Disparities in Mistreatment During Childbirth.

Importance: Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US. Objectives: To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences. Design, Setting, and Participants: This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months' post partum. Data were collected from January 1, 2021, to March 31, 2022. Exposures: Demographic, social, clinical, and birth characteristics that have been associated with patients' health care experiences. Main Outcomes and Measures: Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs. Results: The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being "ignored, refused request for help, or failed to respond in a timely manner" (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous. Conclusions and Relevance: This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Health Insurance Coverage and Access to Care by Sexual Orientation During the COVID-19 Pandemic: United States, January 2021-February 2022.

Objectives. To compare health insurance coverage and access to care by sex and sexual minority status during the COVID-19 pandemic and assess whether lack of insurance hindered access to care by sexual minority status. Methods. Using Behavioral Risk Factor Surveillance System data (January 2021-February 2022), we examined differences by sex and sexual orientation among 158 722 adults aged 18 to 64 years living in 34 states. Outcomes were health insurance coverage type and 3 access to care measures. Results. Sexual minority women were significantly more likely to be uninsured than were heterosexual women, and lack of insurance widened the magnitude of disparity by sexual minority status in all measures of access. Compared with heterosexual men with health insurance, sexual minority men with health insurance were significantly more likely to report being unable to afford necessary care. Conclusions. During the pandemic, 1 in 8 sexual minority adults living in 34 study states were uninsured. Among sexual minority women, lack of insurance widened inequities in access to care. There were inequities among sexual minority men with health insurance. Public Health Implications. Sexual minority adults may be disproportionately affected by the unwinding of the COVID-19 public health emergency and may require tailored efforts to mitigate insurance coverage loss. (Am J Public Health. 2024;114(1):118-128. https://doi.org/10.2105/AJPH.2023.307446).

The Health And Social Needs Of Medicaid Beneficiaries In The Postpartum Year: Evidence From A Multistate Survey.

As of September 2023, thirty-seven states and Washington, D.C., had adopted the option in the American Rescue Plan Act of 2021 to extend pregnancy Medicaid eligibility to one year postpartum. To inform state initiatives to support this newly covered population, we conducted a representative survey of postpartum people in six states and New York City from January 2021 to March 2022. Compared with respondents who had commercial insurance at the time of childbirth, Medicaid respondents were less likely to have a usual source of care and reported less use of primary, specialty, and dental care in the postpartum year. Depression symptoms and social concerns such as food insecurity, intimate partner violence, and financial strain were significantly higher in the Medicaid population. Rates of anxiety symptoms, delaying or not getting needed care, and unsatisfactory child care were similar in both populations. Our findings suggest that postpartum Medicaid extensions should be coupled with state initiatives to address beneficiaries' health and social needs. National investments in data collection on postpartum people will be critical to support evidence-based policy making to improve maternal health and well-being.

Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age.

Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Materials and Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.

Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015.

Importance: Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage. Objective: To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015. Design, Setting, and Participants: This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021. Exposures: Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. Main Outcomes and Measures: Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders. Results: Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04). Conclusions and Relevance: In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Effect of Expanding the Earned Income Tax Credit to Americans Without Dependent Children on Psychological Distress.

Antipoverty policies have the potential to improve mental health. We conducted a randomized trial (Paycheck Plus Health Study Randomized Controlled Trial, New York, New York) to investigate whether a 4-fold increase in the Earned Income Tax Credit for low-income Americans without dependent children would reduce psychological distress relative to the current federal credit. Between 2013 and 2014, a total of 5,968 participants were recruited; 2,997 were randomly assigned to the treatment group and 2,971 were assigned to the control group. Survey data were collected 32 months postrandomization (n = 4,749). Eligibility for the program increased employment by 1.9 percentage points and after-bonus earnings by 6% ($635/year), on average, over the 3 years of the study. Treatment was associated with a marginally statistically significant decline in psychological distress, as measured by the 6-item Kessler Psychological Distress Scale, relative to the control group (score change = -0.30 points, 95% confidence interval (CI): -0.63, 0.03; P = 0.072). Women in the treated group experienced a half-point reduction in psychological distress (score change = -0.55 points, 95% CI: -0.97, -0.13; P = 0.032), and noncustodial parents had a 1.36-point reduction (95% CI: -2.24, -0.49; P = 0.011). Expansion of a large antipoverty program to individuals without dependent children reduced psychological distress for women and noncustodial parents-the groups that benefitted the most in terms of increased after-bonus earnings.

Work-related and personal predictors of COVID-19 transmission: evidence from the UK and USA.

OBJECTIVE: To develop evidence of work-related and personal predictors of COVID-19 transmission. SETTING AND RESPONDENTS: Data are drawn from a population survey of individuals in the USA and UK conducted in June 2020. BACKGROUND METHODS: Regression models are estimated for 1467 individuals in which reported evidence of infection depends on work-related factors as well as a variety of personal controls. RESULTS: The following themes emerge from the analysis. First, a range of work-related factors are significant sources of variation in COVID-19 infection as indicated by self-reports of medical diagnosis or symptoms. This includes evidence about workplace types, consultation about safety and union membership. The partial effect of transport-related employment in regression models makes the chance of infection over three times more likely while in univariate analyses, transport-related work increases the risk of infection by over 40 times in the USA. Second, there is evidence that some home-related factors are significant predictors of infection, most notably the sharing of accommodation or a kitchen. Third, there is some evidence that behavioural factors and personal traits (including risk preference, extraversion and height) are also important. CONCLUSIONS: The paper concludes that predictors of transmission relate to work, transport, home and personal factors. Transport-related work settings are by far the greatest source of risk and so should be a focus of prevention policies. In addition, surveys of the sort developed in this paper are an important source of information on transmission pathways within the community.

Association of Medicaid vs Marketplace Eligibility on Maternal Coverage and Access With Prenatal and Postpartum Care.

Importance: Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown. Objective: To compare maternal coverage and care by Medicaid vs marketplace eligibility. Design, Setting, and Participants: A retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey. Exposures: Eligibility for Medicaid or marketplace coverage under the Affordable Care Act. Main Outcomes and Measures: Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use. Results: The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified. Conclusions and Relevance: In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

A longitudinal analysis of violence and healthcare service utilization in Mexico.

OBJECTIVES: We analyze the degree to which community violence in Mexico, largely due to organized crime violence, affects health care service utilization. METHODS: This study exploits temporal and geographic variation in monthly county-level homicide rates, matching outpatient service utilization from individual longitudinal measures. Sensitivity analyses test for an age specific concentration of violence, respiratory conditions that are likely unrelated to violence, insurance status and health center availability per capita. We test for distributional responses to violence by urban and rural localities. RESULTS: The likelihood of service utilization increases by 5.2% with each additional homicide per 100,000. When we include self-reported health conditions in the model, our main coefficient remains significant at 4.5%. We find no added effect to our results from interaction terms for age specific concentration of violence, respiratory conditions, insurance status, or health center availability. A substantial increase of 11.7% in the likelihood of service utilization occurs in localities with > = 100,000 inhabitants, suggesting that service utilization is sensitive to the location of violence. CONCLUSIONS: Results highlight the relationship between and increase in violence at the local level and an increase in health care service utilization. This study is among the first to examine this relationship empirically in Mexico. Future research is needed to shed more light on this relationship and its mechanisms.

Extending Postpartum Medicaid: State and Federal Policy Options during and after COVID-19.

The United States is facing a maternal health crisis with rising rates of maternal mortality and morbidity and stark disparities in maternal outcomes by race and socioeconomic status. Among the efforts to address this issue, one policy proposal is gaining particular traction: extending the period of Medicaid eligibility for pregnant women beyond 60 days after childbirth. The authors examine the legislative and regulatory pathways most readily available for extending postpartum Medicaid, including their relative political, economic, and public health trade-offs. They also review the state and federal policy activity to date and discuss the impact of the COVID-19 pandemic on the prospects for policy change.

The Health Effects Of Expanding The Earned Income Tax Credit: Results From New York City.

Antipoverty policies may hold promise as tools to improve health and reduce mortality rates among low-income Americans. We examined the health effects of the New York City Paycheck Plus randomized controlled trial. Paycheck Plus tests the impact of a potential fourfold increase in the Earned Income Tax Credit for low-income Americans without dependent children. Starting in 2015, Paycheck Plus offered 5,968 study participants a credit of up to $2,000 at tax time (treatment) or the standard credit of about $500 (control). Health-related quality of life and other outcomes for a representative subset of these participants (n = 3,289) were compared to those of a control group thirty-two months after randomization. The intervention had a modest positive effect on employment and earnings, particularly among women. It had no effect on health-related quality of life for the overall sample, but women realized significant improvements.

Can Medicaid Expansion Prevent Housing Evictions?

Evictions are increasingly recognized as a serious concern facing low-income households. This study evaluated whether expansions of Medicaid can prevent evictions from occurring. We examined data from a privately licensed database of eviction records in fourteen states (286 counties) and used a difference-in-differences research design to compare rates of eviction before and after California's early Medicaid expansion (51 counties). Early Medicaid expansion in California was associated with a reduction in the number of evictions, with 24.5 fewer evictions per month in each county from a pre-expansion average of 224.7. These results imply that for every thousand new Medicaid enrollees in California, Medicaid expansion was associated with roughly twenty-two fewer evictions per year. Additionally, we found a 2.9-percentage-point reduction in evictions per capita associated with early expansion. The effects were concentrated among counties with the highest pre-expansion rates of uninsurance. We conclude that health insurance coverage is associated with improved housing stability.

The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment.

Policy Points: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression. Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40%. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations. CONTEXT: Expanding Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression, but the ways that Medicaid affects mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression remain unclear. METHODS: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage using a randomized-controlled design, drawing on both primary and administrative data sources. FINDINGS: Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40%. The share of respondents screening positive for depression dropped by 9.2 percentage points overall, and by 13.1 for those with preexisting depression diagnoses, with greatest relief in symptoms seen primarily in feeling down or hopeless, feeling tired, and trouble sleeping-consistent with the increase observed not just in medications targeting depression but also in those targeting sleep. CONCLUSIONS: Medicaid coverage had significant effects on the diagnosis, treatment, and outcomes of a population with substantial unmet mental health needs. Coverage increased access to care, reduced the prevalence of untreated and undiagnosed depression, and substantially improved the symptoms of depression. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.

The Effect of Medicaid on Dental Care of Poor Adults: Evidence from the Oregon Health Insurance Experiment.

OBJECTIVE: To evaluate the effect of Medicaid coverage on dental care outcomes, a major health concern for low-income populations. DATA SOURCES: Primary and secondary data on health care use and outcomes for participants in Oregon's 2008 Medicaid lottery. STUDY DESIGN: We used the lottery's random selection to gauge the causal effects of Medicaid on dental care needs, medication, and emergency department visits for dental care. DATA COLLECTION: Data were collected for lottery participants over 2 years, including mail surveys (N = 23,777) and in-person questionnaires (N = 12,229). Emergency department (ED) records were matched to lottery participants in Portland (N = 24,646). PRINCIPAL FINDINGS: Medicaid coverage significantly reduced the share of respondents who reported needing dental care (-9.8 percentage points, p < .001) or having unmet dental care needs (-13.5 percentage points, p < 0.001). Medicaid doubled the share visiting the ED for dental care (+2.6 percentage points, p = .003) and the use of anti-infective medications often prescribed for dental care, but it had no detectable effect on uncovered dental care or out-of-pocket spending. CONCLUSIONS: Expansion of Medicaid covering emergency dental care substantially reduced unmet need for dental care, increasing ED dental visits and medication use, while not changing patient use of uncovered dental services.

The Effect Of Medicaid On Medication Use Among Poor Adults: Evidence From Oregon.

Oregon's 2008 Medicaid expansion significantly increased the use of prescription medications in 2009-10.

A Social Work Approach to Policy: Implications for Population Health.

The substantial disparities in health and poorer outcomes in the United States relative to peer nations suggest the need to refocus health policy. Through direct contact with the most vulnerable segments of the population, social workers have developed an approach to policy that recognizes the importance of the social environment, the value of social relationships, and the significance of value-driven policymaking. This approach could be used to reorient health, health care, and social policies. Accordingly, social workers can be allies to public health professionals in efforts to eliminate disparities and improve population health.