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.

Association between definitive chemoradiotherapy wait-time and survival in locally-advanced cervical cancer: Implications during the coronavirus pandemic.

OBJECTIVE: The current coronavirus pandemic caused a significant decrease in cancer-related encounters resulting in a delay in treatment of cancer patients. The objective of this study was to examine the survival effect of delay in starting concurrent chemo-radiotherapy (CCRT) in women with locally-advanced cervical cancer. METHODS: This is a retrospective observational study querying the National Cancer Database from 2004 to 2016. Women with stage IB2-IVA squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix who received definitive CCRT with known wait-time for CCRT initiation after cancer diagnosis were eligible (N=13,617). Cox proportional hazard regression model with restricted cubic spline transformation was fitted to assess the association between CCRT wait-time and all-cause mortality in multivariable analysis. RESULTS: The median wait-time to start CCRT was 6 (IQR 4-8) weeks. In a multivariable analysis, older age, non-Hispanic black and Hispanic ethnicity, recent year of diagnosis, Medicaid and uninsured status, medical comorbidities, and absence of nodal metastasis were associated with longer CCRT wait-time (P<.05). Women with aggressive tumor factors (poorer differentiation, large tumor size, nodal metastasis, and higher cancer stage) were more likely to have a short CCRT wait-time (P<.05). After controlling for the measured covariates, CCRT wait-time of 6.1-9.8 weeks was not associated with increased risk of all-cause mortality compared to a wait-time of 6 weeks. Similar association was observed when the cohort was stratified by histology, cancer stage, tumor size, or brachytherapy use. CONCLUSION: An implication of this study for the current coronavirus pandemic is that in the absence of aggressive tumor factors, a short period of wait-time to start definitive CCRT may not be associated with increased risk of mortality in women with locally-advanced cervical cancer.

The impact of COVID-19 infection on outcomes after injury in a state trauma system.

BACKGROUND: The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS: We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS: Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION: Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE: Level II, Prognostic Study.

Neighborhood Disadvantage Measures and COVID-19 Cases in Boston, 2020.

OBJECTIVE: Understanding the pattern of population risk for coronavirus disease 2019 (COVID-19) is critically important for health systems and policy makers. The objective of this study was to describe the association between neighborhood factors and number of COVID-19 cases. We hypothesized an association between disadvantaged neighborhoods and clusters of COVID-19 cases. METHODS: We analyzed data on patients presenting to a large health care system in Boston during February 5-May 4, 2020. We used a bivariate local join-count procedure to determine colocation between census tracts with high rates of neighborhood demographic characteristics (eg, Hispanic race/ethnicity) and measures of disadvantage (eg, health insurance status) and COVID-19 cases. We used negative binomial models to assess independent associations between neighborhood factors and the incidence of COVID-19. RESULTS: A total of 9898 COVID-19 patients were in the cohort. The overall crude incidence in the study area was 32 cases per 10 000 population, and the adjusted incidence per census tract ranged from 2 to 405 per 10 000 population. We found significant colocation of several neighborhood factors and the top quintile of cases: percentage of population that was Hispanic, non-Hispanic Black, without health insurance, receiving Supplemental Nutrition Assistance Program benefits, and living in poverty. Factors associated with increased incidence of COVID-19 included percentage of population that is Hispanic (incidence rate ratio [IRR] = 1.25; 95% CI, 1.23-1.28) and percentage of households living in poverty (IRR = 1.25; 95% CI, 1.19-1.32). CONCLUSIONS: We found a significant association between neighborhoods with high rates of disadvantage and COVID-19. Policy makers need to consider these health inequities when responding to the pandemic and planning for subsequent health needs.

Domestic migrant workers in India returning to their homes: emerging socioeconomic and health challenges during the COVID-19 pandemic.

Domestic migrant workers were stranded far from home when India declared nationwide lockdown to combat the pandemic of novel coronavirus (COVID-19). A large number of these workers were left with no economic support, no food and in many cases nowhere to live. The pandemic posed a serious health threat to these people, and the socioeconomic insecurity pushed them towards the edge of sustainability. Many of the migrants began walking home and accepted an uncertain fate if they could not return back home. The Government of India initiated efforts to provide transport support with special train services from the beginning of May 2020. While the migrants have started to return to their villages and towns, the states are facing the challenges of preventing the spread of COVID-19. The point-of-entry screening, quarantine and isolation facilities have increased substantially in capacity, although the quality of care remains a point of concern. Back at their homes, the migrants are enduring stigma, discrimination and poor social security. In order to avert the brewing humanitarian crisis, empathetic administration combined with political will is a must. Prudent, evidence-based decision-making in the economic and health sectors is also necessary.

Modeling the Impact of COVID-19 on Dental Insurance Coverage and Utilization.

Unemployment rates in the United States are rapidly increasing as a result of the COVID-19 pandemic and attendant economic disruption. As employees lose their jobs, many will lose their employer-sponsored dental insurance (ESDI). Changes in insurance coverage are directly related to the oral health of the population, with many at risk of losing access to dental care. We assessed the impact of recent unemployment rates on insurance coverage and dental utilization. We estimated changes in dental insurance coverage at the state level, using previously applied econometric estimates. Expected changes in types of dental procedures performed at dental practices nationwide were assessed using a microsimulation model, using national practice survey data. Changes in emergency department (ED) visits for dental problems were estimated by fitting trendlines to ED visit patterns by payer type. Sensitivity analyses were conducted to assess how variations in unemployment rates and rates of ESDI in response to unemployment could alter the results. Since March 2020, the national unemployment rate has increased by 8.40 percentage points, an increase expected to result in more than 16 million individuals losing ESDI in the United States. Of these individuals, 45.0% are likely to enroll in their state's Medicaid and Children's Health Insurance Program, and 47.0% are expected to become uninsured. With these expected changes in dental insurance coverage, the average dental practice would experience decreases in routine checkup visits but increases in tooth extraction, a procedure that is highly used by publicly insured or uninsured patients. In addition, dental-related ED visits would be expected to grow by 4.0%. Losses of employment caused by the COVID-19 in the United States can have countervailing effects on people's health by impeding access to dental care. Lack of dental insurance is expected to be more pronounced in states that have not expanded Medicaid or do not provide Medicaid dental benefits for adults.

COVID-19 Has Increased Medicaid Enrollment, But Short-Term Enrollment Changes Are Unrelated To Job Losses.

The recent coronavirus disease 2019 (COVID-19) global pandemic has resulted in unprecedented job losses in the United States, disrupting health insurance coverage for millions of people. Several models have predicted large increases in Medicaid enrollment among those who have lost jobs, yet the number of Americans who have gained coverage since the pandemic began is unknown. We compiled Medicaid enrollment reports covering the period from March 1 through June 1, 2020, for twenty-six states. We found that in these twenty-six states, Medicaid covered more than 1.7 million additional Americans in roughly a three-month period. Relative changes in Medicaid enrollment differed significantly across states, although enrollment growth was not systemically related to job losses. Our results point to the important effects of state policy differences in the response to COVID-19.