Rape-Related Pregnancies in the 14 US States With Total Abortion Bans.

This cross-sectional study estimates the incidence of rape-related pregnancies in US states with abortion bans.

Access to care following Planned Parenthood's termination from Texas' Medicaid network: A qualitative study.

OBJECTIVES: This study aimed to explore Planned Parenthood Medicaid patients' experiences getting reproductive health care in Texas after the state terminated Planned Parenthood providers from its Medicaid program in 2021. STUDY DESIGN: Between January and September 2021, we recruited Medicaid patients who obtained care at Planned Parenthood health centers prior to the state termination using direct mailers, electronic messages, community outreach, and flyers in health centers. We conducted baseline and 2-month follow-up semistructured phone interviews about patients' previous experiences using Medicaid at Planned Parenthood and other providers and how the termination affected their care. We qualitatively analyzed the data using the principles of grounded theory. RESULTS: We interviewed 30 patients, 24 of whom completed follow-up interviews. Participants reported that Planned Parenthood reliably accepted different Medicaid plans, worked with patients to ameliorate the structural barriers they face to care, and referred them to other providers as needed. After Planned Parenthood's termination from the Texas Medicaid program, participants faced difficulties accessing care elsewhere, including same-day appointments and on-site medications. Consequences included delayed or forgone reproductive health care, including contraception, and emotional distress. CONCLUSIONS: Planned Parenthood Medicaid patients found it difficult to connect with other providers for reproductive health care and to obtain evidence-based care following the organization's termination from Medicaid. Ensuring all Medicaid patients have freedom to choose providers would improve access to quality contraception and other reproductive health care. IMPLICATIONS: Medicaid-funded reproductive health care access is restricted for people living on low incomes when providers do not reliably accept all Medicaid plans or cannot participate in Medicaid. This situation can lead to lower quality care, delayed or forgone care, and emotional distress.

Projected Health Outcomes Associated With 3 US Supreme Court Decisions in 2022 on COVID-19 Workplace Protections, Handgun-Carry Restrictions, and Abortion Rights.

Importance: Several recent US Supreme Court rulings have drawn criticism from the medical community, but their health consequences have not been quantitatively evaluated. Objective: To model health outcomes associated with 3 Supreme Court rulings in 2022 that invalidated workplace COVID-19 vaccine or mask-and-test requirements, voided state handgun-carry restrictions, and revoked the constitutional right to abortion. Design, Setting, and Participants: This decision analytical modeling study estimated outcomes associated with 3 Supreme Court rulings in 2022: (1) National Federation of Independent Business v Department of Labor, Occupational Safety and Health Administration (OSHA), which invalidated COVID-19 workplace protections; (2) New York State Rifle and Pistol Association Inc v Bruen, Superintendent of New York State Police (Bruen), which voided state laws restricting handgun carry; and (3) Dobbs v Jackson Women's Health Organization (Dobbs), which revoked the constitutional right to abortion. Data analysis was performed from July 1, 2022, to April 7, 2023. Main Outcomes and Measures: For the OSHA ruling, multiple data sources were used to calculate deaths attributable to COVID-19 among unvaccinated workers from January 4 to May 28, 2022, and the share of these deaths that would have been prevented by the voided protections. To model the Bruen decision, published estimates of the consequences of right-to-carry laws were applied to 2020 firearm-related deaths (and injuries) in 7 affected jurisdictions. For the Dobbs ruling, the model assessed unwanted pregnancy continuations, resulting from the change in distance to the closest abortion facility, and then excess deaths (and peripartum complications) from forcing these unwanted pregnancies to term. Results: The decision model projected that the OSHA decision was associated with 1402 additional COVID-19 deaths (and 22 830 hospitalizations) in early 2022. In addition, the model projected that 152 additional firearm-related deaths (and 377 nonfatal injuries) annually will result from the Bruen decision. Finally, the model projected that 30 440 fewer abortions will occur annually due to current abortion bans stemming from Dobbs, with 76 612 fewer abortions if states at high risk for such bans also were to ban the procedure; these bans will be associated with an estimated 6 to 15 additional pregnancy-related deaths each year, respectively, and hundreds of additional cases of peripartum morbidity. Conclusions and Relevance: These findings suggest that outcomes from 3 Supreme Court decisions in 2022 could lead to substantial harms to public health, including nearly 3000 excess deaths (and possibly many more) over a decade.

Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018.

BACKGROUND: Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear. OBJECTIVE: To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. DESIGN: Repeated cross-sectional. SETTING: National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018. PARTICIPANTS: Office-based physicians. MEASURES: Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration. RESULTS: Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care. LIMITATION: Self-reported visit length. CONCLUSION: Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.

Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020.

BACKGROUND: Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE: To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN: Cross-sectional. PARTICIPANTS: Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES: We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS: Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. CONCLUSIONS: VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.

Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States.

Importance: Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade. Objective: To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity. Design, Setting, and Participants: Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022. Exposures: Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8. Main Outcomes and Measures: Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation. Results: Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend). Conclusions and Relevance: Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US.

Importance: Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH). Objective: To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security. Design, Setting, and Participants: Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years. Exposures: Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs. Main Outcomes and Measures: Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity. Results: Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, 51.6% were female, 16.8% Hispanic, 6.0% were non-Hispanic Asian, 11.9% non-Hispanic Black, 62.6% non-Hispanic White, and 2.18% other non-Hispanic. A total of 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates: 15.3%; (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]). In cross-sectional analyses, hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness; residing in a Medicaid-expansion state was protective (2019 odds ratio [OR], 0.76; 95% CI, 0.70-0.83). Prospective findings were similar, eg, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019 (OR, 1.63; 95% CI, 1.23-2.14), as was becoming newly disabled (OR, 2.42; 95% CI, 1.95-3.00) or newly hospitalized (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening SDOHs, with ORs of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019. Conclusions and Relevance: In this cross-sectional and cohort study, medical indebtedness was common, even among insured individuals. Acquiring such debt may worsen SDOHs. Expanded and improved health coverage could ameliorate financial distress, and improve housing and food security.

Trends in Health Care Use Among Black and White Persons in the US, 1963-2019.

Importance: In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking. Objective: To assess trends in Black-White disparities in health care use since 1963. Design, Setting, and Participants: This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians. Exposures: Self-reported race and ethnicity. Main Outcomes and Measures: Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures. Results: Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods. Conclusions and Relevance: This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.

Specialty Care Utilization Among Adults with Limited English Proficiency.

BACKGROUND: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS: 149,611 survey respondents aged 18 and older. EXPOSURE: LEP, defined as taking the survey in a language other than English. MAIN MEASURES: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.

Financial Hardships Caused by Out-of-Pocket Abortion Costs in Texas, 2018.

Objectives. To identify financial hardships related to costs of obtaining abortion care in Texas, which has the highest uninsured rate in the United States and restricts insurance coverage for abortions. Methods. We surveyed patients seeking abortion at 12 Texas clinics in 2018 regarding costs and financial hardships related to abortion care. We compared mean out-of-pocket costs and the percentage reporting hardships across income and insurance categories. Results. Of 603 respondents, 42% were Latinx, 25% White, and 21% Black or African American, and most (62.0%) reported having low incomes (< 200% federal poverty level). Mean out-of-pocket costs were $634, which varied little across insurance groups. Patients with low incomes were more likely to obtain financial assistance from an abortion fund than were wealthier patients (12.3% vs 1.6%, respectively; P < .05). Financial hardships related to abortion costs were more common among uninsured (57.6%) and publicly insured (55.1%) patients than those with private insurance (48.2%). One in 5 (19.8%) uninsured respondents delayed buying food to pay for abortion care. Conclusions. Restrictions on insurance coverage for abortions result in high out-of-pocket costs and major financial hardships for most patients with low incomes in Texas. (Am J Public Health. 2022;112(5):758-761. https://doi.org/10.2105/AJPH.2021.306701).

Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999-2018.

One in seven people in the US speak Spanish at home, and twenty-five million people in the US have limited English proficiency. Using nationally representative data from the Medical Expenditure Panel Survey, we compare health care spending for and health care use by Hispanics adults with limited English proficiency with spending for and use by English-proficient Hispanic and non-Hispanic adults. During 2014-18 mean annual per capita expenditures were $1,463 (35 percent) lower for Hispanic adults with limited English proficiency than for Hispanic adults who were English proficient, after adjustment for respondents' characteristics. Hispanic adults with limited English proficiency also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient. Health care spending gaps between Hispanic adults with limited English proficiency and non-Hispanic adults with English proficiency widened between 1999 and 2018. These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency.

Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis.

We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities. We searched 10 databases for studies published between January 2001 to December 2019 that compared mortality at private hemodialysis facilities. We included observational studies directly comparing adjusted mortality rates between FP and NFP private hemodialysis providers in any language or country. We excluded evaluations of dialysis facilities that changed their profit status, studies with overlapping data, and studies that failed to adjust for patient age and some measure of clinical severity. Pairs of reviewers independently screened all titles and abstracts and the full text of potentially eligible studies, abstracted data, and assessed risk of bias, resolving disagreement by discussion. We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04-1.11). Patients at FP hemodialysis facilities have 7 percent greater odds of death annually than patients with similar risk profiles at NFP facilities. Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.