Rural and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum.

OBJECTIVE: To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents. METHODS: We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016-2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison. RESULTS: Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural-urban differences in uninsurance persisted across both Medicaid expansion and non-expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth. CONCLUSION: Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural-urban inequities in maternity care access and maternal health.

Trends in US Emergency Department Use After Sexual Assault, 2006-2019.

Importance: Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality. Objective: To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019. Design, Setting, and Participants: This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation's Uniform Crime Reporting Program, which includes annual crime data from more than 18 000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022. Main Outcomes and Measures: Annual SA-related ED visits, subsequent hospital admissions, and associated patient-related factors (age, sex, race and ethnicity, income quartile, and insurance) were analyzed using descriptive statistics. Results: Data were from 120 to 143 million weighted ED visits reported annually from 2006 through 2019. Sexual assault-related ED visits increased more than 1533.0% from 3607 in 2006 to 55 296 in 2019. Concurrently, admission rates for these visits declined from 12.6% to 4.3%. Female, younger, and lower-income individuals were more likely to present to the ED after SA. Older and Medicaid-insured patients were more likely to be admitted. Overall, the rate of ED visits for SA outpaced law enforcement reporting. Conclusions and Relevance: This cross-sectional study found that US adult SA ED visits increased from 2006 through 2019 and highlighted the populations who access emergency care most frequently and who more likely need inpatient care. These data can inform policies and the programming needed to support this vulnerable population.

Racial/Ethnic Disparities in Postpartum Health Insurance Coverage Among Rural and Urban U.S. Residents.

Objective: Half of maternal deaths occur during the postpartum year, with data suggesting greater risks among Black, Indigenous, and people of color (BIPOC) and rural residents. Being insured after childbirth improves postpartum health-related outcomes, and recent policy efforts focus on extending postpartum Medicaid coverage from 60 days to 1 year postpartum. The purpose of this study is to describe postpartum health insurance coverage for rural and urban U.S. residents who are BIPOC compared to those who are white. Materials and Methods: Using data from the 2016-2019 Pregnancy Risk Assessment Monitoring System (n = 150,273), we describe health insurance coverage categorized as Medicaid, commercial, or uninsured at the time of childbirth and postpartum. We measured continuity of insurance coverage across these periods, focusing on postpartum Medicaid disruptions. Analyses were conducted among white and BIPOC residents from rural and urban U.S. counties. Results: Three-quarters (75.3%) of rural white people and 85.3% of urban white people were continuously insured from childbirth to postpartum, compared to 60.5% of rural BIPOC people and 65.6% of urban BIPOC people. Postpartum insurance disruptions were frequent among people with Medicaid coverage at childbirth, particularly among BIPOC individuals, compared to those with private insurance; 17.0% of rural BIPOC residents had Medicaid at birth and became uninsured postpartum compared with 3.4% of urban white people. Conclusions: Health insurance coverage at childbirth, postpartum, and across these timepoints varies by race/ethnicity and rural compared with urban residents. Policy efforts to extend postpartum Medicaid coverage may reduce inequities at the intersection of racial/ethnic identity and rural geography.