JAMA Health Forum最新文献

Importance: Housing cost burden is at an all-time high in the US and may disproportionately affect health outcomes among low-income populations. Medicaid-insured individuals and those diagnosed with cardiovascular (CV) disease, such as heart failure (HF), may be especially at increased risk of adverse health outcomes associated with housing cost burden.

Objective: To assess the association between area-level housing cost burden and the probability of CV-related hospitalization or emergency department (ED) visits among Medicaid beneficiaries aged 19 to 64 years with HF.

Design, setting, and participants: This cross-sectional study used individual-level health care utilization data obtained from the Transformed Medicaid Statistical Information System Analytic Files (2018-2019). All zip codes in the US with resident Medicaid beneficiaries aged 19 to 64 years who had a preexisting diagnosis of HF and were continuously enrolled in 2019 were included except for those in Alabama, Rhode Island, and Utah due to data quality issues. Data were analyzed from October 2024 to October 2025.

Exposure: Area-level housing cost burden was defined as the zip code-level proportion of housing units occupied by individuals with an annual household income less than $35 000 who spent 30% or more of their income on housing costs.

Main outcomes and measures: The probability of a CV-related hospitalization and of a CV-related ED visit in 2019. Generalized estimating equation models were used to evaluate the association between housing cost burden and outcomes after adjusting for individual and area-level factors.

Results: This study included 233 195 individuals (mean [SD] age, 51.5 [9.6] years, 107 447 female [46.1%]) who were living in 19 577 zip codes. The mean (SD) zip code housing cost burden was 67.4% (16.5%). In 2019, 42 886 beneficiaries (18.4%) had at least 1 CV-related hospitalization and 75 392 (32.3%) had an ED visit. After covariate adjustment, a 10-percentage point increase in housing cost burden was associated with higher odds of CV-related hospitalizations (odds ratio [OR], 1.03; 95% CI, 1.01-1.06) and ED visits (OR, 1.03; 95% CI, 1.01-1.04). There were also higher odds of HF-related hospitalizations (OR, 1.04; 95% CI, 1.01-1.07).

Conclusions and relevance: The findings of this study suggest that area-level housing cost burden may be associated with outcomes among Medicaid beneficiaries with HF and highlights the need to investigate whether strategies that address housing affordability can play a role in improving health outcomes in this population.

Importance: Food insecurity (FI) is associated with poor health and has risen in the US. The Supplemental Nutrition Assistance Program (SNAP) is the largest US food-purchasing assistance program. Policies related to eligibility assessment and administrative burden that impact SNAP participation vary between states. How such policies influence FI is not well known.

Objectives: To evaluate the association between changes in state SNAP policies and county FI rates.

Design, setting, and participants: This repeated cross-sectional study used annual county-level FI estimates from the Feeding America Map the Meal Gap dataset, state-level SNAP policy data from the US Department of Agriculture from 2009 to 2019, and data on economic and demographic measures from the US Census Bureau for county residents. Data were analyzed from August 2024 to August 2025.

Exposures: Changes in state SNAP policies from 2009 to 2019. Due to incomplete policy data, the analysis was not extended beyond 2019.

Main outcomes and measures: County-level FI rates for individuals. An annual index of SNAP policy adoption was calculated, scaled from 0.1 to 10, with a higher level indicating a greater adoption of policies associated with SNAP participation. G-computation, a robust causal inference methodology, was used to evaluate the association between change in the SNAP index and state-level SNAP participation rates and county-level FI rates. The model accounted for demographic and clinical factors, state and year fixed effects, and baseline SNAP index levels.

Results: Of a total of 3143 US counties, 3134 were included in the analysis. A 1-point increase in the SNAP policy index was associated with a 0.7-percentage point (pp; 95% CI, 0.3-1.2 pp; P = .002) higher state-level SNAP participation rate and a 0.1-pp (95% CI, 0.02-0.2 pp; P = .02) lower county-level FI rate from 2009 to 2019. In 2019, an estimated 6.5 million (95% CI, 3.8-9.1 million) fewer individuals would have experienced FI if all states had adopted policies equivalent to the most generous state in each year compared to if all states had adopted policies equivalent to the least generous state.

Conclusions and relevance: In this cross-sectional study, adoption of state-level policies associated with higher SNAP participation was also associated with lower county-level FI rates. Policies that lower barriers to SNAP participation may help address rising FI rates observed in 2022 and 2023.