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A majority of individuals with limited English proficiency (LEP) in the U.S. are foreign-born, creating a complex intersection of language, socio-economic, and policy barriers to healthcare access and achieving good outcomes. Mapping the research literature is key to addressing how LEP intersects with healthcare. This scoping review followed PRISMA-ScR guidelines and included PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Study selection included quantitative studies since 2000 with outcomes specified for adults with LEP residing in the U.S. related to healthcare service access or defined health outcomes, including healthcare costs. A total of 137 articles met the inclusion criteria. Major outcomes included ambulatory care, hospitalization, screening, specific conditions, and general health. Overall, the literature identified differential access to and utilization of healthcare across multiple modalities with poorer outcomes among LEP populations compared with English-proficient populations. Current research includes inconsistent definitions for LEP populations, primarily cross-sectional studies, small sample sizes, and homogeneous language and regional samples. Current regulations and practices are insufficient to address the barriers that LEP individuals face to healthcare access and outcomes. Changes to EMRs and other data collection to consistently include LEP status and more methodologically rigorous studies are needed to address healthcare disparities for LEP individuals. [ABSTRACT FROM AUTHOR]

Introduction: An appropriate economic evaluation of post-exposure prophylaxis (PEP) should consider the effectiveness of different regimens prescribed for patients. Studies have not evaluated the comparative effectiveness of different PEP antiretrovirals (ARVs) based on their costs. Therefore, the aim of the present study was to determine the cost-effectiveness of ARVs regimens used for PEP in Nigerian tertiary hospitals. Material and methods: This cross-sectional study collated patients' demographic and clinical data from PEP databases of United States' President Emergency Plan for AIDS Relief - AIDS Prevention Initiative in Nigeria hospitals. Costs of ARVs were obtained from donors' price list. Effectiveness was measured as the percentage of human immunodeficiency virus (HIV)-negative patients one-month post-PEP. Average cost-effectiveness ratios (ACERs) were computed as the unit cost of the regimens/HIV infection averted (HIA). Probabilistic sensitivity analysis was conducted using 1,000 iterations using Monte-Carlo simulation. Results: Out of 575 patients identified, 198 (34.4%) had non-occupational exposure. Of the 14 regimens, tenofovir (TDF) + lamivudine (3TC) + ritonavir-boosted atazanavir (ATV/r) was prescribed for 230 (40.00%) patients. HIV-negative results were documented in 129 (22.4%) of the 185 patients with post-PEP test. Zidovudine (AZT) + 3TC + ATV-r was the most effective (95.5%, n = 63 of 66) regimen, while TDF + emtricitabine (FTC) + ritonavir-boosted lopinavir (LPV/r) was the most expensive ($23.66). With an ACER of $8.110/HIV infection prevented (95% CI: $8.052-$8.168), TDF + 3TC + efavirenz (EFV) was the most cost-effective regimen. Conclusions: AZT + 3TC + LPV/r was the most effective regimen, while TDF + FTC + ATV/r was the most expensive. However, TDF + 3TC + EFV combination was the most cost-effective regimen used in providing PEP service to HIV patients in Nigerian hospitals. [ABSTRACT FROM AUTHOR]

Battery-based electric vehicles (BEVs) in the United States (U.S.) set a new sales record in 2022, driven by technology, policy, environmental, and economic objectives. However, the rapid deployment of BEVs and charging infrastructure without a careful review of their integration with the electric grid can have negative economic impacts on reliable and resilient electricity supply. Bi-directional power transfer (Bi-Di) vehicle-grid integration technologies and services such as vehicle-to-home or building (V2H/B) and vehicle-to-grid (V2G) can potentially lower local and system peak demand, improve economics for grid operators, and benefit BEV customers. Original equipment manufacturers (OEMs) in the automotive industry are exploring technologies and economics (techno-economics) for Bi-Di services. The study conducted a literature review of eleven case studies in the U.S. and Europe that featured Bi-Di demonstrations from 2005 to 2022 to highlight insights and techno-economic opportunities and challenges for OEMs. The findings should motivate the OEMs to prioritize technology innovation and business models to increase BEV sales and gain continuous revenue from Bi-Di services, which can potentially transition "car makers" to "technology solution" companies. [ABSTRACT FROM AUTHOR]

Background: Advancing healthcare access and quality for underserved populations requires a diverse, culturally competent interprofessional workforce. However, high educational debt may influence career choice of healthcare professionals. In the United States, health professions lack insight into the maximum educational debt that can be supported by current entry-level salaries. The purpose of this interprofessional economic analysis was to examine whether average educational debt for US healthcare graduates is supportable by entry-level salaries. Additionally, the study explored whether trainees from minoritized backgrounds graduate with more educational debt than their peers in physical therapy. Methods: The study modeled maximum educational debt service ratios for 12 healthcare professions and 6 physician specialties, incorporating profession-specific estimates of entry-level salary, salary growth, national average debt, and 4 loan repayment scenarios offered by the US Department of Education Office of Student Financial Aid. Net present value (NPV) provided an estimate for lifetime "economic power" for the modeled careers. The study used a unique data source available from a single profession (physical therapy, N = 4,954) to examine whether educational debt thresholds based on the repayment model varied between minoritized groups and non-minoritized peers. Results: High salary physician specialties (e.g. obstetrics/gynecology, surgery) and professions without graduate debt (e.g. registered nurse) met debt ratio targets under any repayment plan. Professions with strong salary growth and moderate debt (e.g. physician assistant) required extended repayment plans but had high career NPV. Careers with low salary growth and high debt relative to salary (e.g. physical therapy) had career NPV at the lowest range of modeled professions. 29% of physical therapy students graduated with more debt than could be supported by entry-level salaries. Physical therapy students from minoritized groups graduated with 10–30% more debt than their non-minoritized peers. Conclusions: Graduates from most healthcare professions required extended repayment plans (higher interest) to meet debt ratio benchmarks. For several healthcare professions, low debt relative to salary protected career NPV. Students from minoritized groups incurred higher debt than their peers in physical therapy. [ABSTRACT FROM AUTHOR]

The article examine the factors contributing to the decline of antitrust enforcement in the U.S. It challenge the conventional narrative that attributes this decline solely to the influence of the Chicago School's economic theories. It further explore whether special interests and political factors played a role in shaping antitrust policies.

Policy PointsIn America, wages appear to be growing relative to purchasing power over time. However, while the ability to purchase consumer goods has indeed improved, the cost of basic survival needs such as health care and education has increased faster than wages have grown.America's weakening social policy landscape has led to a massive socioeconomic rupture in which the middle class is disappearing, such that most Americans now cannot afford basic survival needs, such as education and health insurance.Social policies strive to rebalance societal resources from socioeconomically advantaged groups to those in need. Education and health insurance benefits have been experimentally proven to also improve health and longevity. The biological pathways through which they work are also understood. [ABSTRACT FROM AUTHOR]

Policy PointsPublic health science regarding alcohol consumption and problems, alcohol's role in equity and social justice, and identification of effective policy interventions has grown steadily stronger in the past 30 years.Progress on effective alcohol policies has stalled or gone backward in the United States and much of the world.Because alcohol influences at least 14 of the 17 sustainable development goals, as well as more than 200 disease and injury conditions, reducing alcohol problems should offer a platform for collaboration across public health silos but will require that public health itself respect and follow its own science. [ABSTRACT FROM AUTHOR]

We introduce the consideration of human migration into research on economic losses from extreme weather disasters. Taking a comparative case study approach and using data from the Federal Reserve Bank of New York/Equifax Consumer Credit Panel, we document the size of economic losses attributable to migration from 23 disaster-affected areas in the United States before, during, and after some of the most costly hurricanes, tornadoes, and wildfires on record. We then employ demographic standardization and decomposition to determine if these losses primarily reflect changes in out-migration or the economic resources that migrants take with them. Finally, we consider the implications of these losses for changing spatial inequality in the United States. While disaster-affected areas and their populations differ in their experiences of and responses to extreme weather disasters, we generally find that, relative to the year before an extreme weather disaster, economic losses via migration from disaster-affected areas increase the year of and after the disaster, these changes primarily reflect changes in out-migration (vs. the economic resources that migrants take with them), and these losses briefly disrupt the status quo by temporarily reducing spatial inequality. [ABSTRACT FROM AUTHOR]

This article analyzes differences in prescription drug pricing transparency practices among 3 Organisation for Economic Co-operation and Development member nations: the United Kingdom, Germany, and Canada. Specifically, this article compares these countries' policies on list and net price disclosures and on how international reference pricing is used to evaluate merits and drawbacks of different pricing transparency approaches. Finally, the article summarizes what policymakers in the United States should learn from these comparisons. [ABSTRACT FROM AUTHOR]

In many parts of the world including the western United States, the allocation of water is governed by complex water laws that dictate who receives water, how much they receive, and when. Because these rules are generally based on the seniority of water rights, they are not necessarily focused on maximizing economic value across the entire economy. The maximization of value from water use economy-wide is a complex optimization problem that must explicitly consider each user's water demand, willingness to pay (WTP) function, and the feedbacks among users in a coupled natural-human system model. In this study, we distill these complexities into a simple MATLAB® model developed to represent a two-user economy with water-dependent sectors representative of agriculture and industry. We feed the model with realistic values of relative water use, relative willingness to pay, and return flows to explore the relationships among these factors in water-limited systems. We find that the total economic value generated from water-dependent users depends primarily on the total water available in the system. However, for a given volume of water available, economic value is not necessarily maximized when all the water is appropriated to the user with the highest WTP. Rather, total economic value depends on the amount of water available, the relative WTP between the two users, and on the return flows generated from each sector's water use. While our simple two-user model is a significant abstraction of the complexities inherent in natural systems, our study provides important insights into the coupled natural-human system dynamics of water allocation and use in water-limited environments. [ABSTRACT FROM AUTHOR]

Introduction: Points of entry (POE) in Pakistan serve as key conduits for international travel, transport, and trade. Central Health Establishment (CHE) is a key stakeholder in the implementation of the International Health Regulations 2005 (IHR) core capacities at POE and National Action Plan 2020 against COVID-19. A comprehensive screening plan for COVID-19 was carried out effectively despite limitations. Methods: A descriptive study on CDC guidelines for health screening at POE was conducted from February 2020 to March 2021. Guidelines are based on 11 attributes to be implemented; these include legal and regulatory bodies to detain the travelers as suspect, isolate, and coordinate at POEs, funds for screening, well-equipped quarantine facilities, referral health care facilities, protocols for primary and secondary screening, capacity building, supply of personal protective equipment and screening tools, and provision of basic facilities at isolation areas. Data were collected using both qualitative and quantitative methods from health officers and quarantine assistants of PoEs. The analysis of CHE's information system was performed to assess the management of traveler surveillance. Results: Eleven attributes were addressed for health screening according to CDC guidelines and well implemented at POE by CHE under the flagship of the MNHR&C. Primary health screening of 4,088,119 inbound travelers was conducted. Secondary health screening led to the referral of performed at airports for inbound travelers, with a positivity rate of 0.32. Conclusion: Preparedness and response for COVID-19 at POE are in line with the National Action Plan of the Government of Pakistan and IHR (2005). [ABSTRACT FROM AUTHOR]

International research and collaboration has been a part of the National Cancer Institute's (NCI) mission since its creation in 1937. Early on, efforts were limited to international exchange of information to ensure that US cancer patients could benefit from advances in other countries. As NCI's research grant portfolio grew in the 1950s, it included a modest number of grants to foreign institutions, primarily in the United Kingdom and Europe. In the 1960s, the development of geographic pathology, which aimed to study cancer etiology through variations in cancer incidence and risk factors, led to an increase in NCI-funded international research, including research in low- and middle-income countries. In this paper, we review key international research programs, focusing particularly on the first 50 years of NCI history. The first NCI-led overseas research programs, established in the 1960s in Ghana and Uganda, generated influential research but also struggled with logistical challenges and political instability. The 1971 National Cancer Act was followed by the creation of a number of bilateral agreements with foreign governments, including China, Japan, and Russia, to support cooperation in technology and medicine. Although these agreements were broad without specific scientific goals, they provided an important mechanism for sustained collaborations in specific areas. With the creation of the NCI Center for Global Health in 2011, NCI's global cancer research efforts gained sustained focus. Because the global cancer burden has evolved over time, increasingly impacting low- and middle-income countries, NCI's role in global cancer research remains more important than ever. [ABSTRACT FROM AUTHOR]

With the development of the market economy, agricultural trade has become more and more significant for the development of the agricultural economy, which has triggered people's further thinking and exploration on the impact of agricultural trade on agricultural carbon emissions. This paper takes the measurement of trade implied carbon as the carbon dioxide emission index under the impact of agricultural trade and analyzes the impact of trade implied carbon and implied carbon balance on carbon emission. Taking the impact of Sino-US agricultural trade as an empirical background, this paper measures the impact of environmental changes in agricultural trade opening on China's agricultural development and its carbon emissions, so as to predict changes in China's regional agricultural carbon emissions performance. After calculation, it is found that the scale of China's exports has decreased by 0.089%, which is lower than the decline of 0.361% in the United States. The trade conflict has a significant impact on China's import and export structure. Under the scenario of mutual tariffs on agricultural products, China's exports to the United States are expected to decrease by 6.28%, while China's imports from the United States decreased by 13.02%. The Sino-US agricultural trade dispute will reduce China's carbon emissions by 0.013% and the United States' carbon emissions by 0.024%, which is related to the negative impact on the economy. Improving the performance of agricultural carbon emissions is not only the need for the green and sustainable development of the agricultural economy but also conducive to improving the international competitiveness of agricultural products. [ABSTRACT FROM AUTHOR]

Neutropenia and febrile neutropenia (FN) are common complications of myelosuppressive chemotherapy. This review provides an up-to-date assessment of the patient and cost burden of chemotherapy-induced neutropenia/FN in the US, and summarizes recommendations for FN prophylaxis, including the interim guidance that was recommended during the coronavirus disease 2019 (COVID-19) pandemic. This review indicates that neutropenia/FN place a significant burden on patients in terms of hospitalizations and mortality. Most patients with neutropenia/FN presenting to the emergency department will be hospitalized, with an average length of stay of 6, 8, and 10 days for elderly, pediatric, and adult patients, respectively. Reported in-hospital mortality rates for neutropenia/FN range from 0.4% to 3.0% for pediatric patients with cancer, 2.6% to 7.0% for adults with solid tumors, and 7.4% for adults with hematologic malignancies. Neutropenia/FN also place a significant cost burden on US healthcare systems, with average costs per neutropenia/FN hospitalization estimated to be up to $40 000 for adult patients and $65 000 for pediatric patients. Evidence-based guidelines recommend prophylactic granulocyte colony-stimulating factors (G-CSFs), which have been shown to reduce FN incidence while improving chemotherapy dose delivery. Availability of biosimilars may improve costs of care. Efforts to decrease hospitalizations by optimizing outpatient care could reduce the burden of neutropenia/FN; this was particularly pertinent during the COVID-19 pandemic since avoidance of hospitalization was needed to reduce exposure to the virus, and resulted in the adaptation of recommendations to prevent FN, which expanded the indications for G-CSF and/or lowered the threshold of use to >10% risk of FN. [ABSTRACT FROM AUTHOR]

Policy PointsPolicies that increase county income levels, particularly for middle‐income households, may reduce low birth weight rates and shrink disparities between Black and White infants.Given the role of aggregate maternal characteristics in predicting low birth weight rates, policies that increase human capital investments (e.g., funding for higher education, job training) could lead to higher income levels while improving population birth outcomes.The association between county income levels and racial disparities in low birth weight is independent of disparities in maternal risks, and thus a broad set of policies aimed at increasing income levels (e.g., income supplements, labor protections) may be warranted. Context: Low birth weight (LBW; <2,500 grams) and infant mortality rates vary among place and racial group in the United States, with economic resources being a likely fundamental contributor to these disparities. The goals of this study were to examine time‐varying county median income as a predictor of LBW rates and Black‐White LBW disparities and to test county prevalence and racial disparities in maternal sociodemographic and health risk factors as mediators. Methods: Using national birth records for 1992–2014 from the National Center for Health Statistics, a total of approximately 27.4 million singleton births to non‐Hispanic Black and White mothers were included. Data were aggregated in three‐year county‐period observations for 868 US counties meeting eligibility requirements (n = 3,723 observations). Sociodemographic factors included rates of low maternal education, nonmarital childbearing, teenage pregnancy, and advanced‐age pregnancy; and health factors included rates of smoking during pregnancy and inadequate prenatal care. Among other covariates, linear models included county and period fixed effects and unemployment, poverty, and income inequality. Findings: An increase of $10,000 in county median income was associated with 0.34 fewer LBW cases per 100 live births and smaller Black‐White LBW disparities of 0.58 per 100 births. Time‐varying county rates of maternal sociodemographic and health risks mediated the association between median income and LBW, accounting for 65% and 25% of this estimate, respectively, but racial disparities in risk factors did not mediate the income association with Black‐White LBW disparities. Similarly, county median income was associated with very low birth weight rates and related Black‐White disparities. Conclusions: Efforts to increase income levels—for example, through investing in human capital, enacting labor union protections, or attracting well‐paying employment—have broad potential to influence population reproductive health. Higher income levels may reduce LBW rates and lead to more equitable outcomes between Black and White mothers. [ABSTRACT FROM AUTHOR]

Background and Objectives: Despite the prevalence of published opinions about the use of professional academic writers to help disseminate the results of clinical research, particularly opinions about the use of ghost writers, very little information has been published on the possible roles for professional writers within academic medical departments or the mechanisms by which these departments can hire and compensate such writers. To begin addressing this lack of information, the Association of Departments of Family Medicine hosted an online discussion and a subsequent webinar in which we obtained input from three departments of family medicine in the United States regarding their use of academic writers. This discussion revealed three basic models by which academic writers have benefitted these departments: (1) grant writing support, (2) research and academic support for clinical faculty, and (3) departmental communication support. Drawing on specific examples from these institutions, the purpose of this paper is to describe the key support activities, advantages, disadvantages, and funding opportunities for each model for other departments to consider and adapt. [ABSTRACT FROM AUTHOR]

In the article, the author examines the future supply and demand of physical therapists in the U.S. by presenting the 2020 American Council of Academic Physical Therapy (ACAPT) workforce analysis. Other topics include ACAPT's projected 25,000 surplus of therapists by 2030, and the Health Resources and Services Administration's (HRSA) Allied Health Workforce Projections fact sheet.

The increasing agglomeration of people in dense urban areas coupled with the existence of efficient modes of transportation connecting such centers, make cities particularly vulnerable to the spread of epidemics. Here we develop a data-driven approach combines with a meta-population modeling to capture the interplay between population density, mobility and epidemic spreading. We study 163 cities, chosen from four different continents, and report a global trend where the epidemic risk induced by human mobility increases consistently in those cities where mobility flows are predominantly between high population density centers. We apply our framework to the spread of SARS-CoV-2 in the United States, providing a plausible explanation for the observed heterogeneity in the spreading process across cities. Based on this insight, we propose realistic mitigation strategies (less severe than lockdowns), based on modifying the mobility in cities. Our results suggest that an optimal control strategy involves an asymmetric policy that restricts flows entering the most vulnerable areas but allowing residents to continue their usual mobility patterns. The evolution of epidemic outbreaks in urban settings is known to stem from the interplay between demographic, structural, and economical characteristics. Here, the authors combine a data driven approach with meta-population modelling to show that the epidemic vulnerability of cities hinges on the morphology of human flows, and propose how a city's mobility backbone could be modified to minimize the epidemic risk. [ABSTRACT FROM AUTHOR]

Economic crises can be analyzed as part of the economic cycle and from different theoretical perspectives. The article considers economic crises or recessions, in general, as capitalism's own mechanisms to alleviate its contradictions and restore, at least partially, the previous accumulated imbalances. The period 1970 to 2020 covers eight economic crises, some of which determine changes in the internal structure, economic policy trends and the functioning of the U.S. economy, as the main center of the world economy. The purpose of this paper is to examine the set of economic crises of the last fifty years in a panoramic manner, to evaluate them as part of the process of major economic transformations and associated economic policies. [ABSTRACT FROM AUTHOR]

Objective: Given the growth in national disability-associated health care expenditures (DAHE) and the changes in health insurance–specific DAHE distribution, updated estimates of state-level DAHE are needed. The objective of this study was to update state-level estimates of DAHE. Methods: We combined data from the 2013-2015 Medical Expenditure Panel Survey, 2013-2015 Behavioral Risk Factor Surveillance System, and 2014 National Health Expenditure Accounts to calculate state-level DAHE for US adults in total, per adult, and per (adult) person with disability (PWD). We adjusted expenditures to 2017 prices and assessed changes in DAHE from 2003 to 2015. Results: In 2015, DAHE were $868 billion nationally (range, $1.4 billion in Wyoming to $102.8 billion in California) accounting for 36% of total health care expenditures (range, 29%-41%). From 2003 to 2015, total DAHE increased by 65% (range, 35%-125%). In 2015, DAHE per PWD were highest in the District of Columbia ($27 839) and lowest in Alabama ($12 603). From 2003 to 2015, per-PWD DAHE increased by 13% (range, −20% to 61%) and per-capita DAHE increased by 28% (range, 7%-84%). In 2015, Medicare DAHE per PWD ranged from $10 067 in Alaska to $18 768 in New Jersey. Medicaid DAHE per PWD ranged from $9825 in Nevada to $43 365 in the District of Columbia. Nonpublic–health insurer per-PWD DAHE ranged from $7641 in Arkansas to $18 796 in Alaska. Conclusion: DAHE are substantial and vary by state. The public sector largely supports the health care costs of people with disabilities. State policy makers and other stakeholders can use these results to inform the development of public health programs that support and provide ongoing health care to people with disabilities. [ABSTRACT FROM AUTHOR]

This paper quantifies the long-term impact of wind energy development on electricity prices across the residential, commercial, and industrial sectors in the United States. Our data set is made up of state level panel data from 2000 through 2018. This time period covers the vast majority of total wind energy capacity installed in the history of the USA. Our econometric model accounts for the primary factors that influence electricity prices, incorporating both fixed effects and general method of moments in order to more precisely isolate the effect of wind energy. The empirical results conclude that wind energy is positively and significantly related to electricity prices across all sectors, as indicated by the higher average electricity prices in states with higher percentages of wind energy. The price increase is largest in the industrial sector, followed by commercial, then residential. Wind turbine technology has become significantly more efficient, but the technical gains have been offset by the increased indirect costs of incorporating wind energy into the grid. Transmission and balancing costs have increased the final price to consumers. Our results highlight the need to view wind energy development from a more holistic perspective that accounts for structural and systemic costs. This will ensure the continued growth of wind energy. These results provide relevant insight to help wind energy developers, policy makers, and utility companies build a more sustainable energy future. [ABSTRACT FROM AUTHOR]

Perennial grass pastures provide the basis for beef production systems across the Southeast United States. One common management practice that is widely recommended among agronomists is interseeding cool-season legumes. Legumes can serve as a complementary resource for filling in production gaps, reducing supplemental feedstuffs, reducing the need for nitrogen fertilization, increasing the nutritional quality of forage available, increase biomass production, improve animal performance, and can reduce the toxic effects of endophyte-infected tall fescue through dilution. A simulated economic analysis was developed to further the economic understanding of the cost of implementation, the subsequent animal and forage performance benefits, and net returns from the inclusion of legumes over many research trials and years. Data from 15 peer-reviewed papers was used to simulate the economic benefits of implementing this production practice. Cost of production and revenue for each paper were calculated using the 10-year average from 2010 to 2019. This analysis provides users with a further understanding of the net returns, critical breakeven areas, and return on investment that is necessary in order to successfully implement the inclusion of cool-season legumes in perennial grass-based systems. [ABSTRACT FROM AUTHOR]

The article focuses on family medicine has been ahead of the value-based care delivery curve in a policy statement on value-based payment has developed more than a decade ago, the American Academy of Family Physicians has recognized the urgent need to improve both efficiency and effectiveness in the delivery of medical care, and effectiveness means doing the right thing. Topics include the more equitably distributed than any other physician specialists.

Background: The ISPOR Special Task Force (STF) on US Value Assessment Frameworks was agnostic about exactly how to implement the quality-adjusted life year (QALY) as a key element in an overall cost-effectiveness evaluation. But the STF recommended using the cost-per-QALY gained as a starting point in deliberations about including a new technology in a health plan benefit. The STF offered two major alternative approaches—augmented cost-effectiveness analysis (ACEA) and multi-criteria decision analysis (MCDA)—while emphasizing the need to apply either a willingness-to-pay (WTP) or opportunity cost threshold rule to operationalize the inclusion decision. Methods: The MCDA model uses the multi-attribute utility function. The ACEA model is based on the expected utility theory. In both ACEA and MCDA models, value trade-offs are derived in a hierarchical model with two high-level objectives which measure overall health gain separately from financial attributes affecting consumption. Results: Even though value trade-offs can be elicited or revealed without considering budget constraints, we demonstrate that they can be used similarly to WTP-based cost-effectiveness thresholds for resource allocation decisions. The consideration of how costs of medical technology, income, and severity of disease affect value trade-offs demonstrates, however, that reconciling decisions in ACEA and MCDA requires that health and consumption are either complements or independent attributes. Conclusions: We conclude that value trade-offs derived either from ACEA or MCDA move similarly with changes in main factors considered by enrollees and decision makers—costs of the medical technology, income, and severity of disease. Consequently, this complementarity between health and consumption is a necessary condition for reconciling ACEA and MCDA. Moreover, their similarity would be further enhanced if the QALY is used as the key attribute or anchor in the MCDA value function: the choice between the two is a pragmatic question that is still open. [ABSTRACT FROM AUTHOR]

We investigate state‐dependent effects of fiscal multipliers and allow for endogenous sample splitting to determine whether the U.S. economy is in a slack state. When the endogenized slack state is estimated as the period of the unemployment rate higher than about 12%, the estimated cumulative multipliers are significantly larger during slack periods than nonslack periods and are above unity. We also examine the possibility of time‐varying regimes of slackness and find that our empirical results are robust under a more flexible framework. Our estimation results point out the importance of the heterogenous effects of fiscal policy and shed light on the prospect of fiscal policy in response to economic shocks from the current COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Objectives: To estimate additional spending if NHS England paid the same prices as US Medicare Part D for the 50 single-source brand-name drugs with the highest expenditure in English primary care in 2018.Design: Retrospective analysis of 2018 drug prescribing and spending in the NHS England prescribing data and the Medicare Part D Drug Spending Dashboard and Data. We examined the 50 costliest drugs in English primary care available as brand-name-only in the US and England. We performed cost projections of NHS England spending with US Medicare Part D prices. We estimated average 2018 US rebates as 1 minus the quotient of net divided by gross Medicare Part D spending.Setting: England and US.Participants: NHS England and US Medicare systems.Main Outcome Measures: Total spending, prescriptions and claims in NHS England and Medicare Part D. All spending and cost measures were reported in 2018 British pounds.Results: NHS England spent £1.39 billion on drugs in the cohort. All drugs were more expensive under US Medicare Part D than NHS England. The US-England price ratios ranged from 1.3 to 9.9 (mean ratio 4.8). Accounting for prescribing volume, if NHS England had paid US Medicare Part D prices after adjusting for estimated US rebates, it would have spent 4.6 times as much in 2018 on drugs in the cohort (£6.42 billion).Conclusions: Spending by NHS England would be substantially higher if it paid US Medicare Part D prices. This could result in decreased access to medicines and other health services. [ABSTRACT FROM AUTHOR]

Objective: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model.Data Sources: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas.Study Design: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR.Principal Findings: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant.Conclusions: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores. [ABSTRACT FROM AUTHOR]

Objective: To evaluate episode-based payments for upper respiratory tract infections (URI) and perinatal care in Arkansas's Medicaid population.Study Setting: Upper respiratory infection and perinatal episodes among Medicaid-covered individuals in Arkansas and comparison states from fiscal year (FY) 2011 to 2014.Study Design: Cross-sectional observational analysis using a difference-in-difference design to examine outcomes associated with URI and perinatal episodes of care (EOC) from 2011 to 2014. Key dependent variables include antibiotic use, emergency department visits, physician visits, hospitalizations, readmission, and preventive screenings.Data Collection: Claims data from the Medicaid Analytic Extract for Arkansas, Mississippi, and Missouri from 2010 to 2014 with supplemental county-level data from the Area Health Resource File (AHRF).Principal Findings: The URI EOC reduced the probability of antibiotic use (marginal effect [ME] = -1.8, 90% CI: -2.2, -1.4), physician visits (ME = 0.6, 90% CI: -0.8, -0.4), improved the probability of strep tests for children diagnosed with pharyngitis (ME = 9.4, 90% CI: 8.5, 10.3), but also increased the probability of an emergency department (ED) visit (ME = 0.1, 90% CI: 0.1, 0.2), relative to the comparison group. For perinatal EOCs, we found a reduced probability of an ED visit during pregnancy (ME = 0.1, 90% CI: -0.2, -0.0), an increased probability of screening for HIV (ME = 6.2, 90% CI: 4.0, 8.5), chlamydia (ME = 9.5, 90% CI: 7.2, 11.8), and group B strep-test (ME = 2.6, 90% CI: 0.5, 4.6), relative to the comparison group. Predelivery and postpartum hospitalizations also increased (ME = 1.2, 90% CI: 0.4, 2.0; ME = 0.4, 90% CI: 0.0, 0.8, respectively), relative to the comparison group.Conclusion: Upper respiratory infection and perinatal EOCs for Arkansas Medicaid beneficiaries produced mixed results. Aligning shared savings with quality metrics and cost-thresholds may help achieve quality targets and disincentivize over utilization within the EOC, but may also have unintended consequences. [ABSTRACT FROM AUTHOR]

Objective: To assess the extent to which all-cause 30-day readmission rate varies by Medicare program within the same hospitals.Study Design: We used conditional logistic regression clustered by hospital and generalized estimating equations to compare the odds of unplanned all-cause 30-day readmission between Medicare Fee-for-Service (FFS) and Medicare Advantage (MA).Data Collection: Wisconsin Health Information Organization collects claims data from various payers including private insurance, Medicare, and Medicaid, twice a year.Principal Findings: For 62 of 66 hospitals, hospital-level readmission rates for MA were lower than those for Medicare FFS. The odds of 30-day readmission in MA were 0.92 times lower than Medicare FFS within the same hospital (odds ratio, 0.93; 95 percent confidence interval, 0.89-0.98). The adjusted overall readmission rates of Medicare FFS and MA were 14.9 percent and 11.9 percent, respectively.Conclusion: These findings provide additional evidence of potential variations in readmission risk by payer and support the need for improved monitoring systems in hospitals that incorporate payer-specific data. Further research is needed to delineate specific care delivery factors that contribute to differential readmission risk by payer source. [ABSTRACT FROM AUTHOR]

Project management decisions are mostly made based on money. Now, a business's worth and profit are taken into consideration when making technical decisions. Over 80% of the United States GDP is derived from projects that emphasize money as being an essential component involved in the process. On the other hand, all other aspects of a project are becoming more complex, such as equipment installation, the design and manufacturing process, renovation, and replacement. Thus, these factors must be emphasized when making decisions, as well. The private sector and federal institutions view projects as being the newest avenue for creating profits and keeping the economy afloat. As a result, project management should be considered to be an essential component, because it can recognize citizen-paid taxes and can avoid wasting resources. This study will begin with a discussion of how vital economics can be to the project management and the project environment. Second, this study will address the various kinds of useful economic decisions and decision-making methods. Finally, it will send the importance of decision-making methods in projects, which is particularly true for engineering and technicalt projects. [ABSTRACT FROM AUTHOR]

This paper evaluates an editorial and seven invaluable and interesting review papers for the Journal of Risk and Financial Management (JRFM). The topics covered include the rising complexity of bank regulatory capital requirements from global guidelines to their United States (US) implementation, connections among big data, computational science, economics, finance, marketing, management and psychology, factors, outcome, and the solutions of supply chain finance, with a review and future directions, time-varying price-volume relationship, adaptive market efficiency, and a survey of the empirical literature, improved covariance matrix estimation for portfolio risk measurement, stock investment and excess returns, with a critical review in the light of the efficient market hypothesis, and a cross section analysis of country equity returns, and a review of the empirical literature. [ABSTRACT FROM AUTHOR]

This is a study of the politics of "official knowledge" in K-12 economics curriculum in the United States. The purpose of this study is to understand how reviews of literature both promote official knowledge and thus serve as useful sources of uncovering the authorship, or author-function at work in a social science discipline, which are usually thought to be anonymous and author-less. [ABSTRACT FROM AUTHOR]

Objective: To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern U.S. states in which residents have high rates of diabetes.Research Design and Methods: Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50-64 years, the percentage of women, Distressed Communities Index value, and rurality.Results: In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states.Conclusions: ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt. [ABSTRACT FROM AUTHOR]

An introduction to articles published within the issue is presented on topics including the important characteristics of primary care, the implications of the U.S. underinvestment in its public health infrastructure and how it made the country susceptible to the spread of the coronavirus disease-2019 (COVID-19), and another on the trends in public health funding in the U.S.

Objective: To determine whether the exclusion of patients who die from adjusted 30-day readmission rates influences readmission rate measures and penalties under the Hospital Readmission Reduction Program (HRRP).Data Sources/study Setting: 100% Medicare fee-for-service claims over the period July 1, 2012, until June 30, 2015.Study Design: We examine the 30-day readmission risk across the three conditions targeted by the HRRP: acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Using logistic regression, we estimate the readmission risk for three samples of patients: those who survived the 30-day period after their index admission, those who died over the 30-day period, and all patients who were admitted to see how they differ.Data Collection/extraction Methods: We identified and extracted data for Medicare fee-for-service beneficiaries admitted with primary diagnoses of AMI (N = 497 931), CHF (N = 1 047 552), and pneumonia (N = 850 552).Results: The estimated hospital readmission rates for the survived and nonsurvived patients differed by 5%-8%, on average. Incorporating these estimates into overall readmission risk for all admitted patients changes the likely penalty status for 9% of hospitals. However, this change is randomly distributed across hospitals and is not concentrated amongst any one type of hospital.Conclusions: Not accounting for variations in mortality may result in inappropriate penalties for some hospitals. However, the effect of this bias is low due to low mortality rates amongst incentivized conditions and appears to be randomly distributed across hospital types. [ABSTRACT FROM AUTHOR]

Traditionally, financial mathematics has been used to solve financial problems. With globalization, financial transactions require new analysis based on tools of probability, statistics, and economic theory. Global research trends in this topic during the period 1935–2019 have been analyzed. With this objective, a bibliometric methodology of 1486 articles from the Scopus database was applied. The obtained results offer data on the scientific activity of countries, institutions, authors, and institutions that promote this research topic. The results reveal an increasing trend, mainly in the last decade. The main subjects of knowledge are social sciences and economics, econometrics, and finance. The author with the most articles is Khare from the Indian Institute of Management Rohtak. The most prolific affiliation is the British University of Oxford. The country with the most academic publications and international collaborations is the United States. In addition, the most used keywords in articles are "financial management", "financial transaction tax", "banking", "financial service", "blockchain", "decision making", and "financial market". The increase in publications in recent years at the international level confirms the growing trend in research on financial transactions. [ABSTRACT FROM AUTHOR]

Objective: Nonalcoholic steatohepatitis (NASH) is a progressive form of nonalcoholic fatty liver disease (NAFLD) and is strongly associated with type 2 diabetes mellitus (T2DM). Patients with both T2DM and NASH have increased risk for adverse clinical outcomes, leading to higher risk for mortality and morbidity. We built a Markov model with 1-year cycles and 20-year horizon to estimate the economic burden of NASH with T2DM in the U.S.Research Design and Methods: Cohort size was determined by population size, prevalence of T2DM, and prevalence and incidence of NASH in 2017. The model includes 10 health states-NAFL, NASH fibrosis stages F0 through F3, compensated and decompensated cirrhosis, hepatocellular carcinoma, 1 year post-liver transplant, and post-liver transplant-as well as liver-related, cardiovascular, and background mortality. Transition probabilities were calculated from meta-analyses and literature. Annual costs for NASH and T2DM were taken from literature and billing codes.Results: We estimated that there were 18.2 million people in the U.S. living with T2DM and NAFLD, of which 6.4 million had NASH. Twenty-year costs for NAFLD in these patients were $55.8 billion. Over the next 20 years, NASH with T2DM will account for 65,000 transplants, 1.37 million cardiovascular-related deaths, and 812,000 liver-related deaths.Conclusions: This model predicts significant clinical and economic burden due to NASH with T2DM over the next 20 years. In fact, this burden may be greater since we assumed conservative inputs for our model and did not increase costs or the incidence of T2DM over time. It is highly likely that interventions reducing morbidity and mortality in NASH patients with T2DM could potentially reduce this projected clinical and economic burden. [ABSTRACT FROM AUTHOR]

Objective: To compare different methods of indexing health care service prices for the commercially insured population across geographic markets.Data Sources: Health Care Cost Institute commercial claims data from 2012 to 2016.Study Design: We compare price indices computed using methods with differing levels of computational intensity: weighted-average versus regression-based methods. We separately compute indices of the prices paid for set of common inpatient and set of common outpatient services in different markets across the United States using each type of method. We subsequently examined the variation of and correlations between the resulting index values.Data Collection/extraction Methods: We computed health care service price indices separately using samples of inpatient and outpatient facility claims from 2012 to 2016 across 112 Core-Based Statistical Areas. Within each category of services, claims were limited to members under the age of 65 with employer-sponsored insurance. Both samples were limited to a common set of services that made up nearly 80 percent of the service use in the full sample every year.Principal Findings: We found that the methods studied produced highly correlated price indices (r > .94) with similar distributions across years for both inpatient and outpatient services.Conclusions: Our findings suggest that weighted-average methods, which are much less computationally intensive, will generate results similar to regression-based methods. [ABSTRACT FROM AUTHOR]

Objective: There exists enormous variation in estimates of the lifetime cost of adolescent obesity by race. To justify policy measures to reduce obesity rates nationally in this demographic, the costs of obesity in late adolescence must first be discerned. Although several researchers have sought to quantify obesity's true cost, none has accounted for race-specific age-related weight gain, a vital component in producing an accurate estimate.Methods: This paper employs a Markov model of BMI category state changes separately for black and white males and females from age 18 to 75 applied to updated estimates of obesity's costs and effect on mortality to quantify the median lifetime cost of obesity at age 18.Results: This study found lower lifetime costs than previously, largely because of the dramatic gain in weight among normal-weight individuals, particularly black males, that occurs in early adulthood.Conclusions: A substantial portion of obesity's prevalence, and therefore cost, for black males and females comes from age-related weight gain in early adulthood. This speaks to the persistent threat of obesity beyond adolescence for this demographic, and further research should focus on whether policy can modify the behaviors and environment through which and in which this sharp increase in weight occurs. [ABSTRACT FROM AUTHOR]

Côte d'Ivoire's national election in 2010 descended into civil war into 2011 when incumbent President Laurent Gbagbo refused to concede the presidency to the internationally recognized winner Alassane Ouattara. The three political players in this election--the parties of Ouattara, Gbagbo, and France--had deep economic incentives in the outcome of Côte d'Ivoire's election. Drawing from interviews conducted in 2016 and 2017 in Côte d'Ivoire with 24 journalists, findings show that journalists endured many acts of harassment from political parties trying to manipulate the news coverage of this election. I argue that the mechanisms observed in Côte d'Ivoire's electoral crisis reflect how conditions of war activate informal power alliances within the political-economic dynamics of a Global South nation in the postcolonial era. These alliances push on media in ways they would not normally during peacetime. Côte d'Ivoire is a former colony of France. It is a part of "Françafrique," a region of 12 French-speaking African countries where France still retains considerable economic impact and has intervened militarily dozens of times since the colonies were emancipated in the early 1960s. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs.Data Sources and Study Setting: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries.Study Design: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment.Principal Findings: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay.Conclusions: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy.Methods: Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure.Results: After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG).Conclusions: This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations. [ABSTRACT FROM AUTHOR]

Background: Health equity is a multidimensional concept that has been internationally considered as an essential element for health system development. However, our understanding about the root causes of health equity is limited. In this study, we investigated the historical roots and seminal works of research on health equity. Methods: Health equity-related publications were identified and downloaded from the Web of Science database (n = 67,739, up to 31 October 2018). Their cited references (n = 2,521,782) were analyzed through Reference Publication Year Spectroscopy (RPYS), which detected the historical roots and important works on health equity and quantified their impact in terms of referencing frequency. Results: A total of 17 pronounced peaks and 31 seminal works were identified. The first publication on health equity appeared in 1966. But the first cited reference can be traced back to 1801. Most seminal works were conducted by researchers from the US (19, 61.3%), the UK (7, 22.6%) and the Netherlands (3, 9.7%). Research on health equity experienced three important historical stages: origins (1800–1965), formative (1966–1991) and development and expansion (1991–2018). The ideology of health equity was endorsed by the international society through the World Health Organization (1946) declaration based on the foundational works of Chadwick (1842), Engels (1945), Durkheim (1897) and Du Bois (1899). The concept of health equity originated from the disciplines of public health, sociology and political economics and has been a major research area of social epidemiology since the early nineteenth century. Studies on health equity evolved from evidence gathering to the identification of cost-effective policies and governmental interventions. Conclusion: The development of research on health equity is shaped by multiple disciplines, which has contributed to the emergence of a new stream of social epidemiology and political epidemiology. Past studies must be interpreted in light of their historical contexts. Further studies are needed to explore the causal pathways between the social determinants of health and health inequalities. [ABSTRACT FROM AUTHOR]

We aim to determine whether a game-theoretic model between an insurer and a healthcare practice yields a predictive equilibrium that incentivizes either player to deviate from a fee-for-service to capitation payment system. Using United States data from various primary care surveys, we find that non-extreme equilibria (i.e., shares of patients, or shares of patient visits, seen under a fee-for-service payment system) can be derived from a Stackelberg game if insurers award a non-linear bonus to practices based on performance. Overall, both insurers and practices can be incentivized to embrace capitation payments somewhat, but potentially at the expense of practice performance. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between insurer market structure, health plan quality, and health insurance premiums in the Medicare Advantage (MA) program.Data Sources/study Setting: Administrative data files from the Centers for Medicare and Medicaid Services, along with other secondary data sources.Study Design: Trends in MA market concentration from 2008 to 2017 are presented, alongside logistic and linear regression models examining MA plan quality and premiums as a function of insurer market structure for 2011.Data Collection/extraction Methods: Data are publicly available.Principal Findings: MA plans that tend to operate in more concentrated MA markets have a higher predicted probability of receiving a high-quality health plan rating. Operating in more concentrated MA markets was also found to be associated with higher premiums. Among plans that tend to operate in very concentrated MA markets, high-quality MA plans were associated with premiums as much as two times higher than premiums associated with lower-quality plans.Conclusions: Any policies directed at enhancing insurer competition should consider implications for health plan quality, which may be very different than the implications for enrollee premiums. [ABSTRACT FROM AUTHOR]

Background: Chagas disease (CD) affects over 300,000 people in the United States, but fewer than 1% have been diagnosed and less than 0.3% have received etiological treatment. This is a significant public health concern because untreated CD can produce fatal complications. What factors prevent people with CD from accessing diagnosis and treatment in a nation with one of the world’s most advanced healthcare systems? Methodology/Principal findings: This analysis of barriers to diagnosis and treatment of CD in the US reflects the opinions of the authors more than a comprehensive discussion of all the available evidence. To enrich our description of barriers, we have conducted an exploratory literature review and cited the experience of the main US clinic providing treatment for CD. We list 34 barriers, which we group into four overlapping dimensions: systemic, comprising gaps in the public health system; structural, originating from political and economic inequalities; clinical, including toxicity of medications and diagnostic challenges; and psychosocial, encompassing fears and stigma. Conclusions: We propose this multidimensional framework both to explain the persistently low numbers of people with CD who are tested and treated and as a potential basis for organizing a public health response, but we encourage others to improve on our approach or develop alternative frameworks. We further argue that expanding access to diagnosis and treatment of CD in the US means asserting the rights of vulnerable populations to obtain timely, quality healthcare. [ABSTRACT FROM AUTHOR]