Medical Debt and Related Financial Consequences Among Older African American and White Adults.

OBJECTIVES: To evaluate African American-White differences in medical debt among older adults and the extent to which economic and health factors explained these. METHODS: We used nationally representative data from the 2007 and 2010 US Health Tracking Household Survey (n = 5838) and computed population-based estimates of medical debt attributable to economic and health factors with adjustment for age, gender, marital status, and education. RESULTS: African Americans had 2.6 times higher odds of medical debt (odds ratio = 2.62; 95% confidence interval = 1.85, 3.72) than did Whites. Health status explained 22.8% of the observed disparity, and income and insurance explained 19.4%. These factors combined explained 42.4% of the observed disparity. In addition, African Americans were more likely to be contacted by a collection agency and to borrow money because of medical debt, whereas Whites were more likely to use savings. CONCLUSIONS: African Americans incur substantial medical debt compared with Whites, and more than 40% of this is mediated by health status, income, and insurance disparities. Public health implications. In Medicare, low-income beneficiaries, especially low-income African Americans with poor health status, should be protected from the unintended financial consequences of cost-reduction strategies.

African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors.

BACKGROUND: Although research focused on African Americans with mental illness has been increasing, few researchers have addressed gender and age differences in beliefs, attitudes, and coping. OBJECTIVE: The aim of this study was to examine African Americans' beliefs about mental illness, attitudes toward seeking mental health services, and preferred coping behaviors and whether these variables differ by gender and age. METHODS: An exploratory, cross-sectional survey design was used. Participants were 272 community-dwelling African Americans aged 25-72 years. Data analysis included descriptive statistics and general linear regression models. RESULTS: Depression was the most common mental illness, and there were no gender differences in prevalence. Both men and women believed that they knew some of the symptoms and causal factors of mental illness. Their attitudes suggested they are not very open to acknowledging psychological problems, are very concerned about stigma associated with mental illness, and are somewhat open to seeking mental health services, but they prefer religious coping. Significant gender and age differences were evident in attitudes and preferred coping. DISCUSSION: Our findings have implications for gender- and age-specific psychoeducation interventions and future research. For instance, psychoeducation or community awareness programs designed to increase openness to psychological problems and reduce stigma are needed. Also, exploration of partnerships between faith-based organizations and mental health services could be helpful to African Americans.

Exploring differences in trust in doctors among African American men and women.

OBJECTIVES: Low trust in doctors may partially account for African Americans' adverse health outcomes. Understanding the drivers of low trust can guide health care policy to improve trust and delivery of health care for African Americans. This study examines gender differences in trust in doctors among African Americans and explores factors differentially associated with low level trust for men vs women. METHODS AND MEASURES: Cross-sectional analysis of 3649 African Americans using data from the 2003-2004 Community Tracking Study Household Survey, including 4 items measuring trust in doctors (range, 1 = lowest trust and 5 = highest trust). Items were assessed separately and as an index measure. Linear regression analyses adjusted for multiple confounders and accounted for complex data sampling. RESULTS: Overall, men were less trusting of doctors than women. However, men differed from women only on 2 trust measures: "doctor influenced by insurance rules" (adjusted mean scores = 2.48 for men and 2.79 for women, p = .001) and "doctor performs unnecessary tests" (adjusted mean score = 4.00 for men and 4.28 for women, p = .010). Common correlates of low trust in men and women included less than high school education, age of at least 65 years, and having no usual source of care. Unique correlates of lower trust for men included rural living and no doctor visit in the preceding year. Unique correlates for women included low income and poorer health status. CONCLUSIONS: There are differential predictors of low trust among African American men vs women, underscoring the need for gender-based and health care system-level approaches to improve African Americans' trust and health outcomes.

Problems paying medical bills and mental health symptoms post-Affordable Care Act.

Healthcare affordability is a worry for many Americans. We examine whether the relationship between having problems paying medical bills and mental health problems changed as the Affordable Care Act (ACA) was implemented, which increased health insurance coverage. Data from the 2013-2016 Health Reform Monitoring Survey, a survey of Americans aged 18-64, were used. Using zero-inflated negative binomial regression, adjusted for predisposing, enabling, and need factors, we examined differences in days of mental health symptoms by problems paying medical bills (n = 85,430). From 2013 to 2016, the rates of uninsured and problems paying medical bills decreased from 15.1% to 9.0% and 22.0% to 18.6%, respectively. Having one or more days of mental health symptoms increased from 39.3% to 42.9%. Individuals who reported problems paying medical bills had more days of mental health symptoms (Beta = 0.133, p < 0.001) than those who did not have this problem. Insurance was not significantly associated with days of mental health symptoms. Over the 4-year period, there were not significant differences in days of mental health symptoms by problems paying medical bills or insurance status. Despite improvements in coverage, the relationship between problems paying medical bills and mental health symptoms was not modified.

Disentangling the influence of socioeconomic status on differences between African American and white women in unmet medical needs.

OBJECTIVES: We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs. METHODS: Data from the 2003-2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women. RESULTS: No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P = .59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.42, 0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24, 2.31) and 2.18 (95% CI = 1.25, 3.82) among African American women with 13 to 15 years of education and 16 years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women. CONCLUSIONS: Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be an important driver of health disparities, representing a fruitful area for future interventions.

The effects of socioeconomic status on participation in care among middle-aged and older adults.

OBJECTIVE: This study assesses the effects of socioeconomic status (education and poverty) on seeking health information and subsequent use of this information during the medical encounter. METHOD: Data on 19,944 adults (aged 45 and older) were drawn from the 2000-2001 Household Component of the Community Tracking Study, a nationally representative survey of non-institutionalized individuals. RESULTS: Higher levels of education were associated with a greater likelihood of seeking health information and mentioning information to physicians. The poor and near poor were less likely to seek health information, but only the near poor were significantly less likely to mention information to the physician. DISCUSSION: These findings underscore the importance of education in the acquisition and use of health information among middle-aged and older adults.

Differences in Problems Paying Medical Bills between African Americans and Whites from 2007 and 2009: the Underlying Role of Health Status.

OBJECTIVES: Although the proportion of people reporting problems paying medical bills has declined in the aftermath of the Great Recession, it is unclear if this decline has been caused by self-rationing of care, particularly among disadvantaged groups. We examined African American-White differences in problems paying medical bills prevalence along with factors which may account for observed differences. DESIGN: We used cross-sectional data from 2007 (N = 13,064) and 2010 (N = 11,873) waves of the nationally representative, Health Tracking Household Survey. Logistic regression analyses, accounting for complex survey design and weights, were performed to compute population-based estimates. RESULTS: Overall, the prevalence of problems paying medical bills was 18.3 % in 2007 and 19.8 % in 2010. African Americans more frequently reported having problems paying medical bills than Whites. Among African Americans, problems paying medical bills decreased from 30 % in 2007 to 25 % in 2010, which was largely explained by fewer problems reported by those in poor/fair health. Problems paying medical bills significantly declined from 44 % in 2007 to 33 % in 2010 for African Americans in poor/fair health, but remained almost constant for those in good health and very good/excellent health. CONCLUSION: Our findings suggest that African Americans in poor health may be rationing or forgoing necessary care as a result of the recession, which could increase existing health disparities and future health spending. Efforts to reduce racial/ethnic disparities may depend on the extent to which the lingering effects of the Great Recession are mitigated.

Health information seeking and use outside of the medical encounter: is it associated with race and ethnicity?

Increasing numbers of adults in the United States of America (USA) are seeking and using health information within their medical encounters. The theory of uncertainty management suggests that patients reduce health care uncertainty by increasing their understanding of disease etiology or treatment options, improving patient-doctor communication, and enhancing knowledge of disease self-management through health information seeking. However, research shows racial and ethnic minorities are less likely than Whites to seek health information and use it in their physician visits. How racial and ethnic minorities use health information outside of their medical encounters is unknown. In this study we used data from the 2007 USA Health Tracking Household survey, a nationally-representative survey of civilian, non-institutionalized Americans (n = 12,549). Using logistic regression we found African Americans were no different from Whites in seeking health information and using it when they talked with their doctors. Latinos were significantly less likely than Whites to seek health information and less likely to use it when they talked with their doctors. But, among those who sought health information, African Americans and Latinos were significantly more likely than Whites to use health information to change their approach to maintaining their health and better understand how to treat illnesses. Also, education significantly moderated the relationship between race/ethnicity and health information seeking. However, results were mixed for education as a moderator in the relationship between race/ethnicity and health information use. Future research should focus on interventions to improve how African Americans and Latinos interface with providers and ensure that health information sought and used outside of their medical encounters augments treatment protocols.

Gender differences in financial hardships of medical debt.

Women are more likely than men to forgo, delay, and ration medical care because of medical debt. Using 2003-04 Community Tracking Study Household Survey data, this study examined gender differences in five financial hardships associated with medical debt. Regression analyses accounting for predisposing, enabling, and need factors of health services use indicated women were less likely to report being contacted by a collection agency (b=-0.15, p<.05), using savings (b=-0.23, p<.005), or having any financial hardships associated with medical debt (b=-0.24, p<.05). There were no significant gender differences in putting off major purchases, borrowing money, and problems paying for necessities. Similarly, there were positive and negative relationships between medical debt financial hardships and income, insurance, and health status. Findings suggest that making health care affordable and equitable is critically important for both men and women. Research is needed to understand the differential impact of medical debt, especially among disadvantaged populations.

Health information technology and physician career satisfaction.

PURPOSE: Health information technology (HIT) and physician career satisfaction are associated with higher-quality medical care. However, the link between HIT and physician career satisfaction, which could potentially reduce provider burnout and attrition, has not been fully examined. This study uses a nationally representative survey to assess the association between key forms of HIT and career satisfaction among primary care physicians (PCPs) and specialty physicians. METHODS: We performed a retrospective, cross-sectional analysis of physician career satisfaction using the Community Tracking Study Physician Survey, 2004-2005. Nine specific types of HIT as well as the overall adoption of HIT in the practice were examined using multivariate logistic regression. RESULTS: Physicians who used five to six (odds ratio [OR] = 1.46) or seven to nine (OR = 1.47) types of HIT were more likely than physicians who used zero to two types of HIT to be "very satisfied" with their careers. Information technology usages for communicating with other physicians (OR = 1.31) and e-mailing patients (OR = 1.35) were positively associated with career satisfaction. PCPs who used technology to write prescriptions were less likely to report career satisfaction (OR = 0.67), while specialists who wrote notes using technology were less likely to report career satisfaction (OR = 0.75). CONCLUSIONS: Using more information technology was the strongest positive predictor of physicians being very satisfied with their careers. Toward that end, healthcare organizations working in conjunction with providers should consider exploring ways to integrate various forms of HIT into practice.

Separate and unequal: clinics where minority and nonminority patients receive primary care.

BACKGROUND: Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS: Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS: Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION: Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.