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.

Abolition and harm reduction in the struggle for "Care, Not Cages".

Care that is organized around the principles of harm reduction and the movement for police and prison abolition has the potential to uproot and transform structural causes of harm and violence, in the interconnected crises of drug-related harm, policing, and punishment. The United States' crisis of overdose and drug-related harm and its system of policing and punishment are historically and empirically linked phenomena. The abandonment of people whose use of drugs leads to their premature death, in the form of an overdose, is directly and indirectly connected to wider systems of criminalization and incarceration that also produce premature suffering and death. Organizations advocating for harm reduction for people who use drugs (PWUD) and organizations seeking the abolition of police and prisons have developed in parallel albeit with different genealogies. We examine the historical origins, principles, and practical applications of the two movements to identify points of overlap and lessons to be learned for the public health goals of addressing and preventing premature suffering and death in the United States. A case study of Los Angeles (LA) County, where elected officials have promised a new paradigm of care, not punishment, frames our analysis. We show how the principles and strategies of harm reduction and abolition are both necessary to practically realizing a paradigm of care, not punishment, and achieving system transformation.

Involuntary Commitment as "Carceral-Health Service": From Healthcare-to-Prison Pipeline to a Public Health Abolition Praxis.

Involuntary commitment links the healthcare, public health, and legislative systems to act as a "carceral health-service." While masquerading as more humane and medicalized, such coercive modalities nevertheless further reinforce the systems, structures, practices, and policies of structural oppression and white supremacy. We argue that due to involuntary commitment's inextricable connection to the carceral system, and a longer history of violent social control, this legal framework cannot and must not be held out as a viable alternative to the criminal legal system responses to behavioral and mental health challenges. Instead, this article proposes true alternatives to incarceration that are centered on liberation that seeks to shrink the carceral system's grasp on individuals' and communities' lives. In this, we draw inspiration from street-level praxis and action theory emanating from grassroots organizations and community organizers across the country under a Public Health Abolition framework.

Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis.

BACKGROUND: Sharp exacerbations of the US overdose crisis are linked to polysubstance use of synthetic compounds. Xylazine is a veterinary tranquilizer, long noted in the street opioid supply of Puerto Rico, and more recently Philadelphia. Yet its national trends, geographic distribution, and health risks are poorly characterized. METHODS: In this sequential mixed-methods study, xylazine was increasingly observed by ethnographers in Philadelphia among drug-sellers and people who inject drugs (PWID). Subsequently, we systematically searched for records describing xylazine-present overdose mortality across the US and assessed time trends and overlap with other drugs. RESULTS: In 10 jurisdictions - representing all four US Census Regions - xylazine was increasingly present in overdose deaths, rising from 0.36% of deaths in 015m 6.7% in 2020. The highest xylazine prevalence data was observed in Philadelphia, (25.8% of deaths), followed by Maryland (19.3%) and Connecticut (10.2%). Illicitly-manufactured-fentanyls were present in 98.4% of xylazine-present-overdose-deaths - suggesting a strong ecological link - as well as cocaine (45.4%), benzodiazepines (28.4%), heroin (23.3%), and alcohol (19.7%). PWID in Philadelphia described xylazine as a sought-after adulterant that lengthens the short duration of fentanyl injections. They also linked it to increased risk of soft tissue infection and naloxone-resistant overdose. CONCLUSIONS: Xylazine is increasingly present in overdose deaths, linked to the proliferation of illicitly-manufactured-fentanyls. Ethnographic accounts associate it with profound risks for PWID. Nevertheless, many jurisdictions do not routinely test for xylazine, and it is not comprehensively tracked nationally. Further efforts are needed to provide PWID with services that can help minimize additional risks associated with a shifting drug supply.

Elevated Mortality Among People Experiencing Homelessness With COVID-19.

We reviewed publicly available data from major US health jurisdictions to compare severe acute respiratory syndrome coronavirus 2 case fatality rates in people experiencing homelessness with the general population. The case fatality rate among people experiencing homelessness was 1.3 times (95% CI, 1.1-1.5) that of the general population, suggesting that people experiencing homelessness should be prioritized for vaccination.