Specialty Care Utilization Among Adults with Limited English Proficiency.

BACKGROUND: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS: 149,611 survey respondents aged 18 and older. EXPOSURE: LEP, defined as taking the survey in a language other than English. MAIN MEASURES: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.

The Effects on Hospital Utilization of the 1966 and 2014 Health Insurance Coverage Expansions in the United States.

Background: Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth. Objective: To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use. Design: Repeated cross-sectional study. Setting: Nationally representative surveys. Participants: Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015). Measurements: Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression. Results: Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, -0.1 to 0.4 discharges] per 100 persons; P = 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P < 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA's implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, -0.6 discharges [CI, -1.3 to 0.2 discharges] per 100 persons; P = 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health. Limitation: Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited. Conclusion: Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained. Primary Funding Source: None.

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured.

OBJECTIVES: We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care. METHODS: Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485). RESULTS: Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia. CONCLUSIONS: Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

Computed tomography associated cancers and cancer deaths following visits to U.S. emergency departments.

We estimated the number of future cancers and cancer deaths following computed tomography scans (CTs) performed in U.S. emergency departments annually and determined whether increases in the proportion of visits resulting in CTs over the past decade were accompanied by changes in markers of severity of illness or primary reason for visit. We applied national estimates of effective dose to adult emergency department visits in the 2008 National Hospital Ambulatory Medical Care Survey. We utilized the Biologic Effects of Ionizing Radiation Model VII to estimate the number of future cancers and cancer deaths caused by CTs performed in U.S. emergency departments. We calculated the proportion of visits resulting in CTs from 1998 to 2008. In 2008, 16,406,921 CTs were performed nationally on adults, which will cause an estimated 3,750 cancers and 1,994 cancer deaths. The increasing proportion of emergency department visits resulting in CTs was not accompanied by proportional increases in markers of severity of illness or primary reason for visit. The substantial number of future cancers and cancer deaths attributable to CTs and increases in CTs without accompanying increases in markers of severity or changes in primary reason for visit highlight the importance of examining the benefits of CTs.

Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US.

Importance: Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH). Objective: To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security. Design, Setting, and Participants: Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years. Exposures: Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs. Main Outcomes and Measures: Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity. Results: Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, 51.6% were female, 16.8% Hispanic, 6.0% were non-Hispanic Asian, 11.9% non-Hispanic Black, 62.6% non-Hispanic White, and 2.18% other non-Hispanic. A total of 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates: 15.3%; (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]). In cross-sectional analyses, hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness; residing in a Medicaid-expansion state was protective (2019 odds ratio [OR], 0.76; 95% CI, 0.70-0.83). Prospective findings were similar, eg, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019 (OR, 1.63; 95% CI, 1.23-2.14), as was becoming newly disabled (OR, 2.42; 95% CI, 1.95-3.00) or newly hospitalized (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening SDOHs, with ORs of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019. Conclusions and Relevance: In this cross-sectional and cohort study, medical indebtedness was common, even among insured individuals. Acquiring such debt may worsen SDOHs. Expanded and improved health coverage could ameliorate financial distress, and improve housing and food security.

Trends in Health Care Use Among Black and White Persons in the US, 1963-2019.

Importance: In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking. Objective: To assess trends in Black-White disparities in health care use since 1963. Design, Setting, and Participants: This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians. Exposures: Self-reported race and ethnicity. Main Outcomes and Measures: Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures. Results: Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods. Conclusions and Relevance: This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.

Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999-2018.

One in seven people in the US speak Spanish at home, and twenty-five million people in the US have limited English proficiency. Using nationally representative data from the Medical Expenditure Panel Survey, we compare health care spending for and health care use by Hispanics adults with limited English proficiency with spending for and use by English-proficient Hispanic and non-Hispanic adults. During 2014-18 mean annual per capita expenditures were $1,463 (35 percent) lower for Hispanic adults with limited English proficiency than for Hispanic adults who were English proficient, after adjustment for respondents' characteristics. Hispanic adults with limited English proficiency also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient. Health care spending gaps between Hispanic adults with limited English proficiency and non-Hispanic adults with English proficiency widened between 1999 and 2018. These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency.

Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017.

Importance: Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist. Objective: To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States. Design, Setting, and Participants: Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services. Main Outcomes and Measures: The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income. Results: Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]). Conclusions and Relevance: Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.

The Effect Of Veterans Health Administration Coverage On Cost-Related Medication Nonadherence.

High out-of-pocket drug spending worsens adherence and outcomes, especially for patients who are poor, chronically ill, or members of minority groups. The Veterans Health Administration (VHA) system provides drugs at minimal cost, which could reduce cost-related medication nonadherence. Using data for 2013-17 from the National Health Interview Survey, we evaluated the association of VHA coverage with such nonadherence. Although people with VHA coverage were older and in worse health and had lower incomes than those with other coverage, VHA patients had lower rates of cost-related medication nonadherence: 6.1 percent versus 10.9 percent for non-VHA patients, an adjusted 5.9-percentage-point difference. VHA coverage was associated with especially large reductions in nonadherence among people with chronic illnesses and with reduced racial/ethnic and socioeconomic disparities in nonadherence. The VHA pharmacy benefit is a model for reform to address the crisis in prescription drug affordability.

U.S. physicians' views on financing options to expand health insurance coverage: a national survey.

BACKGROUND: Physician opinion can influence the prospects for health care reform, yet there are few recent data on physician views on reform proposals or access to medical care in the United States. OBJECTIVE: To assess physician views on financing options for expanding health care coverage and on access to health care. DESIGN AND PARTICIPANTS: Nationally representative mail survey conducted between March 2007 and October 2007 of U.S. physicians engaged in direct patient care. MEASUREMENTS: Rated support for reform options including financial incentives to induce individuals to purchase health insurance and single-payer national health insurance; rated views of several dimensions of access to care. MAIN RESULTS: 1,675 of 3,300 physicians responded (50.8%). Only 9% of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42% preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance. CONCLUSIONS: The vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.

The health and health care of US prisoners: results of a nationwide survey.

OBJECTIVES: We analyzed the prevalence of chronic illnesses, including mental illness, and access to health care among US inmates. METHODS: We used the 2002 Survey of Inmates in Local Jails and the 2004 Survey of Inmates in State and Federal Correctional Facilities to analyze disease prevalence and clinical measures of access to health care for inmates. RESULTS: Among inmates in federal prisons, state prisons, and local jails, 38.5% (SE = 2.2%), 42.8% (SE = 1.1%), and 38.7% (SE = 0.7%), respectively, suffered a chronic medical condition. Among inmates with a mental condition ever treated with a psychiatric medication, only 25.5% (SE = 7.5%) of federal, 29.6% (SE = 2.8%) of state, and 38.5% (SE = 1.5%) of local jail inmates were taking a psychiatric medication at the time of arrest, whereas 69.1% (SE = 4.8%), 68.6% (SE = 1.9%), and 45.5% (SE = 1.6%) were on a psychiatric medication after admission. CONCLUSIONS: Many inmates with a serious chronic physical illness fail to receive care while incarcerated. Among inmates with mental illness, most were off their treatments at the time of arrest. Improvements are needed both in correctional health care and in community mental health services that might prevent crime and incarceration.

Health insurance and mortality in US adults.

OBJECTIVES: A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data. METHODS: We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death. RESULTS: Among all participants, 3.1% (95% confidence interval [CI]=2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI=1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance. CONCLUSIONS: Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.

A national study of chronic disease prevalence and access to care in uninsured U.S. adults.

BACKGROUND: No recent national studies have assessed chronic illness prevalence or access to care among persons without insurance in the United States. OBJECTIVE: To compare reports of chronic conditions and access to care among U.S. adults, by self-reported insurance status. DESIGN: Population-based survey. SETTING: National Health and Nutritional Examination Survey (1999-2004). PARTICIPANTS: 12,486 patients age 18 to 64 years. MEASUREMENTS: Estimates of national rates of cardiovascular disease, hypertension, diabetes, hypercholesterolemia, active asthma or chronic obstructive pulmonary disease, previous cancer, and measures of access to care. RESULTS: On the basis of National Health and Nutrition Examination Survey (1999-2004) responses, an estimated 11.4 million (95% CI, 9.8 million to 13.0 million) working-age Americans with chronic conditions were uninsured, including 16.1% (CI, 12.6% to 19.6%) of the 7.8 million with cardiovascular disease, 15.5% (CI, 13.4% to 17.6%) of the 38.2 million with hypertension, and 16.6% (CI, 13.2% to 20.0%) of the 8.5 million with diabetes. After the authors controlled for age, sex, and race or ethnicity, chronically ill patients without insurance were more likely than those with coverage to have not visited a health professional (22.6% vs. 6.2%) and to not have a standard site for care (26.1% vs. 6.2%) but more likely to identify their standard site for care as an emergency department (7.1% vs. 1.1%) (P <0.001 for all comparisons). LIMITATION: The study was cross-sectional and used self-reported insurance and disease status. CONCLUSION: Millions of U.S. working-age adults with chronic conditions do not have insurance and have poorer access to medical care than their insured counterparts.

Association Between Forced Sexual Initiation and Health Outcomes Among US Women.

IMPORTANCE: The #MeToo movement has highlighted how frequently women experience sexual violence. However, to date, no recent studies have assessed the prevalence of forced sex during girls' and women's first sexual encounter or its health consequences. OBJECTIVE: To estimate the prevalence of forced sexual initiation among US women and its association with subsequent reproductive, gynecologic, and general health outcomes. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis of the 2011-2017 National Survey of Family Growth was conducted, including a population-based sample of 13 310 US women. The study was conducted from September 2011 to September 2017. EXPOSURES: Self-reported forced vs voluntary first sexual intercourse. MAIN OUTCOMES AND MEASURES: Prevalence of forced sexual initiation, age of woman and partner/assailant at first sexual encounter, and odds ratios (ORs) (adjusted for sociodemographic characteristics) for having an unwanted first pregnancy or abortion, development of painful pelvic conditions, and other reproductive and general health measures. RESULTS: A total of 13 310 women between the ages of 18 and 44 years were included in the study. After survey weights were applied, 6.5% (95% CI, 5.9%-7.1%) of respondents reported experiencing forced sexual initiation, equivalent to 3 351 733 women in this age group nationwide. Age at forced sexual initiation averaged 15.6 (95% CI, 15.3-16.0) years vs 17.4 (95% CI, 17.3-17.5) years for voluntary sexual initiation (P < .001). The mean age of the partner/assailant at first sexual encounter was 6 years older for women with forced vs voluntary sexual initiation (27.0; 95% CI, 24.8-29.2 years vs 21.0; 95% CI, 20.6-21.3 years). Compared with women with voluntary sexual initiation, women with forced sexual initiation were more likely to experience an unwanted first pregnancy (30.1% vs 18.9%; adjusted OR [aOR], 1.9; 95% CI, 1.5-2.4) or an abortion (24.1% vs 17.3%; aOR, 1.5; 95% CI, 1.2-2.0), endometriosis (10.4% vs 6.5%; aOR, 1.6; 95% CI, 1.1-2.3), pelvic inflammatory disease (8.1% vs 3.4%; aOR, 2.2; 95% CI, 1.5-3.4), and problems with ovulation or menstruation (27.0% vs 17.1%; aOR, 1.8; 95% CI, 1.4-2.3). Survivors of forced sexual initiation more frequently reported illicit drug use (2.6% vs 0.7%; aOR, 3.6; 95% CI, 1.8-7.0), fair or poor health (15.5% vs 7.5%; aOR, 2.0; 95% CI, 1.5-2.7), and difficulty completing tasks owing to a physical or mental health condition (9.0% vs 3.2%; aOR, 2.8; 95% CI, 2.0-3.9). CONCLUSIONS AND RELEVANCE: Forced sexual initiation in women appears to be common and associated with multiple adverse reproductive and general health outcomes. These findings highlight the possible need for public health measures and sociocultural changes to prevent sexual violence, particularly forced sexual initiation.

Characteristics of recipients of free prescription drug samples: a nationally representative analysis.

OBJECTIVES: Free prescription drug samples are used widely in the United States. We sought to examine characteristics of free drug sample recipients nationwide. METHODS: We analyzed data on 32681 US residents from the 2003 Medical Expenditure Panel Survey (MEPS), a nationally representative survey. RESULTS: In 2003, 12% of Americans received at least 1 free sample. A higher proportion of persons who had continuous health insurance received a free sample (12.9%) than did persons who were uninsured for part or all of the year (9.9%; P<.001). The poorest third of respondents were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or higher. After we controlled for demographic factors, we found that neither insurance status nor income were predictors of the receipt of drug samples. Persons who were uninsured all or part of the year were no more likely to receive free samples (odds ratio [OR]=0.98; 95% confidence interval [CI]=0.087, 1.11) than those who were continuously insured. CONCLUSIONS: Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples. Our findings suggest that free drug samples serve as a marketing tool, not as a safety net.

Out-of-Pocket Spending and Premium Contributions After Implementation of the Affordable Care Act.

Importance: The Affordable Care Act (ACA) was associated with a reduced number of Americans who reported being unable to afford medical care, but changes in actual health spending by households are not known. Objectives: To estimate changes in household spending on health care nationwide after implementation of the ACA. Design, Setting, and Participants: Population-based data from the Medical Expenditure Panel Survey from January 1, 2012, through December 31, 2015, and multivariable regression were used to examine changes in out-of-pocket spending, premium contributions, and total health spending (out-of-pocket plus premiums) after the ACA's coverage expansions on January 1, 2014. The study population included a nationally representative sample of US adults aged 18 to 64 years (n = 83 431). In addition, changes were assessed in the likelihood of exceeding affordability thresholds for each outcome and spending changes for income subgroups defined under the ACA to determine program eligibility at 138% or less, 139% to 250%, 251% to 400%, and greater than 400% of the federal poverty level (FPL). Exposure: Implementation of the ACA's major insurance programs on January 1, 2014. Main Outcomes and Measures: Mean individual-level out-of-pocket spending and premium payments and the percentage of persons experiencing high-burden spending, defined as more than 10% of family income for out-of-pocket expenses, more than 9.5% for premium payments, and more than 19.5% for out-of-pocket plus premium payments. Results: In this nationally representative survey of 83 431 adults (weighted frequency, 49.1% men and 50.9% women; median age, 40.3 years; interquartile range, 28.6-52.4 years), ACA implementation was associated with an 11.9% decrease (95% CI, -17.1% to -6.4%; P < .001) in mean out-of-pocket spending in the full sample, a 21.4% decrease (95% CI, -30.1% to -11.5%; P < .001) in the lowest-income group (≤138% of the FPL), an 18.5% decrease (95% CI, -27.0% to -9.0%; P < .001) in the low-income group (139%-250% of the FPL), and a 12.8% decrease (95% CI, -22.1% to -2.4%; P = .02) in the middle-income group (251%-400% of the FPL). Mean premium spending increased in the full sample (12.1%; 95% CI, 1.9%-23.3%) and the higher-income group (22.9%; 95% CI, 5.5%-43.1%). Combined out-of-pocket plus premium spending decreased in the lowest-income group only (-16.0%; 95% CI, -27.6% to -2.6%). The odds of household out-of-pocket spending exceeding 10% of family income decreased in the full sample (odds ratio [OR], 0.80; 95% CI, 0.70-0.90) and in the lowest-income group (OR, 0.80; 95% CI, 0.67-0.97). The odds of high-burden premium spending increased in the middle-income group (OR, 1.28; 95% CI, 1.03-1.59). Conclusions and Relevance: Implementation of the ACA was associated with reduced out-of-pocket spending, particularly for low-income persons. However, many of these individuals continue to experience high-burden out-of-pocket and premium spending. Repeal or substantial reversal of the ACA would especially harm poor and low-income Americans.

Lack of health coverage among US veterans from 1987 to 2004.

OBJECTIVES: Veterans Administration health care enrollment is restricted to veterans with service-connected problems and those who are poor. We sought to determine how many veterans were uninsured, trends in veterans' coverage, and whether uninsured veterans lacked access to medical care. METHODS: We analyzed annual data from 2 federal surveys, the Current Population Survey for the years 1988 to 2005 and the National Health Interview Survey for 2002 to 2004. RESULTS: Nearly 1.8 million veterans were uninsured and not receiving Veterans Administration care in 2004. The proportion of working-age veterans lacking coverage peaked in 1993 at 14.2%, fell to 9.9% in 2000, and rose steadily to 12.7% in 2004. Uninsured veterans had substantial access problems; 51.4% had no usual source of care (vs 8.9% of insured veterans), and 26.5% reported failing to get needed care because of the cost (vs 4.3% of insured veterans). CONCLUSIONS: Many US veterans are uninsured and lack adequate access to health care. Expanded funding for veterans' care is urgently needed; only national health insurance could guarantee coverage to both veterans and their family members.

U.S. medical students' knowledge about the military draft, the Geneva Conventions, and military medical ethics.

The objective of this study was to ascertain how much U.S. medical students are taught about and know about military medical ethics, the Geneva Conventions, and the laws governing conscription of medical personnel. The authors developed an Internet-based questionnaire on these matters, and e-mail invitations to participate were sent to approximately 5,000 medical students at eight U.S. medical schools. Thirty-five percent of e-mail recipients participated in the survey. Of those, 94 percent had received less than one hour of instruction about military medical ethics and only 3.5 percent were aware of legislation already passed making a "doctor's draft" possible; 37 percent knew the conditions under which the Geneva Conventions apply; 33.8 percent did not know that the Geneva Conventions state that physicians should "treat the sickest first, regardless of nationality;" 37 percent did not know that the Geneva Conventions prohibit ever threatening or demeaning prisoners or depriving them of food or water; and 33.9 percent could not state when they would be required to disobey an unethical order.