Uninsured Rate Research Articles

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.

Systemic barriers to access pharmaceutical-sponsored patient assistance programs: Implications for health equity and care delivery at safety-net systems.

107 Background: The rising cost of cancer care, driven in large by oncology drugs, has a significant impact on access to care and contributes to disparities. Pharmaceutical-sponsored patient assistance programs (PAPs) are intended to improve access to care; however, vulnerable populations may experience delays, denials, and treatment interruptions due to complexity of the application process and variable qualifying requirements. We present the impact of a pharmacy-run process to facilitate access to PAPs at a safety-net institution. Methods: Parkland Health (PH) is the safety-net system for Dallas County, which has one of the highest uninsured rates in the US. PH provides free health care to uninsured patients below 250% of the federal poverty income level. Hematology-Oncology patients who are prescribed medications with an existing PAP are identified in a work queue within the EHR. A team of licensed pharmacy technicians - Medication Access Technicians (MATs) - screen patients and if eligible, assist in filling and submitting the application, and follow up with PAP sponsors to ensure timely review and approvals. MATs also monitor refills and assist in PAP renewals to prevent interruptions in care. In this study, we used the average wholesale price to quantify the value of the medications provided through PAPs. Data for 10/01/22 through 09/30/23 are presented here. Results: During the study period, MATs enrolled 548 uninsured patients (90% Hispanic/Black) in PAPs for 38 unique clinic-administered drugs, with an estimated value of 45.2 million (M), averaging 78,853 per patient. The highest value and most common clinic-administered PAP drugs were pembrolizumab (96 patients, $8 M) and rituximab (159 patients, $5 M), respectively. For oral agents, MATs enrolled 77 uninsured patients (84% Hispanic/Black) in PAPs for 20 unique medications with an estimated value of 8.8 M, averaging 114,711 per patient. Dasatinib was both the most common and highest value PAP oral drug, with 24 patients and an estimated value of 3.6 M. Of the 38 PAPs for clinic-administered drugs, 25 did not include replacement for dispensed medications. Legal US residence was required by 7 PAPs. The institutional investment by PH (MAT salaries) is estimated at 620,000 annually. Conclusions: A dedicated team of MATs at PH facilitated access to care through PAP enrollments, reduced treatment interruptions by renewing applications, and reduced institutional drug expenditure, allowing investment in other care delivery initiatives. PAPs are philanthropic by nature and requirements such as legal residence and no-replacement for dispensed medications may negatively impact specific segments of our communities, or result in treatment delays. Advocacy by professional organization and patient groups is warranted to expand access to these potentially life-saving programs.

Abstract A126: Cancer screening trends in Louisiana’s sexual gender minority population

Abstract Cancer screenings in Louisiana (LA) have been consistently lower than the national average. Sexual and gender minorities (SGM) are more likely to be non-compliant with cancer screening guidelines and consistently do not meet cancer screening recommendations. This study compares compliance to cervical, breast, and colorectal cancer (CRC) screening guidelines over time between SGM and the non-SGM population in LA. Data were obtained from the LA 2014, 2016, 2018, 2020, and 2022 Behavioral Risk Factor Surveillance System (BRFSS). The sample was divided into gay (including lesbian, gay, bisexual, or other sexual orientation other than straight) and straight. Three primary outcomes of interest were used to measure breast, cervical, and CRC cancer screening adherence based on the U.S. Preventive Services Task Force (USPSTF) screening recommendation at the time of each survey. Descriptive analysis and chi-square tests were conducted using sample weights. CRC had the lowest compliance rate in the entire population and across sexual orientation groups. Twenty-five percent of both populations had never received any CRC screening test. Comparatively, 3.6% of straight and 5.3% of gay populations had never received a mammogram while 6.6% of straight and 13.6% of the population had never received a pap smear. Significant improvements in compliance to breast, cervical, and CRC cancer screenings guidelines was observed among those who identified as straight over the survey years until 2020. Decreases in screening compliance were observed in this population from 2020 to 2022, likely due to the effects of the COVID pandemic. Screening compliance in those who identified as gay showed more variation over time in all three cancers. Screening compliance for CRC and cervical cancer were at its highest in 2016, declined to its lowest point in 2020, but increased in 2022. In 2016, there was a significant decline in breast cancer screening compliance in this population to the lowest ever observed in both groups. The initial increases in colorectal and cervical cancer screening observed from 2014 to 2016 among the gay population may be attributed to significant decreases in uninsured rates following the passage of the Affordable Care Act. Additionally, this population saw increased access to the private insurance market following the Obergefell decision and the Marriage Equality Act of 2015, which extended employer-sponsored coverage to same-sex couples. While breast cancer screenings declined from 2014-2016 in the gay population, there was a sharp increase from 2016 to 2018, which aligns with the 2016 expansion of Medicaid in Louisiana. Despite increases in access to insurance coverage, SGM individuals report being in fair or poor health and having negative experiences with healthcare providers at higher rates than their non-SGM counterparts. More research is needed to understand the healthcare landscape and experiences of SGM Louisianans. This will help to inform targeted interventions to increase screenings and improve cancer outcomes among this population. Citation Format: Bilikisu Elewonibi, Carleigh Baudoin, Ashely Fenton. Cancer screening trends in Louisiana’s sexual gender minority population [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A126.

Emergency Medicaid enrollment after traumatic injury predicts long-term health care utilization.

Injured patients have high rates of uninsurance, which is associated with worse outcomes. Insurance linkage programs that connect patients to Medicaid coverage can prevent catastrophic costs for patients. Less is known about the long-term impact of insurance enrollment. We examined health care utilization for previously uninsured patients, hypothesizing that newly insured patients postinjury would use health care more than those remaining uninsured. We linked institutional trauma registry data to the electronic medical record to identify injured patients aged 18 to 64 years from 2017 to 2021. Patients admitted without insurance and then retroactively insured (RI) during hospitalization were compared with patients with preestablished Medicaid (Medicaid insured [MI]) and those remaining uninsured. We compared demographic and injury characteristics and future health care utilization, including hospitalizations, emergency department (ED) visits, and clinic visits, among groups at 30 days and 12 months postinjury. Patient-reported outcomes (PROs) 6 months after injury were compared by group for a subset of patients participating in an ongoing study of long-term PROs. We compared 494 RI patients with 1,706 MI and 148 uninsured patients. Retroactively insured patients were younger, more likely to have penetrating injuries, and longer hospitalization than other groups. There was a significant increase in ED and clinic visits and hospital admissions at 30 days and 12 months between RI and uninsured patients (p < 0.001). Using multivariable logistic regression, RI was associated with higher future ED utilization, hospital admissions, and specialist visits at 30 days and 12 months compared with uninsured patients. Of the 265 patients with 6-month PROs, Medicaid coverage was not associated with any significant difference in physical function or anxiety. Patients enrolled in insurance postinjury are more likely to use health care in the future than patients without insurance, but the downstream effects are less clear. Health insurance is a necessary step but not independently sufficient to optimize care and improve health outcomes. Prognostic and Epidemiological; Level IV.

Gerrymandering and the Packing and Cracking of Medical Uninsurance Rates in the United States.

Technological innovation and access to big data have allowed partisan gerrymandering to increase dramatically in recent redistricting cycles. To understand whether and how partisan gerrymandering, including "packing" and "cracking" (ie, respectively concentrating within or dividing specified social groups across political boundaries), distorts understanding of public health need when health statistics are calculated for congressional districts (CDs). Cross-sectional study using 2020 CDs and nonpartisan simulated districts. United States, 2017-2021. United States residents. Percent with no medical insurance (uninsured), within-district variance of percent uninsured, and between-district variance of percent uninsured. At the state level, states where partisan redistricting plans showed greater evidence of partisan gerrymandering were more likely to contain CDs with more extreme values of uninsurance rates than districts in states with less evidence for gerrymandering (association between z-scores for gerrymandering and between-district variation in uninsurance=0.25 (-0.04, 0.53), P=.10). Comparing variation in uninsurance rates for observed CDs vs nonpartisan simulated districts across all states with more than 1 CD, in analyses stratified by state gerrymander status (no gerrymander, Democratic gerrymander, and Republican gerrymander), we found evidence of particularly extreme distortion of rates in Republican gerrymandered states, whereby Republican-leaning districts tended to have lower uninsurance rates (the percentage of Republican-leaning districts that were significantly lower than nonpartisan simulated districts was 5.1 times that of Democratic-leaning districts) and Democrat-leaning districts had higher uninsurance rates (the percentage of Democrat-leaning districts that were significantly higher than nonpartisan simulated districts was 3.0 times that of Republican-leaning districts). Partisan gerrymandering can affect determination of CD-level uninsurance rates and distort understanding of public health burdens.

Estimating the uninsured cancer rate: Unraveling the indelible link between insurance, age, and the accessibility of cancer treatment

Estimating the uninsured cancer rate: Unraveling the indelible link between insurance, age, and the accessibility of cancer treatment

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

To examine the impact of the Affordable Care Act (ACA) health insurance exchanges (Marketplace) on the rate of uninsured discharges in Texas. Secondary discharge data from 2011 to 2019 from Texas. 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. 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. 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. These findings indicate that the ACA facilitated a shift in hospital payor mix from uninsured to insured.

Supporting patient access to pharmaceutical-sponsored assistance programs: Implications for health equity and care delivery at safety-net systems.

e13724 Background: The ever-rising cost of cancer care, driven in large by oncology drugs, has a significant impact on access to care and contributes to disparities. Pharmaceutical-sponsored patient assistance programs (PAPs) are intended to improve access to care; however, vulnerable populations may experience delays, denials, and treatment interruptions due to complexity of the application process and variable qualifying requirements. We present the impact of a pharmacy-run process to facilitate access to PAPs at a safety-net institution. Methods: Parkland Health (PH) is the safety-net system for Dallas County, which has one of the highest uninsured rates in the US. PH provides free health care to uninsured patients below 250% of the federal poverty income level. Hematology-Oncology patients who are prescribed medications with an existing PAP are identified in a work queue within the EHR. A team of licensed pharmacy technicians - Medication Access Technicians (MATs) - screen patients and if eligible, assist in filling and submitting the application, and follow up with PAP sponsors to ensure timely review and approvals. MATs also monitor refills and assist in PAP renewals to prevent interruptions in care. In this study, we used the average wholesale price to quantify the value of the medications provided through PAPs. Data for 10/01/22 through 09/30/23 are presented here. Results: During the study period, MATs enrolled 548 uninsured patients (90% Hispanic/Black) in PAPs for 38 unique clinic-administered drugs, with an estimated value of $45.2 million (M), averaging $78,853 per patient. The highest value and most common clinic-administered PAP drugs were pembrolizumab (96 patients, $8 M) and rituximab (159 patients, $5 M), respectively. For oral agents, MATs enrolled 77 uninsured patients (84% Hispanic/Black) in PAPs for 20 unique medications with an estimated value of $8.8 M, averaging $114,711 per patient. Dasatinib was both the most common and highest value PAP oral drug, with 24 patients and an estimated value of $3.6 M. Of the 38 PAPs for clinic-administered drugs, 25 did not include replacement for dispensed medications. Legal US residence was required by 7 PAPs. The institutional investment by PH (MAT salaries) is estimated at $620,000 annually. Conclusions: A dedicated team of MATs at PH facilitated access to care through PAP enrollments, reduced treatment interruptions by renewing applications, and reduced institutional drug expenditure, allowing investment in other care delivery initiatives. PAPs are philanthropic by nature and requirements such as legal residence and no-replacement for dispensed medications may negatively impact specific segments of our communities, or result in treatment delays. Advocacy by professional organization and patient groups is warranted to expand access to these potentially life-saving programs.

Identification of factors associated with opioid-related and hepatitis C virus-related hospitalisations at the ZIP code area level in the USA: an ecological and modelling study

Opioid overdose and related diseases remain a growing public health crisis in the USA. Identifying sociostructural and other contextual factors associated with adverse health outcomes is needed to improve prediction models to inform policy and interventions. We aimed to identify high-risk communities for targeted delivery of screening and prevention interventions for opioid use disorder and hepatitis C virus (HCV). In this ecological and modelling study, we fit mixed-effects negative binomial regression models to identify factors associated with, and predict, opioid-related and HCV-related hospitalisations for ZIP code tabulation areas (ZCTAs) in South Carolina, USA. All individuals aged 18 years or older living in South Carolina from Jan 1, 2016, to Dec 31, 2021, were included. Data on opioid-related and HCV-related hospitalisations, as well as data on additional individual-level variables, were collected from medical claims records, which were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic and socioeconomic variables were obtained from the United States Census Bureau (American Community Survey, 2021) with additional structural health-care barrier data obtained from South Carolina's Center for Rural and Primary Health Care, and the American Hospital Directory. Between Jan 1, 2016, and Dec 31, 2021, 41 691 individuals were hospitalised for opioid misuse and 26 860 were hospitalised for HCV. There were a median of 80 (IQR 24-213) opioid-related hospitalisations and 61 (21-196) HCV-related hospitalisations per ZCTA. A standard deviation increase in ZCTA-level uninsured rate (relative risk 1·24 [95% CI 1·17-1·31]), poverty rate (1·24 [1·17-1·31]), mortality (1·18 [1·12-1·25]), and social vulnerability index (1·17 [1·10-1·24]) was significantly associated with increased combined opioid-related and HCV-related hospitalisation rates. A standard deviation increase in ZCTA-level income (0·79 [0·75-0·84]) and unemployment rate (0·87 [0·82-0·93]) was significantly associated with decreased combined opioid-related and HCV-related hospitalisations. Using 2016-20 hospitalisations as training data, our models predicted ZCTA-level opioid-related hospitalisations in 2021 with a median of 80·4% (IQR 66·8-91·1) accuracy and HCV-related hospitalisations in 2021 with a median of 75·2% (61·2-87·7) accuracy. Several underserved high-risk ZCTAs were identified for delivery of targeted interventions. Our results suggest that individuals from economically disadvantaged and medically under-resourced communities are more likely to have an opioid-related or HCV-related hospitalisation. In conjunction with hospitalisation forecasts, our results could be used to identify and prioritise high-risk, underserved communities for delivery of field-level interventions. South Carolina Center for Rural and Primary Healthcare, National Institute on Drug Abuse, and National Library of Medicine.

Health Insurance Matters: Insurance Coverage and Health Service Use Among Direct Care Workers in the United States

ObjectivesDirect care workers (DCWs) play a central role in supporting individuals' health and well-being across care settings, yet may face barriers to accessing health care themselves, particularly because of high rates of uninsurance. DesignAn observational study using pooled National Health Interview Survey (NHIS) data from 2014 to 2018. Setting and ParticipantsThe sample included survey respondents employed as direct care workers (DCWs), including hospital aides, home care workers, and nursing and residential care aides. MethodsWe used bivariate analyses to compare differences in health insurance coverage and health service use, defined in terms of access, utilization, and affordability, among DCWs by care setting. We then used stepwise multivariable logistic regression analyses to explore the associations between insurance coverage and health service use. ResultsThe sample included 1499 DCWs. Compared with hospital aides, home care workers and nursing and residential care aides had lower insurance coverage rates, were more likely to rely on Medicaid, and reported lower health care utilization and higher cost barriers. Health insurance through Medicaid was associated with the highest odds of health care access and utilization and the lowest odds of cost barriers for DCWs. Conclusions and ImplicationsGiven the projected 9.3 million total job openings in the direct care workforce from 2021 to 2031, policy and practice interventions designed to support DCWs' health are essential for ensuring continuous and quality care for older adults and people with disabilities and serious illness.

Social Determinants of Health Among American Indians and Alaska Natives and Tribal Communities: Comparison with Other Major Racial and Ethnic Groups in the United States, 1990-2022.

Limited research exists on health inequities between American Indians and Alaska Natives (AIANs), tribal communities, and other population groups in the United States. To address this gap in research, we conducted time-trend analyses of social determinants of health and disease outcomes for AIANs as a whole and specific tribal communities and compared them with those from the other major racial/ethnic groups. We used data from the 1990-2022 National Vital Statistics System, 2015-2022 American Community Survey, and the 2018-2020 Behavioral Risk Factor Surveillance System to examine socioeconomic, health, disability, disease, and mortality patterns for AIANs. In 2021, life expectancy at birth was 70.6 years for AIANs, lower than that for Asian/Pacific Islanders (APIs) (84.1), Hispanics (78.8), and non-Hispanic Whites (76.3). All racial/ethnic groups experienced a decline in life expectancy between the pre-pandemic year of 2019 and the peak pandemic year of 2021. However, the impact of COVID-19 was the greatest for AIANs and Blacks whose life expectancy decreased by 6.3 and 5.8 years, respectively. The infant mortality rate for AIANs was 8.5 per 1,000 live births, 78% higher than the rate for non-Hispanic Whites. One in five AIANs assessed their physical and mental health as poor, at twice the rate of non-Hispanic Whites or the general population. COVID-19 was the leading cause of death among AIANs in 2021. Risks of mortality from alcohol-related problems, drug overdose, unintentional injuries, and homicide were higher among AIANs than the general population. AIANs had the highest overall disability, mental and ambulatory disability, health uninsurance, unemployment, and poverty rates, with differences in these indicators varying markedly across the AIAN tribes. AIANs remain a disadvantaged racial/ethnic group in the US in many health and socioeconomic indicators, with poverty rates in many Native American tribal groups and reservations exceeding 40%.

Unwinding And The Medicaid Undercount: Millions Enrolled In Medicaid During The Pandemic Thought They Were Uninsured.

Policy responses to the March 31, 2023, expiration of the Medicaid continuous coverage provision need to consider the difference between self-reported Medicaid participation on government surveys and administrative records of Medicaid enrollment. The difference between the two is known as the "Medicaid undercount." The size of the undercount increased substantially after the continuous coverage provision took effect in March 2020. Using longitudinal data from the Current Population Survey, we examined this change. We found that assuming that all beneficiaries who ever reported enrolling in Medicaid during the COVID-19 pandemic public health emergency remained enrolled through 2022 (as required by the continuous coverage provision) eliminated the worsening of the undercount. We estimated that nearly half of the 5.9million people who we projected were likely to become uninsured after the provision expired, or "unwound," already reported that they were uninsured in the 2022 Current Population Survey. This finding suggests that the impact of ending the continuous coverage provision on the estimated uninsurance rate, based on self-reported survey data, may have been smaller than anticipated. It also means that efforts to address Medicaid unwinding should include people who likely remain eligible for Medicaid but believe that they are already uninsured.

Patterns and Reasons for Being Uninsured Among Sexual Minority Adults Before and After the Affordable Care Act Implementation.

Purpose: We aimed to identify the self-reported reasons for being uninsured and sociodemographic factors associated with uninsurance among lesbian, gay, or bisexual (LGB) adults before and after the Affordable Care Act (ACA). Methods: We analyzed the 2013-2018 National Health Interview Survey data using multivariable logistic regression models to estimate the odds of being uninsured and the prevalence of self-reported reasons for not having insurance among LGB adults aged 18-64 years. Results: The study included 2124 LGB adults. The weighted uninsured rate decreased significantly from 19.6% in 2013 to 13.2% in 2017-2018 (odds ratio 0.61; 95% confidence interval 0.47-0.78). The primary reason cited for not having insurance post-ACA was similar to pre-ACA, with cost-related factors being the most commonly reported (31.5%). Conclusion: The overall uninsured rate decreased among LGB adults from 2013 to 2018, whereas disparities across subpopulations remained. Cost-related factors remained significant barriers to obtaining insurance coverage.

Survey-Reported Coverage in 2019-2022 and Implications for Unwinding Medicaid Continuous Eligibility

Policy changes and the COVID-19 pandemic affected health coverage rates, and the "unwinding" of Medicaid's continuous coverage provision in 2023 and 2024 may cause widespread coverage loss. Recent coverage patterns in national survey and administrative data can inform these issues. To assess national and state changes in survey-based Medicaid, private insurance, and uninsured rates between 2019 and 2022, as well as how these changes compare with administrative Medicaid enrollment totals. This cross-sectional study analyzes nationally representative survey data for all US residents in the American Community Survey (ACS) from 2019 to 2022 compared with administrative data on Medicaid and the Children's Health Insurance Program from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted between June 2023 and January 2024. The COVID-19 pandemic, the Medicaid continuous coverage provision, and policy efforts to increase Marketplace coverage. Medicaid coverage (self-reported [ACS] and administratively recorded [CMS]), survey-reported uninsured, Medicare, and private insurance status. A nationally representative sample consisted of 12 506 584 US residents of all ages (survey-weighted 59.7% aged 19-64 years and 50.6% female). CMS statistics showed an increase in Medicaid coverage of 5.2 percentage points as a share of the population from 2019 to 2022. However, changes in the uninsured rate and survey-reported Medicaid were smaller: -1.2 (95% CI, -1.3 to -1.2) percentage points and 1.3 (95% CI, 1.2-1.4) percentage points, respectively. There was a 3.9 percentage point increase in the ACS's "undercount" of Medicaid enrollment, compared with CMS data, from 2019 to 2022. This undercount was larger among children than adults but smaller in states that recently expanded Medicaid. Rates of additional forms of coverage (such as private insurance) among those in Medicaid also grew during this time. In this cross-sectional study, the uninsured rate declined considerably from 2019 to 2022 but was just one-fourth as large as the growth in administrative Medicaid enrollment under the pandemic continuous coverage provision. Survey-based Medicaid growth was far smaller than administrative growth. This suggests that many people who remained enrolled in Medicaid during the pandemic did not realize that their coverage had continued. These findings have implications for projecting uninsured changes during unwinding, as well as the effect of continuous coverage policies on continuity of care.

Abstract 811: Impact of Medicaid eligibility expansion to adults regardless of immigration status on health insurance access among Latina patients

Abstract Background: Disparities in the receipt of cancer screening and preventive services are strongly associated with health insurance status. Even after federal- and state-wide initiatives to boost access to health insurance such as the Patient Protection and Affordable Care Act (ACA) Medicaid Expansion to all individuals earning ≤138% of the federal poverty level (FPL) and nationwide individual health insurance marketplaces, Latino populations continue to have the highest uninsured rate of any racial or ethnic group in the US, with 17% of Latinos remaining uninsured compared to 5% of non-Hispanic white peers. In 2021, California and Oregon states amended their respective Medicaid program to expand eligibility to adults regardless of immigration status; which could reduce access disparities for patients from Latino communities. This study shows preliminary results of changes in health insurance status among Latina patients (who have multiple cancer prevention services recommended in middle age) receiving care in community health centers. Methods: A retrospective cohort study of Latina, non-Hispanic Black, and non-Hispanic white women ages 50-64 years receiving primary care from 382 community health clinics in California and Oregon. Using 2018, 2019, 2021, and 2022 electronic health record data, we estimated monthly rates of insured-type visits per 100 visits. We compared rates pre- and post-Medicaid eligibility expansion, both within and between race and ethnicity groups. Reported estimates were derived from generalized estimating equations Poisson regression, clustered on clinic, and adjusted for clinic-level demographics. Results: Of 41,960 patients, over half (53%) were Latina, most of whom (83%) preferred Spanish language communication. Latina patients had more uninsured visits pre-Medicaid eligibility expansion than did non-Hispanic Black and white patients (Rate: 27% versus 5% and 4%, respectively). All racial and ethnic groups experienced a decrease in uninsured visit rates, and this change was similar for all groups [Difference-in-difference Latina versus Black patients: 0.77 (95% CI 0.55, 10.7) and versus white patients: 1.02 (95% CI 0.89, 1.17)]. Overall rates of Medicaid-insured visits increased only for Latina patients [pre-to-post Relative Rate=1.06 (95% CI: 1.03-1.10)]. Both non-Hispanic Black and white patients experienced a drop in Medicaid-insured visits. Only Black patients experienced a significant decline in private-insured visits [pre-to-post RR=0.79 (95% CI: 0.70-0.89)]. Conclusion: These early results suggest an uptake of Medicaid-paid visits among Latina patients. This increase in healthcare coverage for Latina patients could significantly reduce disparities in access to primary care and especially in cancer preventive care. Citation Format: Nathalie Huguet, Jorge Kaufmann, Heather Holderness, Margaret Vieira, Gretchen Mertes, Jackilen Shannon, John Heintzman. Impact of Medicaid eligibility expansion to adults regardless of immigration status on health insurance access among Latina patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 811.

United States Healthcare System

United States Healthcare System

Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area.

We examined the geographic distribution and sociodemographic and economic characteristics of chronic disease prevalence in the US. Understanding disease prevalence and its impact on communities is crucial for effective public health interventions. Data came from the American Community Survey, the American Hospital Association Survey, and the Centers for Disease Control and Prevention's PLACES. We used quartile thresholds for 10 chronic diseases to assess chronic disease prevalence by Zip Code Tabulation Areas (ZCTAs). ZCTAs were scored from 0 to 20 based on their chronic disease prevalence quartile. Three prevalence categories were established: least prevalent (score ≤6), moderately prevalent (score 7-13), and highest prevalence (score ≥14). Community characteristics were compared across categories and spatial analyses to identify clusters of ZCTAs with high disease prevalence. Our study showed a high prevalence of chronic disease in the southeastern region of the US. Populations in ZCTAs with the highest prevalence showed significantly greater socioeconomic disadvantages (ie, lower household income, lower home value, lower educational attainment, and higher uninsured rates) and barriers to health care access (lower percentage of car ownership and longer travel distances to hospital-based intensive care units, emergency departments, federally qualified health centers, and pharmacies) compared with ZCTAs with the lowest prevalence. Socioeconomic disparities and health care access should be addressed in communities with high chronic disease prevalence. Carefully directed resource allocation and interventions are necessary to reduce the effects of chronic disease on these communities. Policy makers and clinicians should prioritize efforts to reduce chronic disease prevalence and improve the overall health and well-being of affected communities throughout the US.

Impact of the COVID-19 Pandemic and Vaccine Availability on Utilization of Breast Imaging in a Multistate Radiology Practice.

Data were obtained from medical health records across 77 Radiology Partners practices in the US. The data provided us with the total monthly mammography, breast ultrasound, and breast MRI procedures from January 2019 to September 2022. An interrupted time-series (ITS) analysis was conducted to evaluate the effect of the COVID-19 pandemic and the COVID-19 vaccination. We chose March 2020 and December 2020 as critical time points in the pandemic and analyzed trends before and after these dates. The starting level (at baseline in January 2019) of the total breast imaging procedure volume was estimated at 114,901.5, and this volume appeared to significantly increase every month prior to March 2020 by 4,864.0 (p < 0.0001, CI = [3,077.1, 6,650.9]). In March 2020, there appeared to be a significant decrease in volume by 104,446.3 (p=0.003, CI = [-172,063.1, -36,829.5]), followed by a significant increase in the monthly trend of service volume (relative to the pre-COVID trend) of 20,660.7 per month (p=0.001, CI = [8,828.5, 32,493.0]). In December 2020, there appeared to be a significant decrease in service volume by 69,791.2 (p=0.012, CI = [-123,602.6, -15,979.7]). Compared to the period from March to November 2020, there was a decrease in the monthly trend of service volumes per month by 24,213.9 (p < 0.0001, CI = [-36,027.6, -12,400.2]). After March 2020, the total service volume increased at the rate of 25,524.7 per month (p < 0.0001, CI = [13,828.2, 37,221.2]). In contrast, the service volumes after December 2020 appeared to grow steadily and slowly at a rate of 1,310.8 per month (p=0.118, CI = [-348.8, 2970.3]). Our study revealed that there has been a recovery and a further increase in breast imaging service volumes compared to prepandemic levels. The increase can be best explained by vaccination rollout, reopening of elective/nonemergency healthcare services, insurance coverage expansion, the decline in the US uninsured rate due to government interventions and policies, and the recovery of jobs with employer-provided medical insurance post-pandemic.

Health insurance coverage among incident cancer cases from population-based cancer registries in 49 US states, 2010-2019.

Having health insurance coverage is a strong determinant of cancer care access and survival in the United States. The expansion of Medicaid income eligibility under the Affordable Care Act has increased insurance coverage for working-age adults. Using data from the Cancer Incidence in North America (CiNA) in 2010-2019, we identified 6 432 117 incident cancer cases with known insurance status diagnosed at age 18-64 years from population-based registries of 49 states. Considerable variation in Medicaid coverage and uninsured rate exists across states, especially by Medicaid expansion status. Among expansion states, Medicaid coverage increased from 14.1% in 2010 to 19.9% in 2019, while the Medicaid coverage rate remained lower (range = 11.7% - 12.7%) in non-expansion states. The uninsured rate decreased from 4.9% to 2.1% in expansion states, while in non-expansion states, the uninsured rate decreased slightly from 9.5% to 8.1%. In 2019, 111 393 cancer cases (16.9%) had Medicaid coverage at diagnosis (range = 7.6%-37.9% across states), and 48 357 (4.4%) were uninsured (range = 0.5%-13.2%). These estimates suggest that many patients with cancer may face challenges with care access and continuity, especially following the unwinding of COVID-19 pandemic protections for Medicaid coverage. State cancer prevention and control efforts are needed to mitigate cancer care disparities among vulnerable populations.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.