Examining Pre-Release Interventions on HIV Outcomes 12 Months After Release from Louisiana State Corrections.

Louisiana has the highest proportion of people living with HIV (PLWH) in state prison custody. Linkage to care programs minimize odds of HIV care drop-off after release. Louisiana has two pre-release linkage to HIV care programs, one implemented through Louisiana Medicaid and another through the Office of Public Health. We conducted a retrospective cohort study of PLWH released from Louisiana corrections from January 1, 2017 to December 31, 2019. We compared HIV care continuum outcomes within 12 months after release between intervention groups (received any vs. no intervention) using two proportion z-tests and multivariable logistic regression. Of 681 people, 389 (57.1%) were not released from a state prison facility and thus not eligible to receive interventions, 252 (37%) received any intervention, and 228 (33.5%) achieved viral suppression. Linkage to care within 30 days was significantly higher in people who received any intervention (v. no intervention, p = .0142). Receiving any intervention was associated with higher odds of attaining all continuum steps, though only significantly for linkage to care (AOR = 1.592, p = .0083). We also found differences in outcomes by sex, race, age, urbanicity of the return parish (county), and Medicaid enrollment between intervention groups. Receiving any intervention increased the odds of achieving HIV care outcomes, and was significantly impactful at improving care linkage. Interventions must be improved to enhance long-term post-release HIV care continuity and eliminate disparities in care outcomes.

Reducing Opioid Analgesic Prescribing in Dentistry Through Prescribing Defaults: A Cluster-Randomized Controlled Trial.

OBJECTIVE: To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices. METHODS: We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation. RESULTS: Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (-3.3 tablets; CI: -5.9 to -0.7), and lower morphine milligram equivalents (MME) prescribed (-14.1 MME; CI: -27.8 to -0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9). CONCLUSIONS: Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default. TRIAL REGISTRATION: ClinicalTrials.org ID: NCT03030469.

STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Characteristics and health service use of Medicaid-insured individuals filling naloxone under a standing order in Louisiana.

BACKGROUND: Naloxone distribution is a key intervention to reduce opioid overdose deaths. On January 23, 2017, Louisiana implemented a standing order that permits pharmacies to dispense naloxone to patients without a patient-specific prescription. OBJECTIVES: To examine the characteristics and health service use of Louisiana Medicaid members filling naloxone under the standing order. METHODS: We conducted a retrospective cohort study of Louisiana Medicaid members from January 23, 2017 to December 31, 2019. We extracted fee-for-service claims and managed care encounters for naloxone dispensed under the standing order. RESULTS: Overall, there were 2053 naloxone fills by 1912 unique individuals. The total number of naloxone fills increased from 22 in 2017 to 1218 in 2019. Most members (n = 1,586, 83.0%) received any type of health service and 20.4% (n = 391) received an opioid-related health service in the 30 days prior to filling naloxone. Additionally, 12.7% (n = 242) of members had received medication for opioid use disorder (MOUD), and 42.6% (n = 815) filled a prescription opioid analgesic within the 60 days prior to filling naloxone. Nineteen members (1.0%) had an emergency department visit for overdose within 90 days after filling naloxone. CONCLUSION: Standing orders play an important role in providing access to naloxone, even among Medicaid members who had recent encounters with health care providers. We identified multiple opportunities to improve naloxone prescribing among providers caring for Medicaid-insured people who use opioids, including prescribers of opioid analgesics or MOUD.

Mixed Method Evaluation of Louisiana's Prerelease Medicaid Enrollment Program, 2017-2019.

BACKGROUND: Over 600,000 people leave US prisons annually. Many are eligible for Medicaid upon release but may need support to enroll. Carceral facilities in nearly half of states have implemented systems to facilitate Medicaid access for those leaving incarceration, but there is limited information on program implementation models or outcomes. OBJECTIVES: To evaluate implementation and initial outcomes of Louisiana's prison-based Prerelease Medicaid Enrollment Program. METHODS: In this mixed-methods study, we assessed enrollment in Louisiana Medicaid at time of release from prison in the 2 years (2017-2018) after Program implementation, as well as reasons for Medicaid closure (ie, loss of coverage) and health services use 6 months postrelease. In May-June 2019, we conducted interviews statewide with program implementers (n=16) and focus groups in New Orleans, Louisiana with formerly incarcerated Program participants (n=16). RESULTS: A total of 4476 people were included in the quantitative analysis. There was a 34.3 (95% confidence interval: 20.7-47.9) percentage point increase in Medicaid enrollment upon release. Nearly all (98.6%) attended at least 1 outpatient visit and almost half (46.7%) had 1 emergency department visit within 6 months of release. Not responding to information requests was the most common reason for Medicaid closure. Program implementers and formerly incarcerated participants identified Program strengths, barriers, and suggestions for improvement. CONCLUSIONS: The program was successful in rapidly increasing Medicaid enrollment at the time of prison release and facilitating the use of health care services.

A Policy Approach to Reducing Low-Value Device-Based Procedure Use.

Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.

Impact of a prescription drug monitoring program use mandate on potentially problematic patterns of opioid analgesic prescriptions in New York City.

PURPOSE: To evaluate New York State's mandate that prescribers query the prescription drug monitoring program (PDMP) prior to prescribing Schedule II-IV medications. METHODS: We conducted an interrupted time series analysis of opioid analgesic prescriptions dispensed to adult New York City (NYC) residents using data from New York State's PDMP. Our main outcomes were the rate of (a) greater than or equal to five prescriber episodes, (b) greater than or equal to five prescriber and greater than or equal to five pharmacy episodes, and (c) paying for prescriptions with both cash and insurance, per quarter, per 100 000 NYC residents. We defined three periods: (a) the baseline period (January 2011 to July 2012), (b) the anticipatory period (September 2012 to July 2013) after mandate law enactment but before mandate implementation, and (c) the postmandate period (September 2013 to December 2015). For each outcome, we used autoregressive linear regression models to account for correlation in outcomes over time. RESULTS: At the end of the postmandate period, the rate of greater than or equal to five prescriber episodes was 58% lower than expected (absolute difference: -17.2 per 100 000 NYC residents; 95% CI, -31.2 to -3.1), the rate of greater than or equal to five prescriber and greater than or equal to five pharmacy episodes was 88% lower than expected (absolute difference: -8.6; 95% CI, -11.0 to -6.3), and the rate of cash and insurance payment episodes was 50% lower than expected (absolute difference: -145.4; 95% CI, -279.4 to -11.6). CONCLUSIONS: While outcomes were relatively rare, New York State's PDMP mandate was associated with significant decreases in rates of potentially problematic patterns of opioid analgesic prescriptions.

Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients.

Background: Overdose education and naloxone distribution (OEND) to people at risk of witnessing or experiencing an opioid overdose has traditionally been provided through harm reduction agencies. Expanding OEND to inpatient general medical settings may reach at-risk individuals who do not access harm reduction services and have not been trained. An OEND program targeting inpatients was developed, piloted, and evaluated on 2 general medicine floors at Montefiore Medical Center, a large urban academic medical center in Bronx, New York. Methods: The planning committee consisted of 10 resident physicians and 2 faculty mentors. A consult service model was piloted, whereby the primary inpatient care team paged the consult team (consisting of rotating members from the planning committee) for any newly admitted patient who had used any opioid in the year prior to admission. Consult team members assessed patients for eligibility and provided OEND to eligible patients through a short video training. Upon completion, patients received a take-home naloxone kit. To evaluate the program, a retrospective chart review over the first year (April 2016 to March 2017) of the pilot was conducted. Results: Overall, consults on 80 patients were received. Of these, 74 were eligible and the consult team successfully trained 50 (68%). Current opioid analgesic use of ≥50 morphine milligram equivalents daily was the most common eligibility criterion met (38%). Twenty-four percent of patients were admitted for an opioid-related adverse event, the most common being opioid overdose (9%), then opioid withdrawal (8%), skin complication related to injecting (5%), and opioid intoxication (2%). Twenty-five percent had experienced an overdose, 35% had witnessed an overdose in their lifetime, and 83% had never received OEND previously. Conclusions: Integrating OEND into general inpatient medical care is possible and can reach high-risk patients who have not received OEND previously. Future research should identify the optimal way of implementing this service.

Physician Time Burden Associated with Querying Prescription Drug Monitoring Programs.

Objective: Prescription drug monitoring programs (PDMPs) enable prescribers to review patient prescription histories, and their use is mandatory in many states. We estimated the cost of physicians retrieving PDMP patient reports compared with a model where a delegate (i.e., administrative staff) retrieves reports. Methods: We performed a cost analysis with a one-year time horizon, from the perspective of physicians' employers. We obtained specialty-specific estimates of controlled substance prescribing frequency from the National Ambulatory Medical Care Survey, 2012-2014. We defined three PDMP usage cases based on the frequency of queries: comprehensive (before every Schedule II-IV controlled substance prescription), selective (before new Schedule II-IV prescriptions and every six months for continuing medications), and minimal (before new Schedule II or III prescriptions and annually for continuing medications). Results: The delegate model was less costly for all specialties in the comprehensive usage case and most specialties in the selective usage case, and it was similar to physician model costs in the minimal usage case. Estimated annual costs of the physician model to a large health care system (1,000 full-time equivalent physicians) were $1.6 million for comprehensive usage, $1.1 million for selective usage, and $645,313 for minimal usage. The delegate model was less costly in the comprehensive (savings of $907,283) and selective usage cases (savings of $156,216). Conclusions: Relying on delegates vs physicians to retrieve reports is less costly in most cases. Automation and integration of PDMP data into electronic health records may reduce costs further. Physicians, health care systems, and states should collaborate to streamline access to PDMPs.

Cannabis Use is Associated with Lower Odds of Prescription Opioid Analgesic Use Among HIV-Infected Individuals with Chronic Pain.

BACKGROUND: Chronic pain is common in the United States and prescribed opioid analgesics use for noncancer pain has increased dramatically in the past two decades, possibly accounting for the current opioid addiction epidemic. Co-morbid drug use in those prescribed opioid analgesics is common, but there are few data on polysubstance use patterns. OBJECTIVE: We explored patterns of use of cigarette, alcohol, and illicit drugs in HIV-infected people with chronic pain who were prescribed opioid analgesics. METHODS: We conducted a secondary data analysis of screening interviews conducted as part of a parent randomized trial of financial incentives to improve HIV outcomes among drug users. In a convenience sample of people with HIV and chronic pain, we collected self-report data on demographic characteristics; pain; patterns of opioid analgesic use (both prescribed and illicit); cigarette, alcohol, and illicit drug use (including cannabis, heroin, and cocaine) within the past 30 days; and current treatment for drug use and HIV. RESULTS: Almost half of the sample of people with HIV and chronic pain reported current prescribed opioid analgesic use (N = 372, 47.1%). Illicit drug use was common (N = 505, 63.9%), and cannabis was the most commonly used illicit substance (N = 311, 39.4%). In multivariate analyses, only cannabis use was significantly associated with lower odds of prescribed opioid analgesic use (adjusted odds ratio = 0.57; 95% confidence interval: 0.38-0.87). Conclusions/Importance: Our data suggest that new medical cannabis legislation might reduce the need for opioid analgesics for pain management, which could help to address adverse events associated with opioid analgesic use.

Description and outcomes of a buprenorphine maintenance treatment program integrated within Prevention Point Philadelphia, an urban syringe exchange program.

BACKGROUND: Syringe exchange programs are uniquely positioned to offer treatment services to interested clients. Prevention Point Philadelphia recently expanded to offer buprenorphine maintenance treatment through its Stabilization, Treatment, and Engagement Program (STEP). OBJECTIVE: To describe the STEP model of care and report treatment outcomes. METHODS: Retrospective chart review of patients enrolled in STEP (October 2011-August 2014). Our main outcome measure was time retained in treatment, defined as time from treatment initiation to treatment failure. Secondary outcome measures were buprenorphine and opiate use, from urine toxicology screens. We analyzed retention in treatment using Kaplan-Meier survival estimates; patients who remained in treatment at the end of the study period were censored on that day. For buprenorphine and opiate use, we calculated the percentage of patients who were positive for buprenorphine and opiates in each month of treatment. RESULTS: Of the 124 patients enrolled in STEP, the median age was 41 (range 21 to 63) and 80% reported injection heroin use. Comorbidities were common: 33% had HIV infection, most reported anxiety (78%) or depression (71%), and 20% were homeless. The most common program outcomes were unplanned self-discharge (n = 29; 23%), incarceration (n = 20; 16%), and administrative discharge (n = 19; 15%). The percentage of patients retained in treatment at 3, 6, 9, and 12 months was 77%, 65%, 59%, and 56%, respectively. Among those retained, the percentage with a positive buprenorphine screen at 3, 6, 9, and 12 months was 88%, 100%, 96%, and 95%, respectively. The percentage with a positive opiates screen was 19%, 13%, 17%, and 16%, respectively. CONCLUSIONS: With a program that blended organizational and community resources, retention in buprenorphine maintenance treatment was comparable to retention rates reported from other settings. Further research should directly compare treatment outcomes in syringe exchange program-based settings versus primary care and specialty settings.

Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment.

BACKGROUND: Opioid agonist therapy (OAT) is the standard of care for pregnant women with opioid use disorder (OUD). Medicaid coverage policies may strongly influence OAT use in this group. OBJECTIVE: To examine the association between Medicaid coverage of methadone maintenance and planned use of OAT in the publicly funded treatment system. RESEARCH DESIGN: Retrospective cross-sectional analysis of treatment admissions in 30 states extracted from the Treatment Episode Data Set (2013 and 2014). SUBJECTS: Medicaid-insured pregnant women with OUD (n=3354 treatment admissions). MEASURES: The main outcome measure was planned use of OAT on admission. The main exposure was state Medicaid coverage of methadone maintenance. Using multivariable logistic regression models adjusting for sociodemographic, substance use, and treatment characteristics, we compared the probability of planned OAT use in states with Medicaid coverage of methadone maintenance versus states without coverage. RESULTS: A total of 71% of pregnant women admitted to OUD treatment were 18-29 years old, 85% were white non-Hispanic, and 56% used heroin. Overall, 74% of admissions occurred in the 18 states with Medicaid coverage of methadone maintenance and 53% of admissions involved planned use of OAT. Compared with states without Medicaid coverage of methadone maintenance, admissions in states with coverage were significantly more likely to involve planned OAT use (adjusted difference: 32.9 percentage points, 95% confidence interval, 19.2-46.7). CONCLUSIONS: Including methadone maintenance in the Medicaid benefit is essential to increasing OAT among pregnant women with OUD and should be considered a key policy strategy to enhance outcomes for mothers and newborns.

Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013.

OBJECTIVES: To describe trends in benzodiazepine prescriptions and overdose mortality involving benzodiazepines among US adults. METHODS: We examined data from the Medical Expenditure Panel Survey and multiple-cause-of-death data from the Centers for Disease Control and Prevention. RESULTS: Between 1996 and 2013, the percentage of adults filling a benzodiazepine prescription increased from 4.1% (95% confidence interval [CI] = 3.8%, 4.5%) to 5.6% (95% CI = 5.2%, 6.1%), with an annual percent change of 2.5% (95% CI = 2.1%, 3.0%). The quantity of benzodiazepines filled increased from 1.1 (95% CI = 0.9, 1.2) to 3.6 (95% CI = 3.0, 4.2) kilogram lorazepam equivalents per 100 000 adults (annual percent change = 9.0%; 95% CI = 7.6%, 10.3%). The overdose death rate increased from 0.58 (95% CI = 0.55, 0.62) to 3.07 (95% CI = 2.99, 3.14) per 100 000 adults, with a plateau seen after 2010. CONCLUSIONS: Benzodiazepine prescriptions and overdose mortality have increased considerably. Fatal overdoses involving benzodiazepines have plateaued overall; however, no evidence of decreases was found in any group. Interventions to reduce the use of benzodiazepines or improve their safety are needed.

Deaths From Unintentional Injury, Homicide, and Suicide During or Within 1 Year of Pregnancy in Philadelphia.

OBJECTIVES: To understand the effect of unintentional injuries (e.g., drug overdose), suicide, and homicide on pregnancy-associated death (death during or within 1 year of pregnancy). METHODS: We analyzed all cases of pregnancy-associated death among Philadelphia, Pennsylvania, residents from 2010 to 2014, examining cause of death, contributing factors, and history of health care use. RESULTS: Approximately half (49%; 42 of 85) of pregnancy-associated deaths were from unintentional injuries (n = 31), homicide (n = 8), or suicide (n = 3); drug overdose was the leading cause (n = 18). Substance use was noted during or around events leading to death in 46% (31 of 67) of nonoverdose deaths. A history of serious mental illness was noted in 39% (32 of 82) of nonsuicide deaths. History of intimate partner violence (IPV) was documented in 19% (15 of 77) of nonhomicide deaths. Regardless of cause of death, approximately half of all decedents had an unscheduled hospital visit documented within a month of death. CONCLUSIONS: Unintentional injury, homicide, and suicide contribute to many deaths among pregnant and recently pregnant women. Interventions focused on substance use, mental health, and IPV may reduce pregnancy-associated and pregnancy-related deaths.

The emerging public discourse on state legalization of marijuana for recreational use in the US: Analysis of news media coverage, 2010-2014.

OBJECTIVES: US states have begun to legalize marijuana for recreational use. In the absence of clear scientific evidence regarding the likely public health consequences of legalization, it is important to understand how the risks and benefits of this policy are being discussed in the national dialogue. To assess the public discourse on recreational marijuana policy, we assessed the volume and content of US news media coverage of the topic. METHOD: We analyzed the content of a 20% random sample of news stories published/aired in high circulation/viewership print, television, and Internet news sources from 2010 to 2014 (N=610). RESULTS: News media coverage of recreational marijuana policy was heavily concentrated in news outlets from the four states (AK, CO, OR, WA) and DC that legalized marijuana for recreational use during the study period. Overall, 53% of news stories mentioned pro-legalization arguments and 47% mentioned anti-legalization arguments. The most frequent pro-legalization arguments posited that legalization would reduce criminal justice involvement/costs (20% of news stories) and increase tax revenue (19%). Anti-legalization arguments centered on adverse public health consequences, such as detriments to youth health and well-being (22%) and marijuana-impaired driving (6%). Some evidence-informed public health regulatory options, like marketing and packaging restrictions, were mentioned in 5% of news stories or fewer. CONCLUSION: As additional states continue to debate legalization of marijuana for recreational use, it is critical for the public health community to develop communication strategies that accurately convey the rapidly evolving research evidence regarding recreational marijuana policy.

Profiting and providing less care: comprehensive services at for-profit, nonprofit, and public opioid treatment programs in the United States.

BACKGROUND: Opioid use disorders are frequently associated with medical and psychiatric comorbidities (eg, HIV infection and depression), as well as social problems (eg, lack of health insurance). Comprehensive services addressing these conditions improve outcomes. OBJECTIVE: To compare the proportion of for-profit, nonprofit, and public opioid treatment programs offering comprehensive services, which are not mandated by government regulations. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of opioid treatment programs offering outpatient care in the United States (n=1036). MAIN OUTCOME MEASURE: Self-reported offering of communicable disease (HIV, sexually transmitted infections, and viral hepatitis) testing, psychiatric services (screening, assessment and diagnostic evaluation, and pharmacotherapy), and social services support (assistance in applying for programs such as Medicaid). Mixed-effects logistic regression models were developed to adjust for several county-level factors. RESULTS: Of opioid treatment programs, 58.0% were for profit, 33.5% were nonprofit, and 8.5% were public. Nonprofit programs were more likely than for-profit programs to offer testing for all communicable diseases [adjusted odds ratios (AOR), 1.7; 95% confidence interval (CI), 1.2, 2.5], all psychiatric services (AOR, 8.0; 95% CI, 4.9, 13.1), and social services support (AOR, 3.3; 95% CI, 2.3, 4.8). Public programs were also more likely than for-profit programs to offer communicable disease testing (AOR, 6.4; 95% CI, 3.5, 11.7), all psychiatric services (AOR, 25.8; 95% CI, 12.6, 52.5), and social services support (AOR, 2.4; 95% CI, 1.4, 4.3). CONCLUSIONS: For-profit programs were significantly less likely than nonprofit and public programs to offer comprehensive services. Interventions to increase the offering of comprehensive services are needed, particularly among for-profit programs.

Food insecurity, neighborhood food access, and food assistance in Philadelphia.

An estimated 17.6 million American households were food insecure in 2012, meaning they were unable to obtain enough food for an active and healthy life. Programs to augment local access to healthy foods are increasingly widespread, with unclear effects on food security. At the same time, the US government has recently enacted major cuts to federal food assistance programs. In this study, we examined the association between food insecurity (skipping or reducing meal size because of budget), neighborhood food access (self-reported access to fruits and vegetables and quality of grocery stores), and receipt of food assistance using the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. Of 11,599 respondents, 16.7% reported food insecurity; 79.4% of the food insecure found it easy or very easy to find fruits and vegetables, and 60.6% reported excellent or good quality neighborhood grocery stores. In our regression models adjusting for individual- and neighborhood-level covariates, compared to those who reported very difficult access to fruits and vegetables, those who reported difficult, easy or very easy access were less likely to report food insecurity (OR 0.62: 95% CI 0.43-0.90, 0.33: 95% CI 0.23-0.47, and 0.28: 95% CI 0.20-0.40). Compared to those who reported poor stores, those who reported fair, good, and excellent quality stores were also less likely to report food insecurity (OR 0.81: 95% CI 0.60-1.08, 0.58: 95% CI 0.43-0.78, and 0.43: 95% CI 0.31-0.59). Compared to individuals not receiving food assistance, those receiving Supplemental Nutrition Assistance Program (SNAP) benefits were significantly more likely to be food insecure (OR 1.36: 95% CI 1.11-1.67), while those receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (OR 1.17: 95% CI 0.77-1.78) and those receiving both SNAP and WIC (OR 0.84: 95% CI 0.61-1.17) did not have significantly different odds of food insecurity. In conclusion, better neighborhood food access is associated with lower risk of food insecurity. However, most food insecure individuals reported good access. Improving diet in communities with high rates of food insecurity likely requires not only improved access but also greater affordability.