Antiretroviral Therapy Use and Disparities Among Medicare Beneficiaries with HIV.

BACKGROUND: Antiretroviral therapy (ART) is recommended for all people with HIV. Understanding ART use among Medicare beneficiaries with HIV is therefore critically important for improving quality and equity of care among the growing population of older adults with HIV. However, a comprehensive national evaluation of filled ART prescriptions among Medicare beneficiaries is lacking. OBJECTIVE: To examine trends in ART use among Medicare beneficiaries with HIV from 2013 to 2019 and to evaluate whether racial and ethnic disparities in ART use are narrowing over time. DESIGN: Retrospective observational study. SUBJECTS: Traditional Medicare beneficiaries with Part D living with HIV in 2013-2019. MAIN MEASURES: Months of filled ART prescriptions each year. KEY RESULTS: Compared with beneficiaries not on ART, beneficiaries on ART were younger, less likely to be Black (41.6% vs. 47.0%), and more likely to be Hispanic (13.1% vs. 9.7%). While the share of beneficiaries who filled ART prescriptions for 10 + months/year improved (+ 0.48 percentage points/year [p.p.y.], 95% CI 0.34-0.63, p < 0.001), 25.8% of beneficiaries did not fill ART for 10 + months in 2019. Between 2013 and 2019, the proportion of beneficiaries who filled ART for 10 + months improved for Black beneficiaries (65.8 to 70.3%, + 0.66 p.p.y., 95% CI 0.43-0.89, p < 0.001) and White beneficiaries (74.8 to 77.4%, + 0.38 p.p.y.; 95% CI 0.19-0.58, p < 0.001), while remaining stable for Hispanic beneficiaries (74.5 to 75.0%, + 0.12 p.p.y., 95% CI - 0.24-0.49, p = 0.51). Although Black-White disparities in ART use narrowed over time, the share of beneficiaries who filled ART prescriptions for 10 + months/year was significantly lower among Black beneficiaries relative to White beneficiaries each year. CONCLUSIONS: ART use improved from 2013 to 2019 among Medicare beneficiaries with HIV. However, about 25% of beneficiaries did not consistently fill ART prescriptions within a given year. Despite declining differences between Black and White beneficiaries, concerning disparities in ART use persist.

Coverage and Access Changes During Medicaid Unwinding.

Importance: States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care. Objective: To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states. Design, Setting, and Participants: This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level. Exposure: Medicaid enrollment at any point since March 2020, when continuous coverage began. Main Outcomes and Measures: Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment. Results: The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care. Conclusions and Relevance: The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.

Impact of extreme weather events on healthcare utilization and mortality in the United States.

Climate change is intensifying extreme weather events. Yet a systematic analysis of post-disaster healthcare utilization and outcomes for severe weather and climate disasters, as tracked by the US government, is lacking. Following exposure to 42 US billion-dollar weather disasters (severe storm, flood, flood/severe storm, tropical cyclone and winter storm) between 2011 and 2016, we used a difference-in-differences (DID) approach to quantify changes in the rates of emergency department (ED) visits, nonelective hospitalizations and mortality between fee-for-service Medicare beneficiaries in affected compared to matched control counties in post-disaster weeks 1, 1-2 and 3-6. Overall, disasters were associated with higher rates of ED utilization in affected counties in post-disaster week 1 (DID of 1.22% (95% CI, 0.20% to 2.25%; P < 0.020)) through week 2. Nonelective hospitalizations were unchanged. Mortality was higher in affected counties in week 1 (DID of 1.40% (95% CI, 0.08% to 2.74%; P = 0.037)) and persisted for 6 weeks. Counties with the greatest loss and damage experienced greater increases in ED and mortality rates compared to all affected counties. Thus, billion-dollar weather disasters are associated with excess ED visits and mortality in Medicare beneficiaries. Tracking these outcomes is important for adaptation that protects patients and communities, health system resilience and policy.