Disparities in satisfaction among insured and uninsured adult outpatient department service users in Southern Ethiopia, 2022: a comparative cross-sectional study.

BACKGROUND: Patient satisfaction is a critical measure of the quality of healthcare services provided by healthcare facilities. However, very few studies, particularly in Ethiopia, which includes the study area, have specifically examined these discrepancies among people who use outpatient care. In this study, satisfaction levels and associated factors were compared between insured and uninsured patients receiving outpatient services at public health institutions in Hadiya Zone, southern Ethiopia. METHODS: A facility-based comparative cross-sectional study design was employed on 630 patients using multistage and systematic random sampling. Data were collected using a pretested and structured interviewer-administered questionnaire. Results of the analysis were presented in text, tables, and graphs as appropriate. Multivariable logistic regression was used to predict associations between predictors and the outcome variable. Statistical significance was declared at p-value < 0.05. RESULTS: Overall, 344(55.48%) patients were satisfied with the service they received, of which 206(65.8%) out of 313 with a 95% CI [60.7-71.2%] were insured and 138(44.95%) out of 307 with a 95% CI [39.4-5.1%] were uninsured. Among insured patients, factors associated with higher satisfaction included having a family size less than five members [AOR = 3.3, 95% CI; 1.5, 7.4], perceived fair waiting time to be seen[AOR = 2.35, 95% CI; 1.02, 5.5], perceived short waiting time to be seen[AOR = 8.12, 95% CI; 1.6, 41.3], having all ordered laboratory tests available within the facility[AOR = 7.89, 95% CI; 3.5, 17.5], having some ordered laboratory tests within the facility[AOR = 2.97, 95% CI; 1.25, 7.01] having all prescribed medications available within the facility[AOR = 16.11, 95% CI; 6.25, 41.5], having some prescribed medications available within the facility[AOR = 13.11, 95% CI; 4.7, 36.4]. Among non-insured patients, factors associated with higher satisfaction included urban residency, a fair and short perceived time to be seen, having ordered laboratory tests within the facility, and having prescribed drugs within the facility. CONCLUSION: This study identified lower overall satisfaction, particularly among uninsured patients. Enrollment in the CBHI program significantly impacted satisfaction, with both groups reporting lower levels compared to enrollment periods. Access to essential services, wait times, and socio-demographic factors identified as associated factors with patient satisfaction regardless of insurance status.

Moving Toward Inclusion: Access to Care Models for Uninsured Immigrant Children.

Policy Points Models for access to care for uninsured immigrant children that mitigate structural and sociopolitical barriers to inclusive health care include funding structures (e.g., state-sponsored coverage) and care delivery systems (e.g., federally qualified health centers,). Although the quintessential model of access to care necessitates health coverage for all children regardless of immigration status or date of United States entry, incremental policy change may more realistically and efficiently advance equitable access to high-quality health care. Intentional advocacy efforts should prioritize achievable goals that are grounded in data, are attentive to the sociopolitical milieu, are inclusive of diverse perspectives, and would meaningfully impact health care access and outcomes.

Effectiveness and feasibility of three types of parent reminders to increase adolescent human papillomavirus (HPV) vaccination.

Parent reminders have produced modest improvements in human papillomavirus (HPV) vaccination among adolescents. However, little prior research has compared the effectiveness and feasibility of different HPV reminder types in resource-limited settings. We conducted a quasi-experimental study (2016-2017) to evaluate the effectiveness of three parent reminder types (mailed letters, robocalls, text messages) on next-dose HPV vaccine receipt among 12-year-olds in a large Federally Qualified Health Center in Los Angeles County. Six clinics were matched into three pairs: randomly assigning one clinic within each pair to intervention and control. Intervention clinics were randomly assigned to deliver one of the three parent reminder types. We calculated rates of next-dose vaccine receipt and assessed intervention effects using logistic regression models. We calculated the proportion of each type of reminder successfully delivered as a feasibility measure. The study sample comprised 877 12-year-olds due for an HPV vaccine dose (47% female, >85% Latino). At 4-month follow-up, 23% of intervention patients received an HPV vaccine dose compared to only 12% of control patients. Overall, receipt of any reminder increased rates of the next-needed HPV vaccine compared to usual care (p = 0.046). Significant improvements were observed for text reminders (p = 0.036) and boys (p = 0.006). Robocalls were the least feasible reminder type. Text message reminders are feasible and effective for promoting HPV vaccination. Future research is needed to assess the effectiveness and feasibility of reminders compared to other vaccine promotion strategies.

Healthcare for individuals without health insurance in Germany - a mixed methods approach to assess the situation and current challenges.

BACKGROUND: Health insurance is mandatory in Germany; nevertheless, many individuals there have no health insurance and depend on a parallel healthcare structure. Voluntary associations, such as MediNetz and healthcare vouchers ("Anonymer Krankenschein" - AKS), support uninsured citizens. This study aimed to provide insights into associations, such as MediNetz and AKS that provide healthcare for individuals without health insurance in North Rhine-Westphalia, the largest federal state in Germany. METHODS: A mixed methods approach was chosen. A qualitative study using interviews with experts was performed to gain their knowledge and explore the various challenges that AKS and MediNetz associations faced and the possible improvements that could be made. A quantitative survey was conducted to analyse the demographic data of the patients who required AKS or MediNetz's assistance and the characteristics of each association through a separate questionnaire. Data was received from the association in Aachen, Bielefeld, Bonn, Düsseldorf, and Essen. RESULTS: More women than men sought medical care; most were between 25 and 49 years old. The proportion of individuals without residency status accounted for the largest share (53.6%). Common reasons for patients to make contact were acute illnesses (40.2%) and pregnancies (22.3%). Most patients were sent to gynaecologists and general practitioners. Asking the experts, it became apparent that the existing system could not reach the standard of the regular healthcare in Germany. Financial and human resources were insufficient. Therefore, prevention was limited, especially chronically ill patients or patients with a severe illness requiring hospitalisation could not be treated. AKS had advantages compared to MediNetz, as the care came closer to the expected German medical standards. CONCLUSIONS: The results showed a demand for associations providing healthcare for individuals without health insurance. However, the healthcare provided by MediNetz and AKS did not reach the standard of healthcare in Germany and mainly depended on the organisations' resources. Funded projects such as an AKS combined with clearing centres significantly improved healthcare. Until structural measures are implemented, they can be a transitional solution by spreading nationwide.

Health outcomes, health services utilization, and costs consequences of medicare uninsurance among migrants in Canada: a systematic review.

BACKGROUND: Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This systematic review sought to assess quantitative evidence on health outcomes, health services use, and health care costs among uninsured migrant populations in Canada. METHODS: OVID MEDLINE, Embase, Global Health, EconLit, and grey literature were searched to identify relevant literature published up until March 2021. The Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool was used to assess the quality of studies. RESULTS: Ten studies were included. Data showed that there are differences among insured and uninsured groups in reported health outcomes and health services use. No quantitative studies on economic costs were captured. CONCLUSIONS: Our findings indicate a need to review policies regarding accessible and affordable health care for migrants. Increasing funding to community health centers may improve service utilization and health outcomes among this population.

Outcomes of an integrated practice unit for vulnerable emergency department patients.

BACKGROUND: An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS: We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS: There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS: Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION: IRB201500212. Retrospectively registered.

Controlling Pharmaceutical Costs in a Student-Run Free Clinic in a Resource-Limited Patient Setting.

Our institution's student-run free clinic has been able to offer medication at no out-of-pocket cost to all patients since it opened in 2004. We have employed two strategies to manage prescription drug costs while simultaneously increasing medication coverage: (1) using Patient Drug Assistance Programs (PDAPs) and (2) developing an institutional-level partnership with pharmaceutical charities for medication subsidization. In this study, we aimed to analyze the financial impact of these measures on the clinic.A query of clinic data over the past 5 years identified 299 active PDAPs, corresponding to 299 fully-subsidized prescriptions. In 2017, there were 35 active PDAPs, increasing to 52 (2018), 62 (2019), and 82 (2020) before a decline to 68 PDAPs in 2021. The company affiliated with the most PDAPs varied annually: GlaxoSmithKline (2017), Lilly (2018, 2019, 2020), and both GlaxoSmithKline and Lilly (2021). The most frequent medications were sitagliptin (2017), insulin (2018, 2019), albuterol (2017, 2018), and dulaglutide (2020, 2021).In addition, data extracted from the private company subsidization program was analyzed for the year 2021. Program membership was $10,000 for institution-wide medication subsidization for all uninsured patients in the hospital system. In total, the clinic was able to acquire 220 medications with a 96% subsidy, corresponding to a direct clinic cost of $2,101.28. Comparatively, the market value of these medications was $52,401.51.Utilization of free drug acquisition programs and partnerships with pharmaceutical charities allowed for an increase in cost-savings and medications provided. Although the process for applying for medication assistance programs is complex, these programs serve as powerful tools for providing medications that may otherwise be unavailable due to cost. Other clinics and healthcare settings with uninsured patients should consider these programs as a means to ease medication cost burden.

Results of Leveraging Pharmaceutical Patient Assistance Programs to Expand Access to High Cost Medications in a Student-Run Free Clinic.

High costs make many medications inaccessible to patients in the United States. Uninsured and underinsured patients are disproportionately affected. Pharmaceutical companies offer patient assistance programs (PAPs) to lower the cost-sharing burden of expensive prescription medications for uninsured patients. PAPs are used by various clinics, particularly oncology clinics and those caring for underserved communities, to expand patients' access to medications. Prior studies describing the implementation of PAPs in student-run free clinics have demonstrated cost-savings during the first few years of using PAPs. However, there is a lack of data regarding the efficacy and cost savings of longitudinal use of PAPs across several years. This study describes the growth of PAP use at a student-run free clinic in Nashville, Tennessee over ten years, demonstrating that PAPs can be used reliably and sustainably to expand patients' access to expensive medications. From 2012 to 2021, we increased the number of medications available through PAPs from 8 to 59 and the number of patient enrollments from 20 to 232. In 2021, our PAP enrollments demonstrated potential cost savings of over $1.2 million. Strategies, limitations, and future directions of PAP use are also discussed, highlighting that PAPs can be a powerful tool for free clinics in serving underserved communities.

The Costs of Operating a Student-run Free Clinic.

INTRODUCTION: Free clinics provide care for those who may otherwise not have access. While this care is often free for patients, it is not free to operate such clinics. This review will provide a budget and breakdown of all expenditures at a student-run free clinic along with average costs of services provided to patients. METHODS: Accounting data was used to categorize all expenses and generate an annual budget. An inventory tracking system was developed to measure the costs of all medical supplies and services accurately, providing information on costs per clinic and costs per patient for each provided service. RESULTS: The average cost per clinic was $53.55 (per patient: $2.14) for general clinic supplies, $43.74 (per patient: $7.29) for telehealth, $278.47 (per patient: $12.66) for laboratory services, $247.25 (per patient: $10.75) for pharmacy services, and $8.30 (per patient: $1.19) for social work. These costs contributed to a relative minority (< 33%) of the total costs to run a free clinic, where the highest costs were for volunteer appreciation and administrative overhead. Twelve categories of expenditures (administrative overhead, volunteer appreciation, medical and lab supplies, conferences and special projects, advertising and marketing, telehealth, pharmacy, specialty clinics, chronic care, patient transportation, social work, and accounting services) were ranked in order of necessity, and methods for cost reduction were discussed for each category. CONCLUSIONS: Categorizing costs can show where cost savings and cost-effective additions may be implemented. This study may serve as a financial and budgeting reference for other clinics.

Expanding Access to Psychiatric Care Through Universal Depression Screening: Lessons from an Urban Student-Run Free Clinic.

The purpose of this study is to report the utility of a universal depression screening in a student-run free clinic (SRFC) to improve bridging to psychiatric care. Patients (n = 224) seen by an SRFC between April 2017 and November 2022 were screened for depression in the patient's primary language using the standardized Patient Health Questionnaire (PHQ-9). A PHQ-9 score greater or equal to 5 prompted psychiatry referral. Retrospective chart review was conducted to determine clinical characteristics and length of psychiatry follow-up. Out of 224 patients screened, 77 patients had positive depression screens and were referred to the SRFC's adjacent psychiatry clinic. Of these 77 patients, 56 patients (73%) were female, the average age was 43.7 (SD = 14.5), and the mean PHQ score was 10 (SD = 5.13). Thirty-seven patients (48%) accepted referral, while 40 (52%) declined or were lost to follow-up. There were no statistical differences in age or number of medical comorbidities between the two groups. Patients who accepted referrals were more likely to be female, as well as to have psychiatric histories, higher PHQ-9 scores, and a history of trauma. Reasons for declining and being lost to follow-up included transition to insurance, geographic relocation and deferral due to hesitancy in seeking psychiatric care. Implementation of a standardized depression screening reveals a significant rate of depressive symptoms among an urban uninsured primary care population. Universal screening may serve as a tool to improve the delivery of psychiatric care to underserved patients.

Increased female political representation associated with lower county-level uninsured and preventable hospitalizations rates in the United States, 2013-2018.

OBJECTIVE: Although women comprise 50% of the population, females remain underrepresented in government. Inequitable female political representation, a form of structural sexism, may impact population health. Previous studies focused primarily on individual health behaviors and low- or middle-income countries. To date, no study has examined the association between female political representation and healthcare access and utilization, immediately policy-amenable outcomes, in the United States. STUDY DESIGN: This was a repeated cross-sectional study. METHODS: This study uses 2013-2018 county-level data from the County Rankings. I performed multilevel analyses to determine the relationships between state-level female representation (% female state legislators) and two outcomes-the percentage of county-level population under age 65 years without health insurance (primary outcome) and the county-level preventable hospitalization rates (secondary outcome of interest). Potential confounders included county-level and state-level characteristics such as the unemployment rate. I also examined whether associations differed by political party control of the state legislature. RESULTS: In the fully adjusted model, one standard deviation difference in female political representation was associated with a decrease of 0.22 percentage points in county-level uninsured (95% confidence interval = -0.32, -0.12). The association between female political representation and preventable hospitalization rate differed according to state political party in control, with a decrease found only among counties in democratic/split controlled states (-80.51, 95% confidence interval = -149.65, -11.38). CONCLUSIONS: The results suggest that policy intervention addressing the underrepresentation of women in government may help increase the proportion of uninsured and, under certain circumstances, decrease county-level unnecessary hospitalizations. However, further research is needed to better understand the role of political party control in modifying noted associations.

An exploration of financial toxicity among low-income patients with cancer in Central Texas: A mixed methods analysis.

OBJECTIVE: Financial toxicity is of increasing concern in the United States. The Comprehensive Score for Financial Toxicity (COST) is a validated measure; however, it has not been widely utilized among low-income patients and may not fully capture financial toxicity in this population. Furthermore, the relationships between financial toxicity, quality of life (QOL), and patient well-being are poorly understood. We describe the experience of financial toxicity among low-income adults receiving cancer care. We hypothesized that higher financial toxicity would be associated with less income and lower quality of life. Qualitative interviews focused on the financial impact of cancer treatment. METHOD: This study was conducted at a cancer clinic in Central Texas. Quantitative and qualitative data were collected in Fall and Spring 2018, respectively. The quantitative sample (N = 115) was dichotomized by annual income (<$15,000 vs. >$15,000). Outcomes included financial toxicity (COST), quality of life (FACT-G), and patient well-being (PROMIS measures: Anxiety, Depression, Fatigue, Pain Interference, and Physical Function). Associations between quality of life, patient well-being, and financial toxicity were evaluated using linear regression. Sequential qualitative interviews were conducted with a subsample of 12 participants. RESULTS: Patients with <$15k had significantly lower levels of QOL and patient well-being such as depression and anxiety compared to patients with >$15k across multiple measures. A multivariate linear regression found QOL (Β = 0.17, 95% CI = 0.05, 0.29, p = 0.008) and insurance status (Β = -3.79, 95% CI = -7.42, -0.16, p = 0.04), but not income, were significantly associated with financial toxicity. Three qualitative themes regarding patient's access to cancer care were identified: obtaining healthcare coverage, maintaining financial stability, and receiving social support. SIGNIFICANCE OF RESULTS: Low-income patients with cancer face unique access barriers and are at risk for forgoing treatment or increased symptom burdens. Comprehensive assessment and financial navigation may improve access to care, symptom management, and reduce strain on social support systems.

Assessment of Perceived and Objective Quality of Care Received by Insured versus Uninsured Adult Patients Attending a Tertiary Hospital in Nigeria.

BACKGROUND AND OBJECTIVES: Health insurance relieves problems with out-of-pocket payments. It is uncertain whether equal care is received by insured and uninsured patients. We compared objective and perceived healthcare quality between insured and uninsured adults at the study site to make appropriate recommendations that would improve healthcare quality. METHODS: We conducted a comparative cross-sectional study at the General Outpatient Clinic of National Hospital, Abuja, Nigeria from February to May 2020. Using systematic sampling, we recruited 238 insured and uninsured adults and interviewed them with a semi-structured questionnaire and an observational checklist (for perceived and objective quality of care respectively). We used the independent t-test and chi-square test to assess the relationship between health insurance status and socio-demographic characteristics, clinical characteristics and perceived and objective quality of care. RESULTS: The mean age (±SD) of participants was 42.0 ± 11.6 years with 131 (55.0%) insured respondents. Overall perceived quality of care was higher among the uninsured (P<0.001). There was no significant difference between insured and uninsured patients concerning the comprehensiveness of objective healthcare quality indicators. CONCLUSION: We found that the uninsured perceived healthcare quality to be better than the insured, which is unexpected. Since the uninsured patients were fewer in number, paid immediately, and had shorter waiting times, they perceived that: health providers respected them more, drugs were more available to them and consulting rooms and health providers were more sufficient. We recommended that the hospital management should commence regular healthcare quality assessments to improve healthcare quality. This could increase the patients' confidence in the health system.

CONTEXTE ET OBJECTIFS: L'assurance maladie soulage les problèmes liés au paiement direct. Il n'est pas certain que les patients assurés et non assurés reçoivent les mêmes soins. Nous avons comparé la qualité objective et perçue des soins de santé entre les adultes assurés et non assurés sur le site de l'étude en vue de formuler des recommandations susceptibles d'améliorer la qualité des soins de santé. MÉTHODES UTILISÉES: Nous avons mené une étude transversale comparative au General Outpatient Clinic de l'hôpital national d'Abuja, au Nigéria, de février à mai 2020. En utilisant un échantillonnage systématique, nous avons recruté 238 adultes assurés et non assurés et les avons interrogés à l'aide d'un questionnaire semi-structuré et d'une liste de contrôle observationnelle (pour la qualité perçue et objective des soins respectivement). Nous avons utilisé le test t indépendant et le test chi-carré pour évaluer la relation le statut d'assurance maladie et les caractéristiques sociodémographiques, les caractéristiques cliniques et la qualité perçue et objective des soins. RÉSULTATS: L'âge moyen (±SD) des participants était de 42,0 ± 11,6 ans et 131 (55,0 %) d'entre eux étaient assurés. La qualité globale perçue des soins était plus élevée chez les non-assurés (P<0,001). Il n'y avait pas de différence significative entre les patients assurés et non assurés en ce qui concerne l'exhaustivité des indicateurs objectifs de qualité des soins de santé. CONCLUSION: Nous avons constaté que les non-assurés percevaient la qualité des soins de santé comme étant meilleure que les assurés, ce qui est inattendu. Étant donné que les patients non assurés étaient moins nombreux, qu'ils payaient immédiatement et qu'ils avaient des temps d'attente plus courts, ils avaient l'impression que les prestataires de soins les respectaient davantage, que les médicaments étaient plus disponibles et que les salles de consultation et les prestataires de soins étaient plus nombreux. Nous avons recommandé à la direction de l'hôpital de procéder à des évaluations régulières de la qualité des soins afin d'améliorer la qualité des soins. Cela pourrait accroître la confiance des patients dans le système de santé. Mots clés: Assurance maladie, Qualité perçue des soins, Qualité objective des soins, Patients adultes assurés et non assurés.

Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act.

BACKGROUND: Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. OBJECTIVE: To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA. DESIGN: Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending. PARTICIPANTS: Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey. INTERVENTION: ACA implementation, January 1, 2014. MAIN MEASURES: Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income. KEY RESULTS: Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care. CONCLUSIONS: ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.

Participation, Pricing, and Enrollment in a Health Insurance "Public Option": Evidence From Washington State's Cascade Care Program.

Policy Points Policymakers considering introduction of a health insurance "public option" to lower health spending and reduce the number of uninsured can learn from Washington State, which offered the nation's first public option ("Cascade Care") through its state exchange in 2021. This article examines insurer participation, pricing, and enrollment in the Washington public option. The public option was the lowest-premium standard silver plan in 9 of the 19 counties in which it was offered. Cascade Care is available solely through private insurers. Voluntary participation of these insurers and uncertainty about the willingness of providers to participate may have hindered greater premium reductions and enrollment in the public option's first year. CONTEXT: State and federal policymakers considering introduction of a health insurance "public option" can learn from Washington State, which established the nation's first public option, with coverage beginning in January 2021. Public option plans were offered voluntarily by private insurers through the Washington Health Benefit Exchange and were subject to state-mandated plan design and payment requirements. METHODS: We used plan data from the Washington Health Benefit Exchange, linked to data from the US Census Bureau, the American Hospital Association, and InterStudy. We compared geographic availability and premiums of, and enrollment in, public option and non-public option plans, as well as characteristics of counties where the public option was available and counties where the public option was the lowest-premium plan. FINDINGS: At least one public option plan was available in 19 of 39 counties and was the lowest-premium option in 9 of the 19 counties where it was available. Five insurers offered public option plans, including one new entrant to the state and one new entrant to the Exchange. While public option availability was more common in counties where the Exchange was bigger and more competitive, public option plans had the lowest premium in smaller, less competitive counties. In the first year, 1% of enrollees selected the public option, in part due to automatic reenrollment of the majority of returning enrollees in their 2020 plan. CONCLUSIONS: Public option plans offered a low-premium choice in counties that otherwise had fewer affordable plans, but voluntary participation of insurers and providers and accompanying uncertainty about participation hindered widespread and substantial premium reductions. States should consider tying public option participation by insurers and providers to other state programs and using decision support tools to promote active enrollment. Federal policymakers can support state efforts while considering establishment of a national public option.

Preventative Cancer Screening Rates Among Uninsured Patients in Free Clinics: A Retrospective Cohort Study of Cancer Survivors and Non-cancer Survivors.

BACKGROUND: There is limited research on screening rates among uninsured cancer survivors. Uninsured cancer survivors are at higher risk of poorer health outcomes than the insured due to limited access to preventative screening for secondary cancers. This study examines the rates of surveillance and screening of uninsured cancer survivors and compares to uninsured patients without a cancer history seen in free clinics. METHODS: Data were collected retrospectively from electronic medical records and paper charts of patients from 10 free clinics between January 2016 and December 2018 in the Tampa Bay area. The prevalence of socioeconomic characteristics, cancer diagnoses, and screening practices were compared for cancer survivors and free clinic patients without a history of cancer. Study participants were determined to be eligible for cancer screenings based on the United States Preventive Services Task Force guidelines. RESULTS: Out of 13 982 uninsured patients frequenting free clinics between 2016 and 2018, 402 (2.9%) had a documented history of cancer. Out of the 285 eligible cancer survivors, 44 (15.4%) had completed age-appropriate colon cancer screening. Among the 170 female cancer survivors, 75 (44.1%) had completed breast cancer screenings, and only 5.9% (59/246) had completed cervical cancer screenings. After adjusting for age, gender, race, salary, employment status, and household size, cancer survivors were more likely to undergo colorectal cancer screening (OR: 3.59, 95% CI: 2.10-6.15) and breast cancer screening (OR: 2.13, 95% CI: 1.30-3.84) than patients without a cancer history. This difference was not seen for cervical cancer screening (OR: 0.99, 95% CI: .62-1.58). CONCLUSIONS: Uninsured cancer survivors frequenting free clinics represent a unique population that is underrepresented in the medical literature. Our results suggest that uninsured survivors use screening services at higher rates when compared to uninsured patients without a reported cancer diagnosis. However, these rates are suboptimal when compared to national screening rates of insured cancer survivors.

Impact of birth tourism on health care systems in Calgary, Alberta.

BACKGROUND: Birth tourism refers to non-resident women giving birth in a country outside of their own in order to obtain citizenship and/or healthcare for their newborns. We undertook a study to determine the extent of birth tourism in Calgary, the characteristics and rationale of this population, and the financial impact on the healthcare system. METHODS: A retrospective analysis of 102 women identified through a Central Triage system as birth tourists who delivered in Calgary between July 2019 and November 2020 was performed. Primary outcome measures were mode of delivery, length of hospital stay, complications or readmissions within 6 weeks for mother or baby, and NICU stay for baby. RESULTS: Birth Tourists were most commonly from Nigeria (24.5%). 77% of Birth Tourists stated that their primary reason to deliver their baby in Canada was for newborn Canadian citizenship. The average time from arrival in Calgary to the EDD was 87 days. Nine babies required stay in the neonatal intensive care unit (NICU) and 3 required admission to a non NICU hospital ward in first 6 weeks of life, including 2 sets of twins. The overall amount owed to Alberta Health Services for hospital fees for this time period is approximately $694 000.00. CONCLUSION: Birth Tourists remain a complex and poorly studied group. The process of Central Triage did help support providers in standardizing process and documentation while ensuring that communication was consistent. These findings provide preliminary data to guide targeted public health and policy interventions for this population.

Impact of the COVID-19 Pandemic & Telehealth Implementation in a Student Run Free Clinic.

Student run free clinics (SRFCs) fill a void in healthcare access for many communities and have been subject to unprecedented shifts in care delivery brought about by the coronavirus disease 2019 (COVID-19) pandemic. Our single-center institution serving uninsured patients in central Missouri switched from in-person visits to strictly telehealth visits with the onset of the pandemic. This study investigated the impact of the pandemic and the switch to telehealth on the clinic return rates by ethnicity, race, gender, rurality, and age. The pandemic led to a 47.4% reduction in the number of monthly patient encounters. Of the established SRFC population (N = 309), only 87 patients (28.2%) returned for a telehealth visit during the COVID-19 pandemic. Older patients (≥ 45 years old) were more likely to return (OR 1.71, 95% CI 1.02-2.85) for care via telehealth after the onset of the pandemic than younger patients (< 45 years old). No differences in the likelihood of returning for a telehealth visit were identified by race, ethnicity, gender, or rurality. Telehealth offers an effective solution to the complex problems faced by SRFCs during the COVID-19 pandemic and has not added barriers to care with regards to race, ethnicity, gender, or rurality at our SRFC.

Providing Prenatal Care for Patients with Limited Medical Insurance Coverage.

Newer immigrants to the United States, whether undocumented, recent legal immigrants, those here on temporary visas, or migrant workers, are far less likely than native-born residents of the United States to have reliable health insurance. This entire group of patients is then at risk for delayed or absent medical care. Our study focused on what effects a free, quality prenatal care program had upon prenatal care and delivery outcomes for an underinsured population, primarily of immigrant women. With a recent change in Iowa's eligibility criteria for Presumptive Medicaid (referred to as Temporary Medicaid), pregnant patients who have less than a 5-year legal permanent residency status, undocumented status, or out-of-country resident status can receive up to two months of covered antepartum care, whereas previously eligible for coverage for the entirety of their pregnancy. With that reality, several faculty members from the Department of Family Medicine at the University of Iowa started a weekly prenatal care clinic in collaboration with the longstanding Iowa City Free Medical Clinic. This study sought to compare outcomes for patients who utilized only Temporary Medicaid to those who also had access to this prenatal free medical clinic (FMC), as well as to compare outcomes for the FMC program to typical Medicaid patients who had access to full prenatal care. Compared to the Temporary Medicaid-only group, our FMC patients had a significantly greater number of prenatal visits. This increased access of continuity prenatal care led to increased screening for gestational diabetes, receipt of recommended vaccinations, and screening for group B streptococcus. Our effort has shown that expanding prenatal healthcare coverage to this underinsured population can greatly increase the quality of maternity care and reduce the potential for high-risk pregnancies, bettering the care for these pregnant women and their newborns.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults.

BACKGROUND: Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care. METHODS: Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion). RESULTS: The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period. CONCLUSIONS: The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.