Uninsured Rate Research Articles

Association of hospital and market characteristics with 30-day readmission rates from 2009 to 2015.

The US government implemented the Hospital Readmission Reduction Program on 1 October 2012 to reduce readmission rates through financial penalties to hospitals with excessive readmissions. We conducted a pooled cross-sectional analysis of US hospitals from 2009 to 2015 to determine the association of the Hospital Readmission Reduction Program with 30-day readmissions. We utilized multivariable linear regression with year and state fixed effects. The model was adjusted for hospital and market characteristics lagged by 1 year. Interaction effects of hospital and market characteristics with the Hospital Readmission Reduction Program indicator variable was also included to assess whether associations of Hospital Readmission Reduction Program with 30-day readmissions differed by these characteristics. In multivariable adjusted analysis, the main effect of the Hospital Readmission Reduction Program was a 3.80 percentage point (p < 0.001) decrease in readmission rates in 2013-2015 relative to 2009-2012. Hospitals with lower readmission rates overall included not-for-profit and government hospitals, medium and large hospitals, those in markets with a larger percentage of Hispanic residents, and population 65 years and older. Higher hospital readmission rates were observed among those with higher licensed practical nurse staffing ratio, larger Medicare and Medicaid share, and less competition. Statistically significant interaction effects between hospital/market characteristics and the Hospital Readmission Reduction Program on the outcome of 30-day readmission rates were present. Teaching hospitals, rural hospitals, and hospitals in markets with a higher percentage of residents who were Black experienced larger decreases in readmission rates. Hospitals with larger registered nurse staffing ratios and in markets with higher uninsured rate and percentage of residents with a high school education or greater experienced smaller decreases in readmission rates. Findings of the current study support the effectiveness of the Hospital Readmission Reduction Program but also point to the need to consider the ability of hospitals to respond to penalties and incentives based on their characteristics during policy development.

Implementation of a mobile health clinic framework for Hepatitis C virus screening and treatment: a descriptive study

Although treatment for Hepatitis C Virus (HCV) is effective, individuals face access barriers. The utility of mobile health clinics (MHC), effective mechanisms for providing healthcare to underserved populations, is understudied for HCV-related interventions. We aimed to describe implementation of, and factors associated with, screening and treatment via MHCs. Clemson Rural Health implemented a novel MHC program to reach and treat populations at-risk for HCV with a focus on care for uninsured individuals. We examined HCV screening and treatment initiation/completion indicators between May 2021 and January2023. Among 607 individuals screened across 31 locations, 94 (15.5%) tested positive via antibody and viral load testing. Treatment initiation and completion rates were 49.6% and 86.0%, respectively. Among those screened, the majority were male (57.5%), White (61.3%; Black/Hispanic: 28.2%/7.7%), and without personal vehicle as primary transportation mode (54.4%). Injection drug use (IDU) was 27.2% and uninsured rate was 42.8%. Compared to HCV-negative, those infected included more individuals aged 30-44 (52.1% vs. 36.4%, p=0.023), male (70.2% vs. 55.2%, p=0.009), White (78.5% vs. 60.2%, p<0.0001), without personal vehicle (58.5% vs. 43.5%, p=0.028), IDU (83.7% vs. 21.0%, p<0.0001), and uninsured (61.2% vs. 48.8%, p=0.050). Uninsured rates were higher among those initiating compared to not initiating treatment (74.5% vs. 45.3%, p=0.004). The MHC framework successfully reaching its target population: at-risk individuals with access barriers to healthcare. The high HCV screening and treatment initiation/completion rates demonstrate the utility of MHCs as effective and acceptable intervention settings among historically difficult-to-treat populations. Gilead Sciences, Inc., and SC Center for Rural and Primary Healthcare.

Abstract A134: The impact of the Affordable Care Act on the colorectal cancer landscape in Louisiana

Abstract Louisiana (LA) is the only state in the deep south opting to expand Medicaid. This, along with the federal tax subsidies for low income individual to buy insurance on the health marketplace, facilitated health care access to medically underserved populations in LA. This study examines the differences in sociodemographic characteristics of those diagnosed with colorectal cancer (CRC) before and after the Patient Protection and Affordable Care Act (ACA) was implemented in LA, highlighting differences in receipt of timely CRC treatment and survival rates. Patient demographics, cancer treatment, and outcomes data were obtained from the Louisiana Tumor Registry and the sample population included adults diagnosed with CRC. Pre-ACA was defined from 1/2012-6/30/2016 and the post-ACA was 7/1/2016- 12/31/2020. Variables examined were age, race, sex, poverty, socioeconomic status, insurance, marital status, distance to urban center, stage of diagnosis, number of tumors, type and date of any treatment received. Descriptive analysis summarized sociodemographic and cancer diagnosis variables for the sample across the two time periods. Logistic regression analysis was used to examine the impact of ACA and Kaplan-Meier plots and cox regression analysis was used to examine the impact of ACA on survival rates. 20,497 people were diagnosed with CRC during the study time period (pre-ACA 10,044 vs post-ACA 10,453) and there were significant differences noted with age, marital status, poverty, SES, insurance, and all cancer diagnosis variables. The number of uninsured dropped by two-thirds (6% vs 2%, &amp;lt;0.001) while the number of those on Medicaid increased (6.5% vs 14%, &amp;lt;0.001). There were no significant differences in diagnosis by race in the overall sample however, among the Medicaid population, pre-ACA, 57% of those diagnosed were Black vs 40% who were White. Post-ACA, 50% of those diagnosed were Black vs 46% White. The percentage of patients diagnosed at Stage I increased post-ACA by 1% while the percentage of patients diagnosed at Stage III decreased by 2% (&amp;lt;0.0001). The percentage of those diagnosed without tumors increased from 74% pre-ACA to 78% post-ACA. The number of those who received chemotherapy and radiation also increased pre vs post-ACA. Regression models showed significant impact of ACA on stage of diagnosis, receipt of timely treatment, and uninsured rates. There were no significant differences in survival time across the two time periods, however, separated by insurance status, the Medicaid and private insurance populations saw significant improvements in survival time post-ACA. Expanded Medicaid coverage through Healthy LA began in the summer of 2016. Since then, more than 732,000 individuals have benefited from Medicaid expansion coverage and 92,607 have received federal subsidies. The results of this study present evidence to other southern states on the advantages of Medicaid expansion in cancer treatment and survival. Citation Format: Bilikisu Elewonibi, Malesa Pereira, Yaqi Zou. The impact of the Affordable Care Act on the colorectal cancer landscape in Louisiana [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A134.

Abstract A097: Assessing patterns of cancer screening uptake, healthcare access, health status, and the county-level Social Vulnerability Index in Louisiana

Abstract Background The Social Vulnerability Index (SVI) was originally developed to identify areas of high need prior to a disaster but it can also be used to identify medical underserved communities and areas of shortages of medical care. There are four major themes that contribute to SVI: 1) socioeconomic status, 2) household characteristics, 3) racial and ethnic minority status, and 4) housing type/transportation which can be used to examine cancer screening uptake in communities as their socioeconomic makeup contributes to the ability of individuals to access cancer screening. Cancer screenings are essential and highly effective tools when diagnosing cancer early which significantly improves chances of cancer survival and decreases chances of morbidity. This study aims to examine the association of county-level cancer screening uptake and SVI patterns in Louisiana while adjusting for healthcare utilization and self-reported health status. Methods 2020 county level age-adjusted cancer screening rates for breast, cervical, and colorectal, healthcare utilization rates, and health status rates for Louisiana were obtained from CDC’s PLACES website and SVI were obtained from CDC ATSDR. The county-level SVI was recoded into four categories: very low (0-.2499), low (0.2500-0.4999), high (0.5000-0.7499), and very high (0.7500-1.000) with high SVI implying least amount of resources. Linear regressions were used to assess the associations between screening rates and SVI quartiles while adjusting for healthcare utilization and health status variables. Results Of the 64 counties in Louisiana, the mean for county-level cancer screening rate were 1) breast cancer at 74.93% (range, 70.40%-79.90%), 2) colorectal cancer at 68.60% (range, 62.60%-75.10%), and cervical cancer at 81.57% (range, 77.4%-85.60%). The multivariable regression models showed very high SVI was associated with low cancer screening rates. When comparing very high SVI and very low SVI, the unadjusted odds ratio (OR) for cervical cancer screening, 0.25 (95% CI, 0.11-0.54) and colorectal cancer screening, 0.59 (95% CI, 0.18-0.59) showed significance. After adjusting for healthcare utilization and health status among very high SVI and very low SVI, all three breast, cervical, and colorectal cancer screening showed statistically significant associations. For uninsured rates, unadj. OR for breast, 8.95 (95% CI, 3.32-24.18) cervical, 5.16 (95% CI, 1.90-14.05) and colorectal, 7.12 (95% CI, 2.44-20.76) showed significance. For general health status, unadj. OR for breast, 9.42 (95% CI, 3.60 - 24.63) cervical, 6.64 (95% CI, 2.68 - 16.44) and colorectal, 9.94 (95% CI, 3.46 - 28.58) showed significance. Conclusions This study found that areas with very high SVI had low rates of cancer screening rates, low healthcare utilization, and high levels of self-reported fair/poor general, mental, and physical health status. These areas may benefit from community level interventions to address barriers to care and better dialogues of the importance of keeping up with routine checkup including cancer screenings. Citation Format: Malesa Pereira, Bilikisu Elewonibi. Assessing patterns of cancer screening uptake, healthcare access, health status, and the county-level Social Vulnerability Index in Louisiana [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A097.

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

BackgroundDisparities 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.MethodsThis 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.ResultsThe 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.ConclusionsThe 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.

The Impact of Medicaid Expansion Under the Affordable Care Act on the Gap Between American Indians and Whites in Breast Cancer Management and Prognosis

BackgroundBreast cancer (BC) death rates in the USA have not significantly declined for American Indians (AIs) in comparison to Whites. Our objective was to determine whether Medicaid Expansion as part of the Affordable Care Act led to improved BC outcomes for AIs relative to Whites. Patients and MethodsUsing the National Cancer Database, we conducted a retrospective cohort study. Included were BC patients who were AI and White; 40 to 64 years of age; diagnosed in 2009 to 2016; lived in states that expanded Medicaid in January 2014, and states that did not expand Medicaid. Our outcomes were stage at diagnosis, insurance status, timely treatment, and 3-year mortality. ResultsThere were 359,484 newly diagnosed BC patients, 99.49% White, 0.51% AI. Uninsured rates declined more in the expansion states than in the nonexpansion states (OR = 0.44, 95% CI: 0.15-0.97, P < 0.001). Lower rates of Stage I BC diagnosis was found in AIs compared to Whites (46.58% vs. 55.33%, P < .001); these differential rates did not change after Medicaid expansion. Rates of definitive treatment initiation within 30 days of diagnosis declined after Medicaid expansion (P < .001); there was a smaller decline in the expansion states (OR 1.118, 95% CI: 1.09, 1.15, P < .001). Three year mortality was not different between expansion and nonexpansion states post Medicaid expansion. ConclusionsIn newly diagnosed BCs, uninsured rates declined more in the states that expanded Medicaid in January 2014. Timely treatment post Medicaid expansion declined less in states that expanded Medicaid. There was no differential benefit of Medicaid expansion in the 2 races.

Food environment index and preterm birth rate in the counties of the United States.

To determine the relationship between Food Environment Index (FEI) and Preterm Birth (PTB) rate at the county level of the United States of America (USA) (primary), while evaluating the interaction of multiple factors within a framework of sociodemographic, maternal health, maternal behavioral, and environmental factors. This is a population-based retrospective cohort ecological study from 2015-2018. The study compares the characteristics of the population of the counties of the USA. All counties with complete data on their PTB rate and the independent variables were included in the study. Independent variables with greater than 20% missing data were excluded from the study. Purposive sampling technique was applied. A total of 2983/3142 counties were included in the study. The median PTB rate of all counties was 9.90%. The highest PTB rate (23.3%) was in Tallapoosa County, Alabama and the lowest (3.4%) in San Juan County, Washington State. After adjusting for variables, PTB rate had a significant association with FEI (coefficient of correlation - 0.36, p < 0.01, 95% CI - 0.19 to - 0.04). Increase in the rate of unemployment, African American race, adult smoking, obesity, uninsured rate, sexually transmitted diseases (STD), high school education and air pollution was associated with an increase in PTB rate, while an increase in FEI and alcohol abuse rates was associated with a decrease in PTB rate. FEI can predict the PTB rate in USA counties after adjusting for sociodemographic, health, behavioral and environmental factors. Future studies are needed to confirm these associations and consider them when making policies to reduce PTBs.

Aging Out of Dependent Coverage and Health Insurance Trends, 2014–2019

ObjectiveTo examine changes in health insurance coverage when adults age out of dependent coverage at age 26 after the implementation of most Affordable Care Act (ACA) provisions. Our analysis also documented differences by sex, race and ethnicity, and state Medicaid expansion status. MethodsWe used a regression discontinuity design and the 2014–2019 American Community Survey to estimate coverage changes (uninsured, any private, employer-sponsored coverage, direct purchase, and Medicaid) at age 26. Our main sample consisted of adult citizens aged 22–29 years. ResultsUninsurance increased by 2.7% points [95% CI; 1.8–3.4] at age 26, which was driven by a significant decline in any private insurance (3.7% point decrease). Young adults experienced a smaller increase in the uninsured rate on turning age 26 in states that expanded in 2014 compared to nonexpansion states (2.2% and 3.2% point increases, respectively), but the difference was not significant (P = .07). Changes in the uninsured rate at age 26 did not differ significantly by sex or race and ethnicity. ConclusionsThe 2010 dependent coverage provision led to more coverage options among young adults and in turn the uninsured rate declined among a population historically among the most likely to lack coverage. The 2014 Medicaid and Marketplace expansions reduced the uninsured rate even further among young adults. Despite important progress, our findings for 2014–2019 were similar to previous studies using pre-ACA data suggesting that coverage loss remains a risk when adults age out of dependent coverage at age 26.

Medicaid Expansion Lowered Uninsurance Rates Among Nonelderly Adults In The Most Heavily Redlined Areas.

Medicaid expansion narrowed racial and ethnic disparities in health coverage, but few studies have explored differential impact by exposure to structural racism. We analyzed data on historical residential redlining in US metropolitan areas from the Mapping Inequality project, along with data on uninsurance from the American Community Survey, to test whether Medicaid expansion differentially reduced uninsurance rates among nonelderly adults exposed to historical redlining. Our difference-in-differences analysis compared uninsurance rates in Medicaid expansion and nonexpansion states both before (2009-13) and after (2015-19) the state option to expand Medicaid pursuant to the Affordable Care Act took effect in 2014. We found that Medicaid expansion had the greatest impact on lowering uninsurance rates in census tracts with the highest level of redlining. Within each redline category, there were no significant differences by race and ethnicity. Our results highlight the importance of considering contextual factors, such as structural racism, when evaluating health policies. States that opt not to expand Medicaid delay progress toward health equity in historically redlined communities.

Association of state Medicaid expansion policies with pediatric liver transplant outcomes

Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.

County-Level Sociodemographic Characteristics and Availability of COVID-19 Therapeutic Drugs

This cross-sectional study examines access to COVID-19 treatments in US counties by race and ethnicity, poverty rate, uninsured rate, and other population and community characteristics.

Young, Black/African American, and Latino communities are left behind despite legislative efforts in California to reduce HIV/STI disparities.

Sexually transmitted infections (STI) have been on the rise in the United States with racial/ethnic minority groups, gay and bisexual men, and youth experiencing the highest STI and HIV infection rates. In 2022, California became the first state in the nation to pass legislation, Senate Bill 306 (SB 306), requiring health care plans to cover the costs of home test kits for STIs, including HIV. This study examines provisions within SB 306 and its potential to reduce STI and HIV disparities among key demographic groups and geographic regions within California. Ecological cross-sectional study involving 58 California counties. Descriptive statistics and choropleth maps compared HIV/STI prevalence rates, uninsured rates, demographic composition, and healthcare provider coverage across California counties. Three geographically weighted Poisson regression analyses were conducted to separately examine the association between proportion of uninsured and HIV, gonorrhea, and chlamydia prevalence rates. HIV/STI rates were significantly and positively associated with the proportion of uninsured residents in Central and Southern California counties. These counties had a higher proportion of demographic groups vulnerable to HIV/STI including a large Latino, Black/African American, and younger (age 15-24) population but had a lower rate of healthcare providers with prescription authority for home testing kits, which is a requirement under SB 306. Cutting-edge solutions are needed to stem the rising tide of new STI and HIV infections. While SB 306 is novel and innovative in intent, its coverage gaps will increase disparities and inequities among historically underserved populations.

Adverse Consequences of Food Insecurity Among U.S. Adults Beyond Health Outcomes

Food insecurity is associated with poorer health, but the adverse consequences of food insecurity may extend beyond just health outcomes. Thus, this study examined the association between food insecurity and health insurance coverage, access to care, healthcare utilization, and financial hardships among U.S. adults. This study employed a retrospective longitudinal cohort study design using panel data from the 2016-2017 Medical Expenditure Panel Survey. Linear probability models were used to examine the association between food insecurity in 1 year and outcomes of interest (health insurance coverage, access to care, healthcare utilization, and financial hardships) in the subsequent year. Analysis was conducted in April 2023. Food insecurity was associated with higher uninsured rates and lower private coverage rates (3.5 [95% CI: 1.6-5.5] and -3.9 [95% CI: -6.2, -1.7] percentage points). Moreover, food insecurity was associated with lower access to care, including delay in receiving necessary medical care and delay in obtaining necessary prescription drugs (2.9 [95% CI: 1.0-4.8] and 4.1 [95% CI: 2.1-6.2]). Furthermore, food insecurity was associated with a higher rate of emergency room visits (2.8 [95% CI: 0.1-5.7]), whereas associations with inpatient, outpatient, and prescription drug use were not significant. Food insecurity was also associated with greater financial hardships, such as experiencing difficulties paying medical bills (9.6 [95% CI: 6.7-12.6]). These findings highlight the adverse consequences of food insecurity on access to and affordability of care for U.S. adults and families. Food insecurity can have far-reaching implications for the well-being of individuals and families.

Abstract P226: Length Of Stay Discrepancies Between Rural And Urban Hospital Settings For Hypertension Admissions

Introduction: Rural populations experience greater barriers to healthcare access compared to urban populations. This can be attributed to fewer public health services, greater uninsured rate, and greater burden of healthcare shortages in urban healthcare settings. Our study aims to quantify the disproportionate allocation in healthcare resources through analysis of Length of Stay (LOS) in-respect to hypertensive urgency and hypertensive urgency. Methods: This cross-sectional study reviewed the LOS estimates for patients with ICD-10 diagnoses for Hypertension Emergency or Hypertension Urgency within the state of New York, categorized by the type of community hospital; rural or urban. This study utilizes the 2020 National Inpatient Sample (NIS), specifically for urban and rural hospitals in New York. ICD-10 codes included I16.1 &amp; I16.9 for Hypertensive Emergency and I16.0 for Hypertensive Urgency. Community hospital setting was categorized as either rural or urban based on the overlying zip code of the admitting inpatient hospital. Results: LOS was unique to the community setting (p&lt;0.01), but not to hypertensive disease (p=0.11). In summary, the LOS was longer in rural-level inpatient hospital systems when compared to their urban counterparts in both Hypertensive Urgency, 4.4 days vs 3.1 days (p=0.01), and Hypertensive Emergency, 5.5 days vs 3.4 days (p&lt;0.01). Conclusion: The LOS of patients admitted for both hypertensive urgency and emergency were significantly higher in rural hospitals. Furthermore, increased disease severity emphasizes the divide in LOS between the community healthcare settings. Redistribution of resources to rural communities can enhance access to preventative healthcare services, specialty healthcare, and potentially decrease overall community disease burden.

Medicaid expansion is associated with treatment receipt, timeliness, and outcomes among young adults with breast cancer.

Female breast cancer is a common cancer in young adults, an age group with the highest uninsured rate. Among 51 675 young adult women (ages 18-39 years) diagnosed with breast cancer between 2011 and 2018 in the National Cancer Database, we estimated changes in guideline-concordant treatment receipt, treatment timeliness, and survival associated with the Affordable Care Act Medicaid expansion. Of young adults with stage I-III estrogen receptor-positive or progesterone receptor-positive breast cancer, Medicaid expansion was associated with a net increase of 2.42 percentage points (95% confidence interval [CI] = 0.56 to 4.28 percentage points) in the percentage receiving endocrine therapy. Among all young adults with stage I-III breast cancer, Medicaid expansion was associated with a net reduction of 1.65 percentage points (95% CI = 0.08 to 3.22 percentage points) in treatment delays defined as treatment initiation of at least 60 days after diagnosis and a net increase of 1.00 percentage points (95% CI = 0.21 to 1.79 percentage points) in 2-year overall survival. Our study provides evidence of benefit in cancer care and outcomes from Medicaid expansion among the young adult population.

Dual Barriers: Examining Digital Access and Travel Burdens to Hospital Maternity Care Access in the United States, 2020.

With the increases in nationwide hospital maternity unit closures, there is a greater need for telehealth services for the supervision, evaluation, and management of prenatal and postpartum care. However, challenges in digital access persist. We examined associations between driving time to hospital maternity units and digital access to understand whether augmenting digital access and telehealth services might help mitigate travel burdens to maternity care. This cross-sectional study used 2020 American Hospital Association Annual Survey data for hospital maternity unit locations and 2020 American Community Survey five-year ZIP Code Tabulation Area (ZCTA)-level estimates of household digital access to telecommunication technology and broadband. We calculated driving times of the fastest route from population-weighted ZCTA centroids to the nearest hospital maternity unit. Rural-urban stratified generalized median regression models were conducted to examine differences in ZCTA-level proportions of household lacking digital access equipment (any digital device, smartphones, tablet), and lacking broadband subscriptions by spatial accessibility to maternity units. In 2020, 2,905 (16.6%) urban and 3,394 (39.5%) rural ZCTAs in the United States were located >30 minutes from the nearest hospital maternity units. Regardless of rurality, these communities farther away from a maternity unit had disproportionally lower broadband and device accessibility. Although urban communities have greater digital access to technology and broadband subscriptions compared to rural communities, disparities in the percentage of households with access to digital devices were more pronounced within urban areas, particularly between those with and without close proximity to a hospital maternity unit. Communities where nearest hospital maternity units were >30 minutes away had higher poverty and uninsurance rates than those with <15-minute access. Socioeconomically disadvantaged communities face significant barriers to maternity care access, both with substantial travel burdens and inadequate digital access. To optimize maternity care access, ongoing efforts (e.g., Affordable Connectivity Program introduced in the 2021 Infrastructure Act), should bridge the gaps in digital access and target communities with substantial travel burdens to care and limited digital access.

Early changes in health coverage and access to dental care associated with Medicaid expansion under the COVID-19 pandemic.

The extent to which the COVID-19 pandemic has affected early changes in health coverage and access to dental care services in states that expanded Medicaid versus those that did not is currently not well known. Using data from the National Health Interview Survey, we found that, during the first year of the COVID-19 pandemic, states that had previously expanded their Medicaid programs under the Affordable Care Act had lower uninsurance rates for White low-income adults (-8.8 percentage points; 95% CI: -16.6, -1.0) and lower dental uninsurance rates for all low-income adults (-5.4 percentage points; 95% CI: -10.4, -0.5). Our findings also suggest that the combination of Medicaid expansion with coverage of adult dental benefits in Medicaid was associated with improved dental coverage and access to dental care during the pandemic. With the expiration of the public health emergency declaration, states are considering strategies to prevent disruptions in Medicaid coverage. Our study adds to the evidence of the importance of Medicaid expansion in stabilizing health coverage during a public health crisis.

High out‑of‑pocket spending and financial hardship at the end of life among cancer survivors and their families

Cancer is one of the most expensive medical conditions to treat worldwide, affecting national and local spending, as well as household budgets for patients and their families. In this commentary about a recent paper from Tur‑Sinai et al., we discuss the high out-of-pocket spending and medical and non-medical financial hardship faced by cancer patients and their families at the end-of-life in Israel. We provide recent information about the costs of health care in Israel and other high-income countries with (i.e., Canada, Australia, Japan, and Italy) and without universal health insurance coverage (i.e., United States, a country with high healthcare costs and uninsurance rate), and highlight the role of improving health insurance coverage and benefit design in reducing financial hardship among cancer patients and their families. Recognizing that financial hardship at the end of life affects both patients and their families, developing comprehensive programs and policies in Israel as well as in other countries is warranted.

Balancing weights for region-level analysis: The effect of Medicaid expansion on the uninsurance rate among states that did not expand Medicaid

Balancing weights for region-level analysis: The effect of Medicaid expansion on the uninsurance rate among states that did not expand Medicaid

Healthcare coverage, access, and affordability among adult immigrant cancer survivors in the United States.

6529 Background: Cancer is a leading cause of morbidity and mortality among US immigrants; however, barriers to care remain understudied. This study assessed disparities in health insurance, health care access, and affordability among immigrant cancer survivors in the United States. Methods: Adult cancer survivors aged ≥18 years who participated in the 2019-2022 National Health Interview Survey were classified as 1) natives 2) foreign-born (FB) citizens or 3) noncitizens. Logistic regression tested for associations between nativity/citizenship and insurance, access (i.e., urgent care, emergency room [ER], hospital admissions), and affordability (assessed by social determinants of health [SDoH]: financial hardship, food insecurity, housing assistance). Separate models adjusted for demographics, socioeconomic status, and comorbidities. Results: A total of 8,923 adults (90% natives, 7% FB citizens, 3% noncitizens) were included in the study. There were baseline differences in age &lt;65 (42% natives vs 61% FB citizens vs 76% noncitizens), female sex (57% vs 59% vs 73%), non-White race (15% vs 64% vs 77%), and Hispanic ethnicity (31% vs 62% vs 5%) between groups (all p&lt;0.05). More noncitizens had household incomes &lt;125% of the federal poverty line (12% vs 18% vs 35%). On adjusted analysis, noncitizens were 3x as likely as natives to be uninsured (2.99 [1.36-6.53]; p=0.006) and FB citizens were 2x as likely to have Medicaid (2.10 [1.35-2.35]; p=0.001). Financial hardship was 1.5x more common among FB citizens (1.50 [1.18-1.91]; p&lt;0.001) while receipt of housing assistance was &gt;2x more common among FB citizens (2.98 [1.82-4.88]; p&lt;0.001) and noncitizens (2.37 [1.08-5.22]; p=0.03). While more FB citizens (18%) and noncitizens (33%) were food insecure (vs. 11%), there were no associations with nativity/citizenship (Table). There were no significant differences in health care access across groups. Conclusions: In this nationwide analysis of adult cancer survivors, although there were no differences in health care access/utilization, immigrants and foreign-born citizens had higher rates of uninsurance and affordability concerns—suggestive of barriers to care. This may portend worse health outcomes in cancer survivorship. [Table: see text]