The Impact of Sickle Cell Anemia and Mental Health Diagnoses on Healthcare Use and Preventive Care among Children Enrolled in Medicaid, 2005-2012.

OBJECTIVE: To examine mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care, including antibiotic prophylaxis, hydroxyurea therapy, and transcranial Doppler screenings, among children with sickle cell anemia (SCA). STUDY DESIGN: Children aged 1-17 years with SCA from 6 states having 3 or more Medicaid claims with a SCA diagnosis within a year (2005-2012) were included. Children with mental health diagnoses were identified with 1 or more mental health encounters. Poisson and logistic regression models with general estimating equations assessed the relationship between mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care. RESULTS: In total, 7963 children with SCA were identified (22 424 person-years); 1593 person-years (7.1%) included 1 or more mental health diagnoses. Children with a mental health diagnosis were more likely to have inpatient admissions (incidence rate ratio [IRR] 1.46, 95% CI 1.36-1.56) and outpatient (IRR 1.27, 95% CI 1.21-1.34), emergency department (IRR 1.39, 95% CI 1.30-1.48), and well-child visits (IRR 1.19, 95% CI 1.11-1.29). Those with a mental health diagnosis were more likely to receive hydroxyurea therapy (odds ration [OR] 1.17, 95% CI 1.03-1.33) and less likely to receive transcranial Doppler screenings (OR 0.79, 95% CI 0.68-0.93). CONCLUSIONS: Children with SCA do not receive adequate age-appropriate preventive care. Further research is necessary to identify key points of coordination between mental health and SCA services throughout the life course. This approach may help to increase receipt of age-appropriate preventive care and decrease reliance on acute care.

Preventive medicine's equivalence problem.

The structure of preventive medicine residency training in the U.S. warrants serious examination. U.S. public health and general preventive medicine residencies have suffered a 17% decline in the number of residency programs since 2000, and current residency programs are, on average, half-empty. The required clinical year is not unique to preventive medicine, a basic, undifferentiated MPH for preventive medicine doesn't distinguish the preventive medicine specialist, and practicum year requirements are overly broad and not necessarily specific to the specialty, leaving the specialty vulnerable to equivalence by most other specialties. Strategies including creation of an additional preventive medicine-specific clinical year, developing a new public health degree for the specialty, and more specific practicum rotations, as well as potentially changing the specialty's name and altering the annual structure of training, are proposed along with an equivalence test.

Socio-economic and demographic factors associated with reproductive and child health preventive care in Mozambique: a cross-sectional study.

BACKGROUND: Reproductive and child health interventions are essential to improving population health in Africa. In Mozambique, although some progress on reproductive and child health has been made, knowledge of social inequalities in health and health care is lacking. OBJECTIVE: To investigate socio-economic and demographic inequalities in reproductive and child preventive health care as a way to monitor progress towards universal health coverage. METHODS: A cross-sectional study was conducted, using data collected from the 2015 Immunization, AIDS and Malaria Indicators Survey (IMASIDA) in Mozambique. The sample included 6946 women aged 15 to 49 years. Outcomes variables were the use of insecticide treated nets (ITN) for children under 5 years, full child immunization and modern contraception use, while independent variables included age, marital status, place of residence, region, education, occupation, and household wealth index. Prevalence ratios (PR) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship between the socio-economic and demographic characteristics and the three outcomes of interest. RESULTS: The percentage of mothers with at least one child under 5 years that did not use ITN was 51.01, 46.25% of women had children aged 1 to 4 years who were not fully immunized, and 74.28% of women were not using modern contraceptives. Non-educated mothers (PR = 1.33; 95% CI: 1.16-1.51) and those living in the Southern region (PR = 1.36; 95% CI: 1.17-1.59) had higher risk of not using ITN, while the poorest quintile (PR = 1.34; 95% CI: 1.04-1.71) was more likely to have children who were not fully immunized. Similarly, non-educated women (PR = 1.17; 95% CI: 1.10-1.25), non-working women (PR = 1.09; 95% CI: 1.04-1.16), and those in the poorest quintile (PR = 1.13; 95% CI: 1.04-1.24) had a higher risk of not using modern contraceptives. CONCLUSION: Our study showed a low rate of ITN utilization, immunization coverage of children, and modern contraceptive use among women of reproductive age. Several socio-economic and demographics factors (region, education, occupation, and wealth) were associated with these preventive measures. We recommend an equity-oriented resource allocation across regions, knowledge dissemination on the importance of ITN and contraceptives use, and an expansion of immunization services to reach socio-economically disadvantaged families in order to achieve universal health coverage in Mozambique.

Why do graduates choose to work in a less attractive specialty? A cross-sectional study on the role of personal values and expectations.

BACKGROUND: Primary health care (PHC), of which preventive medicine (PM) is a subspecialty, will have to cope with a deficiency of staff in the future, which makes the retention of graduates urgent. This study was conducted in Vietnam, where PM is an undergraduate degree in parallel to medical training. It aims to identify facilitating and hindering factors that impact recruitment and retention of PM graduates in the specialty. METHODS: A cross-sectional study enrolled 167 graduates who qualified as PM doctors from a Vietnamese medical school, between 2012 and 2018. Data were collected via an online questionnaire that asked participants about their motivation and continuation in PM, the major life roles that they were playing, and their satisfaction with their job. Multiple regression analyses were used to identify which life roles and motivational factors were related to the decision to take a PM position and to stay in the specialty, as well as how these factors held for subgroups of graduates (men, women, graduates who studied PM as their first or second study choice). RESULTS: Half of the PM graduates actually worked in PM, and only one fourth of them expressed the intention to stay in the field. Three years after qualification, many graduates had not yet decided whether to pursue a career in PM. Satisfaction with opportunities for continuous education was rated as highly motivating for graduates to choose and to stay in PM. Responsibility for taking care of parents motivated male graduates to choose PM, while good citizenship and serving the community was associated with the retention of graduates for whom PM was their first choice. CONCLUSIONS: The findings demonstrate the importance of social context and personal factors in developing primary care workforce policy. Providing opportunities for continued education and enhancing the attractiveness of PM as an appropriate specialty to doctors who are more attached to family and the community could be solutions to maintaining the workforce in PM. The implications could be useful for other less popular specialties that also struggle with recruiting and retaining staff.

Health Promotion Programs and Policies in the Workplace: An Exploratory Study With Alaska Businesses.

INTRODUCTION: We examined health insurance benefits, workplace policies, and health promotion programs in small to midsize businesses in Alaska whose workforces were at least 20% Alaska Native. Participating businesses were enrolled in a randomized trial to improve health promotion efforts. METHODS: Twenty-six Alaska businesses completed from January 2009 through October 2010 a 30-item survey on health benefits, policies, and programs in the workplace. We generated frequency statistics to describe overall insurance coverage, and to detail insurance coverage, company policies, and workplace programs in 3 domains: tobacco use, physical activity and nutrition, and disease screening and management. RESULTS: Businesses varied in the number of employees (mean, 250; median, 121; range, 41-1,200). Most businesses offered at least partial health insurance for full-time employees and their dependents. Businesses completely banned tobacco in the workplace, and insurance coverage for tobacco cessation was limited. Eighteen had onsite food vendors, yet fewer than 6 businesses offered healthy food options, and even fewer offered them at competitive prices. Cancer screening and treatment were the health benefits most commonly covered by insurance. CONCLUSION: Although insurance coverage and workplace policies for chronic disease screening and management were widely available, significant opportunities remain for Alaska businesses to collaborate with federal, state, and community organizations on health promotion efforts to reduce the risk of chronic illness among their employees.

Is preventive care utilization associated with lower outpatient and inpatient health-care expenses among Chinese older adults? A longitudinal analysis.

BACKGROUND: China has made major improvements to its health-care system since the early 21st century. However, the effectiveness of preventive care utilization on health-care costs remains limited. This study seeks to understand the effect of preventive care utilization on outpatient and inpatient health-care expenses. METHODS: With the use of the Chinese Longitudinal Healthy Longevity Survey with older adults who were 65 years old or above (n = 2828), Tobit regression models were estimated to examine the association of preventive care utilization and expenses with medical treatments. Preventive care utilization in the previous wave was used to predict health-care costs for treatments in the next wave. Propensity score matching was used to reduce potentially confounding factors. FINDINGS: Results indicated that preventive care utilization was positively associated with outpatient health care among Chinese older adults (ß = 231.8, standard error [SE] = 71.5, P < .01). The association between preventive care utilization and inpatient health-care expenses was not significant. CONCLUSIONS: Despite the results from previous studies suggesting that preventive care utilization can help reduce health-care expenses, this study does not support such a claim among Chinese older adults. The long-term association between preventive care utilization and health-care expenses for treatment should be studied further.

Important oral care needs of older French people: A cross-sectional study.

BACKGROUND: Older persons comprise a growing proportion of the European population and may have a distinct epidemiological oral profile requiring specific preventive and curative care poorly documented. The objectives of this study were to assess the oral health status of people ≥90 years of age in France, to compare their perceived and observed oral care needs and to investigate the oral problems associated with a low oral health-related quality-of-life (OHRQoL). METHODS: An oral cross-sectional study was performed during the 25th follow-up of a cohort of older persons being followed up prospectively for screening of dementia over a 15-year period in Gironde and Dordogne, France. Clinical oral indices were determined by oral examinations conducted at the participants' place of living. Cohen's Kappa coefficient was used to assess the agreement between perceived and observed oral care needs. Oral problems associated with a low OHRQoL, measured with the Geriatric Oral Health Assessment Index (GOHAI<50) were investigated with logistic regression. Odds ratios (OR) were estimated with their 95% confidence intervals (CI). RESULTS: Data from 90 persons were analysed (76% female; median age=93 years; 20% living in an institution). Plaque and calculus were present in 93% and 58% respectively, of the 74 dentate participants. The mean number of decayed, missing, and filled teeth was 26.5 (±5.3); 66% of the participants had at least one untreated decayed tooth. Among the 85 participants with tooth loss not replaced by a fixed denture, two thirds had a removable dental prosthesis; 84% of these prostheses were considered to be maladapted. Among the 39 participants who felt unable to consult a dentist (43%), lack of transportation was the most frequently cited reason. Although 88% of the participants needed oral care, only 26% perceived that they had such a need (Kappa=0.06). Oral problems associated with a GOHAI<50 were the absence of posterior occluding teeth (OR=7.15; 95%CI=1.53-33.35; P=0.012), feeling of dry mouth (OR=11.94; 95%CI=3.21-44.39; P=0.0002) and oral pain (OR=9.06; 95%CI=1.91-69.00; P=0.033). CONCLUSIONS: Persons ≥90 years of age have considerable preventive and curative dental care needs that impact their quality-of-life but they are rarely aware and lack transportation. NCT04065828.

The effectiveness of pressure ulcer prevention programme: A comparative study.

Hospital-acquired pressure ulcers (HAPUs) affect patients during hospitalisation, putting patients at risk for further complications. HAPU is one of the hospital quality indicators that require quality initiatives or programmes to minimise its occurrence and consequences. The aim of this study was to assess the effectiveness of a developed quality improvement programme in preventing HAPUs. This is a retrospective comparative study, which tracked the outcomes of pressure ulcer prevention programme (PUPP) for 5 years from 2014 to 2018. Data from 50 441 patients were collected from different units in a tertiary hospital in the eastern region of Saudi Arabia. The programme focused on building a wound care team; providing education to hospital staff, patients, and their families; and continuous data monitoring, in addition to follow-up visits after discharge. Implementation of the programme was successful showing a statistically significant reduction of HAPUs from 0.20% in 2014 to 0.06% in 2018 (P value <.001). The PUPP was effective in reducing the percentage of pressure ulcer cases. The programme can be extended and implemented in other hospitals.

High-Deductible Health Plans and Prevention.

High-deductible health plans (HDHPs) are becoming more popular owing to their potential to curb rising health care costs. Relative to traditional health insurance plans, HDHPs involve higher out-of-pocket costs for consumers, which have been associated with lower utilization of health services. We focus specifically on the impact that HDHPs have on the use of preventive services. We critique the current evidence by discussing the benefits and drawbacks of the research designs used to examine this relationship. We also summarize the findings from the most methodologically sophisticated studies. We conclude that the balance of the evidence shows that HDHPs are reducing the use of some preventive service, especially screenings. However, it is not clear if HDHPs affect all preventive services. Additional research is needed to determine why variability in conclusions exists among studies. We describe an agenda for future research that can further inform public health decision makers on the impact of HDHPs on prevention.

Persistent Disparities in Medicare's Annual Wellness Visit Utilization.

INTRODUCTION: The Medicare Annual Wellness Visit (AWV) is a preventive care visit introduced in 2011 as part of the Affordable Care Act provided without cost to beneficiaries. The AWV is associated with higher preventive services utilization. Although AWV utilization increased during 2011-2013, utilization was lower among ethnoracial minority beneficiaries who may benefit the most. OBJECTIVES: To determine if AWV utilization disparities have persisted using the most recent data available. RESEARCH DESIGN: The authors analyzed AWV utilization in 2011-2013 and 2015-2016 by beneficiary-reported race and ethnicity, adjusting for potential confounders. SUBJECTS: Weighted sample of 78,639,501 fee-for-service Medicare beneficiaries aged 66 years and older who participated in the Medicare Current Beneficiary Survey 2011-2013 or 2015-2016. MEASURES: AWV utilization was identified using Medicare claims. RESULTS: AWV utilization increased from 8.1% to 23.0% of all beneficiaries between 2011 and 2016. Compared with non-Hispanic white beneficiaries, utilization was significantly lower among non-Hispanic Black and non-Hispanic other race beneficiaries in both the minimally and fully-adjusted models. Hispanic/Latino beneficiaries had lower utilization in the minimally adjusted model, but not in the fully-adjusted model. In 2016, compared with non-Hispanic white beneficiaries, AWV utilization was 10.2 points lower for non-Hispanic black, 11.6 points lower for Hispanic/Latino, and 8.6 points lower for non-Hispanic other race beneficiaries, and these differences were attenuated after adjusting for all covariates to 6.8 points lower, 9.4 points lower, and 7.2 points lower, respectively. CONCLUSIONS: The AWV has the potential to increase the use of preventive care, improve health, and reduce ethnoracial disparities among Medicare beneficiaries, but realizing these goals will require increasing utilization by minority groups. If ethnoracial minority beneficiaries had used the AWV at the same rate as non-Hispanic white beneficiaries during the study period, then ~1.6 million additional AWVs would have been used.

Reasons for accepting or declining participation in the ASPRE trial: A qualitative study with women at high risk of preterm pre-eclampsia.

OBJECTIVE: To identify factors that affected the decision of pregnant women at high risk for pre-eclampsia (PE) in accepting or declining participation in a medicated clinical trial (ASPRE) for the prevention of preterm PE. METHOD: This was a qualitative, cross-sectional study. A purposive sample of 14 participants and 13 decliners of the ASPRE trial were interviewed using semi-structured interviews. Data were analysed using template analysis. RESULTS: For participants, their high-risk status seems to have motivated them to take part in the trial. This was enabled by their perception that the trial drug aspirin was commonly used, the safety of the procedure, and the belief that they will be in receipt of extra monitoring in pregnancy. Decliners expressed discomfort about taking medications in pregnancy, and about the presence of the placebo arm; they seemed to be motivated by desire to reduce harm. Satisfaction with the information provided by the medical professionals was also influential in women's decision making, and so were the views of their partners and other trusted individuals. CONCLUSION: Pregnant women's motivation to take part or to decline participation in a medicated trail can be understood as an attempt to cope with the threat posed by their high-risk status.

Preventable premature deaths (PYLL) in Northern Dimension partnership countries 2003-13.

BACKGROUND: Objective was to measure preventable premature loss of life in countries from same geographical area but with considerable differences in social and economic development. By comparing inter-country differences and similarities in premature mortality, acceleration of health-in-all-policies is enhanced. METHODS: Preventable premature deaths were described by Potential Years of Life Lost (PYLL). Data consisted of death registers for 2003, 2009 and 2013. PYLL-rates were age-standardized by using standard OECD population from 1980 and expressed as sum of lost life years per 100 000 citizens. RESULTS: In Northern Dimension area, PYLL-rates had declined from 2003 to 2013. In 2013, worst PYLL-rate was in Belarus 9851 and best in Sweden 2511. PYLL-rates among men were twice as high as among women. Most premature losses (1023) were due to external causes. Malignant neoplasms came second (921) and vascular diseases third (816). Alcohol was also an important cause (270) and country differences were over 10-fold. CONCLUSIONS: In ND-area, the overall development of public health has been good during 2003-13. Nevertheless, for all countries foci for public health improvement and learning from each other could be identified. Examining the health of populations in countries from relatively similar geographical area with different social history and cultures can provide them with evidence-based tools for health-in-all-policies to advocate health promotion and disease prevention. Gender differences due to preventable premature deaths are striking. The higher the national PYLL-rate, the bigger the PYLL-rate difference between men and women and the loss of human capital.

The impact of Medicaid expansion on postpartum health care utilization among pregnant women with opioid use disorder.

Background: Opioid use disorder (OUD) during pregnancy has increased dramatically over the past decade, as have associated adverse maternal health outcomes. Although Medicaid has long been the largest payer for deliveries in the United States, states' decisions to expand Medicaid eligibility to low-income adults has the potential to increase access to care for women in the postpartum period. This study aimed to determine the impact of the 2015 Pennsylvania Medicaid expansion on postpartum insurance coverage and preventive care utilization among pregnant women with opioid use disorder (OUD). Methods: In 2017, we conducted a retrospective cohort study using 2013-2015 administrative Medicaid data provided by the Pennsylvania Department of Human Services. We identified 1562 women with opioid use disorder who had a live birth delivery in a pre-Medicaid expansion or post-expansion study period. We compared length of continuous enrollment in Medicaid following delivery, postpartum visit attendance, and contraception initiation between groups. Results: More women in the post-expansion group remained enrolled in Medicaid at 300 days postpartum, relative to the pre-expansion group (87% vs. 81%). Medicaid expansion was not associated with differences in postpartum visit attendance or contraceptive use. However, women who remained enrolled in Medicaid for at least 300 days post delivery had an increased odds of postpartum visit attendance (odds ratio [OR]: 1.6, 95% confidence interval [CI]: 1.04, 2.4). Conclusion: The rate of continuous Medicaid enrollment among postpartum women with OUD was significantly higher after expansion, whereas rates of preventive care utilization were unaffected. Although improving insurance coverage for women with OUD is an important step to improve access to recommended preventive care, additional efforts are needed to ensure utilization of such care.

Use of Emergency Departments for Preventative Care Among Adults in the United States: Estimates From the 2017 National Health Interview Survey.

BACKGROUND: Use of the emergency department (ED) for routine or preventative care has been an abiding concern for policy makers and public health practitioners. OBJECTIVES: We utilized recent data to examine health-related, socioeconomic, and demographic factors associated with use of the ED for routine or preventative care using a national sample of adults. METHODS: Data from the 2017 National Health Interview Survey, a nationally representative sample of 26,742 adults ≥18 years of age was used for this investigation. Bivariate and multivariate analyses were used to assess the association between reported use of EDs as a usual source of preventative care and health-related, socioeconomic, and demographic factors. RESULTS: In 2017, approximately 2 million adults nationwide reported the ED as their usual source of preventative health care. Individuals experiencing ≥2 health care-related barriers were more likely to use the ED as a source of usual preventative care (odds ratio = 2.78 [95% confidence interval 1.64-4.72]). Individuals without insurance had higher odds (odds ratio = 9.52 [95% confidence interval 5.60-16.19]) of using the ED for care compared with those who were privately insured. In addition, those using the ED for preventative care were more likely to be younger, poorer, less educated, to identify as Asian or African American, and to reside in the Northeast United States. CONCLUSION: This study provides a current perspective into characteristics and factors contributing to use of the ED for preventative care. Overall, our findings suggest that the ED continues to provide crucial safety net services to a small subset of the population experiencing significant barriers to timely medical care.

Health Care Access and Receipt of Clinical Diabetes Preventive Care for Working-Age Adults With Diabetes in States With and Without Medicaid Expansion: Results from the 2013 and 2015 BRFSS.

OBJECTIVE: This study aimed to assess whether the recent Medicaid expansion, as a natural experiment, was associated with better access to care and, as a consequence, better receipt of clinical diabetes care services. METHODS: Data were from the Behavioral Risk Factor Surveillance System (BRFSS). The analytical sample included 20 708 working-age adults with diabetes aged 18 to 64 years from 22 states. The outcome variables included 4 measures of access to care and 4 measures of receipt of clinical diabetes care services. A difference-in-difference logistic regression model was used to compare changes in outcomes between respondents in Medicaid expansion and nonexpansion states. Data from the 2013 survey provided pre-Medicaid expansion information, and data from the 2015 survey provided postexpansion information. Analyses were conducted using Stata 13 using survey commands to account for the complex survey design of BRFSS. RESULTS: A significant increase was observed in health insurance coverage for people with diabetes from 2013 to 2015 (P < .05) in both Medicaid expansion and nonexpansion states, with a larger increase in the Medicaid expansion states. The Time by Medicaid expansion interaction term was significant for 2 measures of access to care: health insurance coverage (adjusted odds ratio [AOR] = 1.43, 95% confidence interval: 1.04-1.96) and having an annual checkup (AOR = 1.30, 95% confidence interval: 1.00-1.71). Respondents in expansion states were more likely to have a personal doctor and more likely to be able to afford a physician visit than those in nonexpansion states. The Time by Medicaid expansion was close to significance for one of the measures of clinical diabetes care: getting flu shots (AOR = 1.20, P = .08). CONCLUSIONS: Medicaid expansion did improve health care access but no significant improvement was found for receipt of clinical diabetes care for people with diabetes. Resources provided through Medicaid are vital for diabetes control and management.

Disparities in hepatocellular carcinoma incidence by race/ethnicity and geographic area in California: Implications for prevention.

BACKGROUND: The incidence of hepatocellular carcinoma (HCC) has been rising rapidly in the United States. California is an ethnically diverse state with the largest number of incident HCC cases in the country. Characterizing HCC disparities in California may inform priorities for HCC prevention. METHODS: By using data from the Surveillance, Epidemiology, and End Results 18-Registry Database and the California Cancer Registry, age-adjusted HCC incidence in California from 2009 through 2013 was calculated by race/ethnicity and neighborhood ethnic enclave status. A geographic analysis was conducted using Medical Service Study Areas (MSSAs) as the geographic unit, and race/ethnicity-specific standardized incidence ratios (SIRs) were calculated to identify MSSAs with higher-than-expected HCC incidence compared with the statewide average. RESULTS: During 2009 through 2013, the age-adjusted incidence of HCC in California was the highest in Asians/Pacific Islanders (APIs) and Hispanics (>100% higher than whites), especially those living in more ethnic neighborhoods (20%-30% higher than less ethnic neighborhoods). Of the 542 MSSAs statewide, 42 had elevated HCC incidence (SIR ≥ 1.5; lower bound of 95% confidence interval > 1) for whites, 14 for blacks, 24 for APIs, and 36 for Hispanics. These MSSAs have 24% to 52% higher proportions of individuals below the 100% federal poverty line than other MSSAs. CONCLUSIONS: APIs and Hispanics residing in more ethnic neighborhoods and individuals residing in lower income neighborhoods require more extensive preventive efforts tailored toward their unique risk factor profiles. The current race/ethnicity-specific geographic analysis can be extended to other states to inform priorities for HCC targeted prevention at the subcounty level, eventually reducing HCC burden in the country.

The impact of cost sharing on women's use of annual examinations and effective contraception.

BACKGROUND: We sought to describe the relationship between the elimination of out-of-pocket costs and women's use of preventive care office visits and long-acting reversible contraception after accounting for baseline levels of cost sharing. OBJECTIVES: The objective of this analysis was to describe the relationship between the elimination of out-of-pocket costs and utilization of preventive care visits and long-acting reversible contraception insertion while taking baseline cost sharing levels under consideration. STUDY DESIGN: In 2017, we used administrative health plan data to examine changes in out-of-pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer-based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns. RESULTS: Women in this sample generally had low costs at baseline ($24 and $29 for preventive care visits and long-acting reversible contraception insertion, respectively). The elimination of baseline out-of-pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out-of-pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04-1.05), but women with high out-of-pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out-of-pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86-0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09-1.20). CONCLUSION: Out-of-pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective.

Inequalities in health care utilization among migrants and non-migrants in Germany: a systematic review.

BACKGROUND: Despite the growing number of people with migrant background in Germany, a systematic review about their utilization of health care and differences to the non-migrant population is lacking. By covering various sectors of health care and migrant populations, the review aimed at giving a general overview and identifying special areas of potential intervention. METHODS: A systematic review was conducted in PubMed database including records that were published until 1st of June 2017. Further criteria for eligibility were a publication in a peer-reviewed journal written in English or German language. The studies have to report quantitative and original data of a population residing in Germany. The appropriateness of the studies was judged by both authors. Studies were excluded if native controls were not originated from the same sample. Moreover, indicators of health care utilization have to assess individual behaviour like consultation or participation rates. 63 studies met the inclusion criteria for a qualitative synthesis of the findings. RESULTS: The overall findings indicate a lower utilization among migrants, although the results vary in terms of health care sector, indicator of health care utilization and migrant population. For specialist care, medication use, therapist consultations and counselling, rehabilitation as well as disease prevention (early cancer detection, prevention programs for children and oral health check-ups) a lower utilization among people with migrant background was found. The lower usage was particularly shown for migrants of the 1st generation, people with two-sided migrant background, children/adolescents and women. Due to the methodological heterogeneity a meta-analysis was not feasible. As most of the studies were cross-sectional, no causal interpretations could be drawn. CONCLUSIONS: The inequalities in utilization could not substantially be explained by differences in the socioeconomic status. Other reasons of lower utilization could be due to differences in need, preferences, information, language and formal access barriers (e.g. charges, waiting times, travel distances or lost wages). Different migrant-specific and migrant-sensitive strategies are relevant to address the problem for certain health care sectors and migrant populations. TRIAL REGISTRATION: The review protocol was registered on PROSPERO ( CRD42014015162 ).

Effects of health insurance coverage on risky behaviors.

Prior to implementation of the Patient Protection and Affordable Care Act, dependent health insurance coverage was typically available only for young adults under the age of 19. As of September 2010, the Affordable Care Act extended dependent health insurance coverage to include young adults up to the age of 26. I use the National Health Interview Survey for the sample period from 2011 to 2013 to analyze the causal relationship between the expansion of dependent coverage and risky behaviors including smoking and drinking as well as preventive care. I employ a regression discontinuity design to estimate the causal effect of health insurance coverage and overcome the endogeneity problem between insurance status and risky behaviors. When young adults become 26 years old, they are 7 to 10 percentage points more likely to lose health insurance than young adults under the age of 26. Although young adults over the age of 26 are generally aged out of insurance coverage, presence or absence of health insurance does not affect their smoking and drinking behaviors and their access to preventive care.