Uninsured Individuals Research Articles

County-level disparities in care for patients with glioblastoma.

Racial and socioeconomic disparities in neuro-oncological care for patients with brain tumors remain underexplored. This study aimed to analyze county-level disparities in glioblastoma (GBM) care in the United States, focusing on access to surgery and the use of adjuvant temozolomide chemotherapy and radiation therapy. Using repeated cross-sectional data from the Surveillance, Epidemiology, and End Results 17 database; the Area Health Resources File; and the American Community Survey, from 2010 to 2019, the authors performed multivariate regression analyses to understand the associations between county-level racial and socioeconomic characteristics, as well as the rates of surgery performed, delays in surgery, and use of adjuvant chemotherapy and radiation therapy for newly diagnosed GBM. In total, 29,609 GBM patients from 602 different US counties over a decade were included in this study. Counties with lower rates of surgery for GBM were associated with a higher percentage of Black residents (coefficient [CE] -0.001, 95% CI -0.002 to 0; p < 0.05) and being located in the Midwest (CE -0.132, 95% CI -0.195 to -0.069; p < 0.001) or West (CE -0.127, 95% CI -0.189 to -0.065; p < 0.001) relative to the Northeast. Counties with delayed surgical treatment were more likely to lack neurosurgeons (adjusted OR [aOR] 2.52, 95% CI 1.77-3.60; p < 0.001), have a higher percentage of Black residents (aOR 1.011, 95% CI 1.00-1.02; p < 0.05), and be located in the Midwest (aOR 3.042, 95% CI 1.12-8.24; p < 0.05) or West (aOR 3.175, 95% CI 1.12-8.97 p < 0.05). Counties with high rates of adjuvant radiation therapy were less likely to have higher percentages of Black residents (aOR 0.987, 95% CI 0.980-0.995; p < 0.01) and uninsured individuals (aOR 0.962, 95% CI 0.937-0.987; p < 0.01). Counties without neurosurgeons and those with a higher percentage of Black patients have delays in surgical care and demonstrate lower overall rates of surgery and adjuvant therapy for GBM. This study underscores the need for targeted interventions and policies that address structural barriers in healthcare access, improve equitable distribution of the neurosurgery workforce, and ensure timely and comprehensive GBM care to all populations.

Characteristics of Prescription Drug Fills Using Pharmacy-Pharmacy Benefit Manager Discount Programs: The “GoodRx” Model

ObjectivesThis study aimed to characterize products using pharmacy-pharmacy benefit manager (PBM) discounts and to estimate the association among such discounts, prescription utilization, and out-of-pocket costs. MethodsThis is a retrospective cohort study using IQVIA’s Formulary Impact Analyzer, which contains anonymized, individual-level pharmacy claims representing US retail pharmacy transactions. We focused on 20 products with the greatest number of transactions using a pharmacy-PBM discount. Our unit of analysis was a treatment episode, defined as the length of time from an incident fill to no continuous use for 60 consecutive days after allowing for indefinite stockpiling. Outcome measures included products with greatest pharmacy-PBM discount use, characteristics of treatment episodes, and out-of-pocket costs with and without pharmacy-PBM discount. ResultsAcross all products, 3.82% of transactions and 7.69% of treatment episodes were accompanied by a pharmacy-PBM discount. Commonly discounted products included generic treatments for chronic disease (lisinopril, levothyroxine, metformin) and neuropsychiatric conditions (alprazolam, amphetamine, buprenorphine, hydrocodone). The median postdiscount out-of-pocket cost was >2.5-fold higher during treatment episodes with a discount than those without ($15.15, interquartile range [IQR] $8.53-32.00, vs $5.88, IQR $1.40-15.00). Median treatment episode duration was 249 days (IQR 132-418) with discount use compared with 236 days (IQR 121-396) without discount use, although treatment episodes that began with a discount had fewer transactions per treatment episode and were shorter (median 212 days, IQR 114-360) than those that did not (313 days, IQR 178-500). ConclusionsPharmacy-PBM discounts may foster market competition and improve access for under- and uninsured individuals; however, these programs may not generate savings for many insured individuals.

Community Outreach in Breast Imaging: What Radiologists Can Do to Close the Gap for the Uninsured Population.

After implementation of the Affordable Care Act in 2010, the uninsured population of the United States decreased significantly. As of 2022, there were approximately 26.4 million uninsured individuals in the United States. The lack of coverage and access to services disproportionally affect minority groups in the country, reflecting the influence of the social determinants of health in their uninsured status. Use of screening mammography, an effective modality that results in early detection of and decreased mortality from breast cancer, was delayed or postponed by women of all races due to lockdowns and fear during the COVID-19 pandemic. Since then, the return to mammographic screening has lagged among minorities, further increasing their disproportionate screening gap. Radiologists-and more specifically breast imagers-must recognize these issues, as people who are uninsured and part of minority groups are diagnosed with breast cancer at later stages and have higher mortality rates, less continuity of care, and overall lower survival. The purpose of this article is to familiarize radiologists with the uninsured population, explain how they are disproportionally affected by breast cancer, and propose strategies that breast imagers can pursue to improve screening access and decrease compliance gaps for this patient population. ©RSNA, 2023 See the invited commentary by Nguyen in this issue. Quiz questions for this article are available through the Online Learning Center.

Provision of Cognitive Behavior Therapy for Depression and Anxiety Disorders by Medical Student Trainees.

The purpose of the article is to evaluate an innovative education program in which medical students were trained in cognitive behavior therapy (CBT) and provided CBT treatments under supervision to uninsured individuals with depressive, anxiety, adjustment, and trauma-based disorders. The authors assessed improvements in trainees' CBT knowledge using the Cognitive Therapy Awareness Scale before and after their didactic training. CBT supervisors rated trainees' clinical competencies utilizing standardized checklist evaluations based upon supervision reports. The authors employed mixed effects ANOVA and regression modeling to test the association between the addition of CBT to treatment as usual (TAU) and improvements in patients' depressive and anxious symptom severity. The authors collected feedback and self-assessment of functioning with a Psychotherapy Feedback Questionnaire. Medical students showed increases in CBT knowledge that were maintained six months later and demonstrated satisfactory competency in CBT techniques. The addition of CBT to TAU was associated with greater improvements in depressive, but not anxious, symptom severity. However, among the TAU + CBT group, there was an association between the number of CBT sessions received and the magnitude of improvement in anxious symptoms from baseline. Patients gave positive feedback to medical student CBT providers and reported improvements in broad domains of psychosocial functioning. Medical students can provide competent and clinically beneficial CBT treatments for depression and anxiety disorders. These findings have implications for medical training and support the use of medical students to deliver care for individuals with limited access to psychotherapy.

Antivenom for sale? Availability and affordability of snakebite medicines across public and private health facilities in Rwanda

Antivenom is considered the safest and most effective treatment against snake envenomation (SBE); however, global shortages mean that many low-income countries struggle to meet demand. In Rwanda, chronic shortages of essential medicines are an important barrier to robust healthcare delivery and discourage snakebite victims from seeking hospital care. The aim of this retrospective, cross-sectional study was to evaluate the availability and affordability of commodities to treat SBE at hospitals and health centers. In total, our team interviewed pharmacy managers at 111 public and 31 private health facilities (N = 142) to complete a validated quantitative questionnaire, entering data electronically through KoBoCollect. Commodity prices were collected in 2023RWF and for the lowest cost item across any category. A commodity was considered affordable if a treatment regimen cost less than one day's wages, using the international poverty line to approximate a low-income worker's wages. Across all health facilities, mean availability of SBE commodities was relatively good (77.1%). Snake antivenom was only available at public hospitals and was concentrated in urban rather than rural areas. Two snake antivenom types were observed, one of which was not appropriate for treating envenomation by East African snakes. Overall, this meant that only 4.2% of facilities stocked safe and effective antivenom. Black stones, an ineffective traditional treatment, were sold by 5.6% of health providers. Moreover, antivenom did not meet the minimum threshold for affordability, costing on average 10 days of work for a single dose among uninsured individuals. Altogether, this study highlights serious performance gaps among pharmacies responsible for procuring and supplying SBE commodities and helps to explain the widespread belief that SBE treatment is unaffordable at hospitals and health centers. Urgent action is needed to ensure that all hospital and health center pharmacies located in high-risk areas stock appropriate antivenom and that re-stocking time for essential medicines is reduced.

Association between acculturation, dental floss use, dental visits and unmet dental needs among Asians in the United States: Findings from National Health and Nutrition Examination Survey (NHANES) 2011-2018.

The objectives of this study were to examine the associations between acculturation and dental floss, regular dental visits and unmet dental care needs among Asian Americans, as well as the moderating effects of these associations. This study analysed national representative samples from the National Health and Nutrition Examination Survey (NHANES) 2011-2018. A total of 2763 Asian Americans aged 20 and older were included in this analysis. The primary predictor, acculturation score, was determined by three questions: (i) language spoken at home (higher score for English), (ii) country of birth (higher score for United States) and (iii) length of time in the United States. Dental floss use, dental visits and unmet dental care needs were included as outcomes in this study. Descriptive statistics and logistic regressions were used to analyse the samples. Acculturation was significantly associated with dental health behaviours: Individuals with higher levels of acculturation were more likely than less acculturated individuals to use dental floss (81.0% vs. 63.9%, respectively) and visit the dentist regularly (76.7% vs. 66.9% respectively). Insurance status moderated the association between acculturation and dental visits: Acculturation was significantly associated with dental visits in the past year among insured individuals (OR = 1.70, 95% CI: 1.29-2.23), but not among uninsured individuals. Unmet dental care needs were present in 11.1% of participants. While costs and insurance were the top two determinants of access to care, individuals with and without insurance differed with regard to their third major reason for unmet dental care needs: Being 'too busy' and not wanting to spend money on dental care. Among the Asian population in the United States, those with high acculturation scores were more likely to engage in dental flossing and visit the dentist regularly compared to those Asians with lower acculturation scores. To encourage dental flossing and regular dental visits among Asians with lower acculturation scores, cultural adaptation and language accessibility suggests being considered. Future research is necessary to confirm the moderating effect of insurance status on the association between acculturation and regular dental visits. Additionally, our findings emphasize the impact of costs and insurance on access to dental care among Asians in the United States, highlighting the importance of future public health programmes in addressing these barriers.

The role of insurance status in the association between short-term temperature exposure and myocardial infarction hospitalizations in New York State.

To evaluate effect modification of the relationship between short-term ambient temperature and MI, by individual-level insurance status (insured vs. uninsured). We identified MI hospitalizations and insurance status across New York State (NYS) hospitals from 1995 to 2015 in the New York Department of Health Statewide Planning and Research Cooperative System database, using International Classification of Diseases codes. We linked short-term ambient temperature (averaging the 6 hours preceding the event [MI hospitalization]) or nonevent control period in patient residential zip codes. We employed a time-stratified case-crossover study design for both insured and uninsured strata, and then compared the group-specific rate ratios. Over the study period, there were 1,095,051 primary MI admissions, 966,475 (88%) among insured patients. During extremely cold temperatures (<5.8 °C) insured patients experienced reduced rates of MI; this was not observed among the uninsured counterparts. At warmer temperatures starting at the 65th percentile (15.7 °C), uninsured patients had higher rates than insured patients (e.g., for a 6-hour pre-event average temperature increase from the median to the 75th percentile, the rate of MI increased was 2.0% [0.0%-4.0%] higher in uninsured group). Uninsured individuals may face disproportionate rates of MI hospitalization during extreme temperatures.

Cost-based Underinsurance After the Affordable Care Act

Abstract: The Affordable Care Act has significantly reduced the number of uninsured individuals in the U.S., yet millions of insured Americans lack adequate coverage or face substantial health-related financial risks. In this study, we conduct an analysis of a nationally representative sample to generate up-to-date evidence on the association between insurance types and demographic factors and the probability of cost-related underinsurance among continuously insured, lower-income adults in the U.S. We extend the previously established definition of underinsurance by including a measure of subjective financial burden. Our estimates suggest that 33.2% of lower-income individuals in our sample were underinsured, with a fourth of them meeting two or three criteria. We also find that Medicaid beneficiaries were significantly less likely than others to experience underinsurance. Our findings provide evidence that underinsurance is a major concern, and expansion of coverage alone may not suffice to protect individuals from financial risks and cost barriers to health care use.

Perceptions of COVID-19 and the Use of Health Information Technology Among People Who Are Uninsured: Multimethod Survey Study.

As of May 2023, the novel SARS-CoV-2 has claimed nearly 7 million lives globally and >1.1 million lives in the United States. Low-income populations are often disproportionately affected by risk factors such as lifestyle, employment, and limited health literacy. These populations may lack the knowledge of appropriate infection precautions or have reduced access to care during illness, particularly in countries without universal health care. We aimed to explore the perceptions and experiences of COVID-19, including symptoms and risk factors among uninsured individuals seeking care at a free medical clinic, and to obtain respondents' perceptions of and suggestions for adapting a mobile health (mHealth) app to an uninsured population known to have low health literacy. We conducted a prospective multimethod survey study with a convenience sample of uninsured adults seeking care at 3 free clinics in the United States. Respondents were questioned about their risk for and awareness of COVID-19 symptoms, COVID-19 testing, current technology use, and the use of technology to facilitate their health regarding COVID-19. Data were analyzed using descriptive statistics (eg, frequencies and mean differences). In addition, a small subset of respondents from one of the clinics (n=10) participated in interviews to provide feedback about the design of a COVID-19 web-based smartphone (mHealth) app. The survey respondents (N=240) were 53.8% (n=129) female, were primarily White (n=113, 47.1%), and had a mean age of 50.0 (SD 11.67; range 19-72) years. Most respondents (162/222, 73%) did not think that they were at risk for COVID-19. Although respondents reported only moderate confidence in their knowledge of the short- and long-term symptoms of COVID-19, their knowledge of the symptoms aligned well with reports published by the Centers for Disease Control and Prevention of the most common acute (590/610, 96.7%) and long-term (217/271, 80.1%) symptoms. Most respondents (159/224, 71%) reported an interest in using the mHealth app to gain additional information regarding COVID-19 and available community resources. Respondents who were interviewed provided suggestions to improve the mHealth app but had overall positive perceptions about the potential usefulness and usability of the app. It was encouraging that the knowledge of COVID-19 symptoms aligned well with the reports published by the Centers for Disease Control and Prevention and that respondents were enthusiastic about using an mHealth app to monitor symptoms. However, it was concerning that most respondents did not think they were at a risk of contracting COVID-19.

Asian American Enclaves and Healthcare Accessibility: An Ecologic Study Across Five States

Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population. U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders. Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29). Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

Understanding the Primary Care Experience in a Student-Run Free Clinic

Background: Over 100 student-run free clinics (SRFCs) operate in the United States (US), typically serving uninsured populations. To date, there has been no effort to compare the patient-reported primary care experience in SRFCs to those of mainstream primary care (PC) clinics serving similar populations. In this study, we surveyed patients at Equal Access Birmingham (EAB), an SRFC, and compared our results to those from two PC clinics serving homeless-experienced clientele.&#x0D; Methods: We surveyed 60 EAB patients with the validated “Primary Care Quality-Homeless” survey. It generates an overall score and 4 subscale scores (clinician-patient Relationship, perceived inter-provider Cooperation, Accessibility/Coordination, Homeless-Specific Needs). We compared EAB’s ratings to those published for a Veterans Affairs (VA) mainstream PC (n=150) clinic and a homeless-tailored non-VA Health Care for the Homeless (HCH) program (n=195).&#x0D; Results: EAB’s ratings were similar to those of the mainstream VA clinic (p&gt;0.4). EAB scored lower than the homeless-tailored non-VA HCH program in each subscale, though the difference did not achieve statistical significance. EAB patients most often praised the staff’s interpersonal skills. Items in which &gt;25% of respondents gave a negative rating concerned wait times (29%), coordination of care (65%), and perceptions of provider skill (43%).&#x0D; Conclusions: Despite constrained resources, an SRFC scored comparably to a mainstream VA PC setting. SRFCs will play a continuing role in care of uninsured individuals, and while these data suggest SRFC patient experiences are mostly favorable, additional resources may be required to approximate the care experience achieved in clinics tailored for homeless persons.

The effects of the American Rescue Plan Act on racial equity in health insurance coverage.

To evaluate the effects on racial disparities in health insurance coverage from the changes in the Premium Tax Credit (PTC) implemented in March 2021 as part of the American Rescue Plan Act (ARPA). We use nationally representative individual-level data from the Household Pulse Survey (HPS), which provides demographic, economic, and health insurance information for United States residents during the period April 2020-August 2022. While the PTC changes applied to all states, the 14 states that did not expand Medicaid received substantially more benefits than the expansion states since they had more uninsured individuals eligible for the PTC than the expansion states. In our analysis, the treatment (control) group includes all Medicaid nonexpansion (expansion) states. We use a difference-in-difference regression analysis to estimate the increase in the probability of insurance coverage after the expansion of the PTC. Furthermore, we conduct sensitivity and heterogeneity analyses. We focus on survey respondents ages 18-64. The expanded PTC increased the probability of an individual having coverage through the Health Insurance Exchange (HIX) in a nonexpansion state by 0.95 (95% CI: 0.6136, 1.2900), 1.75 (95% CI: 1.1795, 2.3291), and 1.75 (95% CI: 1.1815, 2.3269) percentage points among White, Black, and Hispanic respondents, respectively. It also increased overall health insurance coverage among all groups. The expanded PTC boosted HIX and overall health insurance coverage and reduced racial disparities.

Association Between the Affordable Care Act and Emergency Department Visits for Psychiatric Disease.

Emergency department (ED) utilization for psychiatric disease is increasing, and a lack of health insurance has been identified as a potential cause of preventable or avoidable ED use. Through the Affordable Care Act (ACA), more uninsured individuals gained health insurance; however, the effects of increased health insurance coverage on ED utilization for psychiatric disease have not been examined. We performed a longitudinal, cross-sectional analysis of data from the Nationwide Emergency Department Sample, the largest all-payer ED database in the US, which contains data on over 25 million ED visits each year. We examined ED utilization for psychiatric disease as the primary reason for visit among adults aged 18-64. We compared the proportion of ED visits with a psychiatric diagnosis during post-ACA years (2011-2016) to pre-ACA (2009) using logistic regression adjusted for age, gender, payer, and hospital region. The proportion of ED visits with psychiatric diagnosis increased from pre-ACA (4.9%) to post-ACA years (ranging from 5.0-5.5%). There was a significant difference in the proportion of ED visits with a psychiatric diagnosis when comparing each post-ACA year with pre-ACA, with adjusted odds ratios ranging from 1.01-1.09. Among ED visits with a psychiatric diagnosis, the most common age group was 26-49 years, and patients were more likely to be male than female and to have visited urban rather than rural hospitals. During post-ACA years (2014-2016), private and uninsured payers decreased, Medicaid payers increased, and Medicare payers increased in 2014 and decreased in 2015-2016 compared to pre-ACA. With the ACA more people gained health insurance, yet ED visits for psychiatric disease continued to increase. These results suggest that increasing access to health insurance alone is not sufficient to reduce ED utilization for patients with a psychiatric disease.

Disparities in access to health care in adults with sinusitis in the United States.

Sinusitis can significantly decrease quality of life, is costly in both health care expenditure and lost productivity, and can lead to complications if treatment is delayed. Our objective was to explore disparities in health care access among adults with sinusitis based on sociodemographic factors. A total of 32,994 participants (representing 244,838,261 US adults) who completed the 2016 National Health Interview Survey (NHIS) were analyzed, of whom 12.17% were diagnosed with sinusitis at least once in the prior 12 months. Multivariate regression analyses were performed. In regression analyses, female sex (odds ratio [OR],2.00 [95% confidence interval (CI), 1.79-2.24]; p<0.001) and older age groups were associated with increased odds of having sinusitis. Within the sinusitis cohort, Asian race (OR,5.97 [95% CI, 1.61-22.12]; p=0.008) and Hispanic ethnicity (OR,6.97 [95% CI, 3.22-15.06]; p<0.001) were associated with increased odds of obtaining foreign medications. Individuals with Medicaid had decreased odds of delaying care (OR,0.37 [95% CI, 0.25-0.56]; p<0.001) or not receiving care due to cost (OR,0.40 [95% CI, 0.24-0.65]; p<0.001), but increased odds of delaying care due to transportation barriers (OR,4.64 [95% CI, 2.52-8.55]; p<0.001). Uninsured individuals had higher odds for delaying care (OR,4.97 [95% CI, 3.35-7.38]; p<0.001) and not receiving care (OR,5.46 [95% CI, 3.56-8.38]; p<0.001) due to cost. Income >$100,000 was associated with a nearly 90% reduction in inability to obtain care due to cost (OR,0.11 [95% CI, 0.05-0.21]; p<0.001) and an over 99% reduction in inability to obtain care due to transportation issues compared with income<$35,000 (OR,0.01 [95% CI, 0.00-0.04]; p<0.001). Significant disparities in health care access based on race, health insurance status, and income exist among adults with sinusitis in the United States.

The "Medicare effect" on head and neck cancer diagnosis and survival.

Uninsured individuals age 55-64 experience disproportionately poor outcomes compared to their insured counterparts. Adequate coverage may prevent these delays. This study investigates a "Medicare-effect" on head and neck squamous cell carcinoma (HNSCC) diagnosis and treatment. The Surveillance, Epidemiology, and End Results (SEER) database was queried for persons ages 60-70 years in the United States from 2000 to 2016 with HNSCC. A "Medicare effect" was defined as an increase in incidence, reduction in advanced stage presentation, and/or decrease in cancer-specific mortality (CSM). Compared to their Medicaid or uninsured counterparts, patients age 65 have an increased incidence of HNSCC diagnosis, reduction in advanced stage presentation, decrease in cancer-specific mortality, and higher likelihood of receiving cancer-specific surgery. Patients age 65 with Medicare have decreased incidence of HNSCC, less hazard of late-stage diagnosis, and lower cancer-specific mortality than their Medicaid or uninsured counterparts, supporting the idea of a "Medicare effect" in HNSCC.

Street Psychiatrists Build Trust, Offer Hope to Homeless Patients With SMI

Street Psychiatrists Build Trust, Offer Hope to Homeless Patients With SMI

Factors Affecting Completion of Human Papillomavirus Vaccination Series by Gender in a Predominantly Hispanic Border Town Community.

The human papillomavirus (HPV) vaccine is recommended for females and males aged 9 to 45. Nationally, the HPV vaccination rates are lower for males than females; however, this has not been studied in a US-Mexico border community. Our study aims to report the HPV vaccination completion by gender and determine which sociodemographic factors influence vaccination. This cross-sectional study was conducted among uninsured and underinsured individuals aged between 9 and 26 years served through a community-based HPV vaccine program in El Paso, TX. Data collected included demographic information, psychosocial variables, and vaccine administration data. Descriptive statistics were used to summarize demographic data. Unadjusted t test/Fisher exact test and multivariable relative risk regression were run on significant variables to determine the association with vaccine completion by gender. Most participants were female (63.4%), and an overall vaccine series completion was 30.67%. We found no significant difference in HPV vaccine completion rates by gender. Males who resided in the United States for more than a decade were 31% more likely to complete the vaccine series, and females who had 9 to 13 years of education had lower odds of vaccine completion. Knowledge significantly increased after the intervention for both genders (p = .002). There was no significant change in psychosocial variables from the preintervention to the immediate postintervention survey. Our multicomponent, culturally tailored intervention may equally impact male and female participants and encourages all genders to complete their HPV vaccine series. Additional studies with a larger male sample are needed.

Needs of an uninsured equity-deserving minority patient cohort with physical disabilities during the first wave of the COVID-19 pandemic.

Patients with disabilities and those from diverse equity-deserving backgrounds have been disproportionately affected by the SARS COV-2 ("COVID-19") pandemic. To describe the significant needs and social determinants of health that affected a group of uninsured patients (from equity-deserving groups) with rehabilitation diagnoses during the early months of the COVID-19 pandemic. Retrospective cohort study utilizing a telephone-based needs assessment from April to October, 2020. Free interdisciplinary rehabilitation clinic serving patients with physical disabilities from equity-deserving minority backgrounds. 51 uninsured, diverse patients with spinal cord injuries, brain injuries, amputations, strokes, and other diagnoses requiring interdisciplinary rehabilitation care. Using a non-structured approach, telephone-based needs assessments were collected monthly. Reported needs were summarized into themes and the frequencies of each theme were recorded. From the total number of concerns, medical issues were reported with the highest frequency (46%), followed by equipment needs (30%) and mental health concerns (30%). Other frequently mentioned needs centered around themes of rent, employment, and supplies. Rent and employment were more frequently cited in earlier months, and equipment problems were more frequently cited in later months. A minority of patients reported they had no needs, some of whom had acquired insurance. Our objective was to describe the needs of a racially and ethnically diverse set of uninsured individuals with physical disabilities seen at a specialized interdisciplinary rehabilitation pro bono clinic during the early months of COVID-19. Medical issues, equipment needs, and mental health concerns were the top three needs. To optimally serve them, care providers must be aware of current and future needs for their underserved patients, especially if future lockdowns occur.

Population and Neighborhood Correlates of Cannabis Dispensary Locations in Oklahoma.

Cannabis dispensaries have proliferated exponentially in Oklahoma since the state legalized medical cannabis in 2018. Oklahoma is unique from many other legalized states given its high number of lower income, rural, and uninsured residents, who may seek medical cannabis as an alternative to traditional medical treatment. This study examined demographic and neighborhood characteristics associated with dispensary density (n = 1,046 census tracts) in Oklahoma. Compared to census tracts with no dispensaries, those with at least one dispensary had a higher proportion of uninsured individuals living below the poverty level and a greater number of hospitals and pharmacies. Almost half (42.35%) of census tracts with at least one dispensary were classified as a rural locale. In fully adjusted models, percent uninsured, percent of household rentals, and the number of schools and pharmacies were positively associated with greater number of cannabis dispensaries, while the number of hospitals was negatively associated. In the best fitting interaction models, dispensaries were predominant in areas with a higher percentage of uninsured residents and no pharmacies, suggesting that cannabis retailers may capitalize on the health needs of communities with limited healthcare outlets or access to medical treatment. Policies and regulatory actions that seek to decrease disparities in dispensary locations should be considered. Future studies should examine whether people living in communities with a scarcity of health resources are more likely to associate cannabis with medical uses than those living in communities with more resources.

Health Insurance Status and Access to Healthcare Among Young Adults with Congenital Heart Disease: from the Congenital Heart Survey To Recognize Outcomes, Needs and Well-beinG (CH STRONG), 2016-2019.

Having health insurance is associated with better access to healthcare and lower rates of comorbidity in the general population, but data are limited on insurance's impact on adults with congenital heart disease (ACHD). The Congenital Heart Survey To Recognize Outcomes, Needs and well-beinG (CH STRONG) was conducted among ACHD in three locations from 2016 to 2019. We performed multivariable logistic regression to determine the associations between health insurance and both access to healthcare and presence of comorbidities. We also compared health insurance and comorbidities among ACHD to similarly-aged individuals in the Behavioral Risk Factor Surveillance System (BRFSS) as a proxy for the general population. Of 1354 CH STRONG respondents, the majority were ≤ 30years old (83.5%), and 8.8% were uninsured versus 17.7% in the BRFSS (p < 0.01). Compared to insured ACHD, uninsured were less likely to report regular medical care (adjusted odds ratio [aOR] 0.2, 95% confidence interval [CI] 0.1-0.3) and visited an emergency room more often (aOR 1.6, CI 1.0-2.3). Among all ACHD reporting disability, uninsured individuals less frequently received benefits (aOR 0.1, CI 0.0-0.3). Depression was common among uninsured ACHD (22.5%), but insured ACHD had lower rates of depression than insured in the BRFSS (13.3% vs. 22.5%, p < 0.01). In conclusion, rates of insurance were higher among ACHD compared to the general population. Nonetheless, uninsured ACHD inconsistently accessed healthcare and benefits. Further studies are needed to determine if insurance ameliorates the risk of morbidity as ACHD age.