Assessing patterns in cancer screening use by race and ethnicity during the coronavirus pandemic using electronic health record data.

BACKGROUND: Efforts to prevent the spread of the coronavirus led to dramatic reductions in nonemergency medical care services during the first several months of the COVID-19 pandemic. Delayed or missed screenings can lead to more advanced stage cancer diagnoses with potentially worse health outcomes and exacerbate preexisting racial and ethnic disparities. The objective of this analysis was to examine how the pandemic affected rates of breast and colorectal cancer screenings by race and ethnicity. METHODS: We analyzed panels of providers that placed orders in 2019-2020 for mammogram and colonoscopy cancer screenings using electronic health record (EHR) data. We used a difference-in-differences design to examine the extent to which changes in provider-level mammogram and colonoscopy orders declined over the first year of the pandemic and whether these changes differed across race and ethnicity groups. RESULTS: We found considerable declines in both types of screenings from March through May 2020, relative to the same months in 2019, for all racial and ethnic groups. Some rebound in screenings occurred in June through December 2020, particularly among White and Black patients; however, use among other groups was still lower than expected. CONCLUSIONS: This research suggests that many patients experienced missed or delayed screenings during the first few months of the pandemic, which could lead to detrimental health outcomes. Our findings also underscore the importance of having high-quality data on race and ethnicity to document and understand racial and ethnic disparities in access to care.

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.

Post-ACA, More Than One-Third Of Women With Prenatal Medicaid Remained Uninsured Before Or After Pregnancy.

Medicaid has a long history of serving pregnant women, but many women are not eligible for Medicaid before pregnancy or after sixty days postpartum. We used data for new mothers with Medicaid-covered prenatal care in 2015-18 from forty-three states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) to describe patterns of perinatal uninsurance and health outcomes of women experiencing uninsurance. We found that 26.8 percent of new mothers with Medicaid-covered prenatal care were uninsured before pregnancy, 21.9 percent became uninsured two to six months postpartum, and 34.5 percent were uninsured in either period, with higher perinatal uninsurance rates in nonexpansion states and for Hispanic women who completed the PRAMS survey in Spanish. Together, our findings indicate that despite recent coverage gains, further policy change is needed to help women maintain health insurance coverage before and after pregnancy and to allow them to address ongoing health issues including obesity and depression.

Improving Birth Outcomes And Lowering Costs For Women On Medicaid: Impacts Of 'Strong Start For Mothers And Newborns'.

The federal Strong Start for Mothers and Newborns initiative supported alternative approaches to prenatal care, enhancing service delivery through the use of birth centers, group prenatal care, and maternity care homes. Using propensity score reweighting to control for medical and social risks, we evaluated the impacts of Strong Start's models on birth outcomes and costs by comparing the experiences of Strong Start enrollees to those of Medicaid-covered women who received typical prenatal care. We found that women who received prenatal care in birth centers had lower rates of preterm and low-birthweight infants, lower rates of cesarean section, and higher rates of vaginal birth after cesarean than did the women in the comparison groups. Improved outcomes were achieved at lower costs. There were few improvements in outcomes for participants who received group prenatal care, although their costs were lower in the prenatal period, and no improvements in outcomes for participants in maternity care homes.

The availability and marginal costs of dependent employer-sponsored health insurance.

In this study, we examine differences by firm size in the availability of dependent coverage and the incremental cost of such coverage. We use data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to show that among employees eligible for single coverage, dependent coverage was almost always available for employees in large firms (100 or more employees) but not in smaller firms, particularly those with fewer than 10 employees. In addition, when dependent coverage was available, eligible employees in smaller firms were more likely than employees in large firms to face two situations that represented the extremes of the incremental cost distribution: (1) they paid nothing for single or family coverage or (2) they paid nothing for single coverage but faced a high contribution for family coverage. These results suggest that firm size may be an important factor in policy assessments, such as analyses of the financial implications for families excluded from subsidized Marketplace coverage due to affordable offers of single coverage or of potential rollbacks to public coverage for children.

Marketplace Subsidies: Changing The 'Family Glitch' Reduces Family Health Spending But Increases Government Costs.

Under the Affordable Care Act, if one family member has an employer offer of single coverage deemed to be affordable-that is, costing less than 9.66 percent of family income in 2016-then all family members are ineligible for tax credits for Marketplace coverage, even if the cost of providing coverage to the whole family is greater than 9.66 percent of income. More than six million people live in such families and as a result are ineligible for premium tax credits. These families face premiums that can amount to 15.8 percent of income, or 12.0 percent after the tax advantages of employer-sponsored health coverage are factored in. We modeled the potential impact of changing the affordability test to take into account the cost of family coverage. Doing so would reduce spending on premiums from 12.0 percent to 6.3 percent of income, significantly alleviating financial burdens, but would generate little additional coverage. We estimated the additional costs to the federal government for premium tax credits and cost-sharing reductions to be between $3.7 billion and $6.5 billion in 2016.

Racial Residential Segregation and Disparities in Obesity among Women.

The high rate of obesity among black women in the USA is a significant public health problem. However, there is limited research on the relationship between racial residential segregation and disparities in obesity, and the existing evidence is limited and results are mixed. This study examines the relationship between racial residential segregation and obesity among black and white women. We conducted this cross-sectional study by joining data from the 1999-2004 National Health and Nutrition Examination Survey with data from the 2000 US Census. Multilevel logistic regression models found that for every one-point increase in the black isolation index, there was a 1.06 (95 % confidence interval (CI) = 1.01, 1.11) times higher odds of obesity for black women. In order to address the disparately high rates of obesity among black women, health policies need to address the economic, political, and social forces that produce racially segregated neighborhoods.

Many families may face sharply higher costs if public health insurance for their children is rolled back.

Millions of US children could lose access to public health care coverage if Congress does not renew federal funding for the Children's Health Insurance Program (CHIP), which is set to expire September 30, 2015­the end of the federal fiscal year. Additional cuts in public coverage for children in families with incomes above 133 percent of the federal poverty level are possible if the Affordable Care Act's "maintenance of effort" provisions regarding Medicaid and CHIP are allowed to expire as scheduled in 2019. The potential for a significant rollback of public coverage for children raises important policy questions regarding alternative pathways to affordable and high-quality coverage for low-income children. For many children at risk of losing eligibility for public coverage, the primary alternative pathway to coverage would be through their parents' employer-sponsored insurance, yet relatively little is known about the cost and quality of that coverage. Our estimates, based on data from the Insurance Component of the 2012 and 2013 Medical Expenditure Panel Surveys, show that many families would face sharply higher costs of covering their children. In many cases, the only employer-sponsored coverage available would be a high-deductible plan.

Trade-offs between public and private coverage for low-income children have implications for future policy debates.

Much of the discussion around the Affordable Care Act has focused on likely changes in coverage and access to care for adults. However, the law also alters coverage options for many low-income children. We used data from the new Health Reform Monitoring Survey Child Supplement to examine access to care and related outcomes for low-income publicly and privately insured children. We found that over 90 percent of low-income insured children had a usual source of care and had parents who were confident that their children could get the health care they need, regardless of their type of coverage. However, on a variety of cost-related measures, including difficulty paying the child's medical bills, out-of-pocket expenses, and satisfaction with health insurance premiums and copayments, children with Medicaid or the Children's Health Insurance Program (CHIP) fared better than those with employer-sponsored insurance. These results have implications for debates about the future of CHIP and other policies that affect public and private coverage options available to children and families.

Disparities in diabetes: the nexus of race, poverty, and place.

OBJECTIVES: We sought to determine the role of neighborhood poverty and racial composition on race disparities in diabetes prevalence. METHODS: We used data from the 1999-2004 National Health and Nutrition Examination Survey and 2000 US Census to estimate the impact of individual race and poverty and neighborhood racial composition and poverty concentration on the odds of having diabetes. RESULTS: We found a race-poverty-place gradient for diabetes prevalence for Blacks and poor Whites. The odds of having diabetes were higher for Blacks than for Whites. Individual poverty increased the odds of having diabetes for both Whites and Blacks. Living in a poor neighborhood increased the odds of having diabetes for Blacks and poor Whites. CONCLUSIONS: To address race disparities in diabetes, policymakers should address problems created by concentrated poverty (e.g., lack of access to reasonably priced fruits and vegetables, recreational facilities, and health care services; high crime rates; and greater exposures to environmental toxins). Housing and development policies in urban areas should avoid creating high-poverty neighborhoods.

A new framework for childhood health promotion: the role of policies and programs in building capacity and foundations of early childhood health.

Although the connection between early life experiences and later health is becoming increasingly clear, what is needed, now, is a new organizing framework for childhood health promotion, grounded in the latest science. We review the evidence base to identify the steps in the overall pathway to ensuring better health for all children. A key factor in optimizing health in early childhood is building capacities of parents and communities. Although often overlooked, capacities are integral to building the foundations of lifelong health in early childhood. We outline a framework for policymakers and practitioners to guide future decision-making and investments in early childhood health promotion.

Racial disparities in medical expenditures within body weight categories.

BACKGROUND: Despite federal guidelines calling for the reduction of obesity and elimination of health disparities, black-white differences in obesity prevalence and in medical expenditures and utilization of health care services persist. OBJECTIVES: To examine black-white differences in medical expenditures and utilization of health care services (office-based visits, hospital outpatient visits, ER visits, inpatient stays and prescription medication) within body weight categories. STUDY DESIGN: This study used data from the 2006 Medical Expenditures Panel Survey (MEPS) and included 15,164 non-Hispanic white and non-Hispanic black adults. We used a standard two-part econometric model to examine black-white differences in how expenditures (total annual medical expenditures and expenditures for each type of service) vary within body weight categories. KEY RESULTS: Blacks in each weight category were less likely to use any medical care than their white counterparts, even after controlling for socio-demographic characteristics, perceived health status, health conditions and health beliefs. Among those who received medical care, there is no significant difference in the total amount spent on care between blacks and whites. Compared to whites, blacks in each body weight category were significantly less likely to use office-based visits, hospital outpatient visits, and medications. Among those who used medications, blacks had significantly lower expenditures than whites. Blacks in obese class II/III were significantly less likely to have any medical expenditures on inpatient care than their white counterparts. CONCLUSIONS: Black-white racial differences in total medical expenditures were observed in each body weight category and were significantly different in the obese I class, overweight, and healthy weight categories. Obese blacks also spent a smaller amount than obese whites--the insignificance might be due to the smaller sample size. These differences cannot be fully explained by socio-demographics, health conditions, or health beliefs. Black-white differences in medical expenditures may be largely due to relatively inexpensive types of care (office-based visits, outpatient care, medication) rather than more costly ones (inpatient care, ER).

Health, behavior, and health care disparities: disentangling the effects of income and race in the United States.

The literature on health disparities in the United States typically focuses on race/ethnicity or on socioeconomic status (SES) separately, but not often together. The purpose of the study was to assess the separate effects of race/ethnicity and SES on health status, health behaviors, and health care utilization. Cross-sectional analyses were conducted using the 2008 National Health Interview Survey (n = 17,337 non-elderly adults). SES disparities within specific racial groups were examined, as were race disparities within high and low SES groups. Within each racial/ethnic group, a greater proportion of low versus high SES individuals were in poor health, a lower proportion had healthy behaviors, and a lower proportion had access to care. In both SES groups, blacks and Hispanics had poorer health outcomes than whites. While whites were more likely to exercise than blacks and Hispanics, they are more likely to be smokers and less likely to have no or moderate alcohol consumption. Blacks had similar or better health care use than whites, especially for cancer screening; Hispanics had lower use within each SES group. Race/ethnicity disparities among adults of similar incomes, while important, were dwarfed by the disparities identified between high- and low-income populations within each racial/ethnic group.

Trends of human papillomavirus testing in cervical cancer screening at a large academic cytology laboratory.

OBJECTIVE: To estimate time trends of actual provider use of human papillomavirus (HPV) testing in cervical cancer screening by using laboratory and administrative data from the Johns Hopkins Hospital Division of Cytopathology in Baltimore, Maryland. METHODS: In this ecologic trend study, we analyzed 178,510 Pap specimen records and 12,221 HPV tests among 85,048 patients from 2001 to 2007. Monthly frequencies and proportions of HPV reflex testing and HPV cotesting with Pap (stratified by patient ages 30 and older and 18-29 years) were calculated. Time trends of monthly HPV testing proportions were analyzed using joinpoint regression methods. RESULTS: From April 2002, when the American Society for Colposcopy and Cervical Pathology added HPV reflex testing to its guidelines, to December 2007, the monthly the proportion of reflex testing was 95.8%. From February 2004, when the society added HPV cotesting with Pap among women aged 30 years or older to its guidelines, to December 2007, the overall proportion HPV cotesting with Pap among patients aged 30 years or older was 7.8% (compared with 4.9% among patients 18-29 years [P<.01]). The highest proportion of HPV cotesting among women aged 30 years or older, 15%, was observed in September 2006, and the trend later plateaued around 13%. The monthly proportions of HPV reflex testing and cotesting with Pap changed significantly over time. CONCLUSION: These data reveal that a small percentage of women aged 30 years or older received HPV cotesting with Pap, thus identifying a significant opportunity for providers to improve patient care in cervical cancer prevention. LEVEL OF EVIDENCE: III.

Access to primary and preventive care among foreign-born adults in Canada and the United States.

OBJECTIVE: To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States. DATA SOURCES: Secondary data from the 2002 to 2003 Joint Canada-United States Survey of Health. STUDY DESIGN: Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions. PRINCIPAL FINDINGS: In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders. CONCLUSIONS: In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.

The impact of new health insurance coverage on undocumented and other low-income children: lessons from three California counties.

Three California counties (Los Angeles, San Mateo, and Santa Clara) expanded health insurance coverage for undocumented children and some higher income children not covered by Medi-Cal (Medicaid) or Healthy Families (SCHIP). This paper presents findings from evaluations of all three programs. Results consistently showed that health insurance enrollment increased access to and use of medical and dental care, and reduced unmet need for those services. After one year of enrollment the programs also improved the health status of children, including reducing the percentage of children who missed school due to health.

The impact of CHIP on children's insurance coverage: an analysis using the National Survey of America's Families.

OBJECTIVE: To assess the impact of the Children's Health Insurance Program (CHIP) on the distribution of health insurance coverage for low-income children. DATA SOURCE: The primary data for the study were from the 1997, 1999, and 2002 National Survey of America's Families (NSAF), which includes a total sample of 62,497 children across all 3 years, supplemented with data from other data sources. STUDY DESIGN: The study uses quasi-experimental designs and tests the sensitivity of the results to using instrumental variable and difference-in-difference approaches. A detailed Medicaid and CHIP eligibility model was developed for this study. Balanced repeated replicate weights were used to account for the complex sample of the NSAF. Descriptive and multivariate analyses were conducted. PRINCIPLE FINDINGS: The results varied depending on the approach utilized but indicated that the CHIP program led to significant increases in public coverage (14-20 percentage points); and declines in employer-sponsored coverage (6-7 percentage points) and in uninsurance (7-12 percentage points). The estimated share of CHIP enrollment attributable to crowd-out ranged from 33 to 44 percent. Smaller crowd-out effects were found for Medicaid-eligible children. CONCLUSIONS: Implementation of the CHIP program resulted in large increases in public coverage with estimates of crowd-out consistent with initial projections made by the Congressional Budget Office. This paper demonstrates that public health insurance expansions can lead to substantial reductions in uninsurance without causing a large-scale erosion of employer coverage.

Cancer prevention behaviors in low-income urban whites: an understudied problem.

Low-income urban whites in the United States have largely gone unexamined in health disparities research. In this study, we explored cancer prevention behaviors in this population. We compared data on whites with low socioeconomic status (SES) from the 2003 Exploring Health Disparities in Integrated Communities Study in Southwest Baltimore, Maryland (EHDIC-SWB) with nationally representative data for low SES white respondents from the 2003 National Health Interview Survey (NHIS). Rates for health behaviors and health indicators for whites from the EHDIC-SWB study as compared to NHIS prevalence estimates were as follows: current cigarette smoking, 59% (31% nationally); current regular drinking, 5% (5% nationally); overweight, 26% (32% nationally); obesity, 30% (22% nationally); mammography in the past 2 years, 50% (57% nationally); Pap smear in the past 2 years, 64% (68% nationally); screening for colon cancer in the past 2 years, 41% (30% nationally); and fair or poor self-reported health, 37% (22% nationally). Several cancer prevention behaviors and health indicators for white EHDIC-SWB respondents were far from the Healthy People 2010 objectives. This study provides rare estimates of cancer-related health and health care measures in an understudied population in the United States. Findings illustrate the need for further examination of health behaviors in low SES white urban populations who may share health risks with their poor minority urban counterparts.