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Vadlakonda A, Cho NY, Chervu N, Porter G, Curry J, Sakowitz S, Coaston T, Rook JM, Juillard C, Benharash P. Association of uninsured status and rurality with risk of financial toxicity after pediatric trauma. Surgery 2024; 176:455-461. [PMID: 38772775 DOI: 10.1016/j.surg.2024.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/18/2024] [Accepted: 12/14/2023] [Indexed: 05/23/2024]
Abstract
BACKGROUND Pediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity. METHODS Pediatric patients (<18 years) experiencing traumatic injury were identified in the 2016-2019 National Inpatient Sample. Patients were considered to be at risk of financial toxicity if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with risk of financial toxicity. RESULTS Of an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience risk of financial toxicity (29.1 vs 22.2%, P < .001) compared to Urban patients. After adjustment, rurality (reference: urban status; adjusted odds ratio 1.45, 95% confidence interval 1.36-1.55) and uninsured status (reference: private; adjusted odds ratio 1.85, 95% confidence interval 1.67-2.05) remained linked to increased odds of risk of financial toxicity. Specifically among those with private insurance, Rural patients experienced markedly higher predicted risk of financial toxicity, relative to Urban. CONCLUSION Our findings suggest a complex interplay between rural status and insurance type in the prediction of risk of financial toxicity after pediatric trauma. To target policy interventions, future studies should characterize the patients and communities at greatest risk of financial devastation among rural pediatric trauma patients.
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Affiliation(s)
- Amulya Vadlakonda
- Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/amulyavad
| | - Nam Yong Cho
- Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- Department of Surgery, University of California, Los Angeles, CA
| | - Giselle Porter
- Department of Surgery, University of California, Los Angeles, CA
| | - Joanna Curry
- Department of Surgery, University of California, Los Angeles, CA
| | - Sara Sakowitz
- Department of Surgery, University of California, Los Angeles, CA
| | - Troy Coaston
- Department of Surgery, University of California, Los Angeles, CA
| | - Jordan M Rook
- Department of Surgery, University of California, Los Angeles, CA; Greater Los Angeles Veterans Administration Healthcare System, Los Angeles CA; National Clinician Scholars Program, University of California, Los Angeles, CA; Fielding School of Public Health, University of California, Los Angeles, CA
| | - Catherine Juillard
- Division of General Surgery (Trauma and Surgical Critical Care Section), University of California, Los Angeles, CA
| | - Peyman Benharash
- Department of Surgery, University of California, Los Angeles, CA.
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Schwartz AL, Zlaoui K, Foreman RP, Brennan TA, Newhouse JP. Health Care Utilization and Spending in Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2021; 2:e214001. [PMID: 35977297 PMCID: PMC8796939 DOI: 10.1001/jamahealthforum.2021.4001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Doherty M, Gardner D, Finik J. The financial coping strategies of US cancer patients and survivors. Support Care Cancer 2021; 29:5753-5762. [PMID: 33738592 PMCID: PMC10135417 DOI: 10.1007/s00520-021-06113-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/26/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Coping behaviors may play a mediating role in producing the negative health outcomes observed in financially burdened cancer patients and survivors. METHODS Exploratory factor and latent class analysis of survey data. RESULTS A total of 510 people completed the survey, ages ranged from 25 to over 75 [over half greater than 55 years old (57.8%)]. Most respondents identified as female (64.7%), white (70.8%), or African American (18.6%). A four-factor model of financial coping was revealed: care-altering, lifestyle-altering, self-advocacy, and financial help-seeking. Respondents grouped into three financial coping classes: low burden/low coping (n = 212), high self-advocacy (n = 143), and high burden/high coping (n = 155). African American respondents were at far greater odds than white respondents of being in the high burden/high coping class (OR = 5.82, 95% CI 3.01-6.64) or the self-advocacy class (OR = 1.99, 95% CI 1.19-2.80) than the low burden/low coping class. Compared to respondents aged 65 years and older, those 35-44 were more likely in the high burden/high coping class (OR = 12.27, 95% CI 7.03-19.87) and the high self-advocacy class (OR = 7.08, 95% CI 5.89-8.28) than the low burden/low coping class. CONCLUSION One-third of respondents were in the high burden/high coping class. Age and race/ethnicity were significantly associated with class membership. Some coping strategies may compromise health and well-being. Program and policy interventions that reduce the odds that patients will use strategies that undermine treatment outcomes and increase patient use of protective strategies are needed.
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Affiliation(s)
- Meredith Doherty
- Immigrant Health and Cancer Disparities, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, New York, NY, 10017, USA.
| | - Daniel Gardner
- Silberman School of Social Work, Hunter College City University of New York, New York, NY, 10021, USA
| | - Jackie Finik
- Immigrant Health and Cancer Disparities, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, New York, NY, 10017, USA
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Nieves C, Dannefer R, Zamula A, Sacks R, Ballesteros Gonzalez D, Zhao F. "Come with us for a week, for a month, and see how much food lasts for you": A Qualitative Exploration of Food Insecurity in East Harlem, New York City. J Acad Nutr Diet 2021; 122:555-564. [PMID: 34384908 DOI: 10.1016/j.jand.2021.08.100] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Food insecurity refers to uncertain access to food on a consistent basis and the stress experienced by families who worry about having sufficient resources to provide balanced meals in their households. Food insecurity disproportionately impacts people of color. A robust body of evidence links food insecurity to poor health outcomes. OBJECTIVE To document experiences of food insecurity among linguistically and ethnically diverse residents of the East Harlem neighborhood of New York City (NYC) by exploring the ways in which food availability and cost intersects with household budgets, personal preferences, and shopping strategies. DESIGN In-depth qualitative interviews were conducted with adult residents of NYC's East Harlem neighborhood to provide insights about the links between food insecurity, well-being, and quality of life. PARTICIPANTS/SETTING 37 adult residents of East Harlem were recruited through purposive sampling. Eligibility requirements included living in an East Harlem zip code (10029 or 10035), being 18 years or older, being the main food shopper and food decision-maker in the household, and speaking English, Spanish, or Mandarin Chinese. The study was conducted from February to May 2018. STATISTICAL ANALYSES PERFORMED Interviews were analyzed using a grounded theory approach. Codes were organized into broad thematic topics and cross-case analyses were conducted. RESULTS Participants discussed overall perceptions of food insecurity and seven themes related to the challenges of and strategies for coping with food insecurity: 1) intermittent versus chronic food insecurity, 2) shopping and budgeting strategies, 3) pantries as a vital community resource, 4) social support systems, 5) food insecurity and health, 6) frustration with an unjust system, and 7) pride in "making it work." CONCLUSIONS To manage food insecurity, many study participants carefully managed food spending, dedicated substantial time to visiting stores and accessing food pantries, and relied on a public benefits cycle that left many without sufficient financial resources at the end of each month.
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Affiliation(s)
- Christina Nieves
- Bureau of Harlem Neighborhood Health, Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, 161-169 East 110th Street, New York, NY 10029, United States.
| | - Rachel Dannefer
- Bureau of Harlem Neighborhood Health, Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, 161-169 East 110th Street, New York, NY 10029, United States
| | - Arlen Zamula
- Bureau of Harlem Neighborhood Health, Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, 161-169 East 110th Street, New York, NY 10029, United States
| | - Rachel Sacks
- Bureau of Harlem Neighborhood Health, Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, 161-169 East 110th Street, New York, NY 10029, United States
| | - Diana Ballesteros Gonzalez
- Bureau of Harlem Neighborhood Health, Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, 161-169 East 110th Street, New York, NY 10029, United States
| | - Feng Zhao
- Bureau of Harlem Neighborhood Health, Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, 161-169 East 110th Street, New York, NY 10029, United States
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O'Mahen PN, Petersen LA. Long-Term Implications of Post-ACA Health Reform on State Health Care Policy. J Gen Intern Med 2021; 36:775-778. [PMID: 32901439 PMCID: PMC7478436 DOI: 10.1007/s11606-020-06168-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/14/2020] [Indexed: 10/29/2022]
Abstract
In the midst of the COVID-19 outbreak, health care reform has again taken a major role in the 2020 election, with Democrats weighing Medicare for All against extensions of the Affordable Care Act, while Republicans quietly seem to favor proposals that would eliminate much of the ACA and cut Medicaid. Although states play a major role in health care funding and administration, public and scholarly debates over these proposals have generally not addressed the potential disruption that reform proposals might create for the current state role in health care. We examine how potential reforms influence state-federal relations, and how outside factors like partisanship and exogenous shocks like the COVID-19 pandemic interact with underlying preferences of each level of government. All else equal, reforms that expand the ACA within its current framework would provide the least disruption for current arrangements and allow for smoother transitions for providers and patients, rather than the more radical restructuring proposed by Medicare for All or the cuts embodied in Republican plans.
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Affiliation(s)
- Patrick N O'Mahen
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, , Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, , Houston, TX, USA
| | - Laura A Petersen
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, , Houston, TX, USA.
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, , Houston, TX, USA.
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KINGSDALE JON. Medicare Advantage for Most. Milbank Q 2021; 99:41-61. [PMID: 33463775 PMCID: PMC7984665 DOI: 10.1111/1468-0009.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Policy Points Fixing the ACA requires real cost containment in addition to better subsidies. Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care. Medicare Advantage plans should serve as the public option on the ACA Marketplace. Medicare Advantage plans can also be deployed to voluntarily raise minimum employer-sponsored benefits and contain their costs.
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Affiliation(s)
- JON KINGSDALE
- Boston University School of Public Health, Brown University, andWakely Consulting
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McIntyre A, Blendon RJ, Benson JM, Findling MG, Schneider EC. The Affordable Care Act's Missing Consensus: Values, Attitudes, and Experiences Associated with Competing Health Reform Preferences. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2020; 45:729-755. [PMID: 32589212 DOI: 10.1215/03616878-8543222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency-and the sitting president-have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs.
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Jacobi JV. Payment Theory and the Last Mile Problem. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:474-479. [PMID: 33021174 DOI: 10.1177/1073110520958871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Health reform debate understandably focuses on large system design. We should not omit attention to the "last mile" problem of physician payment theory. Achieving fundamental goals of integrative, patient-centered primary care depends on thoughtful financial support. This commentary describes the nature and importance of innovative primary care payment programs.
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Affiliation(s)
- John V Jacobi
- John V. Jacobi, J.D., is the Dorothea Dix Professor of Health Law & Policy, Seton Hall Law School
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Renzaho AMN. The Need for the Right Socio-Economic and Cultural Fit in the COVID-19 Response in Sub-Saharan Africa: Examining Demographic, Economic Political, Health, and Socio-Cultural Differentials in COVID-19 Morbidity and Mortality. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103445. [PMID: 32429123 PMCID: PMC7277405 DOI: 10.3390/ijerph17103445] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease (COVID-19) has spread quickly across the globe with devastating effects on the global economy as well as the regional and societies' socio-economic fabrics and the way of life for vast populations. The nonhomogeneous continent faces local contextual complexities that require locally relevant and culturally appropriate COVID-19 interventions. This paper examines demographic, economic, political, health, and socio-cultural differentials in COVID-19 morbidity and mortality. The health systems need to be strengthened through extending the health workforce by mobilizing and engaging the diaspora, and implementing the International Health Regulations (2005) core capacities. In the absence of adequate social protection and welfare programs targeting the poor during the pandemic, sub-Saharan African countries need to put in place flexible but effective policies and legislation approaches that harness and formalise the informal trade and remove supply chain barriers. This could include strengthening cross-border trade facilities such as adequate pro-poor, gender-sensitive, and streamlined cross-border customs, tax regimes, and information flow. The emphasis should be on cross-border infrastructure that not only facilitates trade through efficient border administration but can also effectively manage cross-border health threats. There is an urgent need to strengthen social protection systems to make them responsive to crises, and embed them within human rights-based approaches to better support vulnerable populations and enact health and social security benefits. The COVI-19 response needs to adhere to the well-established 'do no harm' principle to prevent further damage or suffering as a result of the pandemic and examined through local lenses to inform peace-building initiatives that may yield long-term gains in the post-COVID-19 recovery efforts.
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Affiliation(s)
- Andre M. N. Renzaho
- School of Social Sciences, Western Sydney University, Penrith 2751, Australia;
- Translational Health Research Institute, Western Sydney University, Penrith 2751, Australia
- Burnet Institute, Maternal, Child and Adolescent Health Program, Melbourne 3004, Australia
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10
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Abstract
Medicare for All plans have many advantages over the status quo. Yet the challenges facing such plans are immense, reflecting their ambitions to achieve universal coverage through a single federal plan and their disruption to existing insurance and financing arrangements. Medicare for All will not become viable unless it can meet the daunting political, economic, and administrative realities that govern US health care.
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Affiliation(s)
- Austin B Frakt
- Austin B. Frakt ( frakt@bu. edu ) is director of the Partnered Evidence-Based Policy Resource Center at the Veterans Affairs Boston Healthcare System; an associate professor at the Boston University School of Public Health; and a senior research scientist at the Harvard T. H. Chan School of Public Health, all in Boston, Massachusetts
| | - Jonathan Oberlander
- Jonathan Oberlander is a professor in and chair of the Department of Social Medicine in the School of Medicine and a professor in the Department of Health Policy and Management in the Gillings School of Global Public Health, both at the University of North Carolina at Chapel Hill
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