Uninsured Rate Research Articles

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 <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<0.05). More noncitizens had household incomes <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<0.001) while receipt of housing assistance was >2x more common among FB citizens (2.98 [1.82-4.88]; p<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]

Access To Oncology Services In Rural Areas: Influence Of The 340B Drug Pricing Program.

Rural-urban cancer disparities, including greater mortality rates, are partially attributable to the limited availability of oncology services in rural communities. Without these services, rural residents may experience delays in timely treatment and may be less likely to complete recommended care. The 340B Drug Pricing Program allows eligible not-for-profit and public hospitals to purchase covered outpatient drugs, including high-cost oncology drugs, at discounted prices. Using 2011-20 data, we evaluated the relationship between new enrollment in the 340B program and oncology services initiation in rural general acute care hospitals that lacked oncology services in 2011. Compared with hospitals that remained unenrolled in the 340B program through 2020, hospitals that enrolled during 2012-18 were 8.3percentage points more likely to have added oncology services as of 2020. The newly participating hospitals that added oncology services were disproportionately located in Medicaid expansion states and in counties with lower uninsurance rates. These findings suggest that the 340B program facilitates expanded access to oncology services in some rural communities, but opportunities remain to address disparities in the most disadvantaged service areas.

Association of Medicaid expansion with treatment receipt, delays in treatment initiation, and survival among young adult women with breast cancer.

1509 Background: Medicaid expansion under the Affordable Care Act has been shown to increase insurance coverage and early-stage cancer diagnoses for young adults (YAs), the age group with the highest uninsured rate. We examined whether Medicaid expansion was associated with increased receipt of timely, guideline-concordant treatment and survival among YA women newly diagnosed with breast cancer, the most common YA cancer diagnosis. Methods: Using the National Cancer Database, we identified 51,675 women aged 18-39 years who were diagnosed with breast cancer in 2011-2018. We applied the difference-in-differences (DD) method to estimate outcome changes pre vs. post Medicaid expansion, in expansion- vs. non-expansion states. Linear probability models estimated associations of Medicaid expansion with receipt of guideline-concordant treatment – including any endocrine therapy among women with ER-positive or PR-positive breast cancer, and any chemotherapy or targeted therapy among women with ER-negative and PR-negative breast cancer – and initiation of guideline-concordant treatment (surgery, chemotherapy, or targeted therapy for stage I-III diagnoses, and systemic therapy for stage IV diagnoses) <60 days after diagnosis. Flexible parametric survival models were used to estimate 2-year overall survival. DD models also adjusted for age, race/ethnicity, rurality, zip code-level income, comorbidity, and diagnosis year, with standard errors clustered at the state level. Analyses were stratified by stage at diagnosis (stage I-III vs. IV). Results: Of the subset of women with stage I-III ER-positive or PR-positive breast cancer, the percentage receiving endocrine therapy increased in expansion states (85.20% pre-expansion to 86.46% post-expansion), but decreased in non-expansion states (84.32% to 82.79%), resulting in a net increase of 2.42 percentage points (ppt; 95% CI = 0.56 to 4.28) associated with Medicaid expansion in the adjusted DD model. Among all women with stage I-III breast cancer, the percentage with treatment initiation <60 days after diagnosis decreased less in expansion states (84.10% pre-expansion to 82.36% post-expansion) than in non-expansion states (86.95% to 83.98%), resulting in a net reduction of 1.61 ppt (95% CI = 0.05 to 3.18) in treatment delays associated with Medicaid expansion. Notably, the 2-year overall survival increased in expansion states (96.84% pre-expansion to 96.99% post-expansion), but decreased in non-expansion states (97.24% to 96.30%), resulting in a net survival increase of 1.00 ppt (95% CI = 0.21 to 1.79) associated with Medicaid expansion. Conclusions: Among YA women with stage I-III breast cancer, Medicaid expansion was associated with increased receipt of guideline-concordant treatment, reduced delays in treatment initiation, and improved 2-year survival.

With End of PHE, States Begin Disenrolling Medicaid Enrollees

With End of PHE, States Begin Disenrolling Medicaid Enrollees

Health Insurance For People Younger Than Age 65: Expiration Of Temporary Policies Projected To Reshuffle Coverage, 2023-33.

The Congressional Budget Office estimates that in 2023, 248million people in the US who are younger than age sixty-five have health insurance coverage (mostly through employment-based plans), and twenty-three million people, or 8.3percent of that age group, are uninsured-with significant variations in coverage by income and, to a lesser extent, by race and ethnicity. The unprecedented low uninsurance rate is largely attributable to temporary policies that kept beneficiaries enrolled in Medicaid and enhanced the subsidies available through the health insurance Marketplaces during the COVID-19 pandemic. As the continuous eligibility provisions unwind in 2023 and 2024, an estimated 9.3million people in that age group will transition to other forms of coverage, and 6.2million will become uninsured. If the enhanced subsidies expire after 2025, 4.9million fewer people are estimated to enroll in Marketplace coverage, instead enrolling in unsubsidized nongroup or employment-based coverage or becoming uninsured. By 2033 the uninsurance rate is projected to be 10.1percent, which is still below the 2019 rate of about 12percent.

Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Historical Redlining, Social Determinants of Health, and Stroke Prevalence in Communities in New York City

Historical redlining was a discriminatory housing policy that placed financial services beyond the reach of residents in inner-city communities. The extent of the impact of this discriminatory policy on contemporary health outcomes remains to be elucidated. To evaluate the associations among historical redlining, social determinants of health (SDOH), and contemporary community-level stroke prevalence in New York City. An ecological, retrospective, cross-sectional study was conducted using New York City data from January 1, 2014, to December 31, 2018. Data from the population-based sample were aggregated on the census tract level. Quantile regression analysis and a quantile regression forests machine learning model were used to determine the significance and overall weight of redlining in relation to other SDOH on stroke prevalence. Data were analyzed from November 5, 2021, to January 31, 2022. Social determinants of health included race and ethnicity, median household income, poverty, low educational attainment, language barrier, uninsurance rate, social cohesion, and residence in an area with a shortage of health care professionals. Other covariates included median age and prevalence of diabetes, hypertension, smoking, and hyperlipidemia. Weighted scores for historical redlining (ie, the discriminatory housing policy in effect from 1934 to 1968) were computed using the mean proportion of original redlined territories overlapped on 2010 census tract boundaries in New York City. Stroke prevalence was collected from the Centers for Disease Control and Prevention 500 Cities Project for adults 18 years and older from 2014 to 2018. A total of 2117 census tracts were included in the analysis. After adjusting for SDOH and other relevant covariates, the historical redlining score was independently associated with a higher community-level stroke prevalence (odds ratio [OR], 1.02 [95% CI, 1.02-1.05]; P < .001). Social determinants of health that were positively associated with stroke prevalence included educational attainment (OR, 1.01 [95% CI, 1.01-1.01]; P < .001), poverty (OR, 1.01 [95% CI, 1.01-1.01]; P < .001), language barrier (OR, 1.00 [95% CI, 1.00-1.00]; P < .001), and health care professionals shortage (OR, 1.02 [95% CI, 1.00-1.04]; P = .03). This cross-sectional study found that historical redlining was associated with modern-day stroke prevalence in New York City independently of contemporary SDOH and community prevalence of some relevant cardiovascular risk factors.

Health uninsurance premium and mortgage interest rates

I show that lenders charge higher interest rates on mortgage-financed houses in areas with a higher rate of health uninsurance to protect themselves against a potential future bankruptcy of the borrower caused by health uninsurance. The health uninsurance premium is higher for applicants who are more likely to file for bankruptcy and for mortgage-financed houses in areas where there are greater benefits to obtaining insurance or where there is a higher percentage of uninsured people who cannot afford insurance. The premium is lower following the implementation of the requirement to have qualifying health insurance coverage under the Affordable Care Act.

The Relationships Among Cash Prices, Negotiated Rates, And Chargemaster Prices For Shoppable Hospital Services.

Hospitals must disclose their cash prices, commercial negotiated rates, and chargemaster prices for seventy common, shoppable services under the hospital price transparency rule. Examining prices reported by 2,379 hospitals as of September9, 2022, we found that a given hospital's cash prices and commercial negotiated rates both tended to reflect a predetermined and consistent percentage discount from its chargemaster prices. On average, cash prices and commercial negotiated rates were 64percent and 58percent of the corresponding chargemaster prices for the same procedures at the same hospital and in the same service setting, respectively. Cash prices were lower than the median commercial negotiated rates in 47percent of instances, and most likely so at hospitals with government or nonprofit ownership, located outside of metropolitan areas, or located in counties with relatively high uninsurance rates or low median household incomes. Hospitals with stronger market power were most likely to offer cash prices below their median negotiated rates, whereas hospitals in areas where insurers had stronger market power were less likely to do so.

Tips for Health Insured Patients When Accessing Care

Despite the uninsured rate declining to an all-time low among USA residents [1], accessing and utilizing primary and/ or specialty care in a timely manner even when having health insurance remains challenging [2,3]. Are there potential tips to give health insured patients to help them navigate the complex and dynamic web of care access? This opinion paper contains a series of categories and questions for brainstorming combinations of care access with health insured patients who are seeking care.

Abstract PD1-10: Impact of Race on Clinical, Socioeconomic, and Genomic Characteristics, Clinical Trial Participation, and Receipt of Genotype-matched Therapy Among Patients with Metastatic Breast Cancer

Abstract Background: Clinical outcomes in breast cancer differ across racial and ethnic populations. We have previously demonstrated that receipt of genotype-matched therapy targeted to an actionable mutation may potentially improve patient outcomes (Vidula, CCR, 2021). We evaluated the impact of race on clinical, socioeconomic, and genomic characteristics, clinical trial participation, and receipt of genotype-matched therapy among patients with metastatic breast cancer (MBC). Methods: We conducted a retrospective study of patients with MBC at an academic institution who underwent cell-free DNA testing (cfDNA, Guardant360, 74 gene panel) as part of routine clinical care from 11/29/2016-11/2/2020. Patient demographics (including self-reported race and ethnicity) and clinical trial enrollment (at same institution) were determined by retrospective data collection. Mutations identified in cfDNA were characterized as actionable based on the variant interpretation performed by Guardant360 using vetted genomic databases, and receipt of genotype-matched therapy targeted to an actionable mutation was determined as previously described (Vidula, CCR, 2021). Pearson’s chi-squared and Wilcoxon rank-sum tests were used to compare categorical and continuous variables between groups, with p&amp;lt; 0.05 indicating statistical significance. Results: Four hundred and twenty-five patients with MBC and cfDNA results were identified, of which 369 were White (87%), 27 Black (6.4%), 15 Hispanic (3.5%), and 14 Asian (3.3%). There were no significant differences in median age at MBC diagnosis (p=0.064), disease subtype distribution (p=0.74), proportions of de-novo/recurrent MBC (p=0.95), presence of visceral metastases (p=0.84), Charleston comorbidity index (p=0.93), menopausal status (p=0.3), and level of education (p=0.44) across racial groups. Higher proportions of non-primary English speakers were seen in Hispanic (80%) and Asian (29%) races (p&amp;lt; 0.001). Median distance traveled to the institution also varied based on race, with White patients traveling further (White: 39.1 miles, Black: 21.8 miles, Hispanic 9.4 miles, Asian 9.1 miles, p&amp;lt; 0.001). In addition, type of insurance varied based on race, with White patients having the highest rates of commercial insurance and Medicare, Black patients having the highest rate of state-supported insurance, and Asian patients having the highest uninsured rates (p&amp;lt; 0.001). Clinical trial enrollment rates did not significantly differ by race (White: 44%, Black: 37%, Hispanic: 47%, and Asian 21%, p=0.34), but patients without insurance were significantly less likely to be enrolled on a trial than those with commercial insurance (p=0.03). The proportion of patients with ≥1 actionable mutation in cfDNA did not vary significantly by race (White: 78%, Black: 56%, Hispanic: 73%, Asian 86%, p=0.18) and the median number of actionable mutations found in cfDNA was similar across races (p=0.31). However, receipt of genotype-matched therapy targeted to an actionable mutation varied by race, with the highest rates of matched therapy in White patients (White: 28%, Black: 11%, Hispanic 13%, Asian 14%, p&amp;lt; 0.001). After multivariable logistic regression adjusting for subtype, commercial insurance versus other insurance types, and proximity to the center, White patients remained significantly more likely to receive matched therapy (p=0.029). Conclusions: We observed significant race-based differences in non-English speaking status, insurance type, and median distance traveled to the institution. Racial/ethnic minority patients were less likely to receive genotype-matched therapy than White patients. Further research is needed to identify barriers and reduce disparities in access to precision medicine. Citation Format: Rupali Sood, Lianne Ryan, Andrzej Niemierko, Laura M. Spring, Dejan Juric, Steven J. Isakoff, Seth A. Wander, Jennifer Shin, Naomi Ko, Leif Ellisen, Beverly Moy, Aditya Bardia, Neelima Vidula. Impact of Race on Clinical, Socioeconomic, and Genomic Characteristics, Clinical Trial Participation, and Receipt of Genotype-matched Therapy Among Patients with Metastatic Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-10.

Rural and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum

To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents. We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016-2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison. Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural-urban differences in uninsurance persisted across both Medicaid expansion and non-expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth. Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural-urban inequities in maternity care access and maternal health.

Increased female political representation associated with lower county-level uninsured and preventable hospitalizations rates in the United States, 2013–2018

ObjectiveAlthough women comprise 50% of the population, females remain underrepresented in government. Inequitable female political representation, a form of structural sexism, may impact population health. Previous studies focused primarily on individual health behaviors and low- or middle-income countries. To date, no study has examined the association between female political representation and healthcare access and utilization, immediately policy-amenable outcomes, in the United States. Study designThis was a repeated cross-sectional study. MethodsThis study uses 2013–2018 county-level data from the County Rankings. I performed multilevel analyses to determine the relationships between state-level female representation (% female state legislators) and two outcomes—the percentage of county-level population under age 65 years without health insurance (primary outcome) and the county-level preventable hospitalization rates (secondary outcome of interest). Potential confounders included county-level and state-level characteristics such as the unemployment rate. I also examined whether associations differed by political party control of the state legislature. ResultsIn the fully adjusted model, one standard deviation difference in female political representation was associated with a decrease of 0.22 percentage points in county-level uninsured (95% confidence interval = −0.32, −0.12). The association between female political representation and preventable hospitalization rate differed according to state political party in control, with a decrease found only among counties in democratic/split controlled states (−80.51, 95% confidence interval = −149.65, −11.38). ConclusionsThe results suggest that policy intervention addressing the underrepresentation of women in government may help increase the proportion of uninsured and, under certain circumstances, decrease county-level unnecessary hospitalizations. However, further research is needed to better understand the role of political party control in modifying noted associations.

Behavioral Health, Nursing Home Workforce, And More

From the Editor-In-Chief Health AffairsVol. 42, No. 2: Behavioral Health, Nursing Home Workforce & More Behavioral Health, Nursing Home Workforce, And MoreAlan R. WeilPUBLISHED:February 2023Free Accesshttps://doi.org/10.1377/hlthaff.2023.00023AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSBehavioral health careNursing homesWorkforce issuesEmergency departmentsTelehealthHealth equityThe February issue of Health Affairs covers behavioral health, including mental health and substance use; the nursing home workforce; and health equity issues such as racial and ethnic disparities in ambulance transportation destinations and adverse birth outcomes.Behavioral HealthIn the midst of a mental health provider shortage, Lisa Rotenstein and coauthors find an almost 50 percent increase in the share of primary care physician visits that address a mental health concern, with growth from 10.7 percent of visits in 2006–07 to 15.9 percent in 2016 and 2018. Black patients and Hispanic patients are 40 percent less likely than White patients and non-Hispanic patients, respectively, to have a mental health concern addressed during a primary care visit.K. John McConnell and colleagues use newly available national Medicaid claims data from 2018 to examine emergency department (ED) visits for mental health conditions among Medicaid beneficiaries. They report substantial state-to-state variation “both in ED visits for mental health conditions and in outpatient mental health visits, with these measures positively correlated.”Lori Uscher-Pines and coauthors explore recent trends in the use of telemedicine to address opioid use disorder (OUD). More than three-quarters of clinicians treating OUD report the use of one or more digital equity strategies designed to address barriers patients may have to using telemedicine, with about one-third offering real-time technical assistance and more than 15 percent supplying patients with electronic devices if they do not have them.Brendan Saloner and coauthors investigate smoking rates among people involved in the criminal legal system—a group of people with relatively high rates of smoking and substance use disorder (SUD). Using data from the period 2010–19, the authors find that “overall smoking rates among people with SUD decreased by 9.4 percentage points…during the study period, but they remained effectively unchanged in the subgroup of people with SUD who had criminal legal involvement.”Nursing Home WorkforceUsing a novel database of real estate investment trust (REIT) investments in US nursing homes and Medicare cost data from the period 2013–19, Robert Tyler Braun and coauthors determine that REIT investment in a nursing home increased licensed practical nurse and certified nursing assistant staffing hours per resident day by 2.15 percent and 1.55 percent, respectively, while decreasing registered nurse staffing in years 2 and 3 after investment.Elizabeth White and coauthors explore the relationship between nursing home staff shift times and COVID-19 testing and vaccination status. They find that day-shift staff had the highest testing rates and odds of vaccination, whereas night-shift staff had the lowest.Adequate staffing is central to ensuring high nursing home quality. To help illuminate the implications of various policy recommendations, John Bowblis and coauthors analyze nursing home staff expenditures and determine that “any specific threshold for nursing staff expenditures…would have a varying degree of effectiveness in ensuring that any given nursing home was adequately staffed.” Ultimately, the authors argue, increased expenditures on staff do not necessarily translate to an increase in staffing levels.EquityChristine Pack and coauthors investigate ambulance destinations for patients transported in 2020 from the same ZIP code and find meaningful differences by race and ethnicity. “In half of the studied ZIP codes, at least 8 percent of White patients would have had to be transported to different hospitals to achieve evenness in the transport destinations of White and non-White patients,” the authors report.Clare Brown and coauthors examine disparities in rates of preterm birth and low birthweight across racial and ethnic subcategories. They find sizable variation in adverse birth outcomes within racial and ethnic groups, demonstrating that broad racial and ethnic categorizations can conceal important intragroup differences.Eunhae Grace Oh and coauthors analyze dialysis facility networks for Medicare Advantage (MA) plans in 2020, one year before changes that significantly increased MA enrollment among patients with end-stage renal disease (ESRD). Nearly one-quarter of dialysis networks were narrow, which the authors define as including 25 percent or less of the dialysis facilities within the plan’s service area. Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native beneficiaries with ESRD were more likely than White beneficiaries to be enrolled in narrow-network MA plans.Examining COVID-19 booster rates at the end of the first Omicron wave in 462 Massachusetts communities, Adam Gaffney and coauthors find lower rates in communities with higher uninsurance rates and lower prevalence of medical checkups, after controlling for demographic factors. They call for “innovative vaccination outreach efforts to communities with a high prevalence of chronic illness…to mitigate the inequitable burden of COVID-19.” Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 February 2023 Information© 2023 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016.

The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected. The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months. A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states. Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.

Effect of Eased Restrictions for Aca-Exempt Short-Term Health Plans on Marketplace Premiums and Uninsured Rate: A Difference in Differences Analysis.

The Affordable Care Act (ACA) established broad standards for private health insurance in the United States including requiring minimum essential benefits and prohibiting medical underwriting, but the law also permitted some exceptions. This paper examines one type of exempt plan option, Short-Term, Limited Duration Insurance (STLDI) that is not required to fully meet ACA benefit and underwriting standards. Federal rules governing STLDI plans have changed over time, with more permissive rules in the Trump administration allowing individuals to remain covered for longer durations of time relative to the original Obama regulations. Within applicable federal guidelines, states have also varied STLDI rules. Using publicly available data measuring state-level variations in STLDI regulations, ACA benchmark premiums, uninsured rates, and population characteristics for 2014 to 2021, we estimate difference-in-differences models to examine if more permissible STLDI policies are associated with higher premiums in the fully regulated non-group market and, also, lower uninsured rates. We find that longer duration, more permissible STLDI is associated with higher benchmark premiums in ACA exchanges and no difference in state-level uninsured rates. Trump administration regulations permitting longer duration STLDI plans to make available more affordable ACA-exempt health insurance were associated with higher premium costs in the ACA-regulated non-group market but we did not observe measurable impact on state uninsured rates. While longer-duration STLDI plans may result in lower costs for some, they have negative consequences for others requiring comprehensive coverage with no discernible benefit in overall coverage rates. Understanding these tradeoffs can help guide future policies regarding exceptions to ACA plan requirements.

Who Accesses Birth Control Online? An Analysis of Requests for Contraception Submitted to an Online Prescribing Platform in the United States.

Telehealth has the potential to increase contraceptive access. Little is known about the characteristics of people using online prescribing platforms or whether these services help fill access gaps. We analyzed requests for contraception submitted between July 2015 and September 2017 to an online prescribing platform that offers sexual and reproductive care in the United States. We analyzed the characteristics of people seeking contraceptives, prevalence of contraindications to hormonal contraception among contraceptive seekers, and extent to which online prescribing may close contraceptive access gaps. A total of 38,439 requests for prescription hormonal birth control were received during the study period, with requests increasing dramatically over this timeframe as the platform expanded operations to an increasing number of states. Methods were dispensed in response to 63% of requests. In this population seeking contraception, an estimated 1.2% had a contraindication to progestin-only pills, and an estimated 12.0% of patients who reported their blood pressurehad a contraindication to combined hormonal methods. Few requests came from patients younger than 18 (1.2%). In multivariable negative binomial models, urban counties had a larger concentration of requests, whereas counties with higher rates of uninsurance and poverty had lower rates of requests. Results suggest that the population seeking contraception from one online prescribing platform has similar levels of contraindications to hormonal contraceptives as found in prior research. Future research should seek to understand why utilization of this online prescribing platform was lower among young people, how to expand outreach to rural populations, and what underlies individuals' decisions about using these services.

The Early Impact of the COVID-19 Pandemic on Hospital Finances.

The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pandemic. In this study, we examined hospitals' financial performance following the onset of the pandemic. We used data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System. The study sample included all general acute care and critical access hospitals that receive Medicare payments. The primary outcomes included operating margins, net patient revenues, operating expenses, and uncompensated care costs. We tested for average changes from 2019 to 2020 in hospitals' financial outcomes. We also tested for changes in financial outcomes across samples stratified by hospital characteristics: ownership type (investor-owned, nonprofit, and public), Medicaid disproportionate share hospital status, rural status, county uninsured rate quartile, and Medicaid expansion status. Our sample consisted of a balanced panel of 4,059 hospitals (8,118 observations) with data spanning 2019 and 2020. Across the full sample of hospitals, operating margins declined by an average of 5.3 percentage points between 2019 and 2020, equating to a 130% reduction from 2019 levels. Underlying these margin declines, net patient revenues declined by 3.2% on average, while operating expenses increased by 1.5%. We observed no changes in uncompensated care costs despite the large number of job losses that accompanied the pandemic. When stratifying the analysis by hospital characteristics, differences were observed across ownership types. Notably, investor-owned facilities were less affected financially than nonprofit and public hospitals. Although safety-net and rural hospitals generally fared no worse than their non-safety-net and nonrural counterparts, hospitals located in Medicaid expansion states experienced steeper declines in operating margins relative to hospitals located in nonexpansion states, driven by larger relative declines in patient revenues. The operating margin declines we observed can be attributed to supply-chain issues, persistent labor shortages, and suspension of elective services. The Affordable Care Act reforms in health insurance markets likely helped to insulate hospitals from increases in uncompensated care costs. In the shifting context of the pandemic, it is important to understand hospitals' financial performance so that measures can be taken to address further financial distress that may eventually lead to increased consolidation, hospital closures, and lower quality of care. Our findings stress the need for targeted responses that are tailored to underlying hospital characteristics. Temporary and targeted increases in inpatient and outpatient service prices can help offset revenue losses from the deferment of nonurgent care. Other policies can address the ongoing workforce challenges and supply-chain issues.

Community sociodemographics and rural hospital survival.

To determine whether community sociodemographic factors are associated with the survival or closure of rural hospitals at risk of financial distress between 2010 and 2019. We use a national sample of 985 rural hospitals at risk of financial distress to analyze the relationship between community sociodemographic characteristics and hospital survival or closure. We control for financial distress using the Financial Distress Index developed by the Sheps Center for Health Services Research. Community characteristics are retrieved from the Census and the Robert Wood Johnson Foundation. We first use Wilcoxon rank-sum tests to demonstrate annual sociodemographic differences between rural communities with financially distressed hospitals that closed between 2010 and 2019, and those that remained open. Multilevel Weibull proportional hazards regressions then uncover which sociodemographic factors are significantly associated with survival. Our initial results confirm that closures of rural hospitals at risk of financial distress disproportionately affect communities with certain sociodemographic characteristics. However, most of these characteristics are not associated with higher rates of closure in the multivariate survival analysis. The final results suggest that financially distressed hospitals are more likely to experience closure if their communities have higher rates of unemployment (Hazard Ratio = 1.36, P < .05) or uninsured residents under 65 (Hazard Ratio = 1.13, P < .05). Among financially distressed rural hospitals, specific community-level sociodemographic characteristics (unemployment and uninsurance rates) are positively associated with the likelihood of closure. Social policies addressing these issues should emphasize their broader relationship with the local health sector.

It Is Time to Rethink Adult Glaucoma Screening Recommendations.

It Is Time to Rethink Adult Glaucoma Screening Recommendations.