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Objective: To improve food insecurity interventions, we sought to better understand the hypothesized bidirectional relationship between food insecurity and health care expenditures. Data Source: Nationally representative sample of the civilian noninstitutionalized population of the United States (2016-2017 Medical Expenditure Panel Survey [MEPS]). Study Design: In a retrospective longitudinal cohort, we conducted two sets of analyses: (a) two-part models to examine the association between food insecurity in 2016 and health care expenditures in 2017; and (b) logistic regression models to examine the association between health care expenditures in 2016 and food insecurity in 2017. We adjusted for demographic and socioeconomic variables as well as 2016 health care expenditures and food insecurity. Data Collection: Health care expenditures, food insecurity, and medical condition data from 10 886 adults who were included in 2016-2017 MEPS. Principal Findings: Food insecurity in 2016, compared with being food secure, was associated with both a higher odds of having any health care expenditures in 2017 (OR 1.29, 95% CI: 1.04 to 1.60) and greater total expenditures ($1738.88 greater, 95% CI: $354.10 to $3123.57), which represents approximately 25% greater expenditures. Greater 2016 health care expenditures were associated with slightly higher odds of being food insecure in 2017 (OR 1.007 per $1000 in expenditures, 95% CI: 1.002 to 1.012, P =0.01). Exploratory analyses suggested that poor health status may underlie the relationship between food insecurity and health care expenditures. Conclusions: A bidirectional relationship exists between food insecurity and health care expenditures, but the strength of either direction appears unequal. Higher health care expenditures are associated with a slightly greater risk of being food insecure (adjusted for baseline food insecurity status) but being food insecure is associated with substantially greater subsequent health care expenditures (adjusted for baseline health care expenditures). Interventions to address food insecurity and poor health may be helpful to break this cycle. KEYWORDS chronic disease, external debt, food insecurity, health expenditures, prescription drugs, 1 | INTRODUCTION Food insecurity, inconsistent access to enough food for an active, healthy life, affected over 37 million Americans in 2018 (11.1% of households). (1) Early reports suggest that [...]

Background: Self-employed workers are 10% of the US labor force, with growth projected over the next decade. Whether existing policy mechanisms are sufficient to ensure health insurance coverage for self-employed workers, who do not have access to employer-sponsored coverage, is unclear. Objective: To determine whether self-employment is associated with lack of health insurance coverage. Data Sources: Secondary analysis of Medical Expenditure Panel Survey (MEPS) data collected 2014-2017. Study Design: Participants were working age (18-64 years), employed, civilian noninstitutionalized US adults with two years of Medical Expenditure Panel Survey (MEPS) participation in 2014-2017. We compared those who were employees vs those who were self-employed. Key outcomes were self-report of health insurance coverage, and of delaying needed medical care. Data Extraction Methods: Longitudinal design among individuals who were employees during study year 1, comparing health insurance coverage among those who did vs did not transition to self-employment in year 2. Principal Findings: 16 335 individuals, representing 121 473 345 working-age adults, met inclusion criteria; of these, 147, representing 1 097 582 individuals, transitioned to self-employment. In unadjusted analyses, 25.7% of those who became self-employed were uninsured in year 2, vs 8.1% of those who remained employees (P < .0001). In adjusted models, self-employment was associated with greater risk of being uninsured (26.1% vs 8.0%, risk difference 18.0%, 95% confidence interval [CI] 9.2% to 26.9%, P = .0001). A time-by-employment type product term suggests that 10.0 percentage points (95%CI 0.3 to 19.7 percentage points, P = .04) of the risk difference may be attributable to the change to self-employment. Self-employment was also associated with delaying needed medical care (12.0% vs 3.1%, risk difference: 8.9%, 95% CI 3.1% to 14.6%, P = .003). Conclusions: One in four self-employed workers lack health insurance coverage. Given the rise in self-employment, it is imperative to identify ways to improve health care insurance access for self-employed working-age US adults. KEYWORDS employment, health insurance, medically uninsured, self-employment, 1 | INTRODUCTION Self-employment is increasing in the American workforce. The US Bureau of Labor Statistics reports that as of 2016, 10% of all workers are self-employed, and that, after [...]

Objective. To determine whether food insecurity, limited or uncertain food access owing to cost, is associated with greater health care expenditures. Data Source/Study Setting. Nationally representative sample of the civilian noninstitutionalized population of the United States (2011 National Health Interview Survey [NHIS] linked to 2012-2013 Medication Expenditure Panel Survey [MEPS]). Study Design. Longitudinal retrospective cohort. Data Collection/Extraction Methods. A total of 16,663 individuals underwent assessment of food insecurity, using the 10-item adult 30-day food security module, in the 2011 NHIS. Their total health care expenditures in 2012 and 2013 were recorded in MEPS. Expenditure data were analyzed using zero-inflated negative binomial regression and adjusted for age, gender, race/ethnicity, education, income, insurance, and residence area. Principal Findings. Fourteen percent of individuals reported food insecurity, representing 41,616,255 Americans. Mean annualized total expenditures were $4,113 (standard error $115); 9.2 percent of all individuals had no health care expenditures. In multivariable analyses, those with food insecurity had significantly greater estimated mean annualized health care expenditures ($6,072 vs. $4,208, p < .0001), an extra $1,863 in health care expenditure per year, or $77.5 billion in additional health care expenditure annually. Conclusions. Food insecurity was associated with greater subsequent health care expenditures. Future studies should determine whether food insecurity interventions can improve health and reduce health care costs. Key Words. Food insecurity, health expenditures, socioeconomic status, diabetes, cardiovascular disease, cardiovascular disease, hypertension, In 2014, food insecurity affected approximately 49 million Americans in 17.4 million U.S. households, or 14 percent of the population (Coleman-Jensen et al. 2015). A growing body of evidence links [...]

Objective. To determine which area-based socioeconomic status (SES) indicator is best suited to monitor health care disparities from a delivery system perspective. Data Sources/Study Setting. 142,659 adults seen in a primary care network from January 1, 2009 to December 31, 2011. Study Design. Cross-sectional, comparing associations between area-based SES indicators and patient outcomes. Data Collection. Address data were geocoded to construct area-based SES indicators at block group (BG), census tract (CT), and ZIP code (ZIP) levels. Data on health outcomes were abstracted from electronic records. Relative indices of inequality (RIIs) were calculated to quantify disparities detected by area-based SES indicators and compared to RIIs from self-reported educational attainment. Principal Findings. ZIP indicators had less missing data than BG or CT indicators [p < .0001). Area-based SES indicators were strongly associated with self-report educational attainment (p < .0001). ZIP, BG, and CT indicators all detected expected SES gradients in health outcomes similarly. Single-item, cut point defined indicators performed as well as multidimensional indices and quantile indicators. Conclusions. Area-based SES indicators detected health outcome differences well and may be useful for monitoring disparities within health care systems. Our preferred indicator was ZIP-level median household income or percent poverty, using cut points. Key Words. Socioeconomic status, delivery of health care, quality of health care, health care disparities, geographic mapping, Tracking 'prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations' is a public health priority (Agency for Healthcare Research and Quality [...]