Health affairs scholar最新文献

Introduction: California's 4.8 million noncitizen adults, half of whom are undocumented, endure substantial exclusions from health care. To address this gap, California policymakers expanded full-scope, state-funded Medicaid without discriminating by immigration status, first extending coverage to undocumented young adults (18-25 years) in 2020 and then to older adults (≥50 years) in 2022.

Methods: Using the American Community Survey (2017-2023), we assessed whether California's Medicaid expansion for young and older undocumented adults was associated with changes in insurance coverage by comparing pre- and post-expansion differences between citizens and noncitizens (difference-in-differences).

Results: Compared to citizens, the expansion was not associated with increased health insurance or Medicaid enrollment among young noncitizens. However, among older adults, the expansion was associated with a modest 1.3% increase in overall insurance coverage for noncitizens, including a 2.4% increase in Medicaid. Following these expansions, noncitizens remain significantly less likely to have insurance: 28% of young noncitizens and 16% of older noncitizens lack coverage, compared to 8% and 3% for young and older citizens, respectively.

Conclusion: Given these persistent inequities-where noncitizens across nearly all sociodemographic factors are less likely to be insured-preserving and strengthening the existing pathways to insurance coverage for noncitizens, including undocumented immigrants, remains critical.

Context: Changes in regulations related to medication for opioid use disorder (MOUD) have expanded access to MOUD in primary care. However, there has been concern that primary care practices are unwilling or unable to treat patients with OUD.

Objective: To describe the practices and patients enrolled in the Patient-Centered Outcomes Research Institute (PCORI)-funded HOMER (Comparing Home, Office, and Telehealth Induction for Medication Enhanced Recovery) research study who delivered MOUD as part of routine primary care practice.

Results: A total of 79 practices from 25 states expressed interest in participation. Sixty-two practices signed up for HOMER. Practices were typical of US primary care, accepting a variety of payers, including commercial insurance, Medicaid, Medicare, and uninsured patients, and caring for patients of across a spectrum of adult ages, races and ethnicity, education, and income. The majority had health insurance (82%). Most patients reported using prescription opioids (59%), while 41% reported other opioid use. Greater than 40% of participating patients reported no prior medication treatment for OUD.

Conclusion: The finding that nearly half of patients had no prior treatment supports the importance of primary care as a crucial component of MOUD. Practices in HOMER were similar to practices across the country. Patients enrolled were typical of family practice patients. Policies that support primary care MOUD may improve access to patients.

Introduction: Physician overprescribing of opioids contributes to chronic opioid use, overdose risk, and the accumulation of unused opioids in the community. While many interventions seek to reduce initial post-operative opioid prescriptions, concerns remain that doing so may lead to increased refill or new prescription requests, and result in inadequate pain management.

Methods: We conducted a three-arm cluster-randomized trial involving 640 surgeons across three surgical specialties in 19 hospitals to evaluate the impact of guideline-based prescribing interventions. In this secondary analysis, we examined whether exposure to the intervention led to no increase in refills within six months, measured by relative risk ratio, which incorporated survival analysis to estimate the hazard ratio of treatment effect compared between intervention and post-intervention periods compared with pre-intervention.

Results: Our findings show that reducing opioid amounts at discharge in the intervention arms did not significantly increase refill or new prescription fills, either overall, within specific surgical specialties, or among patients whose initial prescriptions exceeded recommended guideline quantities.

Conclusion: These results support that guideline-based prescribing interventions can safely reduce opioid exposure without compromising patient pain-control and highlight important policy implications for surgical opioid stewardship.

Introduction: Firearm-related injuries cause far-reaching harm, yet information about the value the public assigns to the benefits of prevention is limited.

Methods: We surveyed California adults from the Ipsos KnowledgePanel (N = 2870) about their willingness to pay (WTP), in taxes or donations, to prevent firearm homicides, firearm suicides, and deaths from mass shootings. WTP was calculated using a double-bounded dichotomous choice contingent valuation model with a log-logistic error distribution.

Results: The mean WTP estimate for a program preventing 1 in 10 deaths ranged from $85.16 annually in donations to prevent firearm suicides to $145.63 in additional taxes to prevent deaths from mass shootings. In general, firearm owners were willing to pay less than non-owners; however, Black firearm owners reported the largest WTP, among subgroups and overall. Most respondents were willing to pay the sum-total of their bids to prevent all 3 types of firearm injury; of those, maximum WTP, on average, was $508.08 annually in donations or $534.82 in additional taxes. This implies a statewide total of up to $6.9 billion in perceived benefit.

Conclusion: As resources for prevention, intervention, and supportive services are threatened or terminated, these findings underscore the substantial public demand for investments in firearm injury reduction efforts.

The federal government and several states have implemented measures to restrict, ban, and increase transparency of promotional payments from pharmaceutical companies to clinicians who prescribe medications. In 2018, New Jersey adopted a novel rule that included a $10 000 restriction on aggregate annual prescriber compensation for promotional speaking, advisory board participation, and consulting arrangements. In this study, we estimated changes associated with the restriction by comparing payments made to physicians in New Jersey to those in a comparator state, Pennsylvania, where no such rule exists. We found that the New Jersey restriction was associated with no significant difference in the proportion of physicians receiving aggregate honoraria and consulting payments above $10 000 annually as compared to physicians in Pennsylvania. Further research is needed to better understand the effect of state policies restricting pharmaceutical industry payments to prescribers.

Introduction: Record numbers of Americans are living with serious illness and disability. Increasingly, older adults and persons with disability will be responsible for managing and financing their care needs into older age, putting more onus on individuals and their families to arrange care. Understanding the current and expected caregiving landscape can inform efforts to prepare for future population needs.

Methods: We used nationally representative survey data collected in Spring 2025 (N = 2020) to estimate the prevalence of past, current, and expected future caregiving and examine the association of sociodemographic characteristics and caregiving responsibilities using logistic regression.

Results: We found that one in four U.S. adults reported caregiving within the last year, and most (60%) expected future caregiving responsibilities, corresponding to over 155 million adults. After adjusting for socioeconomic characteristics, the strongest positive predictors of expected caregiving were prior or current caregiving experiences. We found no significant difference in anticipated future caregiving across political ideology.

Conclusion: Our findings collectively underscore the universality of caregiving, and, within the context of scarce long-term care insurance uptake and declining funding for Medicaid, amplify the importance of scaling policies that support current and future family caregivers who provide the bulk of long-term care in the United States.

Introduction: K-12 schools are not only educational settings but also hubs of social interaction, making them potential drivers of disease transmission within households and communities. While many existing studies have assessed school masking in relation to in-school transmission, the broader community impact of mandatory school masking policies on SARS-CoV-2 infection rates remains poorly understood.

Methods: We conducted a retrospective quasi-experimental study using the synthetic control method to evaluate the association between masking policies and community infection rates during the fall 2021 US school reopening period, when most schools returned to in-person learning but masking policies varied substantially. Analyses accounted for community characteristics prior to reopening and baseline infection rates.

Results: Counties with mandatory school masking experienced significantly lower SARS-CoV-2 infection rates than those without mandates. In the first 9 weeks after reopening, mandatory masking was associated with 820 fewer cases per 100 000 people (95% CI: 444-1185), corresponding to a relative cumulative reduction of 9.4% (95% CI: 7.3%-11.8%). The strength of this association varied by baseline infection rates, population density, and mobility patterns.

Conclusion: Mandatory school masking policies were linked to meaningful reductions in community SARS-CoV-2 transmission and underscore their value as a public health intervention during pandemic surges.