Higher-income Adults Research Articles

Intersectional Analysis of Social Risk and Need Among a Large Representative Sample of Adults From an Integrated Health System in the U.S.

IntroductionSocial health is increasingly a focus of healthcare systems. Representative and intersectional analyses of individuals’ social risks such as food, housing, transportation, and financial insecurity, and their interest in receiving assistance from the healthcare system (social needs), can provide healthcare organizations with more nuanced estimates that can lead to more effective interventions. MethodsWe conducted cross-sectional survey of a representative sample of 43,936 Kaiser Permanente members in December 2019-September 2020. Study inclusion was based on membership, age, address, and absence of dementia. Modified Poisson regression models estimated respondents' social risks and needs overall and within domain (food, housing, finances, or transportation). and by intersectional strata based on a combination of age, income, gender, and race and ethnicity. ResultsOf 10,274 who completed the survey, 52% reported any social risk and 32% had any social need. Financial strain was the most prevalent risk (44%), followed by food insecurity (31%), housing instability (17%), and transportation (7%). Our intersectional analyses generated 74 intersectional groups. Across the intersectional groups, higher income (>$50,000/year) or older age (>60) adults consistently had lower risk and need. However, this pattern varied by race and ethnicity. In particular, older and lower-income, Pacific Islander, African-American/Black and Multiracial adults had the highest estimates of social risk and need. ConclusionsHigher risk and need among particular intersectional groups suggest the importance of tailored interventions for social needs. The high aggregate prevalence of social risks and needs suggests that system and policy changes must compliment universal and population-based social health screening and assistance interventions in healthcare organizations.

Age-related differences in delay discounting: Income matters.

Although the authors of a recent meta-analysis concluded there were no age-related differences in the discounting of delayed rewards, they did not examine the effects of income (Seaman et al., 2022). Accordingly, the present study compared discounting by younger and older adults (Ages 35-50 and 65-80) differing in household income. Two procedures were used: the Monetary Choice Questionnaire and the Adjusting-Amount procedure. Whereas no age difference was observed between the higher income (> $80,000) age groups, a significant difference was observed between younger and older adults with lower incomes (< $50,000): The younger adults discounted more steeply than the older adults. These findings, which were observed with both discounting procedures, support our buffering hypothesis, which assumes that the scarcity associated with a lower income is a stressor that can lead to steeper discounting, but that age-related increases in emotional stability can buffer such stressors, leading to age-related differences between lower income age groups. In contrast, no age difference was observed in higher income adults who experience much less scarcity. Further support for the buffering hypothesis comes from the finding that there was no age-related difference in discounting by the lower income groups when distress was statistically controlled. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Use Of High- And Low-Value Health Care Among US Adults, By Income, 2010-19.

Health care payment reforms in the US have aimed to encourage the use of high-value care while discouraging the use of low-value care. However, little is known about whether the use of high- and low-value care differs by income level. Using data from the 2010-19 Medical Expenditure Panel Survey, we examined the use of specified types of high- and low-value care by income level. We found that high-income adults were significantly more likely than low-income adults to use nearly all types of high-value care. Findings were consistent across age categories, although differences by income level in the use of high-value care were smaller among the elderly. Our analysis of differences in the use of low-value care had mixed results. Among nonelderly adults, significant differences between those with high and low incomes were found for five of nine low-value services, and among elderly adults, significant differences by income level were found for three of twelve low-value services. Understanding the mechanisms underlying these disparities is crucial to developing effective policies and interventions to ensure equitable access to high-value care and discourage low-value services for all patients, regardless of income.

Changes in Health Care and Prescription Medication Affordability in the US During the COVID-19 Pandemic

In the US, the COVID-19 pandemic led to a significant rise in unemployment and economic loss that disproportionately impacted low-income individuals. It is unknown how health care and prescription medication affordability changed among low-income adults during the COVID-19 pandemic overall and compared with their higher-income counterparts. To evaluate changes in health care affordability and prescription medication affordability during the COVID-19 pandemic (2021 and 2022) compared with pre-COVID-19 pandemic levels (2019) and whether income-based inequities changed. This retrospective cross-sectional study included adults 18 years and older participating in the National Health Interview Survey (NHIS) in 2019, 2021, and 2022. Low-income adults were defined as having a household income of 200% or less of the federal poverty level (FPL); middle-income adults, 201% to 400% of the FPL; and high-income adults, more than 400% of the FPL. Data were analyzed from June to November 2023. Measures of health care affordability and prescription medication affordability. The study population included 89 130 US adults. Among the weighted population, 51.6% (95% CI, 51.2-52.0) were female, and the mean (SD) age was 48.0 (0.12) years. Compared with prepandemic levels, during the COVID-19 pandemic, low-income adults were less likely to delay medical care (2022: 11.2%; 95% CI, 10.3-12.1; 2019: 15.4%; 95% CI, 14.3-16.4; adjusted relative risk [aRR], 0.73; 95% CI, 0.66-0.81) or avoid care (2022: 10.7%; 95% CI, 9.7-11.6; 2019: 14.9%; 95% CI, 13.8-15.9; aRR, 0.72; 95% CI, 0.64-0.80) due to cost, while high-income adults experienced no change, resulting in a significant improvement in income-based disparities. Low-income and high-income adults were less likely to experience problems paying medical bills but experienced no change in worrying about medical bills during the COVID-19 pandemic compared with prepandemic levels. Across measures of prescription medication affordability, low-income adults were less likely to delay medications (2022: 9.4%; 95% CI, 8.4-10.4; 2019: 12.7%; 95% CI, 11.6-13.9; aRR, 0.74; 95% CI, 0.65-0.84), not fill medications (2022: 8.9%; 95% CI, 8.1-9.8; 2019: 12.0%; 95% CI, 11.1-12.9; aRR, 0.75; 95% CI, 0.66-0.83), skip medications (2022: 6.7%; 95% CI, 5.9-7.6; 2019: 10.1%; 95% CI, 9.1-11.1; aRR, 0.67; 95% CI, 0.57-0.77), or take less medications (2022: 7.3%; 95% CI, 6.4-8.1; 2019: 11.2%; 95% CI, 10.%-12.2; aRR, 0.65; 95% CI, 0.56-0.74) due to costs, and these patterns were largely similar among high-income adults. Improvements in measures of health care and prescription medication affordability persisted even after accounting for changes in health insurance coverage and health care use. These patterns were similar when comparing measures of affordability in 2021 with 2019. Health care affordability improved for low-income adults during the COVID-19 pandemic, resulting in a narrowing of income-based disparities, while prescription medication affordability improved for all income groups. These findings suggest that the recent unwinding of COVID-19 pandemic-related safety-net policies may worsen health care affordability and widen existing income-based inequities.

Environmental-, Climate-, and Health-Related Dietary Motivations Are Associated With Higher Diet Quality in a National Sample of US Adults With Lower Incomes

BackgroundPlant-based diets can have co-benefits for human and planetary health. Associations between environmental, climate, and health concerns and dietary intake in US adults are understudied, particularly in underserved populations. ObjectiveThe study objectives were to assess how dietary choices motivated by the environment, climate, and health vary by sociodemographic characteristics and how they relate to diet quality and intake frequency of different food groups in US adults with lower incomes. DesignThe study design was cross-sectional. Participants/settingA web-based survey was fielded in December 2022 to 1,798 US adults with lower incomes (<250% of federal poverty guidelines). Main outcome measuresEnvironmental-, climate-, and health-related dietary motivations and diet quality and dietary food group intake frequency were assessed. Statistical analysesDifferences in mean dietary outcomes and dietary motivation ratings by sociodemographic characteristics were evaluated using analysis of variance and Kruskal–Wallis tests. Associations between dietary motivations and diet quality scores and dietary intake frequency were examined using generalized linear models adjusted for sociodemographic covariates. ResultsYounger adults, women, nonbinary people, racial and ethnic minoritized groups, and adults experiencing food insecurity reported higher environmental and climate dietary motivations; older adults, higher-income adults, and food-secure adults reported higher health motivations. Agreeing with environmental- (β = 2.28, 95% CI 1.09 to 3.47), climate- (β = 2.15, 95% CI 0.90 to 3.40), and health-related (β = 5.27, 95% CI 3.98 to 6.56) dietary motivations was associated with higher diet quality scores compared with those with neutral rankings. Similarly, agreement with environmental-, climate-, and health-related dietary motivations was associated with higher intake frequency of fish, fruits and vegetables, and plant proteins, but not with red and processed meat intake frequency. Of several climate-mitigation behaviors presented, participants perceived meat reduction as least effective (P < .001). ConclusionsEnvironment, climate, and health were positive motivators of several healthy dietary choices in US adults with lower incomes. Such motivators did not translate to lower intake frequency of red and processed meat.

Cardiovascular Health of Middle-Aged U.S. Adults by Income Level, 1999 to March 2020 : A Serial Cross-Sectional Study.

Although cardiovascular mortality has increased among middle-aged U.S. adults since 2011, how the burden of cardiovascular risk factors has changed for this population by income level over the past 2 decades is unknown. To evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health. Serial cross-sectional study. NHANES (National Health and Nutrition Examination Survey), 1999 to March 2020. Middle-aged adults (aged 40 to 64 years). Age-standardized prevalence of hypertension, diabetes, hyperlipidemia, obesity, and cigarette use; treatment rates for hypertension, diabetes, and hyperlipidemia; and rates of blood pressure, glycemic, and cholesterol control. The study population included 20 761 middle-aged adults. The prevalence of hypertension, diabetes, and cigarette use was consistently higher among low-income adults between 1999 and March 2020. Low-income adults had an increase in hypertension over the study period (37.2% [95% CI, 33.5% to 40.9%] to 44.7% [CI, 39.8% to 49.5%]) but no changes in diabetes or obesity. In contrast, higher-income adults did not have a change in hypertension but had increases in diabetes (7.8% [CI, 5.0% to 10.6%] to 14.9% [CI, 12.4% to 17.3%]) and obesity (33.0% [CI, 26.7% to 39.4%] to 44.0% [CI, 40.2% to 47.7%]). Cigarette use was high and stagnant among low-income adults (33.2% [CI, 28.4% to 38.0%] to 33.9% [CI, 29.6% to 38.3%]) but decreased among their higher-income counterparts (18.6% [CI, 13.5% to 23.7%] to 11.5% [CI, 8.7% to 14.3%]). Treatment and control rates for hypertension were unchanged in both groups (>80%), whereas diabetes treatment rates improved only among the higher-income group (58.4% [CI, 44.4% to 72.5%] to 77.4% [CI, 67.6% to 87.1%]). Income-based disparities in hypertension, diabetes, and cigarette use persisted in more recent years even after adjustment for insurance coverage, health care access, and food insecurity. Sample size limitations could preclude detection of small changes in treatment and control rates. Over 2 decades in the United States, hypertension increased in low-income middle-aged adults, whereas diabetes and obesity increased in their higher-income counterparts. Income-based disparities in hypertension, diabetes, and smoking persisted even after adjustment for other social determinants of health. National Institutes of Health.

Abstract 12487: Healthcare Access and Cardiovascular Risk Factor Management in Low-Income Working-Age Adults After the COVID-19 Pandemic

Background: Low-income working age adults disproportionately experienced disruptions in care and deepening financial hardship at the onset of the COVID-19 pandemic. Little is known about how health care access and cardiovascular (CV) risk factor management changed as the pandemic went on, and if these patterns differed by state Medicaid expansion status. Methods: We identified adults aged 18-64 using the CDC’s Behavioral Risk Factor Surveillance System. Low-income adults were defined as those with incomes &lt;138% of the federal poverty level (FPL), and high-income adults &gt;400% FPL. We fit logistic regression models to compare changes in measures of health care access and CV risk factor management in 2021 to a pre-pandemic baseline (2019), adjusted for age and sex. We included an interaction term for income level and year, to evaluate whether there was a differential change between low- and high-income adults. We also evaluated changes among low-income adults in Medicaid expansion vs. non-expansion states. Results: As shown in the Table , health insurance coverage, access to personal health care provider, and ability to afford care all improved in 2021 compared to pre-pandemic baseline (2019), although gains were more pronounced for high-income vs low-income groups. In contrast, the proportion of adults with a check-up in the past 12 months, or who received recommended cardiovascular risk factor screening, worsened in both low- and high-income groups. Among the low-income group, those in Medicaid expansion states experienced greater increases in insurance coverage than those in non-expansion states (OR 1.53 [1.40,1.68] vs 1.27 [1.11,1.46], p = 0.0283). Conclusion: In this national study, low- and high-income working-age adults experienced decreases in outpatient check-ups and CV risk factor screening in 2021 compared with pre-pandemic baseline. Public health initiatives are needed to improve screening for CV risk factor as the US emerges from the pandemic.

Abstract 15421: Cardiovascular Health of Middle-Aged US Adults by Income Level, 1999 to March 2020

Introduction: Cardiovascular mortality has increased among middle-aged US adults since 2011. Despite these alarming trends, it is unknown how the burden of cardiovascular risk factors has changed for this population by income level over the past two decades. Methods: We conducted a serial cross-sectional analysis of the NHANES to evaluate changes in the prevalence, treatment, and control of cardiovascular risk factors among low-income (&lt;200% federal poverty threshold) and higher-income middle-aged adults (ages 40-64) between 1999 and March 2020. Results: Among 20,761 middle-aged adults, the prevalence of hypertension, diabetes, and cigarette use was consistently higher among low-income adults between 1999 and March 2020. Low-income adults experienced a significant increase in hypertension (37.2% [95% CI: 33.5-40.9] to 44.7% [95% CI: 39.8-49.5]) over the study period, but no changes in diabetes or obesity. In contrast, higher-income adults did not experience a change in hypertension but had significant increases in diabetes (7.8% [5.0-10.6] to 14.9% [12.4-17.3]) and obesity (33.0% [26.7-39.4] to 44.0% [40.2-47.7]). Hyperlipidemia decreased in both groups. Cigarette use was high and stagnant among low-income adults (33.2% [28.4-38.0] to 33.9% [29.6-38.3]) but significantly decreased among their higher-income counterparts (18.6% [13.5-23.7] to 11.5% [8.7-14.3]). Income-based inequities in cardiovascular risk factors persisted in recent years even after adjustment for insurance coverage, health care access, and food insecurity. Treatment and control rates for hypertension were unchanged in both groups (&gt;80%), while diabetes treatment rates only improved among the higher-income group. Conclusions: The burden of several cardiovascular risk factors worsened among middle-aged adults (ages 40-64) over two decades with varying trends by income level. Income-based inequities in hypertension, diabetes, and smoking have not meaningfully narrowed.

Health Care Access and Cardiovascular Risk Factor Management Among Working-Age US Adults During the Pandemic.

Low-income working-age US adults disproportionately experienced health care disruptions at the onset of the coronavirus disease 2019 pandemic. Little is known about how health care access and cardiovascular risk factor management changed as the pandemic went on or if patterns differed by state Medicaid expansion status. Cross-sectional data from the behavioral risk factor surveillance system were used to compare self-reported measures of health care access and cardiovascular risk factor management among US adults aged 18 to 64 years in 2021 (pandemic) to 2019 (prepandemic) using multivariable Poisson regression models. We assessed differential changes between low-income (<138% federal poverty level) and high-income (>400% federal poverty level) working-age adults by including an interaction term for income group and year. We then evaluated changes among low-income adults in Medicaid expansion versus nonexpansion states using a similar approach. The unweighted study population included 80 767 low-income and 184 136 high-income adults. Low-income adults experienced improvements in insurance coverage (relative risk [RR], 1.10 [95% CI, 1.08-1.12]), access to a provider (RR, 1.12 [95% CI, 1.09-1.14]), and ability to afford care (RR, 1.07 [95% CI, 1.05-1.09]) in 2021 compared with 2019. While these measures also improved for high-income adults, gains in coverage and ability to afford care were more pronounced among low-income adults. However, routine visits (RR, 0.96 [95% CI, 0.94-0.98]) and cholesterol testing (RR, 0.93 [95% CI, 0.91-0.96]) decreased for low-income adults, while diabetes screening (RR, 1.01 [95% CI, 0.95-1.08]) remained stable. Treatment for hypertension (RR, 1.05 [95% CI, 1.02-1.08]) increased, and diabetes-focused visits and insulin use remained stable. These patterns were similar for high-income adults. Across most outcomes, there were no differential changes between low-income adults residing in Medicaid expansion versus nonexpansion states. In this national study of working-age adults in the United States, measures of health care access improved for low- and high-income adults in 2021. However, routine outpatient visits and cardiovascular risk factor screening did not return to prepandemic levels, while risk factor treatment remained stable. As many coronavirus disease-era safety net policies come to an end, targeted strategies are needed to protect health care access and improve cardiovascular risk factor screening for working-age adults.

PCR12 Delayed Care Among Low-Income Adults during the COVID-19 Pandemic: A US Population-Based Study

To characterize delayed care patterns by income status during the COVID-19 pandemic among US adults. This study analyzed the 2020 Medical Expenditure Panel Survey Full Year Consolidated Data File. The study defined low- or middle-income individuals as those in families with income less than 400 percent of the poverty line and selected covariates using Anderson's Behavioral Model of Health Services Use. The sociodemographic and health-related variables were compared by income status using chi-square tests. The sampling weights were applied to account for complex survey design and generate nationally representative estimates. A total of 21,234 US adults answered the COVID-19-related questions, about 46.9% including low- or middle-income adults. During the COVID-19 pandemic, compared to high-income adults, a lower proportion of low/middle-income adults reported delaying medical care (15.8% vs. 17.5%; p=0.005) or dental care (21.1% vs. 30.0%; p=<.0001). However, before the pandemic, low/middle-income adults than high-income adults were more likely to defer medical care (9.2% vs. 4.5%; p=<.0001) or dental care (17.3% vs. 7.3%; p=<.0001) to save costs. Prescription drug filling was not affected much by the COVID-19 pandemic for both low/middle- (1.9%) and high-income adults (1.2%). During the pandemic, low-or middle-income adults were more likely to self-rate their physical (16.7% vs. 7.4%; p=<.0001) and mental health (12.7% vs. 6.4%; p=<.0001) as fair or poor. Most high-income adults, as opposed to low/middle-income counterparts, were covered by private insurance (86.3% vs. 52.6%), non-Hispanic white (71.1% vs. 54.4%), and had a usual source of care provider (75.4% vs. 67.9%). High-income US adults appeared to experience more COVID-19-related delays in health care compared with low- or middle-income counterparts. Multivariable regression will be conducted to produce the adjusted estimates of delayed care prevalence.

Understanding of nutrition information on food labels among higher income adults in India

Objectives: This study assessed food label reading habits and understanding of nutrition information on food labels by higher income adults in India. Design: It involved a cross-sectional study using non-probability purposive sampling. Setting: Data were collected by mixed methods approach between March 2019 and February 2020. Adults were selected from housing colonies in four geographical zones of Delhi, India. Method: A total of 589 adults (20–40 years) belonging to upper middle-income and high-income groups were selected. Associations between gender, family income, age, marital status, and label reading habits were assessed using Chi-square tests. Demographic predictors of food label reading habits were identified using binary logistic regression with a level of significance set at p &lt; .05. Results: Participants read the food labels (79%) and noticed the nutrient claims (76%) on food labels. Female participants were more likely to understand nutrition information as compared with male participants (odds ratio [OR] = 1.52, p = .04). Female participants were also more likely to notice the nutrient claims on the packet of food products (OR = 1.99, p &lt; .01) as compared with male participants. The majority of participants found the ‘traffic light scheme’ format easy to understand. Conclusion: Consumers look for nutrition information on food labels. They value healthier food alternatives but most are unable to decipher the nutrition labels. Food labels should communicate the healthfulness of products in a straightforward manner to enable better food choices.

Socioeconomic, medical and demographic characteristics of early adopters of digital primary care.

In this paper, we investigated which socioeconomic and demographic groups first adopted digital primary care video consultations when they became accessible to the entire population in Sweden. We analysed data on all patients (378,000) who had a consultation with the largest provider of digital healthcare in Sweden - Kry - in the first years of national availability of the service, 2016-2018. We studied their income, education, demographics, and diagnosis backgrounds using matched registry data. Moreover, to compare users and non-users of digital primary care, we used data on all physical primary care users in one Swedish region: Skåne. We found that this digital primary care was first used by young and higher-income adults, but not far from half of adult users had incomes below the national median. Digital care patients were more educated than the general population, reflecting that urban inhabitants were more likely than rural inhabitants to be users. First-generation immigrants were less represented among digital care users than in the population. However, second-generation immigrants with two foreign parents were slightly over-represented. The prevalence of some chronic diseases in pre-digital secondary (specialist and hospital) healthcare data among digital care users was similar to the population adjusted for age. Studying all physical primary care users in Skåne region, young digital care users had more primary care diagnoses and previous in-person primary care appointments than non-users, while the pattern was reversed for older users. When digital primary care became nationally available, younger, urban and more educated patients were the first to adopt the new technology. Regarding medical history, young users of digital care had a higher previous disease burden than young non-users, suggesting that these digital services were first adopted by young people with high primary care needs.

Out-of-Pocket Drug Costs for Medicare Beneficiaries With Cardiovascular Risk Factors Under the Inflation Reduction Act

BackgroundHigh out-of-pocket prescription drug costs contribute to financial toxicity, medication nonadherence, and adverse cardiovascular (CV) outcomes. Policymakers recently passed the Inflation Reduction Act, which will cap Medicare out-of-pocket drug costs at $2,000/year and expand full low-income subsidies (LIS). It is unclear how these provisions will affect Medicare beneficiaries with CV risk factors and/or conditions. ObjectivesThe authors sought to characterize the population of Medicare beneficiaries with CV risk factors/conditions experiencing out-of-pocket prescription drug costs >$2,000/year and estimate their potential savings under the Inflation Reduction Act’s spending cap; identify sociodemographic characteristics associated with out-of-pocket costs >$2,000/year; and characterize beneficiaries newly eligible for LIS under the Inflation Reduction Act. MethodsThis was a cross-sectional study of Medicare beneficiaries aged ≥65 years with ≥1 CV risk factor/condition from 2016 to 2019. ResultsAn annual estimated 34,056,335 ± 855,653 Medicare beneficiaries (mean ± SE) had ≥1 CV risk factor/condition, of whom 1,020,484 ± 77,055 experienced out-of-pocket drug costs >$2,000/year. The likelihood of experiencing out-of-pocket drug costs >$2,000/year was lower among adults ≥75 years vs 65 to 74 years (adjusted OR: 0.67; 95% CI: 0.49-0.93) and for low-income vs higher-income adults. Among beneficiaries currently spending >$2,000/year, estimated median out-of-pocket drug savings would be $855/year and total annual savings $1,723,031,307 ± $91,150,609 under the Inflation Reduction Act. An estimated 1,289,861 beneficiaries would also become newly eligible for LIS. ConclusionsMore than 1 million older adults with CV risk factors and/or conditions spend >$2,000/year out-of-pocket on prescription drugs and will likely benefit from the Inflation Reduction Act’s cap, with estimated total out-of-pocket savings of $1.7 billion/year, while another 1.3 million will also become newly eligible for LIS.

Did Dental Insurance Expansion Improve Dental Care Needs Among Korean Adults? Difference in Difference Analysis.

In 2012, the Korean government expanded dental insurance for the elderly to promote improved access to dental care. We examined the causal effect of this policy on dental care needs, focusing on low-income older adults. We compared data before and after policy implementation using double difference (DD) and triple difference (DDD) analyses. We used the nationally representative data from the Korea National Health and Nutrition Examination Survey from 2010 and 2016-2018. Individuals aged ≥65 years were included in the treatment group, and individuals aged <65 years were included in the control group. Dental insurance expansion was associated with a paradoxical increase in perceived unmet dental needs among elderly individuals (8.8 percentage points increase, 95% CI: 4.7 to 13.0). However, there were improvements in dental prosthetics outcomes (denture wearing [4.0 percentage points, 95% CI: 0.2 to 7.9] and dental implants [5.0 percentage points, 95% CI: 2.1 to 7.9]; P < 0.01). Upon analyzing low-income elderly individuals using DDD analysis, we found that the insurance expansion led to a 21.6% smaller increase in unmet dental needs among low-income adults, compared to high-income adults (95% CI, -35.0 to -8.5; P < 0.01). Dental insurance expansion in South Korea resulted in improvements in access to dental prosthetic services overall. It also led to a smaller increase in unmet dental needs among low-income older adults, compared to high-income adults.

Use Of And Willingness To Use Video Telehealth Through The COVID-19 Pandemic.

We examined use of and willingness to use video telehealth during the COVID-19 pandemic in a longitudinally followed cohort. Between February 2019 and March 2021, use and willingness to use increased among nearly all subgroups, with large increases among Black adults and adults with lower educational attainment. In March 2021 Black adults, adults ages 20-39, and high-income adults reported the greatest willingness to use video telehealth.

Medicare eligibility and healthcare access, affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis.

BackgroundUS policymakers are debating whether to expand the Medicare program by lowering the age of eligibility. The goal of this study was to determine the association of Medicare eligibility and enrollment with healthcare access, affordability, and financial strain from medical bills in a contemporary population of low- and higher-income adults in the US.Methods and findingsWe used cross-sectional data from the National Health Interview Survey (2019) to examine the association of Medicare eligibility and enrollment with outcomes by income status using a local randomization-based regression discontinuity approach. After weighting to account for survey sampling, the low-income group consisted of 1,660,188 adults age 64 years and 1,488,875 adults age 66 years, with similar baseline characteristics, including distribution of sex (59.2% versus 59.7% female) and education (10.8% versus 12.5% with bachelor’s degree or higher). The higher-income group consisted of 2,110,995 adults age 64 years and 2,167,676 adults age 66 years, with similar distribution of baseline characteristics, including sex (40.0% versus 49.4% female) and education (41.0% versus 41.6%). The share of adults age 64 versus 66 years enrolled in Medicare differed within low-income (27.6% versus 87.8%, p < 0.001) and higher-income groups (8.0% versus 85.9%, p < 0.001). Medicare eligibility at 65 years was associated with a decreases in the percentage of low-income adults who delayed (14.7% to 6.2%; −8.5% [95% CI, −14.7%, −2.4%], P = 0.007) or avoided medical care (15.5% to 5.9%; −9.6% [−15.9%, −3.2%], P = 0.003) due to costs, and a larger decrease in the percentage who were worried about (66.5% to 51.1%; −15.4% [−25.4%, −5.4%], P = 0.003) or had problems (33.9% to 20.6%; −13.3% [−23.0%, −3.6%], P = 0.007) paying medical bills. In contrast, there were no significant associations between Medicare eligibility and measures of cost-related barriers to medication use. For higher-income adults, there was a large decrease in worrying about paying medical bills (40.5% to 27.5%; −13.0% [−21.4%, −4.5%], P = 0.003), a more modest decrease in avoiding medical care due to cost (3.5% to 0.6%; −2.9% [−5.3%, −0.5%], P = 0.02), and no significant association between eligibility and other measures of healthcare access and affordability. All estimates were stronger when examining the association of Medicare enrollment with outcomes for low and higher-income adults. Additional analyses that adjusted for clinical comorbidities and employment status were largely consistent with the main findings, as were analyses stratified by levels of educational attainment. Study limitations include the assumption adults age 64 and 66 would have similar outcomes if both groups were eligible for Medicare or if eligibility were withheld from both.ConclusionsMedicare eligibility and enrollment at age 65 years were associated with improvements in healthcare access, affordability, and financial strain in low-income adults and, to a lesser extent, in higher-income adults. Our findings provide evidence that lowering the age of eligibility for Medicare may improve health inequities in the US.

The psychology of poverty and life online: natural experiments on the effects of smartphone payday loan ads on psychological stress

ABSTRACT This study examines how individuals across income classes encountered payday lenders’ appeals online and what their smartphone use reveals about their psychological reactions to these messages. We utilized novel Screenomics data, comprehensive sequences of screenshots (N = 13,498,584) collected every 5 seconds from the smartphones of lower-income and higher-income adults (N = 65) in U.S. metropolitan areas for 2 months. While examining a person’s everyday smartphone use, we observed 103 natural exposures to advertisements of payday lenders who had in the past generated consumer complaints with the Consumer Financial Protection Bureau. We describe how individuals encountered payday loan ads through various digital channels despite the ad bans of major technology companies. We employed a quasi-experimental design to test for differences in participant actions immediately before and after ad exposure. Multilevel analysis results show that exposure to payday loan ads led to notable changes in the lower-income individuals’ smartphone use. Directly after seeing the ads, the lower-income individuals engaged with content that contained fewer future-oriented words, switched between applications more frequently, and avoided content that evoked negative emotions. Such effects were especially pronounced among the lower-income individuals who lacked the support of social safety nets, such as the Supplemental Nutrition Assistance Program (formerly known as food stamps) and unemployment benefits. In contrast, there were no changes noted in smartphone use among the lower-income individuals receiving social safety net assistance and higher-income individuals. These findings highlight the nuanced yet impactful psychological consequences of digital experiences, an underexplored aspect of digital inequalities.

Oral cancer screening prevalence in low-income adults before and after the ACA

BackgroundDetecting oral cancer early is associated with higher probability of survival, reduced treatment costs, and improved quality of life. Unfortunately, <30% of oral cancers are detected early. Recent health insurance expansions from the Affordable Care Act (ACA) could improve outcomes by increasing access to screening. However, due to the differences in screening practices by physicians and dentists, the impact of expanded access to insurance on oral cancer screenings remains unknown. MethodsSelf-reported oral cancer screening data were obtained from The National Health and Nutrition Examination Survey (NHANES) for years 2011–2017. NHANES questionnaires ask respondents if they have received an oral cancer screen from a physician or dentist in the past year. Along with adjusting for demographic characteristics, this study accounts for unobserved heterogeneity by comparing “Differences-in-Differences” estimates of low-income adults (<200 % FPL) with high-income adults, before and after the ACA (2014), for adults most exposed (<age 65) to insurance expansion. ResultsBefore and after the ACA, low-income adults had the lowest prevalence of oral cancer screenings. However, relative to high-income adults, the ACA was associated with a 5–6%-point increase in oral cancer screenings for low-income adults under age 65, but only for screenings performed by dentists. ConclusionsOverall, oral cancer screening rates have been declining across the population, but the ACA may have slowed the decline in low-income adults. Understanding why oral cancer screenings are declining could inform cancer control policies. Research evaluating the impact of access to oral cancer screenings remains warranted.

Evaluation of Temporal Trends in Racial and Ethnic Disparities in Sleep Duration Among US Adults, 2004-2018

Historically marginalized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed during recent years. To evaluate 15-year trends in racial and ethnic differences in self-reported sleep duration among adults in the US. This serial cross-sectional study used US population-based National Health Interview Survey data collected from 2004 to 2018. A total of 429 195 noninstitutionalized adults were included in the analysis, which was performed from July 26, 2021, to February 10, 2022. Self-reported race, ethnicity, household income, and sex. Temporal trends and racial and ethnic differences in short (<7 hours in 24 hours) and long (>9 hours in 24 hours) sleep duration and racial and ethnic differences in the association between sleep duration and age. The study sample consisted of 429 195 individuals (median [IQR] age, 46 [31-60] years; 51.7% women), of whom 5.1% identified as Asian, 11.8% identified as Black, 14.7% identified as Hispanic or Latino, and 68.5% identified as White. In 2004, the adjusted estimated prevalence of short and long sleep duration were 31.4% and 2.5%, respectively, among Asian individuals; 35.3% and 6.4%, respectively, among Black individuals; 27.0% and 4.6%, respectively, among Hispanic or Latino individuals; and 27.8% and 3.5%, respectively, among White individuals. During the study period, there was a significant increase in short sleep prevalence among Black (6.39 [95% CI, 3.32-9.46] percentage points), Hispanic or Latino (6.61 [95% CI, 4.03-9.20] percentage points), and White (3.22 [95% CI, 2.06-4.38] percentage points) individuals (P < .001 for each), whereas prevalence of long sleep changed significantly only among Hispanic or Latino individuals (-1.42 [95% CI, -2.52 to -0.32] percentage points; P = .01). In 2018, compared with White individuals, short sleep prevalence among Black and Hispanic or Latino individuals was higher by 10.68 (95% CI, 8.12-13.24; P < .001) and 2.44 (95% CI, 0.23-4.65; P = .03) percentage points, respectively, and long sleep prevalence was higher only among Black individuals (1.44 [95% CI, 0.39-2.48] percentage points; P = .007). The short sleep disparities were greatest among women and among those with middle or high household income. In addition, across age groups, Black individuals had a higher short and long sleep duration prevalence compared with White individuals of the same age. The findings of this cross-sectional study suggest that from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals in the US. The disparities in short sleep duration appear to be highest among women, individuals who had middle or high income, and young or middle-aged adults, which may be associated with health disparities.

Differential Trends in Disability Among Rich and Poor Adults in the United States and England From 2002 to 2016.

Disability in the United States has not improved in recent decades. Comparing temporal trends in disability prevalence across different income groups, both within and between the United States and England, would inform public policy aimed at reducing disparities in disability. Using the Health and Retirement Study and the English Longitudinal Study of Ageing, we estimated annual percent change from 2002 to 2016 in disability among community-dwelling adults (197,021 person-years of observations). Disability was defined based on self-report of limitations with 5 instrumental activities of daily living and 6 activities of daily living. We examined the trends by age and income quintile and adjusted for individual-level sociodemographic status and survey design. The adjusted annual percent change (AAPC) in disability prevalence declined significantly in both countries for ages 75 and older during 2002-2016. For ages 55-64 and 65-74, disability prevalence was unchanged in the United States but declined in England. Both countries experienced a widening gap in disability between low- and high-income adults among the younger age groups. For example, for those ages 55-64 in each country, there was no significant improvement in disability for the low-income group but a significant improvement for the high-income group (AAPC = -3.60; 95% confidence interval [CI; -6.57, -0.63] for the United States; AAPC = -6.06; 95% CI [-8.77, -3.35] for England). Improvements in disability were more widespread in England than in the United States between 2002 and 2016. In both countries, the disparity in disability between low- and high-income adults widened for middle-aged adults. Policies targeted at preventing disability among low-income adults should be a priority in both countries.