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BACKGROUND: People with disabilities face unique health needs and barriers to perinatal care. The pandemic may have worsened health care access disparities, while pandemic-era Medicaid provisions potentially improved access via increased insurance coverage. OBJECTIVE: We assessed changes in postpartum insurance, visits, and reproductive health care during the COVID-19 public health emergency (PHE) and PHE Medicaid provisions among individuals with disabilities versus individuals without disabilities. METHODS: We used the 2019-2020 Pregnancy Risk Assessment Monitoring System survey and Disability Supplement to compare changes in postpartum outcomes by disability status during COVID-19. Adjusted regression models included an interaction term between disability status and postpartum exposure to the PHE. Comparative differences were examined overall, among low-income respondents, and among respondents with Medicaid-paid deliveries. RESULTS: During the PHE, there was a significant increase in postpartum Medicaid by 7.1% points (95 % CI: 0.6, 13.6) and a decrease in uninsurance by 5.2% points (95 % CI: -9.0, -1.4) among respondents with disabilities relative to those without. There was a significant increase in postpartum contraception during the PHE among respondents with disabilities relative to those without by 6.3% points (95 % CI: -0.1, 12.5). The PHE was associated with larger increases in postpartum Medicaid and larger decreases in postpartum uninsurance among low-income respondents, with similar estimates among respondents with Medicaid-insured deliveries. CONCLUSIONS: During the COVID-19 PHE, individuals with disabilities saw increased postpartum insurance and improved contraceptive use. As PHE Medicaid provisions are rolled back, these differential improvements should be factored into decisions about postpartum Medicaid eligibility.
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COVID-19 , Pessoas com Deficiência , Gravidez , Feminino , Estados Unidos , Humanos , Pandemias , Acessibilidade aos Serviços de Saúde , Medicaid , Período Pós-Parto , Cobertura do Seguro , Seguro SaúdeRESUMO
Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.
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Anticoncepcionais , Medicare Part C , Idoso , Estados Unidos , Feminino , Gravidez , Humanos , Anticoncepção , Medicaid , Custo Compartilhado de SeguroRESUMO
Importance: State Medicaid programs have recently implemented several policies to improve access to health care during the postpartum period. Understanding whether these policies are succeeding will require accurate measurement of postpartum visit use over time and across states; however, current estimates of use vary substantially between data sources. Objectives: To examine disagreement between postpartum visit use reported in the Pregnancy Risk Assessment Monitoring System (PRAMS) and Medicaid claims and assess whether insurance transitions from Medicaid at the time of childbirth to other insurance types after delivery are associated with the degree of disagreement. Design, Setting, and Participants: This cross-sectional study was conducted among individuals in South Carolina after delivery who had completed a PRAMS survey and for whom Medicaid was the payer of their delivery care. PRAMS responses from 2017 to 2020 were linked to inpatient, outpatient, and physician Medicaid claims; survey-weighted logistic regression models were then used to examine the association between postpartum insurance transitions and data source disagreement. Data were analyzed from February through October 2023. Exposure: Insurance transition type: continuous Medicaid, Medicaid to private insurance, Medicaid to no insurance, and Emergency Medicaid to no insurance. Main Outcome and Measure: Data source disagreement due to reporting a postpartum visit in PRAMS without a Medicaid claim for a visit or having a Medicaid claim for a visit without reporting a postpartum visit in PRAMS. Results: Among 836 PRAMS respondents enrolled in Medicaid at delivery (663 aged 20-34 years [82.9%]), a mean of 85.7% (95% CI, 82.1%-88.7%) reported a postpartum visit in PRAMS and a mean of 61.6% (95% CI, 56.9%-66.0%) had a Medicaid claim for a postpartum visit. Overall, 253 respondents (30.3%; 95% CI, 26.1%-34.7%) had data source disagreement: 230 individuals (27.2%; 95% CI, 23.2%-31.5%) had a visit in PRAMS without a Medicaid claim, and 23 individuals (3.1%; 95% CI, 1.8%-5.2%) had a Medicaid claim without a visit in PRAMS. Compared with individuals continuously enrolled in Medicaid, those who transitioned to private insurance after delivery and those who were uninsured after delivery and had Emergency Medicaid at delivery had an increase in the probability of data source agreement of 15.8 percentage points (95% CI, 2.6-29.1 percentage points) and 37.2 percentage points (95% CI, 19.6-54.8 percentage points), respectively. Conclusions and Relevance: This study's findings suggest that Medicaid claims may undercount postpartum visits among people who lose Medicaid or switch to private insurance after childbirth. Accounting for these insurance transitions may be associated with better claims-based estimates of postpartum care.
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Medicaid , Período Pós-Parto , Estados Unidos , Feminino , Gravidez , Humanos , Autorrelato , Estudos Transversais , PartoRESUMO
Importance: Professional medical organizations recommend that adults receive routine postpartum care. Yet, some states restrict public insurance coverage for undocumented immigrants and recently documented immigrants (those who received legal documentation status within the past 5 years). Objective: To examine the association between public insurance coverage and postpartum care among low-income immigrants and the difference in receipt of postpartum care among immigrants relative to nonimmigrants. Design, Setting, and Participants: A pooled, cross-sectional analysis was conducted using data from the Pregnancy Risk Assessment Monitoring System for 19 states and New York City including low-income adults with a live birth between 2012 and 2019. Exposure: Giving birth in a state that offered public insurance coverage for postpartum care to recently documented or undocumented immigrants. Main Outcomes and Measures: Self-reported receipt of postpartum care by the category of coverage offered (full coverage: states that offered publicly funded postpartum care regardless of immigration status; moderate coverage: states that offered publicly funded postpartum care to lawfully residing immigrants without a 5-year waiting period, but did not offer postpartum care to undocumented immigrants; no coverage: states that did not offer publicly funded postpartum care to lawfully present immigrants before 5 years of legal residence or to undocumented immigrants). Results: The study included 72â¯981 low-income adults (20â¯971 immigrants [29%] and 52â¯010 nonimmigrants [71%]). Of the 19 included states and New York City, 6 offered full coverage, 9 offered moderate coverage, and 4 offered no coverage; 1 state (Oregon) switched from offering moderate coverage to offering full coverage. Compared with the states that offered full coverage, receipt of postpartum care among immigrants was 7.0-percentage-points lower (95% CI, -10.6 to -3.4 percentage points) in the states that offered moderate coverage and 11.3-percentage-points lower (95% CI, -13.9 to -8.8 percentage points) in the states that offered no coverage. The differences in the receipt of postpartum care among immigrants relative to nonimmigrants were also associated with the coverage categories. Compared with the states that offered full coverage, there was a 3.3-percentage-point larger difference (95% CI, -5.3 to -1.4 percentage points) in the states that offered moderate coverage and a 7.7-percentage-point larger difference (95% CI, -10.3 to -5.0 percentage points) in the states that offered no coverage. Conclusions and Relevance: Compared with states without insurance restrictions, immigrants living in states with public insurance restrictions were less likely to receive postpartum care. Restricting public insurance coverage may be an important policy-driven barrier to receipt of recommended pregnancy care and improved maternal health among immigrants.
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Emigrantes e Imigrantes , Política de Saúde , Acessibilidade aos Serviços de Saúde , Cobertura do Seguro , Medicaid , Cuidado Pós-Natal , Adulto , Feminino , Humanos , Gravidez , Estudos Transversais , Emigrantes e Imigrantes/legislação & jurisprudência , Emigrantes e Imigrantes/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/legislação & jurisprudência , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/legislação & jurisprudência , Seguro Saúde/estatística & dados numéricos , Medicaid/legislação & jurisprudência , Medicaid/estatística & dados numéricos , Cuidado Pós-Natal/legislação & jurisprudência , Cuidado Pós-Natal/estatística & dados numéricos , Política Pública/legislação & jurisprudência , Estados Unidos/epidemiologia , Política de Saúde/legislação & jurisprudência , Pobreza/estatística & dados numéricos , Imigrantes Indocumentados/legislação & jurisprudência , Imigrantes Indocumentados/estatística & dados numéricosRESUMO
On February 26, 2012, a Black child, Trayvon Martin, was executed in Sanford, Florida. Seventeen months later his killer was found not guilty. This is but one example of the state's brazen disregard for Black life, rooted in the kidnapping and enslavement of Africans more than 400 years ago, and the ways in which they and their descendants were systematically tortured. Trayvon Martin's murder catalyzed the Black Lives Matter (BLM) movement, which names and resists deeply entrenched state violence and inequities against Black people in the U.S. In this manuscript we: (1) summarize examples of structural disregard for Black lives in the U.S.; (2) describe how this disregard is reflected in differential patterns of social inequities, morbidity, and mortality; and (3) discuss how we can better employ the BLM perspective to frame a more historicized understanding of patterns in population health and to envision ways to resist health inequities.
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OBJECTIVE: To examine the qualitative literature on low-income women's perspectives on the barriers to high-quality prenatal and postpartum care. DATA SOURCES AND STUDY SETTING: We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 and 2021. STUDY DESIGN: A systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past 2 years and identified as low-income at delivery. DATA COLLECTION/EXTRACTION METHODS: Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes. PRINCIPAL FINDINGS: We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy, also interfered with the timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common. CONCLUSIONS: Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes, including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage, may help overcome these challenges.
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Cuidado Pós-Natal , Cuidado Pré-Natal , Feminino , Humanos , Cobertura do Seguro , Medicaid , Gravidez , Pesquisa QualitativaRESUMO
The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility for low-income adults regardless of their pregnancy or parental status. Variation in states' adoption of this expansion created a natural experiment to study the effects of expanding public insurance on insurance coverage, health care use, and health outcomes during preconception, pregnancy, and postpartum. We conducted a systematic review of relevant literature on this topic, analyzing twenty-four studies published between January 2014 and April 2021. We found that the ACA Medicaid expansion increased preconception and postpartum Medicaid coverage with corresponding declines in uninsurance, private insurance coverage, and insurance churn. There was limited evidence that Medicaid expansion increased perinatal health care use or improved infant birth outcomes overall, although some studies reported reduced racial and ethnic disparities in rates of prenatal and postpartum visit attendance, maternal mortality, low birthweight, and preterm births. Stronger data collection on preconception and postpartum outcomes with sufficient sample sizes to stratify by race and ethnicity is needed to assess the full impact of the ACA and emerging Medicaid policy changes, such as the postpartum Medicaid extension.
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Medicaid , Patient Protection and Affordable Care Act , Adulto , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Recém-Nascido , Cobertura do Seguro , Seguro Saúde , Pessoas sem Cobertura de Seguro de Saúde , Gravidez , Estados UnidosRESUMO
Background: Disparities in the health and economic burden of gonorrhoea have not been systematically quantified. We estimated population-level health losses and costs associated with gonococcal infection and sequelae in the United States. Methods: We used probability-tree models to capture gonorrhoea sequelae and to estimate attributable disease burden in terms of the discounted lifetime costs and quality-adjusted life-years (QALYs) lost due to incident infections acquired during 2015 from the healthcare system perspective. Numbers of infections in 2015 were obtained from a published gonorrhoea transmission model. We evaluated population-level disease burden, disaggregated by sex, age, race/ethnicity, and for men who have sex with men (MSM). We conducted a multivariate sensitivity analysis for key parameters. Findings: Discounted lifetime QALYs lost per incident gonococcal infection were estimated as 0.093 (95% uncertainty interval [UI] 0.022-0.22) for women, 0.0020 (0.0015-0.0024) for heterosexual men, and 0.0015 (0.00070-0.0021) for MSM. Discounted lifetime costs per incident infection were USD 261 (109-480), 169 (88-263), and 133 (50-239), respectively. At the population level, total discounted lifetime QALYs lost due to infections acquired during 2015 were 53,293 (12,326-125,366) for women, 621 (430-872) for heterosexual men, and 1,078 (427-1,870) for MSM. Total discounted lifetime costs were USD 150 million (64-277 million), 54 million (25-92 million), and 97 million (34-197 million), respectively. The highest total burden of both QALYs and costs at the population-level was observed in Non-Hispanic Black women, and highest burden per 1,000 person-years was identified in MSM among men and American Indian/Alaska Native among women. Interpretation: Gonorrhoea causes substantial health losses and costs in the United States. These results can inform planning and prioritization of prevention services. Funding: Centers for Disease Control and Prevention, Charles A. King Trust.
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BACKGROUND: Men who have sex with men (MSM) experience high rates of gonococcal infection at extragenital (rectal and pharyngeal) anatomic sites, which often are missed without asymptomatic screening and may be important for onward transmission. Implementing an express pathway for asymptomatic MSM seeking routine screening at their clinic may be a cost-effective way to improve extragenital screening by allowing patients to be screened at more anatomic sites through a streamlined, less costly process. METHODS: We modified an agent-based model of anatomic site-specific gonococcal infection in US MSM to assess the cost-effectiveness of an express screening pathway in which all asymptomatic MSM presenting at their clinic were screened at the urogenital, rectal, and pharyngeal sites but forewent a provider consultation and physical examination and self-collected their own samples. We calculated the cumulative health effects expressed as gonococcal infections and cases averted over 5 years, labor and material costs, and incremental cost-effectiveness ratios for express versus traditional scenarios. RESULTS: The express scenario averted more infections and cases in each intervention year. The increased diagnostic costs of triple-site screening were largely offset by the lowered visit costs of the express pathway and, from the end of year 3 onward, this pathway generated small cost savings. However, in a sensitivity analysis of assumed overhead costs, cost savings under the express scenario disappeared in the majority of simulations once overhead costs exceeded 7% of total annual costs. CONCLUSIONS: Express screening may be a cost-effective option for improving multisite anatomic screening among US MSM.
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Infecções por Chlamydia , Gonorreia , Minorias Sexuais e de Gênero , Análise Custo-Benefício , Gonorreia/diagnóstico , Gonorreia/epidemiologia , Homossexualidade Masculina , Humanos , Masculino , Programas de Rastreamento , Prevalência , Estados Unidos/epidemiologiaRESUMO
Adequate supervision is critical to maintain the performance of health workers who provide essential maternal and child health services in low-resource areas. Supportive supervision emphasizing problem-solving, skill development and mentorship has been shown to improve the motivation and effectiveness of health workers, especially at the community level, but it is not always routinely provided. Previous studies have assessed the uptake of supportive supervision among volunteer health workers and paid health centre staff, but less is known about the supervision experiences of paid community-based staff, such as community health nurses (CHNs) in Ghana. This mixed-methods study explores the frequency and content of CHN supervision in five districts in the Greater Accra and Volta regions of Ghana. We analysed quantitative data from 197 satisfaction surveys and qualitative data from 29 in-depth interviews (IDIs) and four focus group discussions (FGDs) with CHNs. While the majority of CHNs received supervision at least monthly, they reported that supervision was primarily focused on meeting clinical targets (48%) rather than on handling specific cases or patients (23%). Over a third (34%) of CHNs did not agree that supervisors help them with job-related challenges and nearly half (43%) were unsatisfied with their jobs. When asked about their mentorship needs, CHNs reported wanting feedback on how to improve their job performance (40%) and encouragement (30%). There were only slight variations in the frequency and content of supervision based on type of supervisor. During IDIs and FGDs, CHNs offered ideas for how to improve supervision, including more frequent field visits so that supervisors could see the on-the-ground realities of their work, greater respect and positive reinforcement. Overall, CHN motivation and job satisfaction may be strengthened by aligning supervision more closely with the principles of supportive supervision.
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Enfermeiros de Saúde Comunitária , Criança , Agentes Comunitários de Saúde , Gana , Humanos , Mentores , MotivaçãoRESUMO
Rationale: Most U.S. residents who develop tuberculosis (TB) were born abroad, and U.S. TB incidence is increasingly driven by infection risks in other countries.Objectives: To estimate the potential impact of effective global TB control on health and economic outcomes in the United States.Methods: We estimated outcomes using linked mathematical models of TB epidemiology in the United States and migrants' birth countries. A base-case scenario extrapolated country-specific TB incidence trends. We compared this with scenarios in which countries achieve 90% TB incidence reductions between 2015 and 2035, as targeted by the World Health Organization's End TB Strategy ("effective global TB control"). We also considered pessimistic scenarios of flat TB incidence trends in individual countries.Measurements and Main Results: We estimated TB cases, deaths, and costs and the total economic burden of TB in the United States. Compared with the base-case scenario, effective global TB control would avert 40,000 (95% uncertainty interval, 29,000-55,000) TB cases in the United States in 2020-2035. TB incidence rates in 2035 would be 43% (95% uncertainty interval, 34-54%) lower than in the base-case scenario, and 49% (95% uncertainty interval, 44-55%) lower than in 2020. Summed over 2020-2035, this represents 0.8 billion dollars (95% uncertainty interval, 0.6-1.0 billion dollars) in averted healthcare costs and $2.5 billion dollars (95% uncertainty interval, 1.7-3.6 billion dollars) in productivity gains. The total U.S. economic burden of TB (including the value of averted TB deaths) would be 21% (95% uncertainty interval, 16-28%) lower (18 billion dollars [95% uncertainty level, 8-32 billion dollars]).Conclusions: In addition to producing major health benefits for high-burden countries, strengthened efforts to achieve effective global TB control could produce substantial health and economic benefits for the United States.