Taxpayers' Share of US Prescription Drug and Insulin Costs: a Cross-Sectional Study.

BACKGROUND: Drug prices affect government budgets directly through spending on public programs like Medicare and Medicaid, and indirectly via private coverage for public employees and tax subsidies for private insurance. Yet, the Senate parliamentarian ruled that the Senate could not use streamlined Budget Reconciliation to extend the Inflation Reduction Act's controls on insulin co-payment or drug prices to private insurers on the grounds that their expenditures do not affect the federal budget. OBJECTIVE: To quantify insulin and other drug costs borne by federal, state, and local governments, including direct expenditures and indirect government subsidies that flow through private insurers. DESIGN: Cross-sectional analysis of expenditures for outpatient retail prescription drugs reported by respondents and their pharmacies in the 2019 Medical Expenditure Panel Survey (adjusted downward for drug rebates), supplemented with information on employment-related insurance from the US Office of Management and Budget and other sources. PARTICIPANTS: The civilian non-institutionalized US population. MAIN MEASURES: Direct (payments by public health insurance programs) and indirect (taxpayer-funded payments via private insurers) government expenditures for outpatient retail drugs. KEY RESULTS: Direct government expenditures for outpatient retail prescription drugs totaled $154.85 billion in 2019, including $15.68 billion for insulin. Indirect government expenditures channeled through private insurers totaled $53.59 billion (including $5.48 billion for insulins). Those indirect expenditures encompassed $32.32 billion in tax subsidies for employer-sponsored private coverage, $25 million for subsidies to private Affordable Care Act marketplace plans, and $21.24 billion for government-paid premiums for public employees and retirees. Overall, government expenditures for outpatient retail prescription drugs totaled $208.44 billion, 58.76% of all-payer spending and 65.96% of spending for insulin. CONCLUSIONS: Governments directly or indirectly fund most drug purchases, including substantial expenditures that flow through private insurers. Hence, prices paid by private insurers impact government budgets, supporting the view that government should be allowed to regulate drug prices.

Sleep Quality among Homeless-Experienced Older Adults: Exploratory Results from the HOPE HOME Study.

BACKGROUND: Sleep is essential to health and affected by environmental and clinical factors. There is limited longitudinal research examining sleep quality in homeless older adults. OBJECTIVE: To examine the factors associated with poor sleep quality in a cohort of older adults in Oakland, California recruited while homeless using venue-based sampling and followed regardless of housing status. DESIGN: Longitudinal cohort study. PARTICIPANTS: 244 homeless-experienced adults aged ≥ 50 from the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) cohort. MAIN MEASURES: We assessed sleep quality using the Pittsburgh Sleep Quality Index (PSQI). We captured variables via biannual questionnaires and clinical assessments. KEY RESULTS: Our sample was predominantly men (71.3%), Black (82.8%), and had a median age of 58.0 years old (IQR 54.0, 61.0). Two-thirds of participants (67.2%) reported poor sleep during one or more study visits; sleep duration was the worst rated subdomain. In a multivariable model, having moderate-to-severe depressive symptoms (AOR 2.03, 95% CI 1.40-2.95), trouble remembering (AOR 1.56, 95% CI 1.11-2.19), fair or poor physical health (AOR 1.49, 95% CI 1.07-2.08), two or more chronic health conditions (AOR 1.76, 95% CI 1.18-2.62), any ADL impairment (AOR 1.85, 95% CI 1.36-2.52), and being lonely (AOR 1.55, 95% CI 1.13-2.12) were associated with increased odds of poor sleep quality. Having at least one confidant was associated with decreased odds of poor sleep (AOR 0.56, 95% CI 0.37-0.85). Current housing status was not significantly associated with poor sleep quality. CONCLUSIONS: Homeless-experienced older adults have a high prevalence of poor sleep. We found that participants' physical and mental health was related to poor sleep quality. Poor sleep continued when participants re-entered housing. Access to physical and mental healthcare, caregiving support, and programs that promote community may improve homeless-experienced older adults sleep quality, and therefore, their overall health.

Stepping into survivorship pilot study: Harnessing mobile health and principles of behavioral economics to increase physical activity in ovarian cancer survivors.

OBJECTIVE: Physical activity improves physical function, quality of life, and mental health, yet fewer than 80% of ovarian cancer survivors meet activity guidelines. This pilot intervention study aimed to increase physical activity in ovarian cancer survivors by leveraging principles of behavioral economics, gamification, and social support. METHODS: This 24-week study (12-week intervention; 12-week follow-up) enrolled women with ovarian cancer after completion of first-line treatment with a self-selected "teammate." Participants used Fitbits to measure daily steps, select an increased step goal, and enroll in a collaborative game, including points and levels for achieving step goals. Primary outcomes were feasibility (defined a priori as ≥60% approach-to-consent ratio and ≥ 70% adherence to Fitbit), acceptability (≤20% of participants reporting burden or regret for participation) and preliminary efficacy (≥70% reporting increased motivation); exploratory outcomes included change in steps. RESULTS: We recruited 24 participants (mean age = 63 years, range = 37-79 years) with a 94% approach-to-consent ratio. All participants completed the intervention with 94% tracker adherence. At 24-week follow-up, 1/24 (≤5%) of participants reported burden; 0/24 (0%) reported regret for study participation; and 22/24 (>90%) agreed/strongly agreed that "the study motivated me to increase activity levels." Participants' mean daily steps were 6210.7 (±3328.1) at baseline and increased to 7643 (± 3610.9) steps (p < 0.001) during the 12-week intervention. CONCLUSIONS: This pilot study demonstrated feasibility, acceptability, and preliminary efficacy, justifying a larger randomized clinical trial to test efficacy at increasing activity levels. Future studies should examine strategies for maintaining increased activity levels in survivors over time.

Qualitative evaluation of a community health representative program on patient experiences in Navajo Nation.

BACKGROUND: Community Health Representatives (CHRs) overcome health disparities in Native communities by delivering home care, health education, and community health promotion. The Navajo CHR Program partners with the non-profit Community Outreach and Patient Empowerment (COPE), to provide home-based outreach to Navajo clients living with diabetes. COPE has created an intervention (COPE intervention) focusing on multiple levels of improved care including trainings for CHRs on Motivational Interviewing and providing CHRs with culturally-appropriate education materials. The objective of this research is to understand the participant perspective of the CHR-COPE collaborative outreach through exploring patient-reported outcomes (PROs) of clients who consent to receiving the COPE intervention (COPE clients) using a qualitative methods evaluation. METHODS: Seven COPE clients were selected to participate in semi-structured interviews one year after finishing COPE to explore their perspective and experiences. Qualitative interviews were recorded, transcribed, and coded to identify themes. RESULTS: Clients revealed that health education delivered by CHRs facilitated lifestyle changes by helping them understand key health indicators and setting achievable goals through the use of accessible material and encouragement. Clients felt comfortable with CHRs who respected traditional practices and made regular visits. Clients also appreciated when CHRs educated their family members, who in turn were better able to support the client in their health management. Finally, CHRs who implemented the COPE intervention helped patients who were unable to regularly see a primary care doctor for critical care and support in their disease management. CONCLUSION: The COPE-CHR collaboration facilitated trusting client-CHR relationships and allowed clients to better understand their diagnoses. Further investment in materials that respect traditional practices and aim to educate clients' families may foster these relationships and improve health outcomes. TRIAL REGISTRATION: clinicaltrials.gov: NCT03326206. Registered 9/26/2017 (retrospectively registered).

Hospital Assets Before and After Private Equity Acquisition.

This study assesses changes in hospitals' capital assets after private equity acquisition.

Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons.

Importance: Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access. Objective: To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state's standard prison co-payment and care receipt in 2016. Design, Setting, and Participants: This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics' 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey. Exposures: The state's standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison's minimum wage. Main Outcomes and Measures: Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level. Results: Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week's prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week's wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week's wage: aOR, 2.17; 95% CI, 1.61-2.93). Conclusions and Relevance: This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.

Changing Preferences for a Cervical Cancer Screening Strategy: Moving Away from Annual Testing.

Background: While annual cytology has not been recommended for many years, it remains many patients' preferred screening strategy for cervical cancer. Patient education and provider recommendations have been found effective in aligning professional society guidelines with patient preferences. We assessed whether an educational video with value elicitation exercises (utility assessments) changed screening strategy preferences among patients who had an initial preference for annual screening. Materials and Methods: We conducted an interventional study of English- or Spanish-speaking women 21-65 years of age, recruited from two women's health clinics in San Francisco, California (n = 262). Participants were asked about their preferred method of screening before viewing a 7-minute educational video and using a computerized tool that elicited values for 23 different health states related to cervical cancer screening. Directly afterward, they were again asked about their preferred screening strategy. Multivariable regression analysis was utilized to identify independent predictors of changing preferences. Results: Of 246 enrollees, 62.6% (154/246) had an initial preference for annual cytology; after viewing the video and completing the values elicitation exercises, about half (72/154, 47%) preferred a strategy other than annual screening. Having attended college and being screened every 3 to 5 years in the recent past were independent predictors of changing preferences away from annual screening. In sensitivity analyses, 53.2% of average-risk participants changed preferences away from annual cytology (p < 0.01). Conclusions: Viewing an educational video and conducting a series of value elicitation exercises were associated with a substantially decreased likelihood of preferring annual screening. These findings underscore the importance of patient-centered education to help support informed patient preferences.

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.

Emotional Experiences of Mothers Living With HIV and the Quest for Emotional Recovery: A Qualitative Study in Lima, Peru.

Little evidence exists about the emotional experiences of mothers with HIV, and a better understanding is essential to support their emotional health and treatment adherence. We describe the emotional experiences of eight mothers who initiated antiretroviral therapy during pregnancy or within a few years of childbirth in Lima, Peru. An interpretive phenomenological approach was used, and the following themes emerged: (a) emotions involved in diagnosis and disclosure, (b) the meaning of motherhood with HIV, (c) the mothers' roles in seeking and maintaining relationships with partners and families, and (d) mechanisms for resilience and emotional recovery. Participants experienced sadness and denial after diagnosis, which gave way to emotional recovery. Participant abilities to find refuge in caring for children and coordinating support from loved ones proved to be essential. Participants recognized that intense emotions motivated them to seek creative solutions and cited personal growth as an important outcome.