Making Communities More Visible: Equity-Centered Data to Achieve Health Equity.

Policy Points Despite decades of research exposing health disparities between populations and communities in the US, health equity goals remain largely unfulfilled. We argue these failures call for applying an equity lens in the way we approach data systems, from collection and analysis to interpretation and distribution. Hence, health equity requires data equity. There is notable federal interest in policy changes and federal investments to improve health equity. With this, we outline the opportunities to align these health equity goals with data equity by improving the way communities are engaged and how population data are collected, analyzed, interpreted, made accessible, and distributed. Policy priority areas for data equity include increasing the use of disaggregated data, increasing the use of currently underused federal data, building capacity for equity assessments, developing partnerships between government and community, and increasing data accountability to the public.

Surveying Hate and Its Effects During the COVID-19 Pandemic Among Asian Americans and Native Hawaiians and Pacific Islanders.

Objectives. To summarize data collection on anti-Asian American and Native Hawaiian/Pacific Islander (AANHPI) experiences during COVID-19 and measure the associations of anti-AANHPI hate incidents with mental health, health access, and public safety among AANHPI adults. Methods. We cataloged COVID-19 surveys conducted in 2020 and 2021 on anti-AANHPI experiences. We then analyzed the 2020 California Health Interview Survey (CHIS) AANHPI COVID-19 module by constructing a variable of experiencing or witnessing a hate incident and estimating its associations with serious psychological distress, forgone care, and perceived neighborhood safety. Results. Estimates of being a victim of a hate incident ranged from 6% to 30%. In the CHIS, 28% of respondents experienced or witnessed a hate incident. Experiencing or witnessing a hate incident was significantly associated with serious psychological distress (adjusted odds ratio [AOR] = 5.33), forgoing care (AOR = 2.27), and not feeling safe in one's neighborhood (AOR = 2.70). Conclusions. Evidence from a multitude of data sources corroborates the toll of hate incidents suffered by AANHPIs. Findings regarding the negative effects of anti-AANHPI hate on mental health, health access, and public safety compel public and private investment to end victimization of AANHPI communities. (Am J Public Health. 2022;112(10):1446-1453. https://doi.org/10.2105/AJPH.2022.306977).

The impact of rising food prices on obesity in women: a longitudinal analysis of 31 low-income and middle-income countries from 2000 to 2014.

OBJECTIVES: To examine whether changes in food prices are associated with changes in obesity prevalence among women in developing countries, and assess effect modification by individual socioeconomic status (SES). METHODS: Longitudinal study of country-level food price inflation temporally and geographically linked to anthropometric data on non-pregnant adult women (n = 295,984) in 31 low-income and middle-income countries over the 2000-2014 time period, using separate multivariable multilevel growth models of five SES indicators. Post-estimation analysis computed the relationship between food price inflation and predicted mean probabilities of being obese, by SES. RESULTS: Rising food price inflation was strongly associated with women's obesity prevalence, and SES consistently modified the relationship. Regardless of indicator used, higher food price inflation was positively associated with obesity among women in top SES categories, but was flat or negative among women in low SES categories, averaging over time. The SES differences were widest across educational strata and were most pronounced when food price inflation was highest. Overall, for every 1-unit increase in food price inflation, predicted mean obesity prevalence was between 0.02 and 0.06 percentage points greater in women of high SES compared to low SES women. CONCLUSION: There is a strong link between food price inflation and obesity in adult women in developing countries which is clearly modified by individuals' SES. Greater food price inflation was associated with greater obesity prevalence only among women in higher SES groups, who may be net food buyers most at risk of obesity in low-income and middle-income countries.

Universal Lead Screening Requirement: A California Case Study.

OBJECTIVES: To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. METHODS: In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. RESULTS: Universal screening requirements would increase child lead testing by 273%, raise affected populations' premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. CONCLUSIONS: The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

Addressing discriminatory benefit design for people living with HIV: a California case study.

Concern is growing in the United States regarding the potential for health insurance benefit designs to discriminate against persons living with HIV as research demonstrates that such practices are occurring. A recent complaint filed against health insurers in seven states alleges that some health insurance companies have been using benefit designs that discourage enrollment of people living with HIV either by not covering essential HIV medications or by requiring cost-sharing for these prohibitively expensive medications. Legislators across the country have reacted by introducing legislation to address these growing problems. This paper describes Assembly Bill 339, legislation passed in California in 2015 and going into effect on 1 January 2017, which provides protection for people living with HIV by requiring coverage for single-tablet regimens to manage HIV while placing a cap on patient cost-sharing. Given California's size and influence, and the uncertainty of the future of the Affordable Care Act, this legislation has the potential to influence the national policy debate.

Social Media Use and Serious Psychological Distress Among Adolescents.

Unlabelled: This Research Letter describes the increasing trend of almost-constant social media use among California adolescents and the association with serious psychological distress, focusing on the influence of familial and experiential factors.

Evolving academic and research partnerships in global health: a capacity-building partnership to assess primary healthcare in the Philippines.

Building fair, equitable, and beneficial partnerships between institutions collaborating in research in low- and middle-income countries (LMIC) and high-income countries (HIC) has become an integral part of research capacity building in global health in recent years. In this paper, we offer an example of an academic collaboration between the University of California Los Angeles, Center for Health Policy and Research (UCLA CHPR) and the University of Philippines, Manila, College of Public Health (UPM CPH) that sought to build an equitable partnership between research institutions. The partnership was built on a project to build capacity for research and produce data for policy action for the prevention and care of non-communicable diseases (NCDs) through primary healthcare in the Philippines. The specific objectives of the project were to: (1) locally adapt the Primary Care Assessment Tool for the Philippines and use the adapted tool to measure facility-level primary care delivery, (2) conduct focus group discussions (FGDs) to gather qualitative observations regarding primary care readiness and capacity, and (3) conduct a comprehensive population-based health survey among adults on NCDs and prior healthcare experience. We describe here the progression of the partnership between these institutions to carry out the project and the elements that helped build a stronger connection between the institutions, such as mutual goal setting, cultural bridging, collaborative teams, and capacity building. This example, which can be used as a model depicting new directionality and opportunities for LMIC-HIC academic partnerships, was written based on the review of shared project documents, including study protocols, and written and oral communications with the project team members, including the primary investigators. The innovation of this partnership includes: LMIC-initiated project need identification, LMIC-based funding allocation, a capacity-building role of the HIC institution, and the expansion of scope through jointly offered courses on global health.

Life Satisfaction and Social and Emotional Support Among Asian American Older Adults.

BACKGROUND: Little data exist on the well-being of older adults from Asian American (AA) communities. METHODS: Using data from the 2018 California Health Interview Survey, we examined 2 well-being metrics among AAs and AA subgroups (Korean, Filipino, Vietnamese, Chinese) 65 years and older. RESULTS: AA older adults reported lower life satisfaction and not having needed social and emotional support compared with all other race/ethnicities. Current life satisfaction among AA older adults was 54% compared with 80% for all other race/ethnicities; 56% of AA older adults reported usually or always receiving social/emotional compared with 80% for all other race/ethnicities. Within the AA category, life satisfaction was 40% for Korean, 48% for Chinese, 47% for Vietnamese, and 77% for Filipino older adults. Among Korean older adults, 30% reported receiving needed social/emotional support, 57% among Chinese, 59% among Filipino, and 65% among Vietnamese older adults. CONCLUSION: AA older adults report lower life satisfaction and not needed receiving social and emotional support compared with all other race/ethnicities. Among AAs, Korean older adults were most likely to report poorer well-being. AA older adult communities may be in urgent need of further research and investment in interventions.

Policy Considerations for Routine Screening for Adverse Childhood Events (ACEs).

In October of 2021, California enacted SB 428, the ACEs Equity Act, which mandates commercial insurance coverage of adverse childhood experiences (ACEs) screening in addition to ACEs screening already covered for the state's Medicaid enrollees. California is the first state to expand ACEs screening coverage, but it is possible other states may follow similar paths given the increasing interest in policy action to address ACEs. Increase in stress and trauma among Americans and evidence of the disproportionate impact ACEs have on historically marginalized and disadvantaged communities has increased the urgency with which policy makers, clinicians and researchers have sought to address ACEs and encourage trauma-informed care delivery to better meet the needs of patients. Family practice and other primary care providers are at the core of prevention and are arguably the largest group of stakeholders at the forefront of movements toward increasing ACEs screenings. However, debate persists among policy makers, clinicians, and researchers on whether the ACEs screening approach improves outcomes and avoids harms. In this health policy article, we describe key issues under debate with regards to ACEs screening and estimate potential change in screening utilization and expenditures due to the new ACEs legislation in California. The lessons being learned in California are applicable to other states and the US as a whole.

Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines.

In this paper, we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a randomized policy experiment known as the Quality Improvement Demonstration Study. Among study participants, using a difference-in-difference regression model, we estimated a 9-12 and 4-9 percentage point reduction in the likelihood of wasting and having an infection, respectively, as measured by a common biomarker C-reactive Protein. Interestingly, these benefits were not apparent at the time of discharge; the beneficial health effects were manifest several weeks after release from the hospital.

Pushing on a String: How policy might encourage private doctors to compete with the public sector on the basis of quality.

Results from the Philippine Quality Improvement Demonstration Study show that a policy that expands insurance coverage improves quality of care, as measured by clinical performance vignettes, among public physicians, and induces a spillover effect that improves quality among private physicians.

Using a Twitter Chat to Rapidly Identify Barriers and Policy Solutions for Metastatic Breast Cancer Care: Qualitative Study.

BACKGROUND: Real-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes. OBJECTIVE: This study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California. METHODS: We provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper. RESULTS: There were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials. CONCLUSIONS: Rapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

Quality variation and its impact on costs and satisfaction: evidence from the QIDS study.

BACKGROUND: Improving the quality of inpatient hospital care is increasingly attainable in a variety of settings. However, the relationship between rising quality and costs is unclear; similarly the relationship between varying levels of quality and a patient's satisfaction remains poorly defined. METHODS: We use data from the Quality Improvement Demonstration Study (QIDS) based in 30 district hospitals in the Philippines. There were 974 children in the study; these children were cared for by 43 physicians. To measure quality of care, the physicians completed vignettes, a valid and inexpensive measure. Patient exit surveys were given to parents of children on the day of discharge, collecting information on services and hospital charges for the inpatient stay, payment sources for the hospitalization, and the Patient Satisfaction Survey (PSQ-18). RESULTS: We found a nonlinear relationship between quality and hospital charges: at low levels of quality improvements are linked to lower hospital charges. However, as quality improves further, these changes lead to higher charges. Higher quality also demonstrated a similar nonlinear relationship with patient satisfaction. CONCLUSIONS: The U-shaped association between quality and hospital charges suggests that targeting the lowest quality providers may decrease costs. The similar relationship between patient-reported satisfaction and quality improvement suggests that investments in quality will raise satisfaction, perhaps even when charges are increased.

The health and cost impact of care delay and the experimental impact of insurance on reducing delays.

OBJECTIVE: To examine whether delays in seeking care are associated with worse health outcomes or increased treatment costs in children, and then assess whether insurance coverage reduces these delays. STUDY DESIGN: We use data on 4070 children younger than 5 years from the Quality Improvement Demonstration Study, a randomized controlled experiment assessing the effects of increasing insurance coverage. We examined whether delay in care, defined as greater than 2 days between the onset of symptoms and admission to the study district hospitals, is associated with wasting or having positive C-reactive protein levels on discharge, and with total charge for hospital admission; we also evaluated whether increased benefit coverage and enrollment reduced the likelihood of delay. RESULTS: Delay is associated with 4.2% and 11.2% percentage point increases in the likelihood of wasting (P = .08) and having positive C-reactive protein levels (P = .03), respectively, at discharge. On average, hospitalization costs were 1.9% higher with delay (P = .04). Insurance intervention results in 5 additional children in 100 not delaying going to the hospital (P = .02). CONCLUSIONS: In this population, delayed care is associated with worse health outcomes and higher costs. Access to insurance reduced delays; thus insurance interventions may have positive effects on health outcomes.

An evaluation of the cost-effectiveness of policy navigators to improve access to care for the poor in the Philippines.

OBJECTIVES: Even when health insurance coverage is available, health policies may not be effective at increasing coverage among vulnerable populations. New approaches are needed to improve access to care. We experimentally introduced a novel intervention that uses Policy Navigators to increase health insurance enrollment in a poor population. METHODS: We used data from the Quality Improvement Demonstration Study (QIDS), a randomized experiment taking place at the district level in the Visayas region of the Philippines. In two arms of the study, we compared the effects of introducing Policy Navigators to controls. The Policy Navigators advocated for improved access to care by providing regular system-level expertise directly to the policy-makers, municipal mayors and governors responsible for paying for and enrolling poor households into the health insurance program. Using regression models, we compared levels of enrollment in our intervention versus control sites. We also assessed the cost-effectiveness of marginal increases in enrollment. RESULTS: We found that Policy Navigators improved enrollment in health insurance between 39% and 102% compared to the controls. Policy navigators were cost-effective at 0.86 USD per enrollee. However, supplementary national government campaigns, which were implemented to further increase coverage, attenuated normal enrollment efforts. CONCLUSION: Policy Navigators appear to be effective in improving access to care and their success underscores the importance of local-level strategies for improving enrollment.

Should we have confidence if a physician is accredited? A study of the relative impacts of accreditation and insurance payments on quality of care in the Philippines.

It is unclear whether health provider accreditation ensures or promotes quality of care. Using baseline data from the Quality Improvement Demonstration Study (QIDS) in the Philippines we measured the quality of pediatric care provided by private and public doctors working at the district hospital level in the country's central region. We found that national level accreditation by a national insurance program influences quality of care. However, our data also show that insurance payments have a similar, strong impact on quality of care. These results suggest that accreditation alone may not be sufficient to promote high quality of care. Further improvements may be achieved with properly monitored and well-designed payment or incentive schemes.

The Quality Improvement Demonstration Study: an example of evidence-based policy-making in practice.

BACKGROUND: Randomized trials have long been the gold-standard for evaluating clinical practice. There is growing recognition that rigorous studies are similarly needed to assess the effects of policy. However, these studies are rarely conducted. We report on the Quality Improvement Demonstration Study (QIDS), an example of a large randomized policy experiment, introduced and conducted in a scientific manner to evaluate the impact of large-scale governmental policy interventions. METHODS: In 1999 the Philippine government proposed sweeping reforms in the National Health Sector Reform Agenda. We recognized the unique opportunity to conduct a social experiment. Our ongoing goal has been to generate results that inform health policy. Early on we concentrated on developing a multi-institutional collaborative effort. The QIDS team then developed hypotheses that specifically evaluated the impact of two policy reforms on both the delivery of care and long-term health status in children. We formed an experimental design by randomizing matched blocks of three communities into one of the two policy interventions plus a control group. Based on the reform agenda, one arm of the experiment provided expanded insurance coverage for children; the other introduced performance-based payments to hospitals and physicians. Data were collected in household, hospital-based patient exit, and facility surveys, as well as clinical vignettes, which were used to assess physician practice. Delivery of services and health status were evaluated at baseline and after the interventions were put in place using difference-in-difference estimation. RESULTS: We found and addressed numerous challenges conducting this study, namely: formalizing the experimental design using the existing health infrastructure; securing funding to do research coincident with the policy reforms; recognizing biases and designing the study to account for these; putting in place a broad data collection effort to account for unanticipated findings; introducing sustainable policy interventions based on the reform agenda; and providing results in real-time to policy makers through a combination of venues. CONCLUSION: QIDS demonstrates that a large, prospective, randomized controlled policy experiment can be successfully implemented at a national level as part of sectoral reform. While we believe policy experiments should be used to generate evidence-based health policy, to do this requires opportunity and trust, strong collaborative relationships, and timing. This study nurtures the growing attitude that translation of scientific findings from the bedside to the community can be done successfully and that we should raise the bar on project evaluation and the policy-making process.

Does health insurance coverage or improved quality protect better against out-of-pocket payments? Experimental evidence from the Philippines.

This paper explores whether health insurance coverage or improved quality at the hospital level protect better against out-of-pocket payments. Using data from a randomized policy experiment in the Philippines, we found that interventions to expand insurance coverage and improve provider quality both had an impact on out-of-pocket payments. The sample consists of 3121 child-patient patient observations across 30 hospitals either at baseline in 2003/04 or at the follow-up in 2007/08. Compared to controls, interventions that expanded insurance and provided performance-based provider payments to improve quality both resulted in a decline in out-of-pocket spending (21% decline, p-value = 0.061; and 24% decline, p-value = 0.017, respectively). With lower out-of-pocket payments for hospital care, monthly household spending on personal hygiene rose by 0.9 (p-value = 0.026) and 0.6 US$ (p-value = 0.098) under the expanded insurance and provider payment interventions, respectively, amounting to roughly a 40-60% increase relative to the controls. With the current surge for health insurance expansion in developing countries, our study suggests paying increased and possibly, equal attention to supply-side interventions will have similar impacts with operational simplicity and greater provider accountability.

Managing Diversity To Eliminate Disparities: A Framework For Health.

By 2044 there will be no single racial or ethnic majority group in the US, according to the Census Bureau. California experienced this shift in 2000, making the state a bellwether in its attempts to bring health equity to a highly diverse population. We used data from the California Health Interview Survey and the California Regional Health Care Cost and Quality Atlas to examine health, health care access, and quality of care by race/ethnicity, payer, and region. Evaluating insurance coverage and diabetes as a sentinel condition, we found that wealthy regions exhibited the widest disparities-with advantages among non-Latino whites and people with commercial coverage. Disparities were narrowest in rural and agricultural regions, but health and quality of care were lower overall in those regions. State initiatives to address health equity include requiring health plans to reduce disparities by language and race/ethnicity and investing carbon cap-and-trade revenues in disadvantaged communities. Prominent advocacy, community engagement, the systematic use of data, local flexibility, and mechanisms for stronger accountability are driving these initiatives. Evidence has yet to emerge on how effective these policies will be in reducing health disparities in the state.