Hospital Capital Assets, Community Health, and the Utilization and Cost of Inpatient Care: A Population-Based Study of US Counties.

BACKGROUND: The provision of high-quality hospital care requires adequate space, buildings, and equipment, although redundant infrastructure could also drive service overprovision. OBJECTIVE: To explore the distribution of physical hospital resources-that is, capital assets-in the United States; its correlation with indicators of community health and nonhealth factors; and the association between hospital capital density and regional hospital utilization and costs. RESEARCH DESIGN: We created a dataset of n=1733 US counties by analyzing the 2019 Medicare Cost Reports; 2019 State Inpatient Database Community Inpatient Statistics; 2020-2021 Area Health Resource File; 2016-2020 American Community Survey; 2022 PLACES; and 2019 CDC WONDER. We first calculated aggregate hospital capital assets and investment at the county level. Next, we examined the correlation between community's medical need (eg, chronic disease prevalence), ability to pay (eg, insurance), and supply factors with 4 metrics of capital availability. Finally, we examined the association between capital assets and hospital utilization/costs, adjusted for confounders. RESULTS: Counties with older and sicker populations generally had less aggregate hospital capital per capita, per hospital day, and per hospital discharge, while counties with higher income or insurance coverage had more hospital capital. In linear regressions controlling for medical need and ability to pay, capital assets were associated with greater hospital utilization and costs, for example, an additional $1000 in capital assets per capita was associated with 73 additional discharges per 100,000 population (95% CI: 45-102) and $19 in spending per bed day (95% CI: 12-26). CONCLUSIONS: The level of investment in hospitals is linked to community wealth but not population health needs, and may drive use and costs.

Health Care Access and COVID-19 Vaccination in the United States: A Cross-Sectional Analysis.

BACKGROUND: Although federal legislation made COVID-19 vaccines free, inequities in access to medical care may affect vaccine uptake. OBJECTIVE: To assess whether health care access was associated with uptake and timeliness of COVID-19 vaccination in the United States. DESIGN: A cross-sectional study. SETTING: 2021 National Health Interview Survey (Q2-Q4). SUBJECTS: In all, 21,532 adults aged≥18 were included in the study. MEASURES: Exposures included 4 metrics of health care access: health insurance, having an established place for medical care, having a physician visit within the past year, and medical care affordability. Outcomes included receipt of 1 or more COVID-19 vaccines and receipt of a first vaccine within 6 months of vaccine availability. We examined the association between each health care access metric and outcome using logistic regression, unadjusted and adjusted for demographic, geographic, and socioeconomic covariates. RESULTS: In unadjusted analyses, each metric of health care access was associated with the uptake of COVID-19 vaccination and (among those vaccinated) early vaccination. In adjusted analyses, having health coverage (adjusted odds ratio [AOR] 1.60; 95% CI: 1.39, 1.84), a usual place of care (AOR 1.58; 95% CI: 1.42, 1.75), and a doctor visit within the past year (AOR 1.45, 95% CI: 1.31, 1.62) remained associated with higher rates of COVID-19 vaccination. Only having a usual place of care was associated with early vaccine uptake in adjusted analyses. LIMITATIONS: Receipt of COVID-19 vaccination was self-reported. CONCLUSIONS: Several metrics of health care access are associated with the uptake of COVID-19 vaccines. Policies that achieve universal coverage, and facilitate long-term relationships with trusted providers, may be an important component of pandemic responses.

Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study.

BACKGROUND: Childhood chronic illness imposes financial burdens that may affect the entire family. OBJECTIVE: The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses. RESEARCH DESIGN: 2009-2018 National Health Interview Survey. SUBJECTS: Adult-child dyads, consisting of one randomly sampled child and adult in each family. MEASURES: The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders. RESULTS: The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64). CONCLUSIONS: Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.

Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018.

BACKGROUND: Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear. OBJECTIVE: To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. DESIGN: Repeated cross-sectional. SETTING: National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018. PARTICIPANTS: Office-based physicians. MEASURES: Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration. RESULTS: Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care. LIMITATION: Self-reported visit length. CONCLUSION: Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.

Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020.

BACKGROUND: Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE: To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN: Cross-sectional. PARTICIPANTS: Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES: We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS: Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. CONCLUSIONS: VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.

The Association of Childbirth with Medical Debt in the USA, 2019-2020.

BACKGROUND: Medical debt affects one in five adults in the USA and may disproportionately burden postpartum women due to pregnancy-related medical costs. OBJECTIVE: To evaluate the association between childbirth and medical debt, and the correlates of medical debt among postpartum women, in the USA. DESIGN: Cross-sectional. PARTICIPANTS: We analyzed female "sample adults" 18-49 years old in the 2019-2020 National Health Interview Survey, a nationally representative household survey. MAIN MEASURES: Our primary exposure was whether the subject gave birth in the past year. We had two family-level debt outcomes: problems paying medical bills and inability to pay medical bills. We examined the association between live birth and medical debt outcomes, unadjusted and adjusted for potential confounders in multivariable logistic regressions. Among postpartum women, we also examined the association between medical debt with maternal asthma, hypertension, and gestational diabetes and several sociodemographic factors. KEY RESULTS: Our sample included n = 12,163 women, n = 645 with a live birth in the past year. Postpartum women were younger, more likely to have Medicaid, and lived in larger families than those not postpartum. 19.8% of postpartum women faced difficulty with medical bills versus 15.1% who were not; in multivariable regression, postpartum women had 48% higher adjusted odds of medical debt problems (95% CI 1.13, 1.92). Results were similar when examining inability to pay medical bills, and similar differences were seen for privately insured women. Among postpartum women, those with lower incomes and with asthma or gestational diabetes, but not hypertension, had significantly higher adjusted odds of medical debt problems. CONCLUSIONS: Postpartum women experience higher levels of medical debt than other women; poorer women and those with common chronic diseases may have an even higher burden. Policies to expand and improve health coverage for this population are needed to improve maternal health and the welfare of young families.

COVID-19 Risk by Workers' Occupation and Industry in the United States, 2020‒2021.

Objectives. To assess the risk of COVID-19 by occupation and industry in the United States. Methods. Using the 2020-2021 National Health Interview Survey, we estimated the risk of having had a diagnosis of COVID-19 by workers' industry and occupation, with and without adjustment for confounders. We also examined COVID-19 period prevalence by the number of workers in a household. Results. Relative to workers in other industries and occupations, those in the industry "health care and social assistance" (adjusted prevalence ratio = 1.23; 95% confidence interval = 1.11, 1.37), or in the occupations "health practitioners and technical," "health care support," or "protective services" had elevated risks of COVID-19. However, compared with nonworkers, workers in 12 of 21 industries and 11 of 23 occupations (e.g., manufacturing, food preparation, and sales) were at elevated risk. COVID-19 prevalence rose with each additional worker in a household. Conclusions. Workers in several industries and occupations with public-facing roles and adults in households with multiple workers had elevated risk of COVID-19. Public Health Implications. Stronger workplace protections, paid sick leave, and better health care access might mitigate working families' risks from this and future pandemics. (Am J Public Health. 2023;113(6):647-656. https://doi.org/10.2105/AJPH.2023.307249).

Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance.

BACKGROUND: Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains. OBJECTIVE: Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans. DESIGN: Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases. MAIN MEASURES: Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain. KEY RESULTS: Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes. CONCLUSION: Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.

Specialty Care Utilization Among Adults with Limited English Proficiency.

BACKGROUND: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS: 149,611 survey respondents aged 18 and older. EXPOSURE: LEP, defined as taking the survey in a language other than English. MAIN MEASURES: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.

Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study.

BACKGROUND: For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence. OBJECTIVE: To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. DESIGN: Repeated cross-sectional survey. SETTING: National Health Interview Survey, 2011-2018. PARTICIPANTS: A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP). MAIN MEASURES: Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models. KEY RESULTS: HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]). CONCLUSION: HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.