Uninsured Adults Research Articles

Cannabis use, use frequency, and use disorder in large metropolitan, small metropolitan, and nonmetropolitan areas

BackgroundDespite significant geographical heterogeneity of sociodemographic and clinical characteristics, little is known about potential differences in cannabis use behaviors in U.S. geographic areas. In this study, we examined cannabis use behaviors in large metropolitan, small metropolitan, and nonmetropolitan areas. We focused on interactions between geographic areas and health insurance status and medical cannabis laws (MCL). MethodsData came from the 2015–2018 National Survey on Drug Use and Health (NSDUH; N = 171,766 adults; N = 36,175 cannabis users). Weighted chi-squares tests of independence and multivariable Poisson regression models were used to examine study questions. ResultsPast-year use was highest in large metropolitan areas (16.08 %). Frequent use was highest among nonmetropolitan area users (48.67 %). Uninsured adults had a higher likelihood of past-year use (RRR = 1.21, 95 % CI = 1.14, 1.29) and frequent use (RRR = 1.27, 95 % CI = 1.14, 1.41), but a lower likelihood of cannabis use disorder (RRR = 0.77, 95 % CI = 0.66, 0.89). Uninsured adults in nonmetropolitan areas had a higher likelihood (RRR = 1.62, 95 % CI = 1.39, 1.88) of past-year use than insured nonmetropolitan area adults. MCL state residency was associated with a higher likelihood of frequent use among nonmetropolitan (RRR = 1.39, 95 % CI = 1.11, 1.74) and small metropolitan users (RRR = 1.30, 95 % CI = 1.15, 1.47). Cannabis use disorder likelihood did not vary by geographic area. ConclusionsLack of health insurance and MCL state residency are significant variables affecting cannabis use behaviors in small metropolitan and/or nonmetropolitan areas.

Delayed emergencies: The composition and magnitude of non-respiratory emergency department visits during the COVID-19 pandemic.

ImportanceCOVID‐19 has been associated with excess mortality among patients not diagnosed with COVID‐19, suggesting disruption of acute health care provision may play a role.ObjectiveTo determine the degree of declines in emergency department (ED) visits attributable to COVID‐19 and determine whether these declines were concentrated among patients with fewer comorbidities and lower severity visits.DesignWe conducted a differences‐in‐differences analysis of all commercial health insurance claims for ED visits in the first 20 weeks of 2018, 2019, and 2020. The intervention period began March 9 (week 11) of 2020, following state stay‐at‐home orders.SettingWe analyzed claims from Blue Cross Blue Shield of Louisiana (BCBSLA), located in a state with an early US COVID‐19 outbreak. Visit and patient risk was assessed through comorbidities previously described as increasing the risk of COVID‐19 decompensation, the hospital location's COVID‐19 outbreak status, and the Ambulatory Care Sensitive Condition algorithm.ParticipantsThe study population comprised all ED visits from all BCBSLA members, whether admitted or discharged. There were 332,917 ED visits over the study period. The study population spanned member demographics including sex, age, and geography. Uninsured adults were not included due to data limitations.Exposure(s)The COVID‐19 outbreak beginning March 9, 2020 in Louisiana.Main outcome(s) and measure(s)The main outcome of interest for this analysis is the difference (percent change) in all ED visits, categorized as either respiratory or non‐respiratory, from week 1–20 in 2019 and week 1–10 in 2020, compared to week 11–20 in 2020.ResultsIn this differences‐in‐differences study using data from a commercial health insurer, we found that non‐respiratory ED visits declined by 39%, whereas respiratory visits did not experience a significant decline. Visits that were potentially deferrable or from lower risk patient populations showed greater declines, but even high‐risk patients and non‐avoidable visits experienced large declines in non‐respiratory ED visits. Non‐respiratory ED visits declined by only 18% in areas experiencing COVID outbreak.Conclusions and relevanceCOVID‐19 has resulted in significant avoidance of ED care, comprising a mix of deferrable and high severity care. Hospital and public health pronouncements should emphasize appropriate care seeking.

The Relationship Between Social Determinants of Health and Racial Disparities in COVID-19 Mortality.

BackgroundThe COVID-19 pandemic has magnified existing health disparities for marginalized populations in the United States (U.S.), particularly among Black Americans. Social determinants of health are powerful drivers of health outcomes that could influence COVID-19 racial disparities.MethodsWe collected data from publicly available databases on COVID-19 death rates through October 28, 2020, clinical covariates, and social determinants of health indicators at the U.S. county level. We utilized negative binomial regression to assess the association between social determinants of health and COVID-19 mortality focusing on racial disparities in mortality.ResultsCounties with higher death rates had a higher proportion of Black residents and greater levels of adverse social determinants of health. A one percentage point increase in percent Black residents, percent uninsured adults, percent low birthweight, percent adults without high school diploma, incarceration rate, and percent households without internet in a county increased COVID-19 death rates by 0.9% (95% CI 0.5%–1.3%), 1.9% (95% CI 1.1%–2.7%), 7.6% (95% CI 4.4%–11.0%), 3.5% (95% CI 2.5%–4.5%), 5.4% (95% CI 1.3%–9.7%), and 3.4% (95% CI 2.5%–4.2%), respectively. Counties in the lowest quintile of a measure of economic privilege had an increased COVID-19 death rates of 67.5% (95% CI 35.9%–106.6%). Multivariate regression and subgroup analyses suggested that adverse social determinants of health may partially explain racial disparities in COVID-19 mortality.ConclusionsThis study demonstrates that social determinants of health contribute to COVID-19 mortality for Black Americans at the county level, highlighting the need for public health policies that address racial disparities in health outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40615-020-00952-y.

Untreated Dental Caries May be Associated with Subsequent Mortality among Working-Age Adults: Evidence from NHANES III.

Poor oral health has been shown to be associated with selected adverse health outcomes. This study assessed the association between untreated dental caries and mortality and examined whether having dental insurance mitigates the risk of mortality among working-age US adults with dental caries. Analysis used the publicly available linked mortality file for NHANES III, an observational study conducted in 1988-1994, with follow-up through December 2015. Propensity score matching was conducted to create similar populations of insured and uninsured adults, resulting in a sample of 4420 matched observations. The Cox proportional hazard model was used to investigate the effect of untreated dental caries and that of dental insurance on risk of all-cause mortality. The descriptive and final outcome statistical analyses were adjusted for complex sampling technique using weights, strata and cluster variables. Adults with untreated dental caries had a higher risk of mortality (HR: 1.33; 95% CI: 1.06-1.68) than those with no dental caries. Having dental insurance was associated with a lower risk of mortality (HR: 0.73; 95% CI: 0.59-0.92). An interaction between caries treatment status and dental insurance was not statistically significant. Adults with untreated dental caries have a higher risk of mortality, even in the presence of dental insurance. Untreated caries may be an indicator for multiple risk factors, including personal attitudes regarding health and healthcare-seeking behaviour.

PCN173 Insurance Status and Health Care Resource Utilization Among NON-Institutionalized Adult Cancer Survivors in the United States

To examine the association between insurance status and healthcare resource utilization among cancer survivors in the United States. A retrospective cross-sectional analysis of 2017 Medical Expenditure Panel Survey for cancer survivors aged ≥18 years, identified using International Classification of Diseases, Tenth Revision codes specific for cancer. Key independent variable was health insurance coverage categorized as private, Medicare, Medicaid and uninsured. Dependent variables consisted of health care visits (office-based, hospital outpatient, emergency room and inpatient hospital stays). Separate multivariable negative binomial regressions were used to assess the adjusted differences in number of healthcare visits by insurance status after controlling for confounding factors. A total of 1140 adult cancer survivors (weighted:138,785,30) were identified. In the unadjusted analysis, adults with Medicare coverage had highest mean office-based visists followed by those with private insurance 15.6 (Standard Deviation(SD):30) vs 14.6 (SD:20.9);p<0.05) while emergency room(ER) visits were greater for adults with Medicaid and least for uninsured (0.58;SD:3.71 vs 0.30;SD:2.02;p<0.0001). When stratified by the type of cancer, patients with lung cancer had higher number of office-based (16.6;SD:7.09), outpatient (4.4;SD:15.5) and inpatient visits (0.42;SD:3.7) when compared to breast, colon, malignant neoplasms of skin and other types of cancer. In the adjusted analyses, the expected office-based visits for uninsured adults decreased by 47% (95% Confidence Interval (CI): 10% to 69%;p<0.05) when compared to those with private insurance. The expected number of ER visits for Medicaid were 2.15(95%CI: 1.24 to 3.7) times and for Medicare were 1.52(95%CI: 1.1 to 2.1) times higher the expected number of ER visits for private insurance(p<0.05). However, hospital outpatient and inpatient stays visits did not differ significantly between the insurance groups. Our findings suggest that office-based and emergency room vists can vary significantly by insurance status among adult cancer survivors. This data can be used for appropriate health care planning, especially for the cancer survivors.

Abstract PO-004: Association between county-level socioeconomic characteristics and health indicators with COVID-19 deaths in Florida

Abstract COVID-19 has exposed the long standing racial health disparities and social inequities in the United States. It has also brought into focus the need of the vulnerable communities including racial and ethnic minority groups. health care reforms. The purpose of this analysis is to investigate county-level COVID-19 death rates with key socioeconomic and health indicators using correlation analysis. Death rates are calculated using deaths that occurred in Florida (n = 7,022 deaths) between March 1, 2020 and July 31, 2020. We hypothesize that counties with higher uninsured and older people have higher COVID-19 death rates. Data on COVID-19 county statistics is obtained from Florida Department of Health. County-level health indicators are obtained from Florida Health Community Health Assessment Resource Tool Set (CHARTS) and the County Health Rankings and Roadmap program of the Robert Wood Johnson Foundation. Spearman rank correlation, a non-parametric method, is applied to measure associations. We find that higher share of uninsured adults in a county is significantly associated with higher death rates from COVID-19. In addition, percent older than 65 is correlated death rates. However, contrary to other previous studies, we do not find a correlation between share of African Americans and death rates in Florida counties. Further, we do not find that death rates are correlated with measures of diabetes, smoking, and obesity. The policy implication of this investigation points to the vulnerability of communities without health insurance to the COVID-19 pandemic and the urgent need for health care reform. This research was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under the Award Number U54 MD007582. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This research was also made possible by Grant Numbers U54CA233396, U54CA233444, &amp; U54CA233465 from the National Institutes of Health (NIH), National Cancer Institute (NCI). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCI. Citation Format: Gebre-Egziabher Kiros, Kira Gaddis. Association between county-level socioeconomic characteristics and health indicators with COVID-19 deaths in Florida [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-004.

Tobacco Product Use Among Adults - United States, 2019.

Cigarette smoking remains the leading cause of preventable disease and death in the United States (1). The prevalence of current cigarette smoking among U.S. adults has declined over the past several decades, with a prevalence of 13.7% in 2018 (2). However, a variety of combustible, noncombustible, and electronic tobacco products are available in the United States (1,3). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC analyzed data from the 2019 National Health Interview Survey (NHIS). In 2019, an estimated 50.6 million U.S. adults (20.8%) reported currently using any tobacco product, including cigarettes (14.0%), e-cigarettes (4.5%), cigars (3.6%), smokeless tobacco (2.4%), and pipes* (1.0%).† Most current tobacco product users (80.5%) reported using combustible products (cigarettes, cigars, or pipes), and 18.6% reported using two or more tobacco products.§ The prevalence of any current tobacco product use was higher among males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Native (AI/AN) adults; those whose highest level of educational attainment was a General Educational Development (GED) certificate; those with an annual household income <$35,000; lesbian, gay, or bisexual (LGB) adults; uninsured adults and those with Medicaid; those with a disability; or those with mild, moderate, or severe generalized anxiety disorder. E-cigarette use was highest among adults aged 18-24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes. Implementing comprehensive, evidence-based, population level interventions (e.g., tobacco price increases, comprehensive smoke-free policies, high-impact antitobacco media campaigns, and barrier-free cessation coverage), in coordination with regulation of the manufacturing, marketing, and sale of all tobacco products, can reduce tobacco-related disease and death in the United States (1,4). As part of a comprehensive approach, targeted interventions are also warranted to reach subpopulations with the highest prevalence of use, which might vary by tobacco product type.

Impact of cash incentives for low-income individuals to seek a primary care visit on mental health outcomes: Evidence from a randomized controlled trial.

We explore whether a cash incentive to see a primary care provider (PCP) improves self-reported depression, anxiety, and pain among low-income patients in a randomized trial. Secondary outcomes of a randomized controlled trial, enrolling low-income uninsured adults to receive cash incentives ($0, $25, $50) to see a PCP. Interview data was collected at enrollment and 12 months later. Health outcomes were measured with the PROMIS depression, anxiety, and pain interference scales. We estimated adjusted logistic regressions to determine whether self-reported improvements occurred in depression, anxiety, or pain. 981 subjects completed surveys 12 months following study enrollment (80% retention). Subjects who were incentivized were 5.7 percentage points more likely to see a PCP in the initial six months (p<0.05). Incentivized subjects were 6 percentage points more likely to experience an improvement in depression and pain at 12 months. Among those who reported high levels of depression and pain at baseline, they were 10.6 and 8 percentage points, respectively, to experience an improvement relative to those who were not incentivized. Meaningful improvements were observed for depression and pain PROMIS domains for subjects randomized to the incentive groups, presumably through their interaction with a PCP and the health care system. This finding was robust for the full sample and a group that reported more severe symptoms at baseline.

Precarious Work and Precarious Welfare: How the Pandemic Reveals Fundamental Flaws of the U.S. Social Safety Net

Almost all forms of social insurance in the United States are tied to employment, or to family ties to an employee. The employment link to social insurance has proved to be a catastrophe during the COVID-19 pandemic and the resulting economic downturn. Yet, however untenable it is in the modern economy and however much it exacerbates inequality, the employment link to social insurance is an institutional design choice that stems from a series of political compromises that were made when the Social Security Act was created in 1934-35, and from the ways that firms and state governments have responded to its requirements in the years since. The systemic weaknesses exist because the interests and voices of workers were largely absent from the program design and legislative debates.The social insurance system built without the voices of workers has huge gaps even in good economic times. Only about half of unemployed workers receive unemployment insurance benefits (“UI”) when they lose their jobs, and only 12 percent of part-time workers received UI. In 2018, 8.5 percent of people lacked health insurance, often because they lived in states that did not expand Medicaid and earned slightly too much to qualify for subsidized insurance, or were immigrants. In July 2020, the percentage of uninsured adults nearly doubled, to 16 percent, on account of job losses and states’ failures to expand eligibility for Medicaid.In this essay, we explain how the pandemic brought into sharp focus the institutional design flaws in tying the American social welfare system to employment. In contrast to experiences in other industrialized countries both before and during the pandemic, these design flaws have magnified hardship for the least privileged members of American society and amplified inequalities of race, class, immigration status, and gender. The pandemic-induced crisis of inadequate protections prompted Congress to pass legislation to address some of these problems of policy design, but most of these reforms are both temporary and inadequate. Much legislative work remains to be done, and we explore some possibilities that Congress and the White House should consider.

Comprehensive Dental Care in Canada: The Choice Between Denticaid and Denticare

A healthy mouth is an essential ingredient for overall good health, but a Canadian’s access to comprehensive dental care is dependent on their ability to attain private insurance. This paper seeks to estimate the gross and net total cost of two policy options for introducing comprehensive dental care into Canadian Medicare. Using a micro-costing approach for estimating the annual clinical costs, and an average-costing approach for annual administrative expenses, this paper estimated the total cost of universal first dollar dental coverage (denticare) and public dental insurance for children and uninsured adults in Canada (denticade). If the denticare option was implemented in the year 2019, the gross total public-sector cost would to be roughly $15.68 billion. This would replace the current $1.02 billion spent on existing public health dentistry programs and $6.27 billion spend on public employee’s dental plans. The total cost could be further offset by the inclusion of income-tiered premiums set at a maximum rate below private insurance provider prices. The net total cost of denticare would then be an aggregate decrease in public spending by $127.08 million. If the denticade option was implemented in the year 2019, the gross total public-sector cost would to be roughly $8.43 billion. This would replace the current $1.02 billion spent on existing public health dentistry programs but would not replace spending on public employee’s dental plans. The total cost could be further offset by the inclusion of income-tiered premiums and copayments. The net total cost of denticade would an aggregate increase in public spending by $1.41 billion. The results of this costing analysis demonstrate that by pursuing the universal first-dollar coverage option, Canadians taxpayers could see a reduction in tax-based spending and a considerable decrease in dental premiums changed than if the denticade approach was pursued.

Healthcare utilisation and expenditure patterns for cardio-metabolic diseases in South Asian cities: the CARRS Study.

ObjectiveTo estimate average annual expenditures per person, total economic burden and distress health financing associated with the treatment of five cardio-metabolic diseases (CMDs—hypertension, diabetes, heart disease (angina, myocardial infarction and heart failure), stroke and chronic kidney disease) in three metropolitan cities in South Asia.DesignCross-sectional surveys.SettingWe analysed community-based baseline data from the Centre for cArdio-metabolic Risk Reduction in South Asia (CARRS) Study collected in 2010–2011 representing Chennai and New Delhi (India), and Karachi (Pakistan).ParticipantsWe used data from non-pregnant adults (≥20 years) from the aforementioned cities that responded to a cost-of-illness questionnaire. We estimated health utilisation and expenditures among those reporting taking treatment(s) for the aforementioned CMDs in the last 1 year. We converted all costs to International Dollars (Int$ 2011) and inflated to 2018 values. The annual costs per person were stratified by city, sociodemographic characteristics, contributor of costs and financing methods. The total economic burden of CMDs for each city was projected using age-standardised prevalence and per-person costs of diseases reported in CARRS, applying these to population data from the most recent census. We also calculated distress financing (DF) as having to borrow or sell assets to pay for CMD treatment and identified sociodemographic groups at most risk of DF using multiple regression.ResultsOf 16 287 CARRS participants, 2883 (17.7%) reported receiving treatment for CMDs. The total annual expenditures reported per patient for CMDs ranged from Int$358 to Int$2425. Medications constituted 46% of total direct expenditures and out-of-pocket (OOP) expenditures accounted for nearly 80% of financing these health expenditures. Total economic burdens of CMDs were Int$0.42 billion, Int$3.4 billion and Int$1.4 billion in Chennai, New Delhi and Karachi, respectively. Overall, 36.1% experienced DF, and women (OR=4.4), unemployed (OR=10.7) and uninsured (OR=8.1) adults experienced higher odds of DF.ConclusionCMDs are associated with large economic burdens in South Asia. Due to most payments coming from OOP expenditures and limited insurance, the odds of DF are high.

Albert Einstein College of Medicine.

Albert Einstein College of Medicine.

P138 An Exploration of Nutrition Education Needs and Barriers of Uninsured Clients of Free Clinics in Western North Carolina

<h3>Background</h3> North Carolina has an uninsured population of 10.7%, the tenth highest in the country, and many uninsured adults must rely on free health clinics for prevention and treatment of chronic disease. However, little is known about the nutrition education needs of uninsured adults served by free health clinics, and potential acceptable strategies for intervention. <h3>Objective</h3> To conduct a needs assessment in western North Carolina to explore nutrition education needs, internet access, barriers, and feasibility of potential nutrition interventions for adults served by free health clinics. <h3>Study Design, Setting, Participants</h3> A semi-quantitative survey was distributed to 156 clients in waiting rooms of 2 free health clinics in western North Carolina. <h3>Measurable Outcome/Analysis</h3> Descriptive analyses were conducted using IBM's SPSS version 26 to determine frequencies for demographics, current nutrition knowledge, barriers, and internet access. <h3>Results</h3> Roughly 60% of participants were female with an average age of 45 (±12.81), and the majority were Caucasian (81%). Nearly one-third of participants requested interventions focused on managing diabetes (32%), hypertension (39%), and heart disease (32%). Most participants were interested in interventions focused on produce (87%) and recipe ideas (73%). Barriers to cooking included: budgeting/cost, time constraints, lack of access to food and cooking equipment, disabilities, and homelessness. The majority reported having regular access to smartphones (70%), internet (60%), and were open to receiving nutrition education through social media (41%) and online videos (43%). <h3>Conclusions</h3> This study adds to the limited body of literature on nutrition education needs and potential strategies/foci of intervention for uninsured adults who rely on free health clinics. Results suggest nutrition interventions should work alongside clinics to address equipment and food access to facilitate the preparation and selection of healthier items. Additionally, future interventions could leverage online modalities to support and enhance in-person nutrition education offered through clinics.

Early Delays in Insurance Coverage and Long-term Use of Home-based Peritoneal Dialysis.

Uninsured patients with end-stage renal disease face barriers to peritoneal dialysis (PD), a type of home dialysis that is associated with improved quality of life and reduced Medicare costs. Although uninsured patients using PD at dialysis start receive retroactive Medicare coverage for required predialysis services, coverage only applies for the calendar month of dialysis start. Thus, initiating dialysis later in the month yields longer retroactive coverage. To examine whether differences in retroactive Medicare were associated with decreased long-term PD use. We exploited the dialysis start date using a regression discontinuity design on a national cohort from the US Renal Data System. 36,256 uninsured adults starting dialysis between January 1, 2006 and December 31, 2014. PD use at dialysis days 1, 90, 180, and 360. Starting dialysis on the first versus last day of the calendar month was associated with an absolute decrease in PD use of 2.7% [95% confidence interval (CI), 1.5%-3.9%], or a relative decrease of 20% (95% CI, 12%-27%) at dialysis day 360. The absolute decrease was 5.5% (95% CI, 3.5%-7.2%) after Medicare established provider incentives for PD in 2011 and 7.2% (95% CI, 2.5%-11.9%) after Medicaid expansion in 2014. Patients were unlikely to switch from hemodialysis to PD after the first month of dialysis (probability of 6.9% in month 1, 1.5% in month 2, and 0.9% in month 4). Extending retroactive coverage for preparatory dialysis services could increase PD use and reduce overall Medicare spending in the uninsured.

Outpatient Visits among Older Adults Living Alone in China: Does Health Insurance and City of Residence Matter?

This study aimed to examine the association between health insurance, city of residence, and outpatient visits among older adults living alone in China. A sample of 3173 individuals was derived from “Survey on Older Adults Aged 70 and Above Living Alone in Urban China” in five different cities. Logistic regression models indicated that older adults living alone who had urban employee basic medical insurance, urban resident basic medical insurance, and public medical insurance were more likely to have outpatient visits than those without any health insurance. After controlling the number of chronic diseases, only those with public medical insurance were more likely to have outpatient visits than uninsured older adults. Additionally, older adults who resided in Shanghai and Guangzhou were more likely to have outpatient visits than those in Chengdu, whereas older adults who were in Dalian and Hohhot were less likely to have outpatient visits. To improve the equity of outpatient visits among older adults living alone in China, policy efforts should be made to reduce fragmentation of different health insurance plans, expand the health insurance coverage for older adults, provide programs that consider the needs of this special group of older adults, and reduce the inequality in health resources and health insurance policies across cities.

Medicaid expansion and trends in cancer stage at diagnosis.

e14129 Background: Cancer stage distribution offers an early window into the effect of the ACA’s 2014 Medicaid expansion. If Medicaid expansion enabled uninsured adults to access preventive care, then the proportion of cancers diagnosed at early stage should be higher in states that adopted it. Methods: Patient level data were retrieved from SEER-18, New York and Texas cancer registries from January 2010 to December 2015, for eight common tumor types; including N = 2,493,589 (breast, cervical, colorectal, prostate, lung) screen detectable and N = 369,203 (testis, kidney and uterine corpus) not detected by routine screening. Patients were categorized by residence in states that were: 1) Non-expanders; 2) Expanders - income eligibility thresholds increased from 0% to 138% of the federal poverty level (FPL) in 2014; and 3) Pre-Expanders, with pre-2014 eligibility thresholds &gt; 70% of FPL. Stage distributions were compared before and after January 2014, categorized by AJCC stage and using ordinal stage equivalent (OSE) which assigns a numeric score based on AJCC stage. Difference in difference in difference (D3) methods compared patients ≥65 versus &lt; 65, and screen-detectable versus not. Multivariable logistic regression was used to adjust for variation in age, sex, race, ethnicity and tumor site across states. Results: No differences in stage distribution were observed across the three categories of state. (Table). D3 analysis revealed no difference between trends in the over 65s, or for screen-detectable cancers. Adjustment for age, sex, race, ethnicity and tumor site made no significant difference to these results. Conclusions: States’ Medicaid expansion status in 2014 was not associated with a significant difference in early stage diagnoses for adults with cancer diagnosed before age 65. Obstacles to early cancer detection other than financial access must be addressed to improve population-level outcomes. [Table: see text]

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

The Affordable Care Act (ACA) introduced wide-ranging health care reforms but faces many challenges. This article reviews 6 key points for today’s nurse leader on the law’s 10th anniversary: a renewed legal battle is on its way to the Supreme Court; 27 million people still lack coverage, partly due to nonexpansion of Medicaid in 15 states; Medicaid waivers provide coverage for some low-income people but leave many people out; value-based purchasing has allocated billions of dollars in rewards and penalties; ACA Marketplace plans are not always affordable, but premiums are stabilizing; and the 2020 elections could result in dramatic consequences for health care reform.

Out of the Woodwork: Enrollment Spillovers in the Oregon Health Insurance Experiment

We analyze the impact of expanded adult Medicaid eligibility on the Medicaid enrollment of already-eligible children. To do so, we exploit the 2008 Oregon Medicaid lottery, in which some low-income uninsured adults were randomly selected for the chance to apply for Medicaid. Children in these households were eligible for Medicaid irrespective of whether the household won the lottery. We estimate statistically significant but transitory impacts of adult lottery selection on children’s Medicaid enrollment: for every 9 adults who enroll in Medicaid due to the lottery, one additional child also enrolls at the same time. Our results shed light on the existence, magnitude, and nature of so-called “woodwork effects.

Prevent and Protect: A Vaccination Initiative for Uninsured Patients at a Student-Run Free Clinic.

Lower vaccination rates in uninsured adults may be related to prohibitive costs of and limited access to vaccines. To compare Tdap and pneumococcal vaccination rates of a student-run free clinic to national averages. A retrospective chart review of 236 adult patients from 05/2017 to 06/2019 was conducted. Vaccine eligibility was determined according to CDC guidelines at the time of the patient visit and according vaccination history by review of medical records. Percent up-to-date was determined by dividing the number of up-to-date individuals by the total number of patients eligible for the vaccine. BRIDGE Healthcare Clinic vaccination rates were near or surpassed national averages. The percent of up-to-date individuals was 63.1% for Tdap, 90% for pneumococcal vaccines in adults 65 or older, and 86.5% for pneumococcal vaccines in high-risk adults 18-64years. This compares with 2017 national averages of 63.4%, 69%, and 24.5%, respectively (Center for Disease Control and Prevention (CDC) Vaccination coverage among adults in the United States, National Health Interview Survey. Retrieved February 8, 2018 from https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2017.html#pneumo , 2017). Of the 197 vaccines provided during the course of this study, 184 were provided by the BRIDGE Healthcare Clinic. In conclusion, with the appropriate funding and stewardship, student-run free clinics play a resourceful role in increasing access to preventative health care for uninsured patients.

Interprofessional Collaborative Practice Model to Advance Population Health

The purpose of this paper is to describe the development, implementation, and lessons learned associated with an interprofessional collaborative practice (IPCP) care delivery model initiated at the University of Alabama at Birmingham (UAB). The model emphasizes transitional care coordination in chronic disease management for underserved and vulnerable populations. The model operates within a clinic environment with care providers from a variety of disciplines who integrate individual case management and actualize leadership taken by the appropriate discipline based on the needs of each patient. Two clinics will be discussed - Providing Access to Healthcare (PATH) and Heart Failure Transitional Care Services for Adults (HRTSA) - both of which leverage the resources of an existing academic-practice partnership between the UAB School of Nursing and UAB Hospital (UABH) and Health System. Clinic target patient populations are uninsured adults with diabetes (PATH Clinic) and uninsured or underinsured adults with heart failure (HRTSA Clinic) who are discharged from UABH with no source for ongoing care. The model uses a nurse-led, team-based approach that involves multiple professions working together to provide care for high-need, high-cost patients. Clinics use 4 simultaneous bundles of care that include evidence-based treatment guidelines, transitional care coordination activities, patient activation strategies, and behavioral health integration. Engaged patients indicate very high levels of satisfaction with care and improved physical and mental health outcomes resulting in significant cost savings for the health system. Finally, IPCP team members report joy in their work within the clinics.