Initial economic damage from the COVID-19 pandemic in the United States is more widespread across ages and geographies than initial mortality impacts.

The economic and mortality impacts of the COVID-19 pandemic have been widely discussed, but there is limited evidence on their relationship across demographic and geographic groups. We use publicly available monthly data from January 2011 through April 2020 on all-cause death counts from the Centers for Disease Control and Prevention and employment from the Current Population Survey to estimate excess all-cause mortality and employment displacement in April 2020 in the United States. We report results nationally and separately by state and by age group. Nationally, excess all-cause mortality was 2.4 per 10,000 individuals (about 30% higher than reported COVID deaths in April) and employment displacement was 9.9 per 100 individuals. Across age groups 25 y and older, excess mortality was negatively correlated with economic damage; excess mortality was largest among the oldest (individuals 85 y and over: 39.0 per 10,000), while employment displacement was largest among the youngest (individuals 25 to 44 y: 11.6 per 100 individuals). Across states, employment displacement was positively correlated with excess mortality (correlation = 0.29). However, mortality was highly concentrated geographically, with the top two states (New York and New Jersey) each experiencing over 10 excess deaths per 10,000 and accounting for about half of national excess mortality. By contrast, employment displacement was more geographically spread, with the states with the largest point estimates (Nevada and Michigan) each experiencing over 16 percentage points employment displacement but accounting for only 7% of the national displacement. These results suggest that policy responses may differentially affect generations and geographies.

Linking Electronic Health Records to the American Community Survey: Feasibility and Process.

Objectives. To assess linkages of patient data from a health care system in the southeastern United States to microdata from the American Community Survey (ACS) with the goal of better understanding health disparities and social determinants of health in the population. Methods. Once a data use agreement was in place, a stratified random sample of approximately 200 000 was drawn of patients aged 25 to 74 years with at least 2 visits between January 1, 2016, and December 31, 2019. Information from the sampled electronic health records (EHRs) was transferred securely to the Census Bureau, put through the Census Person Identification Validation System to assign Protected Identification Keys (PIKs) as unique identifiers wherever possible. EHRs with PIKs assigned were then linked to 2001-2017 ACS records with a PIK. Results. PIKs were assigned to 94% of the sampled patients. Of patients with PIKs, 15.5% matched to persons sampled in the ACS. Conclusions. Linking data from EHRs to ACS records is feasible and, with adjustments for differential coverage, will advance understanding of social determinants and enhance the ability of integrated delivery systems to reflect and affect the health of the populations served. (Am J Public Health. 2022;112(6):923-930. https://doi.org/10.2105/AJPH.2022.306783).

Association of Family Income With Morbidity and Mortality Among US Lower-Income Children and Adolescents.

Importance: Family income is known to be associated with children's health; the association may be particularly pronounced among lower-income children in the US, who tend to have more limited access to health resources than their higher-income peers. Objective: To investigate the association of family income with claims-based measures of morbidity and mortality among children and adolescents in lower-income families in the US enrolled in Medicaid or the Children's Health Insurance Program. Design, Setting, and Participants: This cross-sectional analysis included 795 000 participants aged 5 to 17 years enrolled in Medicaid (Medicaid Analytic eXtract claims, 2011-2012) living in families with income below 200% of the federal poverty threshold (American Community Survey, 2008-2013). Follow-up ended in December 2021. Exposures: Family income relative to the federal poverty threshold. Main Outcomes and Measures: Record of International Classification of Diseases, Ninth Revision codes for an infection, mental health disorder, injury, asthma, anemia, or substance use disorder and death record within 10 years of observation (Social Security Administration death records through 2021). Results: Among 795 000 individuals in the sample (all statistics weighted: mean [SD] income-to-poverty ratio, 90% [53%]; mean [SD] age, 10.6 [3.9] years; 56% aged 10 to 17 years), 33% had a diagnosed infection, 13% had a mental health disorder, 6% had an injury, 5% had asthma, 2% had anemia, 1% had a substance use disorder, and 0.6% died between 2011 and 2021, with the mean (SD) age at death of 19.8 (4.2) years. For those aged 5 to 9 years, higher family income was associated with lower adjusted prevalence of all outcomes, except mortality: children in families with an additional 100% income relative to the federal poverty threshold had 2.3 (95% CI, 1.8-2.9) percentage points fewer infections, 1.9 (95% CI, 1.5-2.2) percentage points fewer mental health diagnoses, 0.7 (95% CI, 0.5-0.8) percentage points fewer injuries, 0.3 (95% CI, 0.09-0.5) percentage points less asthma, 0.2 (95% CI, 0.08-0.3) percentage points less anemia, and 0.06 (95% CI, 0.03-0.09) percentage points fewer substance use disorder diagnoses. Except for injury and anemia, the associations were more pronounced among those aged 10 to 17 years than those 5 to 9 years (P for interaction <.05). For those aged 10 to 17 years, an additional 100% income relative to the federal poverty threshold was associated with a lower 10-year mortality rate by 0.18 (95% CI, 0.12-0.25) percentage points. Conclusions and Relevance: Among children and adolescents in the US aged 5 to 17 years with family income under 200% of the federal poverty threshold who accessed health care through Medicaid or the Children's Health Insurance Program, higher family income was significantly associated with a lower prevalence of diagnosed infections, mental health disorders, injury, asthma, anemia, and substance use disorders and lower 10-year mortality. Further research is needed to understand whether these associations are causal.

Racial Disparities In Excess All-Cause Mortality During The Early COVID-19 Pandemic Varied Substantially Across States.

The impact of the coronavirus disease 2019 (COVID-19) pandemic has been starkly unequal across race and ethnicity. We examined the geographic variation in excess all-cause mortality by race and ethnicity to better understand the impact of the pandemic. We used individual-level administrative data on the US population between January 2011 and April 2020 to estimate the geographic variation in excess all-cause mortality by race and Hispanic origin. All-cause mortality allows a better understanding of the overall impact of the pandemic than mortality attributable to COVID-19 directly. Nationwide, adjusted excess all-cause mortality during that period was 6.8 per 10,000 for Black people, 4.3 for Hispanic people, 2.7 for Asian people, and 1.5 for White people. Nationwide averages mask substantial geographic variation. For example, despite similar excess White mortality, Michigan and Louisiana had markedly different excess Black mortality, as did Pennsylvania compared with Rhode Island. Wisconsin experienced no significant White excess mortality but had significant Black excess mortality. Further work understanding the causes of geographic variation in racial and ethnic disparities-the relevant roles of social and environmental factors relative to comorbidities and of the direct and indirect health effects of the pandemic-is crucial for effective policy making.

Nurse practitioner independence, health care utilization, and health outcomes.

Many states allow nurse practitioners (NPs) to practice and prescribe drugs without physician oversight, increasing the number of autonomous primary care providers. We estimate the causal impact of NP independence on population health care utilization rates and health outcomes, exploiting variation in the timing of state law passage. We find that NP independence increases the frequency of routine checkups, improves care quality, and decreases emergency room use by patients with ambulatory care sensitive conditions. These effects come from decreases in administrative costs for physicians and NPs and patients' indirect costs of accessing medical care.

Macro-level factors impacting geographic disparities in cancer screening.

OBJECTIVES: Examine how differences in state regulatory environments predict geographic disparities in the utilization of cancer screening. DATA SOURCES/SETTING: 100% Medicare fee-for-service population data from 2001-2005 was developed as multi-year breast (BC) and colorectal cancer (CRC) screening utilization rates in each county in the US. STUDY DESIGN: A comprehensive set of supply and demand predictors are used in a multilevel model of county-level cancer screening utilization in the context of state regulatory markets. States dictate insurance mandates/regulations and whether alternative providers (nurse practitioners) can provide preventive care services supplied by MDs. Controlling statistically for the supply of both types of providers, we study the joint effects of two private insurance regulations: one mandating that insureds with serious or chronic health conditions may receive continuity of care from their established physician(s) after changing health insurance plans, and another mandating that external grievance review is an option for all health plan coverage/denial decisions. These private insurance plan regulations are expected to affect the degree of beneficial spillovers from managed care practices, which may have increased area-wide cancer screening rates. PRINCIPAL FINDINGS: The two private insurance regulations under study were significant predictors impacted by local market conditions. Managed care spillovers in local markets were significantly associated with higher BC screening rates, but only in states lacking the two forms of regulation under study. Spillovers were significantly associated with higher CRC cancer screening rates everywhere, but much higher in the unregulated states. Area poverty dampened screening rates, but less so for CRC screening in the states with these regulations. CONCLUSIONS: Two state insurance regulations that empowered consumers with more autonomy to make informed utilization decisions varied across states, and exhibited significant associations with screening rates, which varied with the degree of managed care penetration or poverty in the state's counties. Beneficial spillover effects from managed care practices and negative influences from area poverty are not uniform across the United States. Both variables had stronger associations with CRC than BC screening utilization, as did state regulatory variables. CRC screening by endoscopy was more subject to market and regulatory factors than BC screening.