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The article discusses the position of the American Public Health Association on reduced prescription drug coverage because of increasing drug prices in the U.S. The association has called for the addition of a prescription drug benefit to the Medicare program, at the same time recognizing that drug pricing will be a major factor determining whether a Medicare drug benefit is practicable. Factors that contribute to high drug prices are the large profit margins cleared by the drug industry, advertising and marketing expenditures, and large international price disparities that buyers are subjected to.

The COVID-19 pandemic caused substantial disruptions in the field operations of all 3 major components of the Medical Expenditure Panel Survey (MEPS). The MEPS is widely used to study how policy changes and major shocks, such as the COVID-19 pandemic, affect insurance coverage, access, and preventive and other health care utilization and how these relate to population health. We describe how the MEPS program successfully responded to these challenges by reengineering field operations, including survey modes, to complete data collection and maintain data release schedules. The impact of the pandemic on response rates varied considerably across the MEPS. Investigations to date show little effect on the quality of data collected. However, lower response rates may reduce the statistical precision of some estimates. We also describe several enhancements made to the MEPS that will allow researchers to better understand the impact of the pandemic on US residents, employers, and the US health care system. (Am J Public Health. 2021;111(12):2157–2166. https://doi.org/10.2105/AJPH.2021.306534) [ABSTRACT FROM AUTHOR]

This paper presents trends in the growth in the US uninsured population, using cross-sectional national estimates from 1977, 1987, 1989, and 1992 and focusing specifically on coverage problems experienced by Hispanic Americans. An examination of the composition of uninsured persons added between 1977 and 1992 shows that almost 40% of the difference is accounted for by persons of Hispanic origin, with those of Mexican origin alone constituting 27%. In addition, the annual average rate of growth in the uninsured Hispanic population between 1977 and 1992 was 9.7%, compared with only 2.3% for the uninsured non-Hispanic population. [ABSTRACT FROM AUTHOR]

Objectives. To produce a database of private insurance hearing aid mandates in the United States and quantify the share of privately insured individuals covered by a mandate. Methods. We used health-related policy surveillance methods to create a database of private insurance hearing aid mandates through January 2023. We coded salient features of mandates and combined policy data with American Community Survey and Medicare Expenditure Panel Survey–Insurance Component data to estimate the share of privately insured US residents covered by a mandate from 2008 to 2022. Results. A total of 26 states and 1 territory had private insurance hearing aid mandates. We found variability for mandate exceptions, maximum age eligibility, allowable frequency of benefit use, and coverage amounts. Between 2008 and 2022 the proportion of privately insured youths (aged ≤ 18 years) living where there was a private insurance hearing aid mandate increased from 3.4% to 18.7% and the proportion of privately insured adults (19–64 years) increased from 0.3% to 4.6%. Conclusions. Hearing aid mandates cover a small share of US residents. Mandate exceptions in several states limit coverage, particularly for adults. Public Health Implications. A federal mandate would improve hearing aid access. States can also improve access by adopting exception-free mandates with limited utilization management and no age restrictions. (Am J Public Health. 2024;114(4):407–414. https://doi.org/10.2105/AJPH.2023.307551) [ABSTRACT FROM AUTHOR]

A major effort in preventive care for women has emphasized the obtaining of Pap smears and mammograms. This paper uses survey data from one state to examine issues of access to Pap smears and mammograms. Poor women receiving health care through a managed-care Medicaid program received these services at the same rate as women with other types of health insurance, while the uninsured were less likely to have had either type of service. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents analyses of recent natioanl survey data on access to medical care. In particular, information on major access indicators and special problems associated with the economic and political climate of the 1980s collected in a 1982 national telephone survey of 6.610 United Scales adults and children, representing some 4.802 families, is compared with previous national stirrers for kef population subgroups--by age. place of residence, income, race, insurance coverage, and type of regular source of care In general, the findings show that favorable progress has been made, but some inequities continue to persist. Some traditionally disadvantaged groups are more likely to have a regular family doctor, private insurance coverage, have been to a doctor, or had certain preventive tests and procedures than was true for them in the past. On the other hand, compared to the more economically and/or socially advantaged groups in 1982, they have still not "caught up" entirely. There also is evidence that they may be hardest hit by the exacerbation of the financial barriers to care thai result from unemployment, inflation, and cutbacks in health program eligibility and benefits that have characterized the decade of the 1980s. [ABSTRACT FROM AUTHOR]

Objectives. This paper describes how Ireland created a level playing field for competition in health insurance, the strategies of a major insurer to introduce risk-rated policies that would segment the market, the successful campaign to block these policies, and the policy implications of the European Union requirement of competition in health insurance. Methods. Policy documents, interviews, and press reports were analyzed. Results. The minister of health forced the commercial insurer to withdraw its policies and replace them with community-rated policies. Conclusions. Because it is easier and more profitable for insurers to engage in risk selection than to become more efficient, beneficial competition in health insurance markets is extremely difficult to create. Carefully drawn rules and monitoring are required to overcome inherent causes of market failure. The current enthusiasm for saving money through competitive schemes in health insurance seems likely to produce higher costs and greater inequality. [ABSTRACT FROM AUTHOR]

Objects. This paper examines health expenditure growth under two alternative policy approaches competition-based managed care and state government rate regulation. Methods. Data are presented on cumulative growth in real per capita health expenditures between 1980 and 1991 so as to compare California, a state with a pro-competitive policy, with established regulation programs. Results. Real per capita expenditures for hospital services in the United States grew 54% between 1980 and 1991, while in California the growth was half the national rate, or 27%. Real per capita expenditures for physicians services and drug expenditures in the United States grew by 82% and 65%, respectively, white in California these expenditures in creased only 58% and 41%, respectively. California's growth rate was below that of an four regulatory states for all measures of health care cost inflation. Constitution. On the basis of these findings, a properly structured Competitive approach could play a significant role in controlling health expenditures in the United States. [ABSTRACT FROM AUTHOR]

Objectives. To report insurance-based discrimination rates for nonelderly adults with private, public, or no insurance between 2011 and 2019, a period marked by passage and implementation of the Affordable Care Act (ACA) and threats to it. Methods. We used 2011–2019 data from the biennial Minnesota Health Access Survey. Each year, about 4000 adults aged 18 to 64 years report experiences with insurance-based discrimination. Using logistic regressions, we examined associations between insurance-based discrimination and (1) sociodemographic factors and (2) indicators of access. Results. Insurance-based discrimination was stable over time and consistently related to insurance type: approximately 4% for adults with private insurance compared with adults with public insurance (21%) and no insurance (27%). Insurance-based discrimination persistently interfered with confidence in getting needed care and forgoing care. Conclusions. Policy changes from 2011 to 2019 affected access to health insurance, but high rates of insurance-based discrimination among adults with public insurance or no insurance were impervious to such changes. Public Health Implications. Stable rates of insurance-based discrimination during a time of increased access to health insurance via the ACA suggest deeper structural roots of health care inequities. We recommend several policy and system solutions. (Am J Public Health. 2023;113(2):213–223. https://doi.org/10.2105/AJPH.2022.307126) [ABSTRACT FROM AUTHOR]

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011–2016 and 2018–2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630–1639. https://doi.org/10.2105/AJPH.2022.307027) [ABSTRACT FROM AUTHOR]

Objectives. This paper examines the factors associated with health insurance coverage among Chinese Americans in Los Angeles County. Methods. Data were obtained through interviews conducted in 1993 and 1994 with Chinese Americans (aged 18 through 65 years) residing in Los Angeles County. A multistage probability sample was used to select respondents. Results. The final sample consisted of 1747 respondents, which represented an 82% response rate. Thirty-nine percent of the respondents in the survey were without health insurance at the time of the survey. Conclusions. Logistic regression analysis showed that marital status, length of residence in the United States, education, employment, and household income were associated with health insurance coverage among Chinese Americans. (Am J Public Health. 1998;88:451-453) [ABSTRACT FROM AUTHOR]

Substantial numbers of Indian people rely on Medicaid for their primary health insurance coverage. When state Medicaid programs enroll Indians in managed care programs, several unintended consequences may ensue. This paper identifies some of the perverse consequences of Medicaid reform for Indians and the Indian health care system and suggests strategies for overcoming them. It discusses the desire of Indian people to receive culturally appropriate services, the need to maintain or improve Indian health care system funding, and the duty of state governments to respect tribal sovereignty. Because of their relatively small numbers, Indians may be treated differently under Medicaid managed care systems without significantly endangering anticipated program savings. Failure of Medicaid programs to recognize the uniqueness of Indian people, however, may severely weaken the Indian health care system. [ABSTRACT FROM AUTHOR]

Objectives. To identify financial hardships related to costs of obtaining abortion care in Texas, which has the highest uninsured rate in the United States and restricts insurance coverage for abortions. Methods. We surveyed patients seeking abortion at 12 Texas clinics in 2018 regarding costs and financial hardships related to abortion care. We compared mean out-of-pocket costs and the percentage reporting hardships across income and insurance categories. Results. Of 603 respondents, 42% were Latinx, 25% White, and 21% Black or African American, and most (62.0%) reported having low incomes (< 200% federal poverty level). Mean out-of-pocket costs were $634, which varied little across insurance groups. Patients with low incomes were more likely to obtain financial assistance from an abortion fund than were wealthier patients (12.3% vs 1.6%, respectively; P <.05). Financial hardships related to abortion costs were more common among uninsured (57.6%) and publicly insured (55.1%) patients than those with private insurance (48.2%). One in 5 (19.8%) uninsured respondents delayed buying food to pay for abortion care. Conclusions. Restrictions on insurance coverage for abortions result in high out-of-pocket costs and major financial hardships for most patients with low incomes in Texas. (Am J Public Health. 2022;112(5):758–761. https://doi.org/10.2105/AJPH.2021.306701) [ABSTRACT FROM AUTHOR]

The article discusses patient engagement and empowerment within the National Institute on Minority Health and Disparities Research Framework in relation to the study, published in the issue, which examined insurance-based discrimination in Minnesota. Topics covered include how to enhance patient-physician interactions, the importance of patient activation, confidence and empowerment and the systematic approach to improve patient-centered care.

The public health community has made important, original contributions to the debate over universal access to health services in the United States. Well before the decision of the American Public Health Association in 1944 to endorse a health plan encompassing virtually the entire populace, prominent public health practitioners and scholars embraced universality as an essential principle of health policy. Influenced by Arthur Newsholme, C.-E.A. Winslow began to promote this principle in the 1920s. Many others came to justify universal medical care as a corollary of the traditional ideal of all-inclusive public health services. By the 1940s, most leaders in the field saw national health insurance as the best way to attain universal access. For the past 30 years, advocates of universalism have asserted a social right to health services. [ABSTRACT FROM AUTHOR]

At a time of renewed interest in universal health insurance, an examination of earlier periods when society grappled with the link between socioeconomic status and health is fruitful. Between 1935 and 1947, the federal government sponsored a comprehensive medical care program for low-income farmers, sharecroppers, and migrant workers under the auspices of the Farm Security Administration of the American Medical Association, humanitarian and economic concerns at the local level often promoted physicians' participation in the program's group prepayment plans. Many FSA leaders clearly saw the program a model upon which national health insurance might advance. However, in the wake of World War II, the FSA program declined as physicians' income improved, the rural population declined, and traditional ideological objections to federal intervention in objections to federal intervention in medical care resurfaced. The FSA experience illuminates the complex ideological, economic, and humanitarian motivations of American physicians in the face of health care reform. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this study was to examine differences in adequacy of prenatal care and incidence of low birthweight between low-income women with Medicaid in Washington State and low-income women with Canadian provincial health insurance in British Columbia. Methods. A population-based cross-sectional study was done by using linked birth certificates and claims data. Results. Overall, the adjusted odds ratio for inadequate prenatal care in Washington (comparing women with Medicaid with those with private insurance) was 3.2 However the risk varied by time of Medicaid enrollment relative to pregnancy (2.0, 1.0, 2.7, 6.3; for women who enrolled prior to pregnancy, during the first trimester, during the second trimester, or during the third trimester, respectively). In British Columbia, the adjusted odds ratio for inadequate care (comparing women receiving a health premium subsidy with those receiving no subsidy) was 1.5 for women receiving a 100% subsidy and 1.2 for women receiving a 95% subsidy. The risk for low birthweight followed a similar trend in both regions, but there was no association with enrollment period in Washington. Conclusion. Overall, the risk for inadequate prenatal care among poor women was much greater in Washington than in British Columbia. Most of the difference was due to Washington women's delayed enrolled in Medicated. In both regions, the poor were at similar risk for low birth-weight relative to their more affluent counterparts. [ABSTRACT FROM AUTHOR]

Objectives. This study sought to examine racial differences in the use of medical procedures and diagnostic tests by elderly Americans. Methods. We used 1986 physician claims data for a 5% national sample of Medicare enrollees aged 65 years and older to study 32 procedures and tests. For each service, we calculated the age- and sex-adjusted rate of use by race and the corresponding White-Black relative risk. Results. Whites were more likely than Blacks to receive 23 services, and for many of these services, the differences in use were substantial. In contrast, Blacks were more likely than Whites to receive seven services. Whites had a particular advantage in access to higher-technology or newer services. Racial differences in use Medicaid in addition to Medicare coverage and increased among rural elders. Conclusions. There are pervasive racial differences in the use of medical services by elderly Americans that cannot be explained by differences in the prevalence of specific clinical conditions. Financial barriers to care do not fully account for these findings. Race may exacerbate the impact of other barriers to access. [ABSTRACT FROM AUTHOR]

We used Medicare data bases and U.S. Census data to address two questions critical to the use of Medicare files for epidemiologic research. First, we examined the degree to which the population enrolled in the Medicare program is similar to the elderly resident population of the United States, as estimated by the US Census. We found small differences in the total population estimates hut substantial differences by age and race. Second, we found that among Medicare enrollees, physician claims identify a small proportion of hip fracture cases which are not documented in the hospital discharge files. This proportion varies by age region, and state within the United States. Calculation of rates based on Medicare hospital discharge data, and probably other hospital discharge data sets as well, must take these limitations into account. Use of all available Medicare data files can overcome these limitations. [ABSTRACT FROM AUTHOR]

The onset of the Cold War had a blighting effect on the campaign for a national health insurance program in the United States. In the highly charged atmosphere of the late 1940s, proponents of social insurance spent considerable time and energy denying that they were agents of foreign powers. In one widely promoted conspiratorial formulation, some on the right traced the origins of subversion not only to Moscow but also to Geneva, Switzerland, home of the International Labor Organization. In the fractiously partisan context of the period, conservative political leaders amplified concerns over disloyal bureaucrats' manipulating the levers of legislative politics as well as the design of health policy. One federal official in particular. I. S. Falk, became the object of outright demonization. The paranoid attacks took their toll on the drive to extend social protection. The reformers' difficulties suggest the limitations of heavy dependence on bureaucratic expertise in the pursuit of health security. [ABSTRACT FROM AUTHOR]

Objectives. In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should he mandatory or voluntary. This study describes characteristics of low-income people who were more likely or less likely to be covered by a voluntary plan. Methods. Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics. Results. There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance. Conclusions. If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care. [ABSTRACT FROM AUTHOR]

Based on three years experience in the New York City Health Department, abuses in the provision of Medicaid are analyzed and methods for dealing with those involved are described. [ABSTRACT FROM AUTHOR]

Clinical trials have demonstrated that preexposure prophylaxis (PrEP) protects against HIV infection; yet, even with its approval by the Food and Drug Administration (FDA) in 2012, less than 10% of eligible users in the United States are currently taking PrEP. While there are multiple factors that influence PrEP uptake and pose barriers to PrEP implementation, here we focus on PrEP's cost in the United States, which, at the current list price of $2000 per month and with high levels of cost sharing, can leave insured users with more than $1000 in out-of-pocket costs every year. We discuss how patient deductibles, monthly premiums, copayments, and coinsurance vary widely and may increase the financial burden. Although drug payment-assistance programs have made PrEP more affordable to uninsured and underinsured users, lack of insurance is a barrier to PrEP accessibility. The FDA approved a generic version in 2017; however, that version has not been distributed to US consumers and may not be more affordable. As other countries begin implementing PrEP programs, the extent of PrEP's availability as a tool in the global fight against HIV remains to be seen. [ABSTRACT FROM AUTHOR]

Estimates from the 1977 National Medical Care Expenditure Survey suggest that divorced women are twice as likely as married women to be uninsured, and also more likely to depend on Medicaid assistance. Divorced women use slightly more health services than married women, but also appear to have somewhat poorer health status. (Am J Public Health 1984: 74:1276-1278.) [ABSTRACT FROM AUTHOR]

Objectives. To examine whether the expansion of Medicaid under the Affordable Care Act (ACA) decreased the prevalence of severe food insecurity. Methods. With data on adult respondents to the Food Security Supplement to the Current Population Survey in US states for the years 2010 to 2013 and 2015 to 2016, I used a difference-in-difference design to compare trends in very low food security (VLFS) among low-income childless adults in states that did and did not expand Medicaid in 2014 under the ACA. Results. Among low-income, nonelderly childless adults, VLFS rose from 17.4% before ACA to 17.5% after ACA in nonexpansion states, and fell from 17.6% to 15.9% in expansion states. In difference-in-difference analysis, Medicaid expansion was associated with a significant adjusted 2.2-percentage-point decline in rates of VLFS, equivalent to a 12.5% relative reduction. Conclusions. The improvement in food security after the ACA's health insurance expansion suggests that health insurance provision has spillover effects that reduce other dimensions of poverty. Public Health Implications. Providing free or low-cost health insurance coverage may free up household funds, reducing food insecurity and improving this important social determinant of health. [ABSTRACT FROM AUTHOR]

Objectives. To determine whether the 2014 Affordable Care Act Medicaid expansion affected well-being in the low-income and general adult US populations. Methods. We obtained data from adults aged 18 to 64 years in the nationally representative Gallup-Sharecare Well-Being Index from 2010 to 2016 (n = 1 674 953). We used a difference-in-differences analysis to compare access to and difficulty affording health care and subjective well-being outcomes (happiness, sadness, worry, stress, and life satisfaction) before and after Medicaid expansion in states that did and did not expand Medicaid. Results. Access to health care increased, and difficulty affording health care declined following the Medicaid expansion. Medicaid expansion was not associated with changes to emotional states or life satisfaction over the study period in either the low-income population who newly gained health insurance or in the general adult population as a spillover effect of the policy change. Conclusions. Although the public health benefits of the Medicaid expansion are increasingly apparent, improved population well-being does not appear to be among them. Public Health Implications. Subjective well-being indicators may not be informative enough to evaluate the public health impact of expanded health insurance. [ABSTRACT FROM AUTHOR]

Objectives.To determine whether privately insured female rape victims were billed for charges associated with a specific rape in the United States. Methods. We examined 2013 de-identified patient data from Truven Analytics Health MarketScan database for an assault that occurred by using International Classification of Diseases, Ninth Revision, code E960.1. Results. Analysis of insurance providers' payment patterns for 1355 incident events to female victims aged between 16 and 61 years revealed that victims remit, on average, 14% or $948 of the rape cost, whereas insurance providers pay 86% or $5789 of the total cost. Conclusions. Hospital billing procedures for privately insured victims of rape across the United States are not separate from billing procedures for privately insured nonrape patients. This standardized procedure leads hospitals to bill victims directly for services not paid under the victims' insurance policy. Public Health Implications. The Violence Against Women Act (passed in 1994, reauthorized in 2000, 2005, and 2013) must be amended to mandate that all costs incurred because of rape are not passed on to the victim. [ABSTRACT FROM AUTHOR]

The article explores how credit scores might be interpreted as predictors and consequences of disease. Particular focus is given to how this relates to the public health in the U.S. Topics discussed include the relationship between economic well-being and health, how consumer credit works in the U.S. and the financial consequences of health care treatments.

Objectives. We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues. Methods. In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity. Results. Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic. Conclusions. Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients. [ABSTRACT FROM AUTHOR]

Objectives. We qualitatively assessed patients' perceptions of discrimination and patient satisfaction in the health care setting specific to interactions with nonphysician health care staff. Methods. We conducted 12 focus-group interviews with African American and European American participants, stratified by race and gender, from June to November 2008. We used a topic guide to facilitate discussion and identify factors contributing to perceived discrimination and analyzed transcripts for relevant themes using a codebook. Results. We enrolled 92 participants: 55 African Americans and 37 European Americans, all of whom reported perceived discrimination and lower patient satisfaction as a result of interactions with nonphysician health care staff. Perceived discrimination was associated with 2 main characteristics: insurance or socioeconomic status and race. Both verbal and nonverbal communication style on the part of nonphysician health care staff were related to individuals' perceptions of how they were treated. Conclusions. The behaviors of nonphysician health care staff in the clinical setting can potentially contribute to patients' perceptions of discrimination and lowered patient satisfaction. Future interventions to reduce health care discrimination should include a focus on staff cultural competence and customer service skills. [ABSTRACT FROM AUTHOR]

Objectives. We estimated changes in children's insurance status (publicly insured, privately insured, or uninsured) and crowd-out rates during the 2007 to 2009 US recession in Ohio. Methods. We conducted an estimate of insurance coverage from statewide, randomized telephone surveys in 2004, 2008, 2010, and 2012. We estimated crowd-out by using regression discontinuity. Results. From 2004 to 2012, private insurance rates dropped from 67% to 55% and public rates grew from 28% to 40%, with no change in the uninsured rate for children. Despite a 12.0% decline in private coverage and a corresponding 12.6% increase in public coverage, we found no evidence that crowd-out increased during this period. Conclusions. Children, particularly those with household incomes lower than 400% of the federal poverty level, were enrolled increasingly in public insurance rather than private coverage. Near the Medicaid eligibility threshold, this is not from an increase in crowd-out. An alternative explanation for the increase in public coverage would be the decline in incomes for households with children. [ABSTRACT FROM AUTHOR]

Objectives. We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision. Methods. Hospital discharge data from the 2000-2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence. Results. Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend<.001), suggesting 390 000 additional circumcisions might have occurred nationwide had insurance coverage remained constant. Conclusions. Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure [ABSTRACT FROM AUTHOR]

Successful implementation of the Affordable Care Act (ACA) depends on the capacity of local communities to mobilize for action. Yet the literature offers few systematic investigations of what communities are doing to ensure support for enrollment. In this empirical case study, we report implementation and outcomes of Enroll Wyandotte, a community mobilization effort to facilitate enrollment through the ACA in Wyandotte County, Kansas. We describe mobilization activities during the first round of open enrollment in coverage under the ACA (October 1, 2013-March 31, 2014), including the unfolding of community and organizational changes (e.g., new enrollment sites) and services provided to assist enrollment over time. The findings show an association between implementation measures and newly created accounts under the ACA (the primary outcome). [ABSTRACT FROM AUTHOR]

The idea of tobacco or nicotine dependence as a specific psychiatric diagnosis appeared in 1980 and has evolved through successive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual. Not surprisingly, the tobacco industry attempted to challenge this diagnosis through behind-the-scenes influence. But another entity put corporate muscle into supporting the diagnosis—the pharmaceutical industry. Psychiatry’s ongoing professional challenges have left it vulnerable to multiple professional, social, and commercial forces. The example of tobacco use disorder illustrates that mental health concepts used to develop public health goals and policy need to be critically assessed. I review the conflicting commercial, professional, and political aims that helped to construct psychiatric diagnoses relating to smoking. This history suggests that a diagnosis regarding tobacco has as much to do with social and cultural circumstances as it does with science. [ABSTRACT FROM AUTHOR]

Abstract: An evaluation of the effect on total health care costs of a Medicaid demonstration project to provide coverage for alcoholism and substance abuse was conducted in Illinois in 1983. A pre/post-treatment analysis of expenditures for a subgroup of demonstration clients suggests that the addition of the alcohol and drug benefit did not result in higher total expenditures. [An important policy implication is that, when medical services substitute for one another, costs savings (increases) will not necessarily be realized when benefit packages are cut (expanded).] (Am J Public Health 1987; 77:503-504.) [ABSTRACT FROM AUTHOR]

A list of books related to public health and health insurance is presented. These books include "Prescription for National Health Insurance: A Proposal for the USA Based on Canadian Experience," by Peter Fisher, "Practical Aspects of Mental Health Consultation," by Jack Zusman, David L. Davidson and edited by Charles C. Thomas, and "It's So Good Don't Even Try It Once: Heroin in Perspective," by David E. Smith and George R. Gay.

I review the current status of transgender people's access to health care in the United States and analyze federal policies regarding health care services for transgender people and the limitations thereof. I suggest a preliminary outline to enhance health care services and recommend the formulation of explicit federal policies regarding the provision of health care services to transgender people in accordance with recently issued medical care guidelines, allocation of research funding, education of health care workers, and implementation of existing nondiscrimination policies. Current policies denying medical coverage for sex reassignment surgery contradict standards of medical care and must be amended. [ABSTRACT FROM AUTHOR]

To assess the experienced or perceived barriers and facilitators to health research participation for major US racial/ethnic minority populations, we conducted a systematic review of qualitative and quantitative studies from a search on PubMed and Web of Science from January 2000 to December 2011. With 44 articles included in the review, we found distinct and shared barriers and facilitators. Despite different expressions of mistrust, all groups represented in these studies were willing to participate for altruistic reasons embedded in cultural and community priorities. Greater comparative understanding of barriers and facilitators to racial/ethnic minorities' research participation can improve population-specific recruitment and retention strategies and could better inform future large-scale prospective quantitative and in-depth ethnographic studies. [ABSTRACT FROM AUTHOR]

We applied an alternative conceptual framework for analyzing health insurance and financial protection grounded in the health capability paradigm. Through an original survey of 706 households in Dai Dong, Vietnam, we examined the impact of Vietnamese health insurance schemes on inpatient and outpatient health care access, costs, and health outcomes using bivariate and multivariable regression analyses. Insured respondents had lower outpatient and inpatient treatment costs and longer hospital stays but fewer days of missed work or school than the uninsured. Insurance reform reduced household vulnerability to high health care costs through direct reduction of medical costs and indirect reduction of income lost to illness. However, from a normative perspective, out-of-pocket costs are still too high, and accessibility issues persist; a comprehensive insurance package and additional health system reforms are needed. [ABSTRACT FROM AUTHOR]

Objectives. We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm. Methods. Using National Medicaid Analytic Extract Files (2006) and Market- Scan Research Databases (2005-2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n = 8228) and privately (n = 2352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients. Results. Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively). Conclusions. Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid insured patients. [ABSTRACT FROM AUTHOR]

Objectives. We estimated associations between payer status, race/ethnicity, and acceptance of nontargeted opt-out rapid HIV screening in the emergency department (ED). Methods. We analyzed data from a prospective clinical trial between 2007 and 2009 at Denver Health. Patients in the ED were offered free HIV testing. Patient demographics and payer status were collected, and we used multivariable logistic regression to estimate associations with HIV testing acceptance. Results. A total of 31 525 patients made 44 765 unique visits: 40% were White, 37% Hispanic, 14% Black, 1% Asian, and 7% unknown race/ethnicity. Of all visits, 10 237 (23%) agreed to HIV testing; 27% were self-pay, 23% state-sponsored, 18% Medicaid, 13% commercial insurance, 12% Medicare, and 8% another payer source. Compared with commercial insurance patients, self-pay patients (odds ratio [OR] = 1.63; 95% confidence interval [CI] = 1.51, 1.75), state-sponsored patients (OR = 1.64; 95% CI = 1.52, 1.77), and Medicaid patients (OR = 1.24; 95% CI = 1.14, 1.34) had increased odds of accepting testing. Compared with White patients, Black (OR = 1.29; 95% CI = 1.21, 1.38) and Hispanic (OR = 1.17; 95% CI = 1.11, 1.23) patients had increased odds of accepting testing. Conclusions. Many ED patients are uninsured or subsidized through government programs and are more likely to consent to free rapid HIV testing. [ABSTRACT FROM AUTHOR]

United v Federal Election Commission 130 US 876 (2010) case concerned the plans of a nonprofit organization to distribute a film about presidential candidate Hillary Clinton. The Court ruled that prohibiting corporate independent expenditures for advocacy advertising during election campaigns unconstitutionally inhibits free speech. Corporations can now make unlimited contributions to election advocacy advertising directly from the corporate treasury. Candidates who favor public health positions may be subjected to corporate opposition advertising. Citizen groups and legislators have proposed remedies to ameliorate the effects of the Court's ruling. The public health field needs to apply its expertise, in collaboration with others, to work to reduce the disproportionate influence of corporate political speech on health policy and democracy. INSETS: Corporate Campaign Contributions Related to US Health Care...;Rights of Corporations;Proposed Actions to Ameliorate the Effects of the Citizens.... [ABSTRACT FROM AUTHOR]

Objectives. We sought to determine how part-year and full-year gaps in health insurance coverage affected working-aged persons with chronic health care needs. Methods. We conducted multivariate analyses of the 2002-2004 Medical Expenditure Panel Survey to compare access, utilization, and out-of-pocket spending burden among key groups of persons with chronic conditions and disabilities. The results are generalizable to the US community-dwelling population aged 18 to 64 years. Results. Among 92 million adults with chronic conditions, 21% experienced at least 1 month uninsured during the average year (2002-2004). Among the 25 million persons reporting both chronic conditions and disabilities, 23% were uninsured during the average year. These gaps in coverage were associated with significantly higher levels of access problems, lower rates of ambulatory visits and prescription drug use, and higher levels of out-of-pocket spending. Conclusions. Implementation of health care reform must focus not only on the prevention of chronic conditions and the expansion of insurance coverage but also on the long-term stability of the coverage to be offered. [ABSTRACT FROM AUTHOR]

We examined eligibility and enrollment among parents of children in New Jersey's State Children's Health Insurance Program following expansion of parental eligibility for NJ FamilyCare coverage. Data were from the 2003 NJ FamilyCare Family Health Survey (n=416 families). Parental eligibility was higher in households without a full-time employed parent(odds ratio [OR]=5.50; 95% confidence interval [CI]=2.72, 11.14) and lower among single parents (OR=0.38; 95% CI=0.23, 0.61). Enrollment was higher among single parents (OR=2.24; 95% CI=1.17, 4.31). Roughly one third of eligible parents did not enroll, suggesting the need to increase awareness of parental eligibility and reduce barriers to enrollment. [ABSTRACT FROM AUTHOR]

Objectives. We compared the quality of care received by managed care Medicaid beneficiaries in counties with a choice of health plans and counties with no choice. Methods. This cross-sectional study among California Medicaid beneficiaries was conducted during 2002. We used a multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care--sensitive conditions by duration of plan enrollment. Results. Among beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%; P<.001). Annual ambulatory care--sensitive admission rates adjusted for age, gender, and race/ethnicity were significantly higher among beneficiaries living in counties with a choice of plans (6.58 admissions per 1000 beneficiaries; 95% confidence interval [CI]=6.57, 6.58) than among those in counties with no choice (6.27 per 1000; 95% CI=6.27, 6.28). Conclusions. Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care--sensitive conditions. [ABSTRACT FROM AUTHOR]

Proposals to improve the US health system are commonly supported by models that have only a few variables and overlook certain processes that may delay, dilute, or defeat intervention effects. We use an evidence-based dynamic simulation model with a broad national scope to analyze 5 policy proposals. Our results suggest that expanding insurance coverage and improving health care quality would likely improve health status but would also raise costs and worsen health inequity, whereas a strategy that also strengthens primary care capacity and emphasizes health protection would improve health status, reduce inequities, and lower costs. A software interface allows diverse stakeholders to interact with the model through a policy simulation game called Health Bound. (Am J Public Health. 2010;100:811-819. doi:10.2105/AJPH.2009.174490) [ABSTRACT FROM AUTHOR]

Objective. We sought to determine whether lack of state Medicaid coverage for infant male circumcision correlates with lower circumcision rates. Methods. We used data from the Nationwide Inpatient Sample on 417282 male newborns to calculate hospital-level circumcision rates. We used weighted multiple regression to correlate hospital circumcision rates with hospital-level predictors and state Medicaid coverage of circumcision. Results. The mean neonatal male circumcision rate was 55.9%. When we controlled for other factors, hospitals in states in which Medicaid covers routine male circumcision had circumcision rates that were 24 percentage points higher than did hospitals in states without such coverage (P<.001). Hospitals serving greater proportions of Hispanic patients had lower circumcision rates; this was not true of hospitals serving more African Americans. Medicaid coverage had a smaller effect on circumcision rates when a hospital had a greater percentage of Hispanic births. Conclusions. Lack of Medicaid coverage for neonatal male circumcision correlated with lower rates of circumcision. Because uncircumcised male face greater risk of HIV and other sexually transmitted infections, lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families covered by Medicaid. (Am J Public Health. 2009;99:138-145. doi: 10.2105/AJPH.2008.134403) [ABSTRACT FROM AUTHOR]

Health services at the community level are organized and financed in such a way that men need access but encounter barriers to care such as poor service design, lack of insurance, and the absence of health literacy. Community health delivery systems may not be appropriate, effective, fit, or able to meet the needs they are charged to fill. Community-based health services, including health departments, are underfunded, understaffed, and unable to carry out their mission in a way that protects the health of the community. The current design for funding and delivering health care services excludes poor men, particularly men of color. Improving the health of men requires modifications in the way health care is financed, delivered, and managed. {Am J Public Health. 2003;93:749-752) [ABSTRACT FROM AUTHOR]

Objectives. Profound and growing disparities exist in oral health among certain US populations. We sought here to determine the prevalence of oral health complaints among Harlem adults by measures of social class, as well as their access to oral health care. Methods. A population-based survey of adults in Central Harlem was conducted from 1992 to 1994. Two questions on oral health were included: whether participants had experienced problems with their teeth or gums during the past 12 months and, if so, whether they had seen a dentist. Results. Of 50 health conditions queried about, problems with teeth or gums were the chief complaint among participants (30%). Those more likely to report oral health problems than other participants had annual household incomes of less than $9000 (36%), were unemployed (34%), and lacked health insurance (34%). The privately insured were almost twice as likely to have seen a dentist for oral health problems (87%) than were the uninsured (48%). Conclusions. There is an urgent need to provide oral health services for adults in Harlem. Integrating oral health into comprehensive primary care is one promising mechanism. {Am J Public Health. 2002; 92:49-52) [ABSTRACT FROM AUTHOR]

Costa Rica is a middle-income country with a strong governmental emphasis on human development. For more than half a century, its health policies have applied the principles of equity and solidarity to strengthen access to care through public services and universal social health insurance. Costa Rica's population measures of health service coverage, health service use, and health status are excellent, and in the Americas, life expectancy in Costa Rica is second only to that in Canada. Many of these outcomes can be linked to the performance of the public health care system. However, the current emphasis of international aid organizations on privatization of health services threatens the accomplishments and universality of the Costa Rican health care system. (Am J Public Health. 2008;98:636-643. doi:10. 2105/AJPH.2006.099598) [ABSTRACT FROM AUTHOR]