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The Affordable Care Act includes financial assistance that reduces both premiums and cost-sharing amounts for lower-income Americans, to increase the affordability of health insurance coverage and care. To receive both types of assistance, enrollees must purchase a qualified health plan through a public insurance exchange, and those eligible for the cost-sharing reduction must purchase a silver-tier plan. We estimate that 31 percent of individual-market enrollees in California who were likely eligible for financial assistance purchased plans that were not silver tier or that were not sold on the state's exchange and thus missed opportunities to receive premium or cost-sharing assistance or both. Lower-income enrollees who chose plans not eligible for subsidies had two to three times higher odds of reporting difficulty paying premiums and out-of-pocket expenses during the year, compared to those who chose eligible plans. Regardless of how the structure of the individual market evolves in the coming years, efforts are likely needed to steer lower-income enrollees away from financially suboptimal plan choices. [ABSTRACT FROM AUTHOR]

Food insecurity and poor nutrition are prevalent in the United States and associated with chronic diseases. Understanding relationships among food insecurity, diet, and health care utilization can inform strategies to reduce health disparities. Our aim was to determine associations between food security status and inpatient and outpatient health care utilization and whether they differed by dietary quality in lower-income adults. This was a cross-sectional study of data from the 2009-2016 National Health and Nutrition Examination Survey. Participants were 13,956 lower-income (<300% federal poverty level) adults 18 years and older in the United States. Self-reported health care utilization in the past 12 months included no usual source of care, any outpatient visit, any mental health service use, and any hospitalization. Multiple logistic regression was used to study the association between food insecurity and health care utilization. Analyses were stratified by diet-related comorbidities to account for potential confounding and mediation of health care utilization, and by dietary quality. In a sample of lower-income adults <300% federal poverty level, 4,319 participants (27.4%) were food insecure, 2,208 (15.0%) were marginally food secure, and 7,429 (57.6%) were food secure. Food insecurity was associated with having no usual source of care (adjusted odds ratio [aOR] 1.30; 95% CI 1.11 to 1.52), any mental health service use (aOR 2.02; 95% CI 1.61 to 2.52), and any hospitalization (aOR 1.19; 95% CI 1.01 to 1.41). Food-insecure adults were more likely to report no outpatient visits if they had diet-related comorbidities (aOR 1.45; 95% CI 1.10 to 1.92) or the lowest dietary quality (aOR 1.53; 95% CI 1.06 to 2.23). Marginal food security was associated with having no usual source of care (aOR 1.22; 95% CI 1.04 to 1.44). Adults with food insecurity were more likely to be hospitalized, use mental health services, and have no usual source of care. Food-insecure participants with diet-related comorbidities or poor diet were less likely to have outpatient visits. Hospitalizations and mental health visits represent underused opportunities to identify and address food insecurity and dietary intake in lower-income patients. [ABSTRACT FROM AUTHOR]

Adults with mental illnesses are more likely to have low income and diet-related chronic diseases. This study examined associations of mental illness diagnosis status with food insecurity and diet quality and whether the relationship between food security status and diet quality differed by mental illness diagnosis status in adult Medicaid beneficiaries. This was a secondary cross-sectional analysis of baseline (2019–2020) data collected as part of the LiveWell study, a longitudinal study evaluating a Medicaid food and housing program. Participants were 846 adult Medicaid beneficiaries from an eastern Massachusetts health system. Food security was measured with the 10-item US Adult Food Security survey module (0 = high food security, 1–2 = marginal food security, 3–10 = low/very low food security). Mental illness diagnoses included health record–documented anxiety, depression, or serious mental illness (eg, schizophrenia, bipolar disorder). Healthy Eating Index (HEI-2015) scores were calculated from 24-hour dietary recalls. Multivariable regression analyses adjusted for demographics, income, and survey date. Participants' mean (standard deviation) age was 43.1 (11.3) years, and 75% were female, 54% Hispanic, 33% non-Hispanic White, and 9% non-Hispanic Black. Fewer than half (43%) of participants reported high food security, with almost one third (32%) reporting low or very low food security. The 341 (40%) participants with one or more mental illness diagnosis had greater odds of low/very low food security (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.38–2.70) and had similar mean HEI-2015 scores (53.1 vs 56.0; P = 0.12) compared with participants with no mental illness diagnosis. Mean adjusted HEI-2015 scores did not significantly differ by high vs low/very low food security for those without a mental illness diagnosis (57.9 vs 54.9; P = 0.052) or those with a mental illness diagnosis (53.0 vs 52.9; P = 0.99). In a cohort of adults with Medicaid, those with mental illness diagnoses had higher odds of experiencing food insecurity. Overall, diet quality among adults in this sample was low but did not differ by mental illness diagnosis or food security status. These results highlight the importance of augmenting efforts to improve both food security and diet quality among all Medicaid participants. [ABSTRACT FROM AUTHOR]