Mapping Health Disparities in 11 High-Income Nations.

Importance: Health care delivery faces a myriad of challenges globally with well-documented health inequities based on geographic location. Yet, researchers and policy makers have a limited understanding of the frequency of geographic health disparities. Objective: To describe geographic health disparities in 11 high-income countries. Design, Setting, and Participants: In this survey study, we analyzed results from the 2020 Commonwealth Fund International Health Policy (IHP) Survey-a nationally representative, self-reported, and cross-sectional survey of adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK, and the US. Eligible adults older than age 18 years were included by random sampling. Survey data were compared for the association of area type (rural or urban) with 10 health indicators across 3 domains: health status and socioeconomic risk factors, affordability of care, and access to care. Logistic regression was used to determine the associations between countries with area type for each factor, controlling for individuals' age and sex. Main Outcomes and Measures: The main outcomes were geographic health disparities as measured by differences in respondents living in urban and rural settings in 10 health indicators across 3 domains. Results: There were 22 402 survey respondents (12 804 female [57.2%]), with a 14% to 49% response rate depending on the country. Across the 11 countries and 10 health indicators and 3 domains (health status and socioeconomic risk factors, affordability of care, access to care), there were 21 occurrences of geographic health disparities; 13 of those in which rural residence was a protective factor and 8 of those where rural residence was a risk factor. The mean (SD) number of geographic health disparities in the countries was 1.9 (1.7). The US had statistically significant geographic health disparities in 5 of 10 indicators, the most of any country, while Canada, Norway, and the Netherlands had no statistically significant geographic health disparities. The indicators with the most occurrences of geographic health disparities were in the access to care domain. Conclusions and Relevance: In this survey study of 11 high-income nations, health disparities across 10 indicators were identified. Differences in number of disparities reported by country suggest that health policy and decision makers in the US should look to Canada, Norway, and the Netherlands to improve geographic-based health equity.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March--June 2017.

Issue: After Congress's failure to repeal and replace the Affordable Care Act, some policy leaders are calling for bipartisan approaches to address weaknesses in the law's coverage expansions. To do this, policymakers will need data about trends in insurance coverage, reasons why people remain uninsured, and consumer perceptions of affordability. Goal: To examine U.S. trends in insurance coverage and the demographics of the remaining uninsured population, as well as affordability and satisfaction among adults with marketplace and Medicaid coverage. Methods: Analysis of the Commonwealth Fund Affordable Care Act Tracking Survey, March­June 2017 Findings and Conclusions: The uninsured rate among 19-to-64-year-old adults was 14 percent in 2017, or an estimated 27 million people, statistically unchanged from one year earlier. Uninsured rates ticked up significantly in three subgroups: 35-to-49-year-olds, adults with incomes of 400 percent of poverty or more (about $48,000 for an individual), and adults living in states that had not expanded Medicaid. Half of uninsured adults, or an estimated 13 million, are likely eligible for marketplace subsidies or the Medicaid expansion in their state. Four of 10 uninsured adults are unaware of the marketplaces. Adults in marketplace plans with incomes below 250 percent of poverty are much more likely to view their premiums as easy to afford compared with people with higher incomes. Policies to improve coverage include a federal commitment to supporting the marketplaces and the 2018 open enrollment period, expansion of Medicaid in 19 remaining states, and enhanced subsidies for people with incomes of 250 percent of poverty or more.

How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.

ISSUE: Prior to the Affordable Care Act (ACA), one-third of women who tried to buy a health plan on their own were either turned down, charged a higher premium because of their health, or had specific health problems excluded from their plans. Beginning in 2010, ACA consumer protections, particularly coverage for preventive care screenings with no cost-sharing and a ban on plan benefit limits, improved the quality of health insurance for women. In 2014, the law's major insurance reforms helped millions of women who did not have employer insurance to gain coverage through the ACA's marketplaces or through Medicaid. GOALS: To examine the effects of ACA health reforms on women's coverage and access to care. METHOD: Analysis of the Commonwealth Fund Biennial Health Insurance Surveys, 2001­2016. FINDINGS AND CONCLUSIONS: Women ages 19 to 64 who shopped for new coverage on their own found it significantly easier to find affordable plans in 2016 compared to 2010. The percentage of women who reported delaying or skipping needed care because of costs fell to an all-time low. Insured women were more likely than uninsured women to receive preventive screenings, including Pap tests and mammograms.

How Medicaid Enrollees Fare Compared with Privately Insured and Uninsured Adults: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.

ISSUE: The number of Americans insured by Medicaid has climbed to more than 70 million, with an estimated 12 million gaining coverage under the Affordable Care Act's Medicaid expansion. Still, some policymakers have questioned whether Medicaid coverage actually improves access to care, quality of care, or financial protection. GOALS: To compare the experiences of working-age adults who were either: covered all year by private employer or individual insurance; covered by Medicaid for the full year; or uninsured for some time during the year. METHOD: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. FINDINGS AND CONCLUSIONS: The level of access to health care that Medicaid coverage provides is comparable to that afforded by private insurance. Adults with Medicaid coverage reported better care experiences than those who had been uninsured during the year. Medicaid enrollees have fewer problems paying medical bills than either the privately insured or the uninsured.

Insurance Coverage, Access to Care, and Medical Debt Since the ACA: a Look at California, Florida, New York, and Texas.

ISSUE: The Affordable Care Act has significantly increased health insurance coverage and access to care among U.S. adults nationwide. However, the law gives states flexibility in implementing certain provisions, leading to wide variations between states in consumers' experiences. GOAL: To examine the differences in insurance coverage, access to care, and medical bill problems in the four largest states­California, Florida, New York, and Texas­all of which have made different choices in implementing the law. METHODS: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. FINDINGS AND CONCLUSIONS: In 2016, uninsured rates among adults ages 19 to 64 across the four states varied from 7 percent in New York and 10 percent in California to 16 percent in Florida and 25 percent in Texas. This variation was also apparent in the proportions of residents reporting problems getting needed care because of the cost­significantly lower in California and New York than in Florida and Texas. Lower percentages of Californians and New Yorkers reported having a medical bill problem in the past 12 months or having accrued medical debt compared to Floridians and Texans. These variations might be explained by several factors: whether the state expanded Medicaid eligibility; whether it ran its own health insurance marketplace; what the uninsured rate was prior to the Affordable Care Act; differences in the cost protections provided by private health plans; and demographic differences.

How the Affordable Care Act Has Improved Americans' Ability to Buy Health Insurance on Their Own: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.

Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers' experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people's ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.

The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch.

Issue: Although predictions that the Affordable Care Act (ACA) would lead to reductions in employer-sponsored health coverage have not been realized, some of the law's critics maintain the ACA is nevertheless driving higher premium and deductible costs for businesses and their workers. Goal: To compare cost growth in employer-sponsored health insurance before and after 2010, when the ACA was enacted, and to compare changes in these costs relative to changes in workers' incomes. Methods: The authors analyzed federal Medical Expenditure Panel Survey data to compare cost trends over the 10-year period from 2006 to 2015. Key findings and conclusions: Compared to the five years leading up to the ACA, premium growth for single health insurance policies offered by employers slowed both in the nation overall and in 33 states and the District of Columbia. There has been a similar slowdown in growth in the amounts employees contribute to health plan costs. Yet many families feel pinched by their health care costs: despite a recent surge, income growth has not kept pace in many areas of the U.S. Employee contributions to premiums and deductibles amounted to 10.1 percent of U.S. median income in 2015, compared to 6.5 percent in 2006. These costs are higher relative to income in many southeastern and southern states, where incomes are below the national average.

Who Are the Remaining Uninsured and Why Haven't They Signed Up for Coverage?

The number of uninsured people in the United States has declined by an estimated 20 million since the Affordable Care Act went into effect in 2010. Yet, an estimated 24 million people still lack health insurance. Goal: To examine the characteristics of the remaining uninsured adults and their reasons for not enrolling in marketplace plans or Medicaid. Methods: Analysis of the Commonwealth Fund ACA Tracking Survey, February--April 2016. Key findings and conclusions: There have been notable shifts in the demographic composition of the uninsured since the law's major coverage expansions went into effect in 2014. Latinos have become a growing share of the uninsured, rising from 29 percent in 2013 to 40 percent in 2016. Whites have become a declining share, falling from half the uninsured in 2013 to 41 percent in 2016. The uninsured are very poor: 39 percent of uninsured adults have incomes below the federal poverty level, twice the rate of their overall representation in the adult population. Of uninsured adults who are aware of the marketplaces or who have tried to enroll for coverage, the majority point to affordability concerns as a reason for not signing up.

Americans' Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction: Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016.

For people with low and moderate incomes, the Affordable Care Act's tax credits have made premium costs roughly comparable to those paid by people with job-based health insurance. For those with higher incomes, the tax credits phase out, meaning that adults in marketplace plans on average have higher premium costs than those in employer plans. The law's cost-sharing reductions are reducing deductibles. Lower-income adults in marketplace plans were less likely than higher-income adults to report having deductibles of $1,000 or more. Majorities of new marketplace enrollees and those who have changed plans since they initially obtained marketplace coverage are satisfied with the doctors participating in their plans. Overall, the majority of marketplace enrollees expressed confidence in their ability to afford care if they were to become seriously ill. This issue brief explores these and other findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016.

How Much Financial Protection Do Marketplace Plans Provide in States Not Expanding Medicaid?

The Affordable Care Act's premium subsidies and cost-sharing reductions have helped to reduce out-of-pocket costs for low-income people enrolled in marketplace plans. This financial protection has been particularly important for people with incomes above 100 percent of poverty who live in states that have not expanded Medicaid. However, a key question for policymakers is how this protection compares to Medicaid. This brief analyzes a sample of silver plans offered in the largest markets in 18 states that use the federal website for marketplace enrollment and have not expanded Medicaid eligibility. It finds that marketplace enrollees at this income level in most plans analyzed are at risk of incurring premium and out-of-pocket costs that are higher than what they would pay under Medicaid. For people with significant health needs, costs are estimated to be much higher in marketplace plans than what they would be under Medicaid.

Americans' Experiences with ACA Marketplace and Medicaid Coverage: Access to Care and Satisfaction: Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February­April 2016.

The fourth wave of the Commonwealth Fund Affordable Care Act Tracking Survey, February--April 2016, finds at the close of the third open enrollment period that the working-age adult uninsured rate stands at 12.7 percent, statistically unchanged from 2015 but significantly lower than 2014 and 2013. Uninsured rates in the past three years have fallen most steeply for low-income adults though remain higher compared to wealthier adults. ACA marketplace and Medicaid coverage is helping to end long bouts without insurance, bridge gaps when employer insurance is lost, and improve access to health care. Sixty-one percent of enrollees who had used their insurance to get care said they would not have been able to afford or access it prior to enrolling. Doctor availability and appointment wait times are similar to those reported by insured Americans overall. Majorities with marketplace or Medicaid coverage continue to be satisfied with their insurance.

How Will the Affordable Care Act's Cost-Sharing Reductions Affect Consumers' Out-of-Pocket Costs in 2016?

Health insurers selling plans in the Affordable Care Act's market­places are required to reduce cost-sharing in silver plans for low- and moderate-income people earning between 100 percent and 250 percent of the federal pov­erty level. In 2016, as many as 7 million Americans may have plans with these cost-sharing reductions. In the largest markets in the 38 states using the federal website for marketplace enrollment, the cost-sharing reductions substantially lower projected out-of-pocket costs for people who qualify for them. However, the degree to which consumers' out-of-pocket spending will fall varies by plan and how much health care they use. This is because insurers use deductibles, out-of-pocket limits, and copayments in different combinations to lower cost-sharing for eligible enrollees. In 2017, marketplace insurers will have the option of offering standard plans, which may help simplify consumers' choices and lead to more equal cost-sharing.

How High is America's Health Care Cost Burden? Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July-August 2015.

One-quarter of privately insured working-age adults have high health care cost burdens relative to their incomes in 2015, according to the Commonwealth Fund Health Care Affordability Index, a comprehensive measure of consumer health care costs. This figure, which is based on a nationally representative sample of people with private insurance who are mainly covered by employer plans, is statistically unchanged from 2014. When looking specifically at adults with low incomes, more than half have high cost burdens. In addition, when privately insured adults were asked how they rated their affordability, greater shares reported their premiums and deductible costs were difficult or impossible to afford than the Index would suggest. Health plan deductibles and copayments had negative effects on many people's willingness to get needed health care or fill prescriptions. In addition, many consumers are confused about which services are free to them and which count toward their deductible.

To Enroll or Not to Enroll? Why Many Americans Have Gained Insurance Under the Affordable Care Act While Others Have Not. Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March-May 2015.

According to the most recent Commonwealth Fund Affordable Care Act Tracking Survey, March-May 2015, an estimated 25 million adults remain uninsured. To achieve the Affordable Care Act's goal of near-universal coverage, policymakers must understand why some people are enrolling in the law's marketplace plans or in Medicaid coverage and why others are not. This analysis of the survey finds that affordability--whether real or perceived--is playing a significant role in adults' choice of marketplace plans and the decision whether to enroll at all. People who have gained coverage report significantly more positive experiences shopping for health plans than do those who did not enroll. Getting personal assistance--from telephone hotlines, navigators, and insurance brokers, among other sources--appears to make a critical difference in whether people gain health insurance

Are Marketplace Plans Affordable? Consumer Perspectives from the Commonwealth Fund Affordable Care Act Tracking Survey, March-May 2015.

Most employers who provide health insurance to employees subsidize their premiums and provide a comprehensive benefit package. Before the Affordable Care Act, people who lacked health insurance through a job and purchased it on their own paid the full cost of their plans, which often came with skimpy benefit packages and high deductibles. Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March--May 2015, indicate that the law's tax credits have made premium costs in health plans sold through the marketplaces roughly comparable to employer plans, at least for people with low and moderate incomes. At higher incomes, the phase-out of the subsidies means that adults in marketplace plans have higher premium costs than those in employer plans. Overall, larger shares of adults in marketplace plans reported deductibles of $1,000 or more, compared with those in employer plans, though these differences were narrower among low-and moderate-income adults.

Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act.

IMPORTANCE: The Affordable Care Act (ACA) completed its second open enrollment period in February 2015. Assessing the law's effects has major policy implications. OBJECTIVES: To estimate national changes in self-reported coverage, access to care, and health during the ACA's first 2 open enrollment periods and to assess differences between low-income adults in states that expanded Medicaid and in states that did not expand Medicaid. DESIGN, SETTING, AND PARTICIPANTS: Analysis of the 2012-2015 Gallup-Healthways Well-Being Index, a daily national telephone survey. Using multivariable regression to adjust for pre-ACA trends and sociodemographics, we examined changes in outcomes for the nonelderly US adult population aged 18 through 64 years (n = 507,055) since the first open enrollment period began in October 2013. Linear regressions were used to model each outcome as a function of a linear monthly time trend and quarterly indicators. Then, pre-ACA (January 2012-September 2013) and post-ACA (January 2014-March 2015) changes for adults with incomes below 138% of the poverty level in Medicaid expansion states (n = 48,905 among 28 states and Washington, DC) vs nonexpansion states (n = 37,283 among 22 states) were compared using a differences-in-differences approach. EXPOSURES: Beginning of the ACA's first open enrollment period (October 2013). MAIN OUTCOMES AND MEASURES: Self-reported rates of being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, overall health status, and health-related activity limitations. RESULTS: Among the 507,055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes. Compared with the pre-ACA trends, by the first quarter of 2015, the adjusted proportions who were uninsured decreased by 7.9 percentage points (95% CI, -9.1 to -6.7); who lacked a personal physician, -3.5 percentage points (95% CI, -4.8 to -2.2); who lacked easy access to medicine, -2.4 percentage points (95% CI, -3.3 to -1.5); who were unable to afford care, -5.5 percentage points (95% CI, -6.7 to -4.2); who reported fair/poor health, -3.4 percentage points (95% CI, -4.6 to -2.2); and the percentage of days with activities limited by health, -1.7 percentage points (95% CI, -2.4 to -0.9). Coverage changes were largest among minorities; for example, the decrease in the uninsured rate was larger among Latino adults (-11.9 percentage points [95% CI, -15.3 to -8.5]) than white adults (-6.1 percentage points [95% CI, -7.3 to -4.8]). Medicaid expansion was associated with significant reductions among low-income adults in the uninsured rate (differences-in-differences estimate, -5.2 percentage points [95% CI, -7.9 to -2.6]), lacking a personal physician (-1.8 percentage points [95% CI, -3.4 to -0.3]), and difficulty accessing medicine (-2.2 percentage points [95% CI, -3.8 to -0.7]). CONCLUSIONS AND RELEVANCE: The ACA's first 2 open enrollment periods were associated with significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health. Low-income adults in states that expanded Medicaid reported significant gains in insurance coverage and access compared with adults in states that did not expand Medicaid.

Cell-cycle protein expression in a population-based study of ovarian and endometrial cancers.

Aberrant expression of cyclin-dependent kinase (CDK) inhibitors is implicated in the carcinogenesis of many cancers, including ovarian and endometrial cancers. We examined associations between CDK inhibitor expression, cancer risk factors, tumor characteristics, and survival outcomes among ovarian and endometrial cancer patients enrolled in a population-based case-control study. Expression (negative vs. positive) of three CDK inhibitors (p16, p21, and p27) and ki67 was examined with immunohistochemical staining of tissue microarrays. Logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between biomarkers, risk factors, and tumor characteristics. Survival outcomes were only available for ovarian cancer patients and examined using Kaplan-Meier plots and Cox proportional hazards regression. Among ovarian cancer patients (n = 175), positive p21 expression was associated with endometrioid tumors (OR = 12.22, 95% CI = 1.45-102.78) and higher overall survival (log-rank p = 0.002). In Cox models adjusted for stage, grade, and histology, the association between p21 expression and overall survival was borderline significant (hazard ratio = 0.65, 95% CI = 0.42-1.05). Among endometrial cancer patients (n = 289), positive p21 expression was inversely associated with age (OR ≥ 65 years of age = 0.25, 95% CI = 0.07-0.84) and current smoking status (OR: 0.33, 95% CI 0.15, 0.72) compared to negative expression. Our study showed heterogeneity in expression of cell-cycle proteins associated with risk factors and tumor characteristics of gynecologic cancers. Future studies to assess these markers of etiological classification and behavior may be warranted.

Discovery and validation of methylation markers for endometrial cancer.

The prognosis of endometrial cancer is strongly associated with stage at diagnosis, suggesting that early detection may reduce mortality. Women who are diagnosed with endometrial carcinoma often have a lengthy history of vaginal bleeding, which offers an opportunity for early diagnosis and curative treatment. We performed DNA methylation profiling on population-based endometrial cancers to identify early detection biomarkers and replicated top candidates in two independent studies. We compared DNA methylation values of 1,500 probes representing 807 genes in 148 population-based endometrial carcinoma samples and 23 benign endometrial tissues. Markers were replicated in another set of 69 carcinomas and 40 benign tissues profiled on the same platform. Further replication was conducted in The Cancer Genome Atlas and in prospectively collected endometrial brushings from women with and without endometrial carcinomas. We identified 114 CpG sites showing methylation differences with p values of ≤ 10(-7) between endometrial carcinoma and normal endometrium. Eight genes (ADCYAP1, ASCL2, HS3ST2, HTR1B, MME, NPY and SOX1) were selected for further replication. Age-adjusted odds ratios for endometrial cancer ranged from 3.44 (95%-CI: 1.33-8.91) for ASCL2 to 18.61 (95%-CI: 5.50-62.97) for HTR1B. An area under the curve (AUC) of 0.93 was achieved for discriminating carcinoma from benign endometrium. Replication in The Cancer Genome Atlas and in endometrial brushings from an independent study confirmed the candidate markers. This study demonstrates that methylation markers may be used to evaluate women with abnormal vaginal bleeding to distinguish women with endometrial carcinoma from the majority of women without malignancy.

Physical activity and sedentary behavior in relation to esophageal and gastric cancers in the NIH-AARP cohort.

INTRODUCTION: Body mass index is known to be positively associated with an increased risk of adenocarcinomas of the esophagus, yet there is there limited evidence on whether physical activity or sedentary behavior affects risk of histology- and site-specific upper gastrointestinal cancers. We used the NIH-AARP Diet and Health Study to assess these exposures in relation to esophageal adenocarcinoma (EA), esophageal squamous cell carcinoma (ESCC), gastric cardia adenocarcinoma (GCA), and gastric non-cardia adenocarcinoma (GNCA). METHODS: Self-administered questionnaires were used to elicit physical activity and sedentary behavior exposures at various age periods. Cohort members were followed via linkage to the US Postal Service National Change of Address database, the Social Security Administration Death Master File, and the National Death Index. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95 percent confidence intervals (95%CI). RESULTS: During 4.8 million person years, there were a total of 215 incident ESCCs, 631 EAs, 453 GCAs, and 501 GNCAs for analysis. Strenuous physical activity in the last 12 months (HR(>5 times/week vs. never)=0.58, 95%CI: 0.39, 0.88) and typical physical activity and sports during ages 15-18 years (p for trend=0.01) were each inversely associated with GNCA risk. Increased sedentary behavior was inversely associated with EA (HR(5-6 hrs/day vs. <1 hr)=0.57, 95%CI: 0.36, 0.92). There was no evidence that BMI was a confounder or effect modifier of any relationship. After adjustment for multiple testing, none of these results were deemed to be statistically significant at p<0.05. CONCLUSIONS: We find evidence for an inverse association between physical activity and GNCA risk. Associations between body mass index and adenocarcinomas of the esophagus do not appear to be related to physical activity and sedentary behavior.