Changes in Health Care Access by Race, Income, and Medicaid Expansion During the COVID-19 Pandemic.

BACKGROUND: The intersecting crises of the COVID-19 pandemic, job losses, and concomitant loss of employer-sponsored health insurance may have disproportionately affected health care access within minorized and lower-socioeconomic status communities. OBJECTIVE: To describe changes in access to care during the COVID-19 pandemic, stratified by race/ethnicity, household income, and state Medicaid expansion status. RESEARCH DESIGN: We used interrupted time series and difference-in-differences regression models, controlling for respondent characteristics and preexisting trends. SUBJECTS: Data were extracted for all adults aged 18-64 surveyed in the 2015-2020 Behavioral Risk Factor Surveillance System (N=1,731,699) from all 50 states and the District of Columbia. MEASURES: Our outcomes included indicators for whether respondents had any health insurance coverage or avoided seeking care because of cost within the prior year. The primary exposure was the onset of the COVID-19 pandemic in the United States in March 2020. RESULTS: The pandemic was associated with a 1.2 percentage point (pp) decline in uninsurance for Medicaid expansion states (95% CI, -1.8, -0.6); these reductions were concentrated among respondents who were Black, multiracial, or low income. The rates of uninsurance were generally stable in nonexpansion states. The rates of avoided care because of cost fell by 3.5 pp in Medicaid expansion states (95% CI, -3.9, -3.1), and by 3.6 pp (95% CI, 4.3-2.9) in nonexpansion states. These declines were concentrated among respondents who were Hispanic, Other Race, or low income. CONCLUSIONS: Our findings reinforce the value of Medicaid expansion as one tool to improve access to health insurance and care for marginalized and vulnerable populations.

Excess Mortality at Veterans Health Administration Facilities During the COVID-19 Pandemic.

IMPORTANCE: The COVID-19 pandemic resulted in excess mortality among the general US population and at Veterans Health Administration (VHA) facilities. It is critical to understand the characteristics of facilities that experienced the highest and lowest pandemic-related mortality to inform future mitigation efforts. OBJECTIVE: To identify facility-level excess mortality during the pandemic and to correlate these estimates with facility characteristics and community-wide rates of COVID-19 burden. DESIGN: We used pre-pandemic data to estimate mortality risk prediction models using 5-fold cross-validation and Poisson quasi-likelihood regression. We then estimated excess mortality and observed versus expected (O/E) mortality ratios by the VHA facility from March to December 2020. We examined facility-level characteristics by excess mortality quartile. PARTICIPANTS: Overall, there were 11.4 million VHA enrollees during 2016 and 2020. MAIN MEASURES: Facility-level O/E mortality ratios and excess all-cause mortality. RESULT: VHA-enrolled veterans experienced 52,038 excess deaths from March to December 2020, equating to 16.8% excess mortality. Facility-specific rates ranged from -5.5% to +63.7%. Facilities in the lowest quartile for excess mortality experienced fewer COVID-19 deaths (0.7-1.51, P <0.001) and cases (52.0-63.0, P =0.002) per 1,000 population compared with the highest quartile. The highest quartile facilities had more hospital beds (276.7-187.6, P =0.024) and a higher percent change in the share of visits conducted via telehealth from 2019 to 2020 (183%-133%, P <0.008). CONCLUSIONS: There was a large variation in mortality across VHA facilities during the pandemic, which was only partially explained by the local COVID-19 burden. Our work provides a framework for large health care systems to identify changes in facility-level mortality during a public health emergency.

Using antenatal care as a platform for malaria surveillance data collection: study protocol.

BACKGROUND: While many malaria-endemic countries have health management information systems that can measure and report malaria trends in a timely manner, these routine systems have limitations. Periodic community cross-sectional household surveys are used to estimate malaria prevalence and intervention coverage but lack geographic granularity and are resource intensive. Incorporating malaria testing for all women at their first antenatal care (ANC) visit (i.e., ANC1) could provide a more timely and granular source of data for monitoring trends in malaria burden and intervention coverage. This article describes a protocol designed to assess if ANC-based surveillance could be a pragmatic tool to monitor malaria. METHODS: This is an observational, cross-sectional study conducted in Benin, Burkina Faso, Mozambique, Nigeria, Tanzania, and Zambia. Pregnant women attending ANC1 in selected health facilities will be tested for malaria infection by rapid diagnostic test and administered a brief questionnaire to capture key indicators of malaria control intervention coverage and care-seeking behaviour. In each location, contemporaneous cross-sectional household surveys will be leveraged to assess correlations between estimates obtained using each method, and the use of ANC data as a tool to track trends in malaria burden and intervention coverage will be validated. RESULTS: This study will assess malaria prevalence at ANC1 aggregated at health facility and district levels, and by gravidity relative to current pregnancy (i.e., gravida 1, gravida 2, and gravida 3 +). ANC1 malaria prevalence will be presented as monthly trends. Additionally, correlation between ANC1 and household survey-derived estimates of malaria prevalence, bed net ownership and use, and care-seeking will be assessed. CONCLUSION: ANC1-based surveillance has the potential to provide a cost-effective, localized measure of malaria prevalence that is representative of the general population and useful for tracking monthly changes in parasite prevalence, as well as providing population-representative estimates of intervention coverage and care-seeking behavior. This study will evaluate the representativeness of these measures and collect information on operational feasibility, usefulness for programmatic decision-making, and potential for scale-up of malaria ANC1 surveillance.

Improving Access to High-Value, High-Cost Medicines: The Use of Subscription Models to Treat Hepatitis C Using Direct-Acting Antivirals in the United States.

State payers may face financial incentives to restrict use of high-cost medications. Yet, restrictions on access to high-value medications may have deleterious effects on population health. Direct-acting antivirals (DAAs), available since 2013, can cure chronic infection with hepatitis C virus (HCV). With prices upward of $90,000 for a treatment course, states have struggled to ensure access to DAAs for Medicaid beneficiaries and the incarcerated, populations with a disproportionate share of HCV. Advance purchase commitments (APCs), wherein a payer commits to purchase a certain quantity of medications at lower prices, offer payers incentives to increase access to high-value medications while also offering companies guaranteed revenue. This article discusses the use of subscription models, a type of APC, to support increased access to high-value DAAs for treating HCV. First, the authors provide background information about HCV, its treatment, and state financing of prescription medications. They then review the implementation of HCV subscription models in two states, Louisiana and Washington, and the early evidence of their impact. The article discusses challenges to evaluating state-sponsored subscription models, and it concludes by discussing implications of subscription models that target DAAs and other high-value, high-cost medicines.

Changes in Health Care Access, Behaviors, and Self-reported Health Among Low-income US Adults Through the Fourth Year of the Affordable Care Act.

BACKGROUND: Health care access increased for low-income Americans under the Affordable Care Act (ACA). It is unknown whether these changes in access were associated with improved self-reported health. OBJECTIVE: Determine changes in health care access, health behaviors, and self-reported health among low-income Americans over the first 4 years of the ACA, stratified by state Medicaid expansion status. DESIGN: Interrupted time series and difference-in-differences analysis. SUBJECTS: Noninstitutionalized US adults (18-64 y) in low income households (<138% federal poverty level) interviewed in the Behavioral Risk Factor Surveillance System 2011-2017 (N=505,824). MEASURES: Self-reported insurance coverage, access to a primary care physician, avoided care due to cost; self-reported general health, days of poor physical health, days of poor mental health days, and days when poor health limited usual activities; self-reported health behaviors, use of preventive services, and diagnoses. RESULTS: Despite increases in access, the ACA was not associated with improved physical or general health among low-income adults during the first 4 years of implementation. However, Medicaid expansion was associated with fewer days spent in poor mental health (-1.1 d/mo, 95% confidence interval: -2.1 to -0.5). There were significant changes in specific health behaviors, preventive service use, and diagnosis patterns during the same time period which may mediate the relationship between the ACA rollout and self-reported health. CONCLUSION: In nationally-representative survey data, we observed improvements in mental but not physical self-reported health among low-income Americans after 4 years of full ACA implementation.

An Economic Analysis of the Implementation of Team-based Collaborative Care in Outpatient General Mental Health Clinics.

BACKGROUND: Collaborative Chronic Care Models represent an evidence-based way to structure care for chronic conditions, including mental health conditions. Few studies, however, have examined the cost implications of collaborative care for mental health. OBJECTIVE: We aimed to conduct an economic analysis of implementing collaborative care in 9 outpatient general mental health clinics. RESEARCH DESIGN: Analyses were derived from a stepped wedge hybrid implementation-effectiveness trial. We conducted cost-minimization analyses from the health system perspective, incorporating implementation costs, outpatient costs, and inpatient costs for the year before collaborative care implementation and the implementation year. We used a difference-in-differences approach and conducted 1-way sensitivity analyses to determine the robustness of results to variations ±15% in model parameters, along with probabilistic sensitivity analysis using Monte Carlo simulation. SUBJECTS: Our treatment group included 5507 patients who were initially engaged in care within 9 outpatient general mental health teams that underwent collaborative care implementation. We compared costs for this group to 45,981 control patients who received mental health treatment as usual at the same medical centers. RESULTS: Collaborative care implementation cost about $40 per patient and was associated with a significant decrease in inpatient costs and a nonsignificant increase in outpatient mental health costs. This implementation was associated with $78 in cost savings per patient. Monte Carlo simulation suggested that implementation was cost saving in 78% of iterations. CONCLUSIONS: Collaborative care implementation for mental health teams was associated with significant reductions in mental health hospitalizations, leading to substantial cost savings of about $1.70 for every dollar spent for implementation.

First-Generation Immigrant Mothers Report Less Spanking of 1-Year-Old Children Compared with Mothers of Other Immigrant Generations.

Introduction The American Academy of Pediatrics discourages spanking, especially of infants and young toddlers. This study examines the association between maternal immigrant generation and reported spanking of 1-year-old children, and whether this association is impacted by domestic violence (DV). Methods We conducted a cross-sectional secondary data analysis using 1-year wave data from the Fragile Families and Child Wellbeing Study. We used descriptive statistics to explore demographic differences among first-generation, second-generation, and third-generation or higher (reference group) mothers. We conducted logistic regression to examine the association between immigrant generation and spanking, controlling for covariates. We used stratified logistic regression to evaluate how experiencing DV may impact the association between immigrant generation and spanking. Results The study included 370 first-generation mothers, 165 second-generation mothers, and 1754 reference group mothers. The prevalence of spanking differed across immigrant generations (p = 0.004). First-generation mothers had statistically significant lower odds of spanking compared with the reference group (adjusted OR 0.26; CI 0.11-0.64). Second-generation mothers also had lower odds of spanking compared with the reference group, although this result did not reach statistical significance (adjusted OR 0.60; CI 0.22-1.63). Mothers' report of experiencing DV appeared to impact the relationship between immigrant generation and spanking. Discussion First-generation immigrant mothers had lower odds of reported spanking compared to reference group mothers, an association which is attenuated for both second-generation immigrant mothers and mothers who have experienced DV. Future work should explore the potential factors that drive variations in spanking between immigrant generations.

Characterization of a Novel Iron Acquisition Activity That Coordinates the Iron Response with Population Density under Iron-Replete Conditions in Bacillus subtilis.

Iron is an essential micronutrient required for the viability of many organisms. Under oxidizing conditions, ferric iron is highly insoluble (∼10-9 to 10-18 M), yet bacteria typically require ∼10-6 M for survival. To overcome this disparity, many bacteria have adopted the use of extracellular iron-chelating siderophores coupled with specific iron-siderophore uptake systems. In the case of Bacillus subtilis, undomesticated strains produce the siderophore bacillibactin. However, many laboratory strains, e.g., JH642, have lost the ability to produce bacillibactin during the process of domestication. In this work, we identified a novel iron acquisition activity from strain JH642 that accumulates in the growth medium and coordinates the iron response with population density. The molecule(s) responsible for this activity was named elemental Fe(II/III) (Efe) acquisition factor because efeUOB (ywbLMN) is required for its activity. Unlike most iron uptake molecules, including siderophores and iron reductases, Efe acquisition factor is present under iron-replete conditions and is regulated independently of Fur repressor. Restoring bacillibactin production in strain JH642 inhibits the activity of Efe acquisition factor, presumably by sequestering available iron. A similar iron acquisition activity is produced from a mutant of Escherichia coli unable to synthesize the siderophore enterobactin. Given the conservation of efeUOB and its regulation by catecholic siderophores in B. subtilis and E. coli, we speculate that Efe acquisition factor is utilized by many bacteria, serves as an alternative to Fur-mediated iron acquisition systems, and provides cells with biologically available iron that would normally be inaccessible during aerobic growth under iron-replete conditions. IMPORTANCE: Iron is an essential micronutrient required for a variety of biological processes, yet ferric iron is highly insoluble during aerobic growth. In this work, we identified a novel iron acquisition activity that coordinates the iron response with population density in laboratory strains of Bacillus subtilis We named the molecule(s) responsible for this activity elemental Fe(II/III) (Efe) acquisition factor after the efeUOB (ywbLMN) operon required for its uptake into cells. Unlike most iron uptake systems, Efe acquisition factor is present under iron-replete conditions and is regulated independently of Fur, the master regulator of the iron response. We speculate that Efe acquisition factor is highly conserved among bacteria and serves as a backup to Fur-mediated iron acquisition systems.

Successful Treatment of Human Plague with Oral Ciprofloxacin.

The US Food and Drug Administration recently approved ciprofloxacin for treatment of plague (Yersina pestis infection) based on animal studies. Published evidence of efficacy in humans is sparse. We report 5 cases of culture-confirmed human plague treated successfully with oral ciprofloxacin, including 1 case of pneumonic plague.

Patterns of Human Plague in Uganda, 2008-2016.

Plague is a highly virulent fleaborne zoonosis that occurs throughout many parts of the world; most suspected human cases are reported from resource-poor settings in sub-Saharan Africa. During 2008-2016, a combination of active surveillance and laboratory testing in the plague-endemic West Nile region of Uganda yielded 255 suspected human plague cases; approximately one third were laboratory confirmed by bacterial culture or serology. Although the mortality rate was 7% among suspected cases, it was 26% among persons with laboratory-confirmed plague. Reports of an unusual number of dead rats in a patient's village around the time of illness onset was significantly associated with laboratory confirmation of plague. This descriptive summary of human plague in Uganda highlights the episodic nature of the disease, as well as the potential that, even in endemic areas, illnesses of other etiologies might be being mistaken for plague.

Novel mechanisms of controlling the activities of the transcription factors Spo0A and ComA by the plasmid-encoded quorum sensing regulators Rap60-Phr60 in Bacillus subtilis.

Bacillus subtilis and its closest relatives have multiple rap-phr quorum sensing gene pairs that coordinate a variety of physiological processes with population density. Extra-chromosomal rap-phr genes are also present on mobile genetic elements, yet relatively little is known about their function. In this work, we demonstrate that Rap60-Phr60 from plasmid pTA1060 coordinates a variety of biological processes with population density including sporulation, cannibalism, biofilm formation and genetic competence. Similar to other Rap proteins that control sporulation, Rap60 modulates phosphorylation of the transcription factor Spo0A by acting as a phosphatase of Spo0F∼P, an intermediate of the sporulation phosphorelay system. Additionally, Rap60 plays a noncanonical role in regulating the autophosphorylation of the sporulation-specific kinase KinA, a novel activity for Rap proteins. In contrast, Rap proteins that modulate genetic competence interfere with DNA binding by the transcription factor ComA. Rap60 regulates the activity of ComA in a unique manner by forming a Rap60-ComA-DNA ternary complex that inhibits transcription of target genes. Taken together, this work provides new insight into two novel mechanisms of regulating Spo0A and ComA by Rap60 and expands our general understanding of how plasmid-encoded quorum sensing pairs regulate important biological processes.

Novel use of the AngioVac® system to remove thrombus during simultaneous extracorporeal membrane oxygenation life support.

Extracorporeal membrane oxygenation (ECMO) was introduced to clinical medicine over 40 years ago. While initially used as a treatment for acute respiratory failure in infants, the use of ECMO has grown to include respiratory and circulatory failure in both children and adults, cardiogenic shock, pulmonary embolism, sepsis, trauma, malignancy, pulmonary hemorrhage and as a treatment for hypothermic drowning.(1) Recent technological improvements in ECMO circuitry make it possible to minimize anticoagulation of the ECMO patient, decreasing the incidence of bleeding. Thrombus deposition within the ECMO circuit can be a life-threating complication. ECMO circuit thrombus can be contained in the circuit, adherent to cannula and deposited within the patient. The ability to remove thrombus while the patient remains on ECMO support could be a life-saving measure for some patients. The present case report outlines use of the AngioVac(®) thrombus removal system in concert with ECMO to remove a large thrombus adherent to an ECMO cannula.

Clinical Outreach Training and Supportive Supervision Quality-of-Care Analysis: Impact of Readiness Factors on Health Worker Competencies in Malaria Case Management in Cameroon, Mali, and Niger.

Improving the quality of malaria clinical case management in health facilities is key to improving health outcomes in patients. The U.S. President's Malaria Initiative Impact Malaria Project has supported implementation of the Outreach Training and Supportive Supervision (OTSS) approach in 11 African countries to improve the quality of malaria care in health facilities through the collection and analysis of observation-based data on health facility readiness and health provider competency in malaria case management. We conducted a secondary analysis of longitudinal data collected during routine supervision in Cameroon (April 2021-March 2022), Mali (October 2020-December 2021), and Niger (November 2020-September 2021) using digitized checklists to assess how service readiness affects health worker competencies in managing patients with fever correctly and providing those with confirmed uncomplicated malaria cases with appropriate treatment and referral. Linear or logistic regression analyses were conducted to assess the effect of facility readiness and its components on observed health worker competencies. All countries demonstrated significant associations between health facility readiness and malaria case management competencies. Data from three rounds of OTSS visits in Cameroon, Mali, and Niger showed a statistically significant positive association between greater facility readiness scores (including the availability of commodities, materials, and trained staff) and health worker competency in case management. These findings provide evidence that health worker performance is likely affected by the tools and training available to them. These results reinforce the need for necessary tools and properly trained staff if high-quality malaria case management services are to be delivered at health facilities.

Trends in U.S. self-reported health and self-care behaviors during the COVID-19 pandemic.

IMPORTANCE: The COVID-19 pandemic represents a unique stressor in Americans' daily lives and access to health services. However, it remains unclear how the pandemic impacted perceived health status and engagement in health-related behaviors. OBJECTIVE: To assess changes in self-reported health outcomes during the COVID-19 pandemic, and to explore trends in health-related behaviors that may underlie the observed health changes. DESIGN: Interrupted time series stratified by age, gender, race/ethnicity, educational attainment, household income, and employment status. SETTING: United States. PARTICIPANTS: All adult respondents to the 2016-2020 Behavioral Risk Factor Surveillance System (N = 2,146,384). EXPOSURE: Survey completion following the U.S. public health emergency declaration (March-December 2020). January 2019 to February 2020 served as our reference period. MAIN OUTCOMES AND MEASURES: Self-reported health outcomes included the number of days per month that respondents spent in poor mental health, physical health, or when poor health prevented their usual activities of daily living. Self-reported health behaviors included the number of hours slept per day, number of days in the past month where alcohol was consumed, participation in any exercise, and current smoking status. RESULTS: The national rate of days spent in poor physical health decreased overall (-1.00 days, 95% CI: -1.10 to -0.90) and for all analyzed subgroups. The rate of poor mental health days or days when poor health prevented usual activities did not change overall but exhibited substantial heterogeneity by subgroup. We also observed overall increases in mean sleep hours per day (+0.09, 95% CI 0.05 to 0.13), the percentage of adults who report any exercise activity (+3.28%, 95% CI 2.48 to 4.09), increased alcohol consumption days (0.27, 95% CI 0.18 to 0.37), and decreased smoking prevalence (-1.11%, 95% CI -1.39 to -0.83). CONCLUSIONS AND RELEVANCE: The COVID-19 pandemic had deleterious but heterogeneous effects on mental health, days when poor health prevented usual activities, and alcohol consumption. In contrast, the pandemic's onset was associated with improvements in physical health, mean hours of sleep per day, exercise participation, and smoking status. These findings highlight the need for targeted outreach and interventions to improve mental health in individuals who may be disproportionately affected by the pandemic.

Validation of the Clinicians' Cultural Sensitivity Survey for Use in Pediatric Primary Care Settings.

Incorporating cultural sensitivity into healthcare settings is important to deliver high-quality and equitable care, particularly for marginalized communities who are non-White, non-English speaking, or immigrants. The Clinicians' Cultural Sensitivity Survey (CCSS) was developed as a patient-reported survey assessing clinicians' recognition of cultural factors affecting care quality for older Latino patients; however, this instrument has not been adapted for use in pediatric primary care. Our objective was to examine the validity and reliability of a modified CCSS that was adapted for use with parents of pediatric patients. A convenience sampling approach was used to identify eligible parents during well-child visits at an urban pediatric primary care clinic. Parents were administered the CCSS via electronic tablet in a private location. We first conducted exploratory factor analyses (EFAs) to explore the dimensionality of survey responses in the adapted CCSS, and then conducted a series of confirmatory factor analyses (CFAs) using maximum likelihood estimation based on the results of the EFAs. Exploratory and confirmatory factor analyses (N = 212 parent surveys) supported a three-factor structure assessing racial discrimination ([Formula: see text]=0.96), culturally-affirming practices ([Formula: see text]=0.86), and causal attribution of health problems ([Formula: see text]=0.85). In CFAs, the three-factor model also outperformed other potential factor structures in terms of fit statistics including scaled root mean square error approximation (0.098), Tucker-Lewis Index (0.936), Comparative Fit Index (0.950), and demonstrated adequate fit according to the standardized root mean square residual (0.061). Our findings support the internal consistency, reliability, and construct validity of the adapted CCSS for use in a pediatric population.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. DATA SOURCES: Administrative data from the Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN: We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. DATA COLLECTION: We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. PRINCIPAL FINDINGS: Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. CONCLUSIONS: Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Impact of notification policy on patient-before-clinician review of immediately released test results.

The 21st Century Cures Act mandates immediate availability of test results upon request. The Cures Act does not require that patients be informed of results, but many organizations send notifications when results become available. Our medical center implemented 2 sequential policies: immediate notifications for all results, and notifications only to patients who opt in. We used over 2 years of data from Vanderbilt University Medical Center to measure the effect of these policies on rates of patient-before-clinician result review and patient-initiated messaging using interrupted time series analysis. When releasing test results with immediate notification, the proportion of patient-before-clinician review increased 4-fold and the proportion of patients who sent messages rose 3%. After transition to opt-in notifications, patient-before-clinician review decreased 2.4% and patient-initiated messaging decreased 0.4%. Replacing automated notifications with an opt-in policy provides patients flexibility to indicate their preferences but may not substantially alleviate clinicians' messaging workload.

Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019.

Importance: The Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear. Objectives: To describe individual marketplace enrollees' metal tier selections by risk score and assess enrollees' health spending by metal tier, risk score, and spending type. Design, Setting, and Participants: This retrospective, cross-sectional study analyzed claims data from the Wakely Consulting Group ACA database, a deidentified claims database built on data voluntarily submitted by insurers. Enrollees with continuous, full-year enrollment in on-exchange or off-exchange ACA-qualified health plans during the 2019 contract year were included. Data analysis was conducted from March 2021 to January 2023. Main Outcomes and Measures: Enrollment totals, total spending, and out-of-pocket cost were calculated, stratified by metal tier and the Department of Health and Human Services (HHS) Hierarchical Condition Category (HCC) risk score for 2019. Results: Enrollment and claims data were obtained for 1 317 707 enrollees (53.5% female; mean [SD] age, 46.35 [13.43] years) across all census areas, age groups, and sexes. Of these, 34.6% were on plans with cost-sharing reductions (CSRs), 75.5% did not have an assigned HCC, and 84.0% submitted at least 1 claim. Compared with enrollees in bronze plans (17.2%), enrollees were more likely to be classified in the top HHS-HCC risk quartile if they selected platinum (42.0%), gold (34.4%), or silver (29.7%) plans. The highest share of enrollees with $0 total spending was noted with the catastrophic (26.4%) and bronze (22.7%) plans, while gold plans had the lowest share (8.1%). Median total spending was lower among bronze plan enrollees ($593; IQR, $28-$2100) vs platinum ($4111; IQR, $992-$15 821) or gold ($2675; IQR, $728-$9070). Within the top risk score decile, CSR enrollees had less average total spending than any other metal tier by more than 10%. Conclusions and Relevance: In this cross-sectional study of the ACA individual marketplace, enrollees who selected plans with higher actuarial value also had greater mean HHS-HCC risk scores and health spending. The findings suggest these differences may be associated with variation in benefit generosity by metal tier, enrollee's perceptions of future health needs, or other barriers to care access.