Health affairs scholar最新文献

Extending pregnancy-related Medicaid eligibility from 60 days to 12 months postpartum represents an important opportunity to reduce maternal mortality and racial inequities in maternal health outcomes. However, patterns of health care service use after 60 days postpartum among Medicaid enrollees are not well understood. We use Medicaid claims data representing Medicaid-covered live births in 46 states in 2018 to examine outpatient visits during the postpartum year. We find that more than three-quarters of enrollees with full-year Medicaid coverage have at least one outpatient visit between 61 days and 12 months postpartum. The share of enrollees with visits varies from 51.5% to 88.0% across states and is higher among enrollees with diagnosed physical or mental/behavioral health conditions or pregnancy/delivery complications. We also find that visits including mental/behavioral health care are more common for non-Hispanic white enrollees than non-Hispanic Black and Hispanic enrollees and for rural enrollees than urban enrollees during the postpartum year, controlling for other characteristics. These findings suggest that many Medicaid enrollees who maintain Medicaid coverage beyond 60 days postpartum will receive outpatient care but also suggest that there may be inequities in receipt of postpartum health care across and within states.

Many neighborhoods with concentrated racial and ethnic minority older adult populations experience high neighborhood disadvantage. Yet, to date, no studies have analyzed how neighborhood disadvantage affects the relationship between race and hospitalization among older adults. To fill this gap, we examined if neighborhood disadvantage moderates the relationship between race and hospitalization among older adults in the United States. Medicare claims data from 2018 on 530 962 beneficiary hospitalizations were merged with neighborhood data, and regression models assessed if the Area Deprivation Index (ADI) moderated the association between race and hospitalization. At the highest ADI score, the odds ratio (OR) for hospitalization for Black compared with White beneficiaries was the lowest (OR: 0.96; 95% CI: 0.89-1.04). At the lowest ADI score, the OR for hospitalization for Black compared with White beneficiaries was the highest (OR: 1.19; 95% CI: 1.09-1.29). When Black and White beneficiaries reside in severely deprived areas, the disparity in their outcomes is narrower. However, when they reside in areas with more advantages, White beneficiaries experience better outcomes than Black beneficiaries. Our findings have implications for practice and policy to invest resources in communities to assure health equity.

Although pandemic-era telemedicine flexibilities may have preserved access to care, concerns remain that telemedicine may have been inequitably distributed among older adults, especially those with mild cognitive impairment or dementia (MCID). As telemedicine flexibilities are set to fully expire on December 31, 2024, we aimed to examine pandemic-era and future-intended telemedicine use among older Americans to help inform post-pandemic telemedicine policy design. We hypothesized that telemedicine would be disproportionately underutilized among older adults with MCID or with racial and ethnic minority status. We used nationally representative survey data from the Health and Retirement Study and analyzed pandemic-era and future-intended telemedicine use among 10 075 Medicare beneficiaries aged >50 years during 2020-2022 by cognition across beneficiaries-level characteristics such as age, gender, insurance status, education, and multimorbidity. Results were adjusted by survey weights and nonresponse rates for national representativeness. Contrary to our hypothesis, compared with White Medicare beneficiaries, Hispanic and Black beneficiaries with normal cognition reported 44% and 57% greater pandemic-era and future-intended telemedicine use, respectively, while Black beneficiaries with MCID reported 57% greater pandemic-era telemedicine use. Our findings suggest that pandemic-era telemedicine utilization was especially common among racial and ethnic minority groups and those with MCID.

Long-acting injectable antiretroviral therapy (LAI-ART) is expected to improve health outcomes among persons with HIV. Yet, uptake has been slow and data on potential barriers to access are sparse. We used medication formulary data from state Medicaid and AIDS Drug Assistance Programs (ADAPs) to examine state-level variation in access to LAI-ART among uninsured and low-income persons with HIV. We identified substantial coverage gaps: cabotegravir/rilpivirine was not covered without prior authorization by 26 state Medicaid programs and not covered at all by 15 state ADAPs; lenacapavir was not covered without prior authorization by 32 Medicaid programs and not covered at all by 18 ADAPs. As a result of these gaps, many US persons with HIV are currently unable to access LAI-ART. Policies that increase access are needed to ensure the equitable distribution of LAI-ART. As states work to reduce supply and payment chain barriers, the US Department of Health and Human Services, notably its Centers for Medicare & Medicaid Services and the Health Resources and Services Administration, should provide increased federal assistance, guidance, and oversight to improve LAI-ART access among people with HIV.

To combat antimicrobial resistance (AMR), advocates have called for passage of the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance (PASTEUR) Act in the United States, which would appropriate $6 billion in new taxpayer-funded subsidies for antibiotic development. However, the number of antibiotics in clinical development, and US Food and Drug Administration approvals of new antibiotics, have already markedly increased in the last 15 years. Thus, instead of focusing on more economic subsidies, we recommend reducing selective pressure driving AMR by (1) establishing pay-for-performance mechanisms that disincentivize overprescribing of antibiotics, (2) focusing existing research and development funding on strategies that decrease reliance on antibiotics, and (3) changing regulation or law to require specialized training in antibiotic stewardship for a clinician to be able to prescribe new antibiotics that target unmet AMR need. To stabilize the antibiotic market, we recommend (1) establishment of an advisory board of clinical practitioners to more accurately target existing antibiotic incentives and (2) endowment of nonprofit companies that sustainably self-fund antibiotic discovery, creating a bench of molecules that can be partnered with industry at later stages of development.

Over-the-counter diet pills and muscle-building supplements are linked to increased eating disorder diagnoses, especially among youth. With limited regulatory oversight, minors may unknowingly consume harmful substances leading to other adverse effects. Massachusetts has proposed restricting sales to individuals under 18 years. However, concerns about health equity and unintended consequences arise when proposing new policies. We conducted a cost-effectiveness analysis of the proposed age-restriction policy compared to the status quo, focusing on 2 closed cohorts of males and females aged 0-17 years in Massachusetts over a 30-year time horizon. We evaluated the impact from both societal and health systems' perspectives and further assessed equity implications by modeling 3 racial/ethnic subgroups. The policy is projected to prevent 57 034 eating disorder cases and over 46 000 additional adverse medical events (eg, liver injuries). It would yield 51 749 quality-adjusted life years and generate healthcare savings of $14 million and societal savings of $30 million annually. The Latine subpopulation would see the highest per capita health benefits followed by Black and White residents, respectively. Restricting the sale of these supplements to minors offers both health and economic benefits. These findings underscore the policy's effectiveness, fiscal responsibility, and positive equity impacts, providing confidence for policymakers and the public.

Immigrants in the United States are at increased risk of diabetes-related complications due to delayed diagnoses compared with US-born individuals. Immigration-related federal policies may support immigration enforcement activities and restrict some immigrants' access to health insurance and other publicly funded resources. Conversely, state and county-level sanctuary policies may reduce the fear of deportation and increase mobility in the community, improving the accessibility of essential pharmacological treatment for type 2 diabetes patients. This retrospective cohort study estimated the odds of receiving glucose-lowering medication prescriptions by the county's sanctuary policy environment for patients within a nationwide network of community health centers. We did not find statistically significant associations between sanctuary policies and annual prescription rates. The associations were not modified by nativity or race/ethnicity. Notably, compared to US-born patients, immigrants had higher odds of receiving prescriptions regardless of the sanctuary policy environment, emphasizing other potential influences on the receipt of anti-diabetes prescriptions for community health center patients.

Competition in health care markets should lead to lower prices and less dispersion, with consumer choice as the driving mechanism. Several studies document price variation, suggesting room for improvement; however, they relied on selected data from insurers who provide access to data, limiting generalizability. We document the nature of price variation in the private US market across geography, payer, and provider by leveraging a new dataset, implementing a descriptive analysis using the most comprehensive data available: Transparency-in-Coverage. We measured health care prices in 3 ways: percentile distribution prices for common services, state-level and insurer-level facility fee price indices, and regression-adjusted mean inpatient and outpatient prices. Variation is large: the mean facility fee for a foot X-ray, for example, is $86 at Anthem and $190 at UnitedHealth. Pricing does not appear to be uniform; there is just 22% correlation between an insurer's inpatient price and outpatient facility price. And there is little difference in ordering of high-price states depending on alternative measures, such as relative to Medicare. Results suggest greater consideration of policies to address high and variable prices for US health care.

Understanding the downstream consequences of initial Medicare plan selection is necessary to ensure access to and affordability of health care services, especially for older adults with serious illness. We used 2008-2020 data from the Health and Retirement Study to estimate financial and health burden by initial Medicare plan selection (traditional Medicare without supplemental coverage, traditional Medicare plus supplemental coverage, or Medicare Advantage) and self-reported history of cancer. Initially choosing benefits with greater financial protections (either traditional Medicare plus supplemental coverage or Medicare Advantage) relative to traditional Medicare without supplemental coverage was associated with lower levels of out-of-pocket spending and a lower likelihood of reporting cost-related medication nonadherence and fair or poor health. Policymakers should consider improving the adequacy of traditional Medicare coverage to ensure the affordability of health care services and reduce the burden of serious illness among older adults, especially those with a history of cancer.