95% CI, 1.18 to 1.21]) and ESKD survival (OR, 1.06 [95% CI, 1.04 to 1.07]).

Conclusions

Among Medicaid enrollees and uninsured adults with incident kidney failure, higher CHC penetration was associated with a lower prevalence of kidney disease risk factors and better preparedness for, and higher survival after, ESKD onset. These findings warrant additional study into the role and effect of CHCs in addressing long-standing disparities in kidney health.

Delayed Healthcare Due to Cost Among Adults with Multimorbidity in the United States

BACKGROUND/OBJECTIVES

Multimorbidity, defined as two or more chronic diseases co-occurring in an individual, has been linked to elevated healthcare utilization and out-of-pocket expenses. Yet, the barriers to healthcare access due to the health profile of multimorbid adults are underexplored. This study investigates the differences in delayed healthcare due to cost among adults with multimorbidity and those with one chronic disease condition.

METHODS

Data from the National Health Interview Survey from the years 2016-2018 and 2020-2021 were examined. The sample included 13,439 adults with at least one of the chronic disease conditions outlined by the US Department of Health and Human Services. Logistic regression models were used to estimate odd ratios of delayed healthcare due to cost among participants.

RESULTS

Multimorbid adults were 1.29 times more likely to delay healthcare compared to adults living with one chronic disease (p < 0.01). Other influencing factors include being female, Asian, unmarried, uninsured, age, worsening self-rated health, region, and poverty threshold of 100-199%.

CONCLUSIONS

Our findings highlight the disparities in healthcare success experienced by adults living with multimorbidity and indicate the need for policymakers to implement targeted measures such as subsidized costs for comorbidities to alleviate the financial burdens experienced by this population.

Headache Disorders in VHA Primary Care: Prevalence, Psychiatric Comorbidity, and Health Care Utilization

Military veterans are at increased risk for headache disorders compared to the general population, yet the prevalence and burden associated with headache disorders among veterans is not yet well understood. In this electronic medical record study, we examined the prevalence of headache disorders among veterans seen in a northeastern network of Veterans Health Administration (VHA) primary care during 2017-2018. We also examined rates of psychiatric comorbidity and health care utilization of veterans with headache disorders for the year following the date of the first headache code in the medical record. Of the total population of veterans in the network, 1.3% had a headache disorder and another 3.5% had a possible headache disorder. Migraine and chronic migraine represented the majority of cases. Posttraumatic stress disorder was the most frequent psychiatric comorbidity. Having a headache disorder was associated with higher rates of primary care, neurology, pain clinic, and mental health service use but not higher rates of emergency department or Whole Health (e.g., patient-centered, holistic health services) use. Prevalence findings are comparable to those previously found among veterans, but a substantial proportion of veterans may have been misdiagnosed. Veterans with headache disorders have high rates of psychiatric comorbidity and use several types of health services at higher rates. Findings highlight the need for interdisciplinary care and further education and support for primary care providers. Primary care settings that integrate evidence-based behavioral and Whole Health services may be an optimal way of providing more holistic care for headache disorders.

Insights from a COVID-era health needs assessment of rural Midwestern Latinos

Latino health and well-being are crucial to the growth and vibrancy of rural areas across the United States, particularly at a time when the demographics of many rural communities are transitioning from minority Latino to majority Latino populations. This manuscript details the findings of a study that explored the health and healthcare benefit status of 524 Latino households in rural Indiana during the COVID-19 pandemic. Via 20-minute, door-to-door interviews conducted by bilingual researchers, survey participants answered questions about access to healthcare services and benefits, dietary and safety habits, medical issues, and vaccination status. The study found that slightly more than half of those surveyed were enrolled in healthcare benefit plans; approximately a third were unsatisfied with their health/health status; almost two-thirds had not received a flu shot and were eating fast food/processed food on a daily basis. Top health concerns reported included: stress (52%), vision problems (34%), neck and back pain (30%), headaches/migraines (28%), anxiety and depression (28%) and weight problems (26%). The study also discovered that half of the respondents could not identify a primary healthcare provider (PCP) by name and that pregnant women faced a lack of resources for maternal health in the county where the study was conducted. The results indicate that Latinos in rural communities continue to endure significant health issues and barriers to healthcare. The study provides an excellent model of how a rural community can monitor the health of its residents, which can inform health interventions for underserved populations.

Exploration of individual socioeconomic and health-related characteristics associated with human papillomavirus vaccination initiation and vaccination series completion among adult females: A comprehensive systematic evidence review with meta-analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination rates among females are lower than the World Health Organization target and vaccination rates specifically among adult females are even much lower.

METHODS

We systematically evaluated individual socioeconomic and health-related characteristics associated with HPV vaccination initiation and vaccination series completion among adult females (PROSPERO: CRD42023445721). We performed a literature search on December 14, 2022, and supplemented the search on August 1, 2023. We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model and expressed the results as odds ratios with associated 95 % confidence intervals. A point pooled significantly increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥ 70 % was very strongly associated.

RESULTS

We included 63 cross-sectional studies. There were strongly increased odds of vaccination initiation among White women compared with Black or Asian women, and those with higher education, health insurance, a history of sexually transmitted infection (STI), receipt of influenza vaccination in the preceding year, not married/cohabiting, not smoking, using contraception, and having visited a healthcare provider in the preceding year. We observed very strongly increased odds of vaccination initiation among those younger and having been born in the country of study. Similarly, there were strongly increased odds of completing the vaccination series for the same variables as initiating vaccination, except for higher education, prior STI, smoking and contraception use. Additional variables associated with strongly increased odds of vaccination series completion not seen in initiation were higher annual household income, being lesbian/bisexual, and having a primary care physician. We observed very strongly increased odds of vaccination series completion similar to vaccination initiation but including for White compared with Black women, higher education, and prior cervical cancer screening.

CONCLUSIONS

These individual characteristics may be the key to identifying women at increased risk of not being vaccinated against HPV and could inform targeted messaging to drive HPV vaccination.

Racial/Ethnic Disparities in HRQoL and Associated Risk Factors in Colorectal Cancer Survivors: With a Focus on Social Determinants of Health (SDOH)

PURPOSE

This study aimed to understand how health-related quality of life (HRQoL) differs by race/ethnicity in colorectal (CRC) survivors. We aimed to 1) examine racial/ethnic disparities in HRQoL, and 2) explore the roles of social determinants of health (SDOH) risk factors for HRQoL differ by racial/ethnic groups.

METHODS

In 2,492 adult CRC survivors using Behavioral Risk Factor Surveillance System (BRFSS) survey data (from 2014 to 2021, excluding 2015 due to the absence of CRC data), we used the Centers for Disease Control and Prevention (CDC) HRQoL measure, categorized into "better" and "poor." Multivariate logistic regressions with prevalence risk (PR) were employed for our primary analyses.

RESULTS

Compared with non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB) (PR = 0.61, p = .045) and Hispanics (PR = 0.32, p < .001) reported worse HRQoL in adjusted models. In adjusted models, unemployed/retired and low-income levels were common risk factors for worse HRQoL across all comparison groups (NHW, NHB, non-Hispanic other races, and Hispanics). Other SDOH associated with worse HRQoL include divorced/widowed/never married marital status (non-Hispanic other races and Hispanics), living in rural areas (NHW and NHB), and low education levels (NHB and Hispanics). Marital status, education, and employment status significantly interacted with race/ethnicity, with the strongest interaction between Hispanics and education (PR = 2.45, p = .045) in adjusted models.

CONCLUSION

These findings highlight the need for culturally tailored interventions targeting modifiable factors (e.g., social and financial supports, health literacy), specifically for socially vulnerable CRC survivors, to address the disparities in HRQoL among different racial/ethnic groups.

International Medical Graduates and the Physician Workforce

Importance

Physician shortages and the geographic maldistribution of general and specialist physicians impair health care delivery and worsen health inequity in the US. International medical graduates (IMGs) represent a potential solution given their ready supply.

Observations

Despite extensive clinical experience, evidence of competence, and willingness to practice in underserved communities, IMGs experience multiple barriers to entry in the US, including the immigration process, the pathways available for certification and licensing, and institutional reluctance to consider non-US-trained candidates. International medical graduates applying to postgraduate training programs compare favorably with US-trained candidates in terms of clinical experience, prior formal postgraduate training, and research, but have higher application withdrawal rates and significantly lower residency and fellowship match rates, a disparity that may be exacerbated by the recent elimination of objective performance metrics, such as the US Medical Licensing Examination Step 1 score. Once legally in the US, IMGs encounter additional obstacles to board eligibility, research funding, and career progression.

Conclusions and Relevance

International medical graduates offer a viable and available solution to bridge the domestic physician supply gap, while improving workforce diversity and meaningfully addressing the public health implications of geographic maldistribution of general and specialist physicians, without disrupting existing physician stature and salaries. The US remains unable to integrate IMGs until systematic policy changes at the national level are implemented.

Racial Concordance on Healthcare Use within Hispanic Population Subgroups

OBJECTIVE

To examine the association of patient-provider racial and ethnic concordance on healthcare use within Hispanic ethnic subgroups.

METHODS

We estimate multivariate probit models using data from the Medical Expenditure Panel Survey, the only national data source measuring how patients use and pay for medical care, health insurance, and out-of-pocket spending. We collect and utilize data on preventive care visits, visits for new health problems, and visits for ongoing health problems from survey years 2007-2017 to measure health outcomes. Additionally, we include data on race and ethnicity concordance, non-health-related socioeconomic and demographic factors, health-related characteristics, provider communication characteristics, and provider location characteristics in the analysis. The sample includes 59,158 observations: 74.3% identified as Mexican, 10.6% identified as Puerto Rican, 5.1% identified as Cuban, 4.8% identified as Dominican, and 5.2% classified in the survey as Other Hispanics. Foreign-born respondents comprised 56% of the sample. A total of 8% (4678) of cases in the sample involved Hispanic provider-patient concordance.

RESULTS

Hispanic patient-provider concordance is statistically significant and positively associated with higher probabilities of seeking preventive care (coef=.211, P<.001), seeking care for a new problem (coef=.208, P<.001), and seeking care for an ongoing problem (coef=.208, P<.001). We also find that the association is not equal across the Hispanic subgroups. The association is lowest for Mexicans in preventive care (coef=.165, P<.001) and new problems (coef=.165, P<.001) and highest for Cubans in preventive care (coef=.256, P<.001) and ongoing problems (coef=.284, P<.001). Results are robust to the interaction of the Hispanic patient-provider concordance for the Hispanic patient categories and being foreign-born.

CONCLUSIONS

In summary, racial disparities were observed in health utilization within Hispanic subgroups. While Hispanic patient-provider concordance is statistically significant in associating with healthcare utilization, the findings indicate that this association varies across Hispanic subpopulations. The observations suggest the importance of disaggregating Hispanic racial and ethnic categories into more similar cultural or origin groups. Linked with the existence of significant differences in mortality and other health outcomes across Hispanic subgroups, our results have implications for the design of community health promotion activities which should take these differences into account. Studies or community health programs which utilize generalized findings about Hispanic populations overlook differences across subgroups which may be crucial in promoting healthcare utilization.

National Estimates of Incremental Work Absenteeism Costs Associated With Adult Children of Parents With Alzheimer's Disease and Related Dementias

OBJECTIVE

More than half of primary caregivers for ADRD patients are adult children, yet there is little empirical evidence on how caring for parents with ADRD affects their employment. Using a nationally representative dataset, this study aimed to estimate incremental work absenteeism costs for adult children of parents with ADRD.

DESIGN, SETTING, AND PARTICIPANTS

The study used the data from the 2015-2021 Medical Expenditure Panel Survey (MEPS). Multivariate regressions and two-part models were employed to estimate the incremental work absenteeism costs among adult children aged 40 to 64 who had at least one parent diagnosed with ADRD, compared with those who did not have ADRD parents.

MEASUREMENTS

The incremental work absenteeism costs due to caregiving for adult children with ADRD parents was a cumulated estimation of labor productivity cost at three stages: (1) the likelihood of not working due to unemployment, (2) the likelihood of missing any workdays for caregiving, and (3) the number of workdays missed due to caregiving.

RESULTS

Adult children with ADRD parents were more likely to be unemployed (OR = 1.80, p = 0.024) and 2.95 times more likely to miss work for caregiving (p = 0.002) than those with non-ADRD parents. The difference in the number of workdays missed for caregiving between children with and without ADRD parents was not significant. The incremental effects of having ADRD parents were estimated to be $4,510.29 ($1,702.09-$6,723.69) per person per year.

CONCLUSIONS

Having ADRD parents significantly increases the chances of unemployment and missing any workdays for caregiving, leading to higher lost labor productivity costs for adult children with ADRD parents.

Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Compare disparities in lumbar surgical care utilization in Commercially insured versus Medicare patients.

SUMMARY OF BACKGROUND DATA

While disparities in spinal surgery have been previously described, less evidence exists on effective strategies to mitigate them. Theoretically, universal health care coverage under Medicare should improve health care access.

MATERIALS AND METHODS

Utilizing National Inpatient Sample data (2003-2018), we included inpatient lumbar discectomy or laminectomy/fusion cases in black, white, or Hispanic patients aged 18-74 years, with Commercial or Medicare insurance. A multivariable Poisson distribution model determined race/ethnicity subgroup-specific rate ratios (RRs) of patients undergoing lumbar surgery compared to their respective population distribution (using US Census data) based on race/ethnicity, region, gender, primary payor, and age (Commercially insured age subgroups: 18-39, 40-54, and 55-64 y; Medicare age subgroup: 65-74 y).

RESULTS

Of the 2,310,956 lumbar spine procedures included, 88.9%, 6.1%, and 5.0% represented white, black, and Hispanic patients, respectively. Among Commercially insured patients, black and Hispanic (compared to white) patients had lower rates of surgical care utilization; however, these disparities decreased with increasing age: black (RR=0.37, 95% CI: 0.37-0.38) and Hispanic patients (RR=0.53, 95% CI: 0.52-0.54) aged 18-39 years versus black (RR=0.72, 95% CI: 0.71-0.73) and Hispanic patients (RR=0.64, 95% CI: 0.63-0.65) aged 55-64 years. Racial/ethnic disparities persisted in Medicare patients, especially when compared to the neighboring age subgroup that was Commercially insured: black (RR=0.61, 95% CI: 0.60-0.62) and Hispanic patients (RR=0.61, 95% CI: 0.60-0.61) under Medicare.

CONCLUSIONS

Disparities in surgical care utilization among black and Hispanic patients persist regardless of health care coverage, and an expansion of Medicare eligibility alone may not comprehensively address health care disparities.

LEVEL OF EVIDENCE

Level III.

Effects of Affordable Care Act on uninsured hospitalization: Evidence from Texas

OBJECTIVE

To examine the impact of the Affordable Care Act (ACA) health insurance exchanges (Marketplace) on the rate of uninsured discharges in Texas.

DATA SOURCE AND STUDY SETTING

Secondary discharge data from 2011 to 2019 from Texas.

STUDY DESIGN

We conducted a retrospective study estimating the effects of the ACA Marketplace using difference-in-difference regressions, with the main outcome being the uninsured discharge rate. We stratified our sample by patient's race, age, gender, urbanicity, major diagnostic categories (MDC), and emergent type of admissions.

DATA COLLECTION/EXTRACTION METHODS

We used Texas hospital discharge records for non-elderly adults collected by the state of Texas and included acute care hospitals who reported data from 2011 to 2019.

PRINCIPAL FINDINGS

The expansion of insurance through ACA Marketplaces led to reductions in the uninsured discharge rate by 9.9% (95% CI, -17.5%, -2.3%) relative to the baseline mean. The effects of the ACA were felt strongest in counties with any share of Hispanic, in counties with a larger population of Black, and other racial groups, in counties with a significant share of female and older age individuals, in counties considered to be urban, in high-volume diagnoses, and emergent type of admissions.

CONCLUSIONS

These findings indicate that the ACA facilitated a shift in hospital payor mix from uninsured to insured.

Social Determinants of Health and Healthcare Utilization Disparities among Older Adults with and Without Cognitive Impairment

The purpose of this study was to determine the healthcare utilization patterns in a national sample of older adults across several social determinants of health factors (ethnicity, gender, race, education) with normal and dementia/impaired cognition. We used datasets from the Health and Retirement Study (HRS, 2018) to evaluate healthcare utilization, including metrics such as hospital and nursing home stays, hospice care, and number of visits to the doctor. Logistic models were used to predict healthcare utilization separately in those with normal cognition and dementia. Our final sample comprised 15,607 adults (mean age: 65.2 normal cognition, mean age 71.5 dementia). Hispanics with normal cognition were less likely to stay in a hospital than non-Hispanic respondents (OR: 0.52-0.71, p<0.01). Being female was associated with a higher risk for shorter nursing home days (OR: 1.41, p<0.01) and doctor visits (OR: 1.63-2, p<0.01) in cognitively normal older adults. Being female was associated with a lower risk for hospital stay in those with dementia (OR: 0.50-0.78, p<0.01). Respondents identifying as Black or other races with dementia were less likely to experience nursing home days (OR: 0.42, p<0.04). Black respondents with normal cognition were less likely to experience doctor visits (OR: 0.32-0.37, p<0.01). Those with more than a high school education in both groups were more likely to experience doctors' visits. The study points to the continued disparities in healthcare utilization linked to participants' social determinants of health factors and cognition.

Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease: Development of a Situation-Specific Theory for African American Emerging Adults

BACKGROUND

Emerging adulthood (18-25 years old) is a distinct developmental period in which multiple life transitions pose barriers to engaging in healthy lifestyle behaviors that reduce cardiovascular disease risk. There is limited theory-based research on African American emerging adults.

OBJECTIVE

This article introduces a synthesized empirically testable situation-specific theory for cardiovascular disease prevention in African American emerging adults.

METHODOLOGY

Im and Meleis' integrative approach was used to develop the situation-specific theory.

RESULTS

Unlocking Population-Specific Treatments to Render Equitable Approach and Management in Cardiovascular Disease is a situation-specific theory developed based on theoretical and empirical evidence and theorists' research and clinical practice experiences.

DISCUSSION

African American emerging adults have multifaceted factors that influence health behaviors and healthcare needs. Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease has the potential to inform theory-guided clinical practice and nursing research. Recommendations for integration in nursing practice, research, and policy advocacy are presented. Further critique and testing of the theory are required.

Performance of the Modified Caregiver Strain Index in a Sample of Black and White Persons Living With Dementia and Their Caregivers

BACKGROUND AND OBJECTIVES

This study examined the performance of the Modified Caregiver Strain Index (MCSI) in a sample of Black and White caregivers of persons living with dementia.

RESEARCH DESIGN AND METHODS

Data on 153 dyads enrolled in the Care Ecosystem dementia care management program were analyzed, including sociodemographic variables, dementia severity, and caregiver burden and wellbeing. Factor structure, item-response patterns, and concurrent validity were assessed across racial groups.

RESULTS

Differences between Black and White caregivers included gender, dyad relation, and socioeconomic disadvantage. Factor structure and item loadings varied by racial cohort, with parameters supporting a 3-factor model. For Black caregivers, finances and work, emotional and physical strain, and family and personal adjustment items loaded together on individual factors. For White caregivers physical and emotional strain items loaded on separate factors, although personal and family adjustment items loaded with work and financial strain items. Item-level analysis revealed differences between groups, with Black caregivers endorsing physical strain to a greater degree (p = .003). Total MCSI scores were positively correlated with concurrent measures like the PHQ-9 (White: r = 0.67, Black: r = 0.54) and the GAD-2 (White: r = 0.47, Black: r = 0.4), and negatively correlated with self-efficacy ratings (White: r = -0.54, Black: r = -0.55), with a p < .001 for all validity analysis.

DISCUSSION AND IMPLICATIONS

The MCSI displayed acceptable statistical performance for Black and White caregivers of persons living with dementia and displayed a factor structure sensitive to cultural variations of the construct. Researchers results highlight the inherent complexity and the relevance of selecting inclusive measures to appropriately serve diverse populations.

Culturally and Linguistically Diverse Community Access and Utilisation of the Mental Health Service: An Explanation Using Andersen's Behavioural Model

Andersen's Behavioural Model of Health Service Use (ABMHSU) is a multilevel model that helps understand the factors influencing health service access and utilisation. This framework is a widely used model for health service use in general, as well as in immigrant populations and vulnerable populations. ABMHSU, in this project, provided a framework to explain how the mental health nurses' cultural competence can influence the Victorian CALD community members' mental health care access and utilisation. A unique model of ABMHSU in the current multiple-method project provided a theoretical framework for examining the factors associated with people from the CALD community accessing mental health services in an Australian context to answer the research questions. The key findings of the research were discussed with reference to the extant literature and with triangulation of research results with the ABMHSU in the context of Victoria. The researchers argue that even though predisposing, enabling, and need factors are necessary to determine whether a person is selected for expert care for mental health issues, these factors alone are insufficient. Ongoing research is essential to ascertain the potential of mental health nurses' cultural competence education and cultural responsiveness in addressing the mental health service access and utilisation of the heterogeneous CALD communities. Additional research is advocated to identify the supplementary factors, as there is a dearth of research exploring the potential of ABMHSU worldwide.

Healthcare Disparities Among Older Adults: Exploring Social Determinants of Health and Cognition Levels

Background

The purpose was to investigate the impact of sociodemographic factors on healthcare utilization among adults with different cognition levels (normal and impairment/dementia).

Methods

We used cross-sectional data from the Health and Retirement Study (N=17,698) to assess healthcare utilization: hospital stay, nursing home stay, hospice care, and doctor visits.

Results

A cohort comparison between normal and dementia/impaired cognition groups revealed significant differences. The dementia/impaired group had lower education levels, higher single/widowed status, and more racial and ethnic minorities. They experienced longer hospital and nursing home stays, varied doctor visit frequencies, and had higher mean age, greater loneliness scores, and lower family social support scores. Differences in hospitalization, nursing home, hospice care, and doctor visits were influenced by factors such as race, age, marital status, education, and rurality.

Conclusion

There were disparities in healthcare utilization based on participants' characteristics and cognition levels, especially in terms of race/ethnicity, education, and rural location.

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Phenotyping Down syndrome: discovery and predictive modelling with electronic medical records

BACKGROUND

Individuals with Down syndrome (DS) have a heightened risk for various co-occurring health conditions, including congenital heart disease (CHD). In this two-part study, electronic medical records (EMRs) were leveraged to examine co-occurring health conditions among individuals with DS (Study 1) and to investigate health conditions linked to surgical intervention among DS cases with CHD (Study 2).

METHODS

De-identified EMRs were acquired from Vanderbilt University Medical Center and facilitated creating a cohort of N = 2282 DS cases (55% females), along with comparison groups for each study. In Study 1, DS cases were one-by-two sex and age matched with samples of case-controls and of individuals with other intellectual and developmental difficulties (IDDs). The phenome-disease association study (PheDAS) strategy was employed to reveal co-occurring health conditions in DS versus comparison groups, which were then ranked for how often they are discussed in relation to DS using the PubMed database and Novelty Finding Index. In Study 2, a subset of DS individuals with CHD [N = 1098 (48%)] were identified to create longitudinal data for N = 204 cases with surgical intervention (19%) versus 204 case-controls. Data were included in predictive models and assessed which model-based health conditions, when more prevalent, would increase the likelihood of surgical intervention.

RESULTS

In Study 1, relative to case-controls and those with other IDDs, co-occurring health conditions among individuals with DS were confirmed to include heart failure, pulmonary heart disease, atrioventricular block, heart transplant/surgery and primary pulmonary hypertension (circulatory); hypothyroidism (endocrine/metabolic); and speech and language disorder and Alzheimer's disease (neurological/mental). Findings also revealed more versus less prevalent co-occurring health conditions in individuals with DS when comparing with those with other IDDs. Findings with high Novelty Finding Index were abnormal electrocardiogram, non-rheumatic aortic valve disorders and heart failure (circulatory); acid-base balance disorder (endocrine/metabolism); and abnormal blood chemistry (symptoms). In Study 2, the predictive models revealed that among individuals with DS and CHD, presence of health conditions such as congestive heart failure (circulatory), valvular heart disease and cardiac shunt (congenital), and pleural effusion and pulmonary collapse (respiratory) were associated with increased likelihood of surgical intervention.

CONCLUSIONS

Research efforts using EMRs and rigorous statistical methods could shed light on the complexity in health profile among individuals with DS and other IDDs and motivate precision-care development.

Race and ethnicity are inadequate predictors of ambulatory visit length and utilization of preventive services

Health disparities can be experienced by any disadvantaged group who has limited access to healthcare or decreased quality of care. Quality of care can be measured by physician-patient communication measures such as length of visit, health outcomes, patient satisfaction, or by the services one receives such as screening or health education. This study aims to determine the relationship between length of physician-patient encounter, number of preventive services, ethnicity, and race. This study utilizes data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016. Visits with a single diagnosis were selected. Visits with the five most frequent diagnoses were selected by International Classification of Diseases, Ninth or Tenth Revision (ICD-9/ICD-10) classification. The primary outcome is time spent with a physician in minutes and the number of preventive services provided represented by the Preventive Service Index (PSI). Of 255,916 visits, non-white individuals made up 16.2% (95% Confidence Interval 15.9-16.4) while Latinos represented 13.4% (95%CI 13.2-13.6) of individuals. Multivariate analysis revealed minimal differences in visit length in race and ethnic groups regardless of diagnosis. Greater PSI was associated with individuals less than 43 years old (Odds Ratio (OR) 2.0, 95% CI 1.8-2.3, p =< 0.0001), those who reside in metropolitan statistical areas (MSAs) (OR 1.2, 95% CI 1.1-1.4, p = 0.006), non-white individuals (OR 1.2, 95% CI 1.1-1.3, p = 0.004), and those with private insurance (OR 1.3, 95% CI 1.1-1.4, p =< 0.0001). Race and ethnicity do not predict length of time with a physician regardless of diagnosis. Age, race, location within a metropolitan area, and insurance are significant but minimal predictors of receiving preventive services in the rank-order leading five most frequent diagnoses. This large, population-based study highlights improvements in the distribution of healthcare services from previous studies.

Causal machine learning for predicting treatment outcomes

Causal machine learning (ML) offers flexible, data-driven methods for predicting treatment outcomes including efficacy and toxicity, thereby supporting the assessment and safety of drugs. A key benefit of causal ML is that it allows for estimating individualized treatment effects, so that clinical decision-making can be personalized to individual patient profiles. Causal ML can be used in combination with both clinical trial data and real-world data, such as clinical registries and electronic health records, but caution is needed to avoid biased or incorrect predictions. In this Perspective, we discuss the benefits of causal ML (relative to traditional statistical or ML approaches) and outline the key components and steps. Finally, we provide recommendations for the reliable use of causal ML and effective translation into the clinic.

Feasibility and Acceptability of the Project Faith Influencing Transformation Intervention in Faith-Based Settings

African Americans (AAs) are disproportionately burdened with diabetes and prediabetes. Predominately AA churches may be optimal settings for reaching AAs at greatest diabetes risk, along with related morbidities and mortalities. The current study used the RE-AIM framework to qualitatively examine the feasibility, acceptability, and satisfaction with the Project Faith Influencing Transformation (FIT) intervention, a diabetes risk reduction intervention in AA churches. Participants were (N = 21) church and community members who also participated in the larger Project FIT intervention and were primarily female, with an average age of 60 years (SD = 11.1). Participants completed a brief survey and focus group discussion. Participants discussed intervention effectiveness in changing health behaviors and outcomes, with high rates of adoption, acceptability, and satisfaction across churches that conducted the intervention. Participants also discussed outreach to members of the broader community, the role of the pastor, and challenges to intervention implementation and maintenance-tailored strategies to improve intervention effectiveness are discussed. Given the significant diabetes disparities that exist for AAs, it is imperative to continue to investigate best practices for reaching communities served by churches with sustainable, relevant health programming. This study has the potential to inform more effective, tailored diabetes prevention interventions for high-risk AAs in faith-based settings.

Trends in Health Care Coverage and Out-Of-Pocket Cost Barriers: A Gender Comparison

Objective: The presence of disparities in access to health care and insurance coverage can have a tremendous impact on health care outcomes. Programs like the Affordable Care Act were implemented to improve health care access and to address the existing inequities. The objective of this study was to identify any disparities that exist between males and females regarding health care coverage and out-of-pocket cost to health care. Methods: This analysis was a cross-sectional study using the Behavioral Risk Factor Surveillance System survey data collected between 2013 and 2018. The primary predictor was sex assigned at birth (with the binary option of male vs. female). The primary outcome was adequate health coverage. Survey participants who indicated that they had health insurance with no out-of-pocket cost barriers to receiving medical care were considered to have adequate health coverage, while participants who did not meet these criteria were considered to have inadequate health coverage. Covariates measured were age, race/ethnicity, educational level, employment status, and annual household income. SAS survey procedures and weighting methods were used to measure the association between the sex and adequate health coverage, after controlling for covariates. Results: The data spanning 6 years included 2,249,749 adults, of whom 1,898,097 (84.4%) had adequate health coverage. Females made up 55.8% (N = 1,256,243) of the total sample. About 32.6% (N = 733,216) survey participants were aged ≥65 years. Most respondents, 77.6%, were White (Non-Hispanic). Across the 6-year period, females were more likely to have health insurance but with out-of-pocket costs that served as a barrier to their medical care (adjusted odds ratios with 95% CI from 2013 to 2018 were 1.36 [1.29-1.43], 1.38 [1.32-1.46], 1.31 [1.24-1.38], 1.33 [1.26-1.40], and 1.32 [1.25-1.40], respectively). Conclusions: Females were more likely than males to indicate an out-of-pocket cost barrier to medical care despite having health insurance.

Examining Health-Seeking Behavior among Diverse Ethnic Subgroups within Black Populations in the United States and Canada: A Cross-Sectional Study

The Black populations, often treated as ethnically homogenous, face a constant challenge in accessing and utilizing healthcare services. This study examines the intra-group differences in health-seeking behavior among diverse ethnic subgroups within Black communities. A cross-sectional analysis included 239 adults ≥18 years of age who self-identified as Black in the United States and Canada. Multiple logistic regression assessed the relationship between health-seeking behaviors and ethnic origin, controlling for selected social and health-related factors. The mean age of the participants was 38.6 years, 31% were male, and 20% were unemployed. Sixty-one percent reported a very good or excellent health status, and 59.7% were not receiving treatment for chronic conditions. Advancing age (OR = 1.05, CI: 1.01-1.09), female gender (OR = 3.09, CI: 1.47-6.47), and unemployment (OR = 3.46, CI: 1.35-8.90) were associated with favorable health-seeking behaviors. Compared with the participants with graduate degrees, individuals with high school diplomas or less (OR = 3.80, CI: 1.07-13.4) and bachelor's degrees (OR = 3.57, CI: 1.3-9.23) were more inclined to have engaged in favorable health-seeking behavior compared to those with graduate degrees. Across the Black communities in our sample, irrespective of ethnic origins or country of birth, determinants of health-seeking behavior were age, gender, employment status, and educational attainment.

Trends in sleep duration in the U.S. from 2004 to 2018: A decomposition analysis

Average sleep duration in the United States declined in recent years, and the decline may be linked with many biopsychosocial factors. We examine how a set of biopsychosocial factors have differentially contributed to the temporal trends in self-reported sleep duration across racial groups between 2004-2005 and 2017-2018. Using repeated nationally representative cross-sections from the National Health Interview Survey, we decompose the influence of biopsychosocial factors on sleep duration trends into two components. One component corresponds to coefficient changes (i.e., changes in the associations between behaviors or exposures and sleep duration) of key biopsychosocial factors, and the other part accounts for the compositional changes (i.e., changes in the distributions of exposures) in these biopsychosocial factors during the study period. We reveal that changes in the coefficients of some biopsychosocial factors are more important than compositional changes in explaining the decline in sleep duration within each racial/ethnic group. Our findings highlight racial differences manifest across multiple biopsychosocial domains that are shifting in terms of association and composition. Methodologically, we note that the standard regression approach for analyzing temporal trends neglects the role of coefficient changes over time and is thus insufficient for fully capturing how biopsychosocial factors may have influenced the temporal patterns in sleep duration and related health outcomes.

Medicaid Expansion and Racial-Ethnic and Sex Disparities in Cardiovascular Diseases Over 6 Years: A Generalized Synthetic Control Approach

BACKGROUND

Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex.

METHODS

Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasi-experimental approach, to estimate effects.

RESULTS

Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19).

CONCLUSIONS

Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates.

Impact of the Affordable Health Care Act (ACA) on Racial/Ethnic Inequities in Access to and Utilization of Healthcare in New York City

The Affordable Care Act (ACA) expanded health insurance coverage in the USA, but whether it increased healthcare utilization or reduced racial/ethnic inequities in access to and utilization of care is unclear. We evaluated the ACA impact on health insurance coverage, unmet medical need, and having a personal doctor and whether this impact was modified by racial/ethnic identity among New York City (NYC) residents. We used data from multiple years of the Community Health Survey (2009-2017) and used logistic regression to assess whether having health insurance, unmet medical need, or a personal doctor varied pre- (2009-2012) versus post-ACA (2013-2017), adjusting for age, sex, nativity status, and general health. We assessed effect measure modification by race/ethnicity and stratified if we found significant interaction. We found that health insurance coverage and having a personal doctor increased post-ACA (aOR = 1.44, p < 0.001 and aOR = 1.09, p = 0.024, respectively) while having unmet medical need decreased (aOR = 0.90, p = 0.004). There was little indication of interaction between ACA and race/ethnicity; in stratified models, the ACA had a stronger impact on health insurance coverage for those of other race than all other groups (aOR = 2.16, p = 0.002 versus aOR 1.22-1.54 for white, Black, and Hispanic adults) and a stronger impact on having a personal doctor for Hispanic adults (aOR 1.27, p < 0.001 versus weaker non-significant associations for other groups), with no effect modification for unmet medical need. Thus, it appears that ACA improved healthcare access and utilization but did not have a major impact on reducing racial/ethnic inequities in these outcomes in NYC.

"It's Not That We Care Less": Insights into Health Care Utilization for Comorbid Diabetes and Depression among Latinos

Despite robust knowledge regarding the socio-economic and cultural factors affecting Latino* access to healthcare, limited research has explored service utilization in the context of comorbid conditions like diabetes and depression. This qualitative study, embedded in a larger mixed-methods project, aimed to investigate perceptions held by Latinos and their social support systems (i.e., family members) regarding comorbid diabetes and depression and to identify barriers and facilitators to their help-seeking behaviors and treatment engagement. Bilingual and bicultural researchers conducted eight focus groups with 94 participants in a large U.S. metropolitan area and were primarily conducted in Spanish. The participants either had a diagnosis of diabetes and depression or were closely associated with someone who did. This study identified key individual and structural barriers and facilitators affecting healthcare access and treatment for Latinos living with comorbid diagnoses. A thematic analysis revealed structural barriers to healthcare access, including financial burdens and navigating healthcare institutions. Personal barriers included fears, personal responsibility, and negative family dynamics. Facilitators included accessible information, family support, and spirituality. These findings underscore the need to address these multi-level factors and for healthcare institutions and providers to actively involve Hispanic community members in developing services and interventions.

Eliminating health care inequities through strengthening access to care

OBJECTIVE

To provide a research agenda and recommendations to address inequities in access to health care.

DATA SOURCES AND STUDY SETTING

The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government.

STUDY DESIGN

Multi-stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations.

DATA COLLECTION/EXTRACTION METHODS

Through a stakeholder-engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased.

PRINCIPAL FINDINGS

The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti-racist practices (e.g., co-production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access.

CONCLUSIONS

AHRQ is well-positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations.

Discrepancies in Race and Ethnicity in the Electronic Health Record Compared to Self-report

OBJECTIVE

Racial and ethnic disparities are commonplace in health care. Research often relies on sociodemographic information recorded in the electronic health record (EHR). Little evidence is available about the accuracy of EHR-recorded sociodemographic information, and none in pediatrics. Our objective was to determine the accuracy of EHR-recorded race and ethnicity compared to self-report.

METHODS

Patients/guardians enrolled in two prospective observational studies (10/2014-1/2019) provided self-reported sociodemographic information. Corresponding EHR information was abstracted. EHR information was compared to self-report, considered "gold standard." Agreement was evaluated with Cohen's kappa.

RESULTS

A total of 503 patients (42% female, median age 12.8 years) were identified. Self-reported race (N = 484) was 73% White, 16% Black or African American (AA), 4% Asian, 5% multiracial, and 2% other. Self-reported ethnicity (N = 410) was 9% Hispanic/Latino, and 88% non-Hispanic/Latino. Agreement between self-reported and EHR-recorded race was substantial (kappa = 0.77, 95% CI 0.72-0.83). Race was discordant among 10% (47/476). Hispanic/Latino ethnicity also had strong agreement (kappa = 0.77, 95% CI 0.65-0.89). Among those who self-reported Hispanic/Latino and reported race (N = 21), race was less accurately recorded in the EHR (kappa = 0.26, 95% CI 0-0.54). Race did not match among 43% with recorded race (9/21). Among self-reported racial and/or ethnic minorities, 13% (12/164) were misclassified in the EHR as non-Hispanic White.

CONCLUSIONS

We found race and ethnicity are often inaccurately recorded in the EHR for patients who self-identify as minorities, leading to under-representation of minorities in the EHR. Inaccurately recorded race and ethnicity has important implications for disparity research, and for informing health policy. Reliable processes are needed to incorporate self-reported race and ethnicity in the EHR at institutional and national levels.

Association of the affordable care act with racial and ethnic disparities in uninsured emergency department utilization

BACKGROUND

Disparities in uninsured emergency department (ED) use are well documented. However, a comprehensive analysis evaluating how the Affordable Care Act (ACA) may have reduced racial and ethnic disparities is lacking. The goal was to assess the association of the ACA with racial and ethnic disparities in uninsured ED use.

METHODS

This study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for Georgia, Florida, Massachusetts, and New York from 2011 to 2017. Participants include non-elderly adults between 18 and 64 years old. Outcomes include uninsured rates of ED visits by racial and ethnic groups and stratified by medical urgency using the New York University ED algorithm. Visits were aggregated to year-quarter ED visits per 100,000 population and stratified for non-Hispanic White, non-Hispanic Black, and Hispanic non-elderly adults. Quasi-experimental difference-in-differences and triple differences regression analyses to identify the effect of the ACA and the separate effect of the Medicaid expansion were used comparing uninsured ED visits by race and ethnicity groups pre-post ACA.

RESULTS

The ACA was associated with a 14% reduction in the rate of uninsured ED visits per 100,000 population (from 10,258 pre-ACA to 8,877 ED visits per 100,000 population post-ACA) overall. The non-Hispanic Black compared to non-Hispanic White disparity decreased by 12.4% (-275.1 ED visits per 100,000) post-ACA. About 60% of the decline in the Black-White disparity was attributed to disproportionate declines in ED visit rates for conditions classified as not-emergent (-93.2 ED visits per 100,000), and primary care treatable/preventable (-64.1 ED visits per 100,000), while the disparity in ED visit rates for injuries and not preventable conditions also declined (-106.57 ED visits per 100,000). All reductions in disparities were driven by the Medicaid expansion. No significant decrease in Hispanic-White disparity was observed.

CONCLUSIONS

The ACA was associated with fewer uninsured ED visits and reduced the Black-White ED disparity, driven mostly by a reduction in less emergent ED visits after the ACA in Medicaid expansion states. Disparities between Hispanic and non-Hispanic White adults did not decline after the ACA. Despite the positive momentum of declining disparities in uninsured ED visits, disparities, especially among Black people, remain.

Black Moms Matter: A Qualitative Approach to Understanding Barriers to Service Utilization at a Children's Advocacy Center Following Childhood Abuse

Black families are significantly less likely to receive evidence-based trauma treatment services; however, little is known about factors impacting engagement, particularly at Children's Advocacy Centers (CACs). The goal of this study is to better understand barriers and facilitators of service utilization for Black caregivers of CAC referred youth. Participants (n = 15) were randomly selected Black maternal caregivers (ages 26-42) recruited from a pool of individuals who were referred to receive CAC services. Black maternal caregivers reported barriers to accessing services at CACs including a lack of assistance and information in the referral and onboarding process, transportation issues, childcare, employment hours, system mistrust, stigma associated with the service system, and outside stressors such as stressors related to parenting. Maternal caregivers also shared suggestions for improving services at CACs including increasing the length, breadth, and clarity of investigations conducted by child protection services and law enforcement (LE) agencies, providing case management services, and having more diverse staff and discussing racial stressors. We conclude by identifying specific barriers to the initiation and engagement in services for Black families, and we provide suggestions for CACs seeking to improve engagement of Black families referred for trauma-related mental health services.

The Intersection of State-Level Immigrant Policy Climates and Medicaid Expansion: an Examination Among Immigrants

States have broad discretion over the implementation of policies like Medicaid expansion and other policies that impact the well-being and integration of immigrants. While numerous studies document Medicaid expansion on immigrants' health insurance coverage and the role of state immigrant policy climates on immigrants' well-being, no research to date has studied whether the association between a state's Medicaid expansion on immigrants' health insurance coverage varies based on the inclusiveness or exclusiveness of a state's immigrant policy climate. We combine nationally representative data from the 2014-2018 American Community Survey (ACS) with state policy data and estimate multivariate regression models. The results reveal a state immigrant policy climate gradient whereby ACA Medicaid expansion on noncitizens is negative and most severe in exclusionary climates. This study highlights how state policies intersect as important structural forces that influence immigrant health and well-being.

Impact of the First Year of the COVID-19 on Unmet Healthcare Need among New York City Adults: a Universal Healthcare Experiment

We examined the impact of the first year of the COVID-19 pandemic on unmet healthcare need among New Yorkers and potential differences by race/ethnicity and health insurance. Data from the Community Health Survey, collected in 2018, 2019, and 2020, were merged to compare unmet healthcare need within the past 12 months during the pandemic versus the 2 years prior to 2020. Univariate and multivariable logistic regression models evaluated change in unmet healthcare need overall, and we assessed whether race/ethnicity or health insurance status modified the association. Overall, 12% of New Yorkers (N = 27,660) experienced unmet healthcare during the 3-year period. In univariate and multivariable models, the first year of the pandemic (2020) was not associated with change in unmet healthcare need compared with 2018-2019 (OR = 1.04, p = 0.548; OR = 1.03, p = 0.699, respectively). There was no statistically significant interaction between calendar year and race/ethnicity, but there was significant interaction with health insurance status (interaction p = 0.009). Stratifying on health insurance status, those uninsured had borderline significant lower odds of experiencing unmet healthcare need during 2020 compared to the 2 years prior (OR = 0.72, p = 0.051) while those with insurance had a slight increase that was not significant (OR = 1.12, p = 0.143). Unmet healthcare need among New Yorkers during the first year of the pandemic did not differ significantly from 2018-2019. Federal pandemic relief funding, which offered no-cost COVID-19 testing and care to all, irrespective of health insurance or legal status, may have helped equalized access to healthcare.

Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States

BACKGROUND & AIMS

Liver disease is associated with substantial morbidity and mortality, likely incurring financial distress (i.e. healthcare affordability and accessibility issues), although long-term national-level data are limited.

METHODS

Using the National Health Interview Survey from 2004 to 2018, we categorised adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and Cox regression were used to assess the association of liver disease with financial distress and financial distress with all-cause mortality, respectively.

RESULTS

Among adults with liver disease (n = 19,407) vs. those without liver disease (n = 996,352), those with cancer history (n = 37,225), those with emphysema (n = 7,937), and those with coronary artery disease (n = 21,510), the age-adjusted proportion reporting healthcare affordability issues for medical services was 29.9% (95% CI 29.7-30.1%) vs. 18.1% (95% CI 18.0-18.3%), 26.5% (95% CI 26.3-26.7%), 42.2% (95% CI 42.1-42.4%), and 31.6% (31.5-31.8%), respectively, and for medications: 15.5% (95% CI 15.4-15.6%) vs. 8.2% (95% CI 8.1-8.3%), 14.8% (95% CI 14.7-14.9%), 26.1% (95% CI 26.0-26.2%), and 20.6% (95% CI 20.5-20.7%), respectively. In multivariable analysis, liver disease (vs. without liver disease, vs. cancer history, vs. emphysema, and vs. coronary artery disease) was associated with inability to afford medical services (adjusted odds ratio [aOR] 1.84, 95% CI 1.77-1.92; aOR 1.32, 95% CI 1.25-1.40; aOR 0.91, 95% CI 0.84-0.98; and aOR 1.11, 95% CI 1.04-1.19, respectively) and medications (aOR 1.92, 95% CI 1.82-2.03; aOR 1.24, 95% CI 1.14-1.33; aOR 0.81, 95% CI 0.74-0.90; and aOR 0.94, 95% CI 0.86-1.02, respectively), delays in medical care (aOR 1.77, 95% CI 1.69-1.87; aOR 1.14, 95% CI 1.06-1.22; aOR 0.88, 95% CI 0.79-0.97; and aOR 1.05, 95% CI 0.97-1.14, respectively), and not receiving the needed medical care (aOR 1.86, 95% CI 1.76-1.96; aOR 1.16, 95% CI 1.07-1.26; aOR 0.89, 95% CI 0.80-0.99; aOR 1.06, 95% CI 0.96-1.16, respectively). In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality (aHR 1.24, 95% CI 1.01-1.53).

CONCLUSIONS

Adults with liver disease face greater financial distress than adults without liver disease and adults with cancer history. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritised in this population.

IMPACT AND IMPLICATIONS

Adults with liver disease use many medical services, but long-term national studies regarding the financial repercussions and the effects on mortality for such patients are lacking. This study shows that adults with liver disease are more likely to face issues affording medical services and prescription medication, experience delays in medical care, and needing but not obtaining medical care owing to cost, compared with adults without liver disease, adults with cancer history, are equally likely as adults with coronary artery disease, and less likely than adults with emphysema-patients with liver disease who face these issues are at increased risk of death. This study provides the impetus for medical providers and policymakers to prioritise interventions to improve healthcare affordability for adults with liver disease.

Postpartum Medicaid coverage and outpatient care utilization among low-income birthing individuals in Oregon: impact of Medicaid expansion

Objective

This study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the postpartum period.

Methods

We linked Oregon birth certificates, Medicaid enrollment files, and claims to identify postpartum individuals (N = 73,669) who gave birth between 2011 and 2015. We created one pre-Medicaid expansion (2011-2012) and two post-expansion (2014-2015) cohorts (i.e., previously covered and newly covered by Medicaid). We used ordinary least squares and negative binomial regression models to examine changes in postpartum coverage duration and number of outpatient visits within a year of delivery for the post-expansion cohorts compared to the pre-expansion cohort. We examined monthly and overall changes in outpatient utilization during 0-2 months, 3-6 months, and 7-12 months after delivery.

Results

Postpartum coverage duration increased by 3.14 months and 2.78 months for the post-Medicaid expansion previously enrolled and newly enrolled cohorts (p < 0.001), respectively. Overall outpatient care utilization increased by 0.06, 0.19, and 0.34 visits per person for the previously covered cohort and 0.12, 0.13, and 0.26 visits per person for newly covered cohort during 0-2 months, 3-6 months, and 7-12 months, respectively. Monthly change in utilization increased by 0.006 (0-2 months) and 0.004 (3-6 months) visits per person for post-Medicaid previously enrolled cohort and decreased by 0.003 (0-2 months) and 0.02 (7-12 months) visits per person among newly enrolled cohort.

Conclusion

Medicaid expansion increased insurance coverage duration and outpatient care utilization during postpartum period in Oregon, potentially contributing to reductions in pregnancy-related mortality and morbidities among birthing individuals.