Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Health Insurance For People Younger Than Age 65: Expiration Of Temporary Policies Projected To Reshuffle Coverage, 2023-33.

The Congressional Budget Office estimates that in 2023, 248 million people in the US who are younger than age sixty-five have health insurance coverage (mostly through employment-based plans), and twenty-three million people, or 8.3 percent of that age group, are uninsured-with significant variations in coverage by income and, to a lesser extent, by race and ethnicity. The unprecedented low uninsurance rate is largely attributable to temporary policies that kept beneficiaries enrolled in Medicaid and enhanced the subsidies available through the health insurance Marketplaces during the COVID-19 pandemic. As the continuous eligibility provisions unwind in 2023 and 2024, an estimated 9.3 million people in that age group will transition to other forms of coverage, and 6.2 million will become uninsured. If the enhanced subsidies expire after 2025, 4.9 million fewer people are estimated to enroll in Marketplace coverage, instead enrolling in unsubsidized nongroup or employment-based coverage or becoming uninsured. By 2033 the uninsurance rate is projected to be 10.1 percent, which is still below the 2019 rate of about 12 percent.

Changes In Health Coverage During The COVID-19 Pandemic.

The COVID-19 pandemic had the potential to alter patterns of health insurance coverage in the US. Using data from the Medical Expenditure Panel Survey, we found increased stability of Medicaid coverage for children and nonelderly adults during the first year of the pandemic. Fewer people who had Medicaid in 2019 became uninsured in 2020 (4.3 percent) than in 2018-19 (7.8 percent).

Older adults' perspectives on emergency department costs during COVID-19.

Objectives: COVID-19 has strained the household finances of many Americans who are already experiencing increasing health care expenses. Concerns about the cost of care may deter patients from seeking even urgent care from the emergency department (ED). This study examines predictors of older Americans' concerns about ED visit costs and how cost concerns may have influenced their ED use in the early stages of the pandemic. Study Design: This was a cross-sectional survey study using a nationally representative sample of US adults aged 50 to 80 years (N = 2074) in June 2020. Methods: Multivariate logistic regressions assessed the relationships of sociodemographic, insurance, and health factors with cost concerns for ED care. Results: Of the respondents, 80% were concerned (45% very, 35% somewhat) about costs of an ED visit and 18% were not confident in their ability to afford an ED visit. Of the entire sample, 7% had avoided ED care because of cost concerns in the past 2 years. Of those who may have needed ED care, 22% had avoided care. Predictors of cost-related ED avoidance included being aged 50 to 54 years (adjusted odds ratio [AOR], 4.57; 95% CI, 1.44-14.54), being uninsured (AOR, 2.93; 95% CI, 1.35-6.52), having poor or fair mental health (AOR, 2.82; 95% CI, 1.62-4.89), and having an annual household income of less than $30,000 (AOR, 2.30; 95% CI, 1.19-4.46). Conclusions: During the early COVID-19 pandemic, most older US adults expressed concerns about the financial impact of ED use. Further research should examine how insurance design could alleviate the perceived financial burden of ED use and prevent cost-related care avoidance, especially for those at higher risk in future pandemic surges.

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic.

Uninsured or underinsured individuals with cancer are likely to experience financial hardship, including forgoing healthcare or non-healthcare needs such as food, housing, or utilities. This study evaluates the association between health insurance coverage and financial hardship among cancer survivors during the COVID-19 pandemic. This cross-sectional analysis used Patient Advocate Foundation (PAF) survey data from May to July 2020. Cancer survivors who previously received case management or financial aid from PAF self-reported challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic. Associations between insurance coverage and payment challenges were estimated using Poisson regression with robust standard errors, which allowed for estimation of adjusted relative risks (aRR). Of 1,437 respondents, 74% had annual household incomes <$48,000. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an Affordable Care Act (ACA) plan, and 3% were uninsured. Approximately 31% of respondents reported trouble paying for healthcare during the COVID-19 pandemic. Respondents who were uninsured (aRR 2.58, 95% confidence interval [CI] 1.83-3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28-2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23-2.34), or Medicare (aRR 1.49, 95% CI 1.09-2.03) had higher risk of trouble paying for healthcare compared to Medicaid enrollees. Challenges paying for non-healthcare needs were reported by 57% of respondents, with 40% reporting trouble paying for food, 31% housing, 28% transportation, and 20% internet. In adjusted models, Medicare and employer-sponsored insurance enrollees were less likely to have difficulties paying for non-healthcare needs compared to Medicaid beneficiaries. Despite 97% of our cancer survivor sample being insured, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectively. Greater attention to both medical and non-medical financial burden is needed given the economic pressures of the COVID-19 pandemic.

Financial Instability of Federal Navigator Program Challenges Organizations to Help Uninsured Enroll in Health Insurance Coverage.

Under the Affordable Care Act, the federal Health Insurance Navigator Program aims to reduce the rate of uninsured in the United States. Under this program, navigators help people obtain insurance coverage through federally facilitated Marketplaces. However, the program's financial instability and substantial budget cuts created a severe shortage of navigator assistance for the uninsured and underserved. The COVID-19 pandemic added further pressure to the already-strained program. Our study examined how unstable and unpredictable federal funding and the COVID-19 pandemic affected organizations' navigator work in the federal program in 2020. The results study show (1) that navigator organizations provide vital, year-round resources; (2) that organizations feel pushed to direct scarce resources to grant management and cut service provision; and (3) that there are policy changes that can support navigator organizations in the future. Increased and ongoing federal investment is needed to support this vital health workforce and expand enrollment assistance for underserved communities.

COVID-19-related Medicaid enrollment in Medicaid expansion and non-expansion states.

RESEARCH OBJECTIVE: To explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID-19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss. DATA SOURCE: Phase 1 of the Census Bureau's Experimental Household Pulse Survey covering April 23, 2020-July 21, 2020. STUDY DESIGN: We compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID-19 pandemic in states that expanded Medicaid against states that did not expand Medicaid. DATA COLLECTION/EXTRACTION METHODS: Our analytical dataset was limited to 733,181 non-elderly adults aged 20-64. PRINCIPAL FINDINGS: Twenty-six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey-16% experienced job losses (e.g., layoff, furlough) due to the COVID-19 crisis, and 11% had other reasons they were not working. COVID-linked job losses were associated with a 20 (p < 0.01) percentage-point (PPT) lower likelihood of having employer-sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID-linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously. CONCLUSIONS: Our findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed.

Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic.

The fragmented and inefficient healthcare system in the United States leads to many preventable deaths and unnecessary costs every year. During a pandemic, the lives saved and economic benefits of a single-payer universal healthcare system relative to the status quo would be even greater. For Americans who are uninsured and underinsured, financial barriers to COVID-19 care delayed diagnosis and exacerbated transmission. Concurrently, deaths beyond COVID-19 accrued from the background rate of uninsurance. Universal healthcare would alleviate the mortality caused by the confluence of these factors. To evaluate the repercussions of incomplete insurance coverage in 2020, we calculated the elevated mortality attributable to the loss of employer-sponsored insurance and to background rates of uninsurance, summing with the increased COVID-19 mortality due to low insurance coverage. Incorporating the demography of the uninsured with age-specific COVID-19 and nonpandemic mortality, we estimated that a single-payer universal healthcare system would have saved about 212,000 lives in 2020 alone. We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a single-payer universal healthcare system over the course of the pandemic. These economic benefits are in addition to US$438 billion expected to be saved by single-payer universal healthcare during a nonpandemic year.

Experiences of COVID-19 infection in North Carolina: A qualitative analysis.

BACKGROUND AND AIM: It has been demonstrated that marginalized populations across the U.S. have suffered a disproportionate burden of the coronavirus disease 2019 (COVID-19) pandemic, illustrating the role that social determinants of health play in health outcomes. To better understand how these vulnerable and high-risk populations have experienced the pandemic, we conducted a qualitative study to better understand their experiences from diagnosis through recovery. METHODS: We conducted a qualitative study of patients in a North Carolina healthcare system's registry who tested positive for COVID-19 from March 2020 through February 2021, identified from population-dense outbreaks of COVID-19 (hotspots). We conducted semi-structured phone interviews in English or Spanish, based on patient preference, with trained bilingual study personnel. Each interview was evaluated using a combination of deductive and inductive content analysis to determine prevalent themes related to COVID-19 knowledge, diagnosis, disease experience, and long-term impacts. FINDINGS: The 10 patients interviewed from our COVID-19 hotspot clusters were of equal distribution by sex, predominantly Black (70%), aged 22-70 years (IQR 45-62 years), and more frequently publicly insured (50% Medicaid/Medicare, vs 30% uninsured, vs 20% private insurance). Major themes identified included prior knowledge of COVID-19 and patient perceptions of their personal risk, the testing process in numerous settings, the process of quarantining at home after a positive diagnosis, the experience of receiving medical care during their illness, and difficulties with long-term recovery. DISCUSSION: Our findings suggest areas for targeted interventions to reduce COVID-19 transmission in these high-risk communities, as well as improve the patient experience throughout the COVID-19 illness course.

Assessment of the Provider Relief Fund Distribution for Treatment of Uninsured Patients With COVID-19.

This cross-sectional study uses US Health Resources and Services Administration data to assess the distribution of claims reimbursement funds to health care professionals and facilities for uninsured patients with COVID-19.

COVID-19 Reflections: We Are Not OK: Safety Net Primary Care Access in a Non-Expansion State Amid COVID-19.

In North Carolina, rural health care-especially the primary care safety net-is a remarkable but under-resourced vital support system. COVID-19 stressed that already precarious system. While the acute COVID-19 crisis may be receding, we are concerned about the long-term effects of the pandemic on both individuals and the rural primary care safety net.

Missed Vaccination Opportunities Among U.S. Adolescents by Area Characteristics.

INTRODUCTION: A total of 3 vaccines are recommended for U.S. adolescents: tetanus, diphtheria, and acellular pertussis; meningococcal conjugate; and human papillomavirus. To understand the disparities in vaccine availability and hesitancy, adolescent-, household-, and area-level characteristics associated with patterns of vaccine coverage are described. METHODS: In 2020-2021, the authors generated national estimates among 8 possible combinations of vaccine coverage and identified the associated characteristics using 2015-2017 National Immunization Survey-Teen for male and female adolescents aged 13-17 years (N=63,299) linked to area (ZIP code) characteristics. Next, the factors associated with a missed opportunity for human papillomavirus vaccine (i.e., receipt of tetanus, diphtheria, and acellular pertussis and meningococcal conjugate only compared with coverage of all the 3 vaccines) were identified using logistic regression. RESULTS: Most U.S. adolescents received all the 3 vaccines (42.9%) or tetanus, diphtheria, and acellular pertussis and meningococcal conjugate only (32.1%); fewer received no vaccines (7.7%) or tetanus, diphtheria, and acellular pertussis only (6.6%); and the remainder received some combination of 1-2 vaccines. Missed opportunities for human papillomavirus vaccination were more likely among adolescents who were male, were of White race, were uninsured, were in middle-income households, and were living in rural areas and were less likely among adolescents who were older, who were Medicaid insured, whose parents completed surveys in Spanish, who were in poverty-level households, and who were living in high-poverty areas. CONCLUSIONS: A substantial number of U.S. adolescents are not fully vaccinated, and coverage varies by vaccine type, population, and place. Providers should routinely stock all the 3 vaccines and promote simultaneous, same-day vaccination to avoid missed vaccine opportunities. More research and interventions are needed to understand and modify patient, provider, payer, vaccine supply/storage, or other reasons for suboptimal coverage of all the recommended vaccines.

Insurance coverage and financing landscape for HIV treatment and prevention in the USA.

In 2010, the US health insurance system underwent one of its most substantial transformations with the passage of the Affordable Care Act, which increased coverage for millions of people in the USA, including those with and at risk of HIV. Even so, the system of HIV care and prevention services in the USA is a complex patchwork of payers, providers, and financing mechanisms. People with HIV are primarily covered by Medicaid, Medicare, private insurance, or a combination of these; many get care through other programmes, particularly the Ryan White HIV/AIDS Program, which serves as the nation's safety net for people with HIV who remain uninsured or underinsured but offers modest to no support for prevention services. While uninsurance has drastically declined over the past decade, the USA trails other high-income countries in key HIV-specific metrics, including rates of viral suppression. In this paper in the Series, we provide an overview of the coverage and financing landscape for HIV treatment and prevention in the USA, discuss how the Affordable Care Act has changed the domestic health-care system, examine the major programmes that provide coverage and services, and identify remaining challenges.

Vaccine perceptions in a free urban clinic for underserved, uninsured adults.

BACKGROUND: Adult vaccine rates remain low despite public health efforts. Despite the likelihood that underserved patients face more barriers to vaccination, little is known on the perceptions underserved patients have about vaccines as a whole. Additional information could guide health care providers in efforts to improve adult vaccination rates in the medically underserved population. OBJECTIVES: The primary objective of this survey was to assess perceived susceptibility to and severity of vaccine-preventable disease (VPD) and perceived safety and effectiveness of vaccines in a medically underserved population. METHODS: This cross-sectional, descriptive study evaluated vaccine perceptions using a self-administered paper survey in a free clinic providing care to uninsured, low-income adults. All patients with scheduled appointments in the clinic were eligible to participate. Two Likert-type items were used to define responses regarding trust and beliefs. Level of trust was defined as "Not at all" (1), "A little" (2), "Not sure" (3), "Some" (4), and "A lot" (5). Responses to vaccine belief items were defined as "Strongly disagree" (1), "Disagree" (2), "Neither agree nor disagree" (3), "Agree" (4), and "Strongly agree" (5). Statistical analyses were descriptive in nature. RESULTS: Final analysis included 131 surveys. Health care providers were the most common patient-reported vaccine information source (73.3%) and the most trusted (median: 5). Despite clear agreement among respondents that vaccines are safe (median: 3.94) and effective (median: 4) in adults, with similar results regarding children, the results regarding personal risk from VPDs were less definitive (median: 3). CONCLUSION: Overall, survey responses in this uninsured, low-income population indicate that vaccines are perceived as safe and effective, but there is less consensus regarding the individual risk patients face from VPD. Focusing patient education on individual risk as much as overall vaccine safety and efficacy may help improve low adult vaccination rates in the medically underserved.

Trends in US Health Insurance Coverage During the COVID-19 Pandemic.

Importance: While most working-age adults in the US obtain health insurance through an employer, little is known about the implications of the massive pandemic-related job loss in March 2020 and subsequent rebound for rates of employer-sponsored coverage and uninsurance. Objective: To determine how health insurance coverage changed during the COVID-19 pandemic. Design Setting and Participants: Analysis of trends in insurance coverage based on repeated cross sections of the US Census Bureau's Household Pulse Survey data, using linear regression to adjust for respondent's demographic and socioeconomic characteristics and state of residence. More than 1.2 million US adults aged 18 to 64 years were surveyed from April 23 through December 21, 2020. Exposures: The COVID-19 pandemic, separated into spring and summer and fall and winter time periods during 2020, as well as state Medicaid expansion status. Main Outcomes and Measures: Regression-based estimates of the weekly percentage-point change in respondents' health insurance status, including having any health insurance, any employer-sponsored health insurance, or only nonemployer sponsored coverage. Nonemployer-sponsored coverage is categorized into private, Medicaid, and other public in some analyses. Results: The study population included 1 212 816 US adults (51% female; mean [SD] age, 42 [13] years) across all 50 US states and Washington DC. Among these respondents, rates of employer-sponsored coverage declined by 0.2 percentage points each week during the COVID-19 pandemic. Other types of coverage, particularly from public sources, increased by 0.1 and 0.2 percentage points in the spring and summer and fall and winter periods, respectively. Overall, health insurance coverage of any type declined, particularly during the spring and summer period, during which uninsurance increased by 1.4 percentage points, representing more than 2.7 million newly uninsured people, over a 12-week period. Conclusions and Relevance: In this cross-sectional study of data from the US Census Bureau's Household Pulse Survey, results showed that while public programs played an important role in protecting US adults from pandemic-driven declines in employment-sponsored coverage, many people became uninsured during 2020.