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Venkataramani AS, Bair EF, Bor J, Jackson CL, Kawachi I, Lee J, Papachristos A, Tsai AC. Officer-Involved Killings of Unarmed Black People and Racial Disparities in Sleep Health. JAMA Intern Med 2024; 184:363-373. [PMID: 38315465 PMCID: PMC10845041 DOI: 10.1001/jamainternmed.2023.8003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/27/2023] [Indexed: 02/07/2024]
Abstract
Importance Racial disparities in sleep health may mediate the broader health outcomes of structural racism. Objective To assess changes in sleep duration in the Black population after officer-involved killings of unarmed Black people, a cardinal manifestation of structural racism. Design, Setting, and Participants Two distinct difference-in-differences analyses examined the changes in sleep duration for the US non-Hispanic Black (hereafter, Black) population before vs after exposure to officer-involved killings of unarmed Black people, using data from adult respondents in the US Behavioral Risk Factor Surveillance Survey (BRFSS; 2013, 2014, 2016, and 2018) and the American Time Use Survey (ATUS; 2013-2019) with data on officer-involved killings from the Mapping Police Violence database. Data analyses were conducted between September 24, 2021, and September 12, 2023. Exposures Occurrence of any police killing of an unarmed Black person in the state, county, or commuting zone of the survey respondent's residence in each of the four 90-day periods prior to interview, or occurence of a highly public, nationally prominent police killing of an unarmed Black person anywhere in the US during the 90 days prior to interview. Main Outcomes and Measures Self-reported total sleep duration (hours), short sleep (<7 hours), and very short sleep (<6 hours). Results Data from 181 865 Black and 1 799 757 White respondents in the BRFSS and 9858 Black and 46 532 White respondents in the ATUS were analyzed. In the larger BRFSS, the majority of Black respondents were between the ages of 35 and 64 (99 014 [weighted 51.4%]), women (115 731 [weighted 54.1%]), and college educated (100 434 [weighted 52.3%]). Black respondents in the BRFSS reported short sleep duration at a rate of 45.9%, while White respondents reported it at a rate of 32.6%; for very short sleep, the corresponding values were 18.4% vs 10.4%, respectively. Statistically significant increases in the probability of short sleep and very short sleep were found among Black respondents when officers killed an unarmed Black person in their state of residence during the first two 90-day periods prior to interview. Magnitudes were larger in models using exposure to a nationally prominent police killing occurring anywhere in the US. Estimates were equivalent to 7% to 16% of the sample disparity between Black and White individuals in short sleep and 13% to 30% of the disparity in very short sleep. Conclusions and Relevance Sleep health among Black adults worsened after exposure to officer-involved killings of unarmed Black individuals. These empirical findings underscore the role of structural racism in shaping racial disparities in sleep health outcomes.
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elizabeth F. Bair
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Jacob Bor
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Chandra L. Jackson
- Epidemiology Branch, National Institutes of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Ichiro Kawachi
- Department of Social Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jooyoung Lee
- Department of Sociology, University of Toronto, Toronto, Ontario, Canada
| | | | - Alexander C. Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Himmelstein KEW, Tsai AC, Venkataramani AS. Wealth Redistribution to Extend Longevity in the US. JAMA Intern Med 2024; 184:311-320. [PMID: 38285594 PMCID: PMC10825783 DOI: 10.1001/jamainternmed.2023.7975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/10/2023] [Indexed: 01/31/2024]
Abstract
Importance The US is unique among wealthy countries in its degree of wealth inequality and its poor health outcomes. Wealth is known to be positively associated with longevity, but little is known about whether wealth redistribution might extend longevity. Objective To examine the association between wealth and longevity and estimate the changes in longevity that could occur with simulated wealth distributions that were perfectly equal, similar to that observed in Japan (among the most equitable of Organisation for Economic Co-operation and Development [OECD] countries), generated by minimum inheritance proposals, and produced by baby bonds proposals. Design, Setting, and Participants This longitudinal cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study (1992-2018), a nationally representative panel study of middle-aged and older (≥50 years) community-dwelling, noninstitutionalized US adults. The data analysis was performed between November 15, 2022, and September 24, 2023. Exposure Household wealth on study entry, calculated as the sum of all assets minus the value of debts and classified into deciles. Main Outcomes and Measures Weibull survival models were used to estimate the association between per-person wealth decile and survival, adjusting for age, sex, marital status, household size, and race and ethnicity. Changes in longevity that might occur under alternative wealth distributions were then estimated. Results The sample included 35 164 participants (mean [SE] age at study entry, 59.1 [0.1] years; 50.1% female and 49.9% male [weighted]). The hazard of death generally decreased with increasing wealth, wherein participants in the highest wealth decile had a hazard ratio of 0.59 for death (95% CI, 0.53-0.66) compared with those in the lowest decile, corresponding to a 13.5-year difference in survival. A simulated wealth distribution of perfect equality would increase populationwide median longevity by 2.2 years (95% CI, 2.2-2.3 years), fully closing the mortality gap between the US and the OECD average. A simulated minimum inheritance proposal would increase populationwide median longevity by 1.7 years; a simulated wealth distribution similar to Japan's would increase populationwide median longevity by 1.2 years; and a simulated baby bonds proposal would increase populationwide median longevity by 1.0 year. Conclusions and Relevance These findings suggest that wealth inequality in the US is associated with significant inequities in survival. Wealth redistribution policies may substantially reduce those inequities and increase population longevity.
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Affiliation(s)
- Kathryn E. W. Himmelstein
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Alexander C. Tsai
- Harvard Medical School, Boston, Massachusetts
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Atheendar S. Venkataramani
- Division of Health Policy, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Matta S, Chatterjee P, Venkataramani AS. Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion. JAMA 2024; 331:687-695. [PMID: 38411645 PMCID: PMC10900969 DOI: 10.1001/jama.2023.27014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Importance The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.
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Affiliation(s)
- Sasmira Matta
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Kakara M, Venkataramani AS. Earnings of US Physicians With and Without Disabilities. JAMA Health Forum 2023; 4:e233954. [PMID: 38038987 PMCID: PMC10692836 DOI: 10.1001/jamahealthforum.2023.3954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/19/2023] [Indexed: 12/02/2023] Open
Abstract
This cross-sectional study uses American Community Survey data to assess disability earnings gaps for physicians between 2005 and 2019.
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Affiliation(s)
- Mihir Kakara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Vasan A, Kyle MA, Venkataramani AS, Kenyon CC, Fiks AG. Inequities in Time Spent Coordinating Care for Children and Youth With Special Health Care Needs. Acad Pediatr 2023; 23:1526-1534. [PMID: 36918094 PMCID: PMC10495536 DOI: 10.1016/j.acap.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care. METHODS This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care. RESULTS Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours. CONCLUSIONS Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN.
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Affiliation(s)
- Aditi Vasan
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
| | - Michael Anne Kyle
- Department of Health Care Policy (MA Kyle), Harvard Medical School and Dana Farber Cancer Institute, Boston, Mass.
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa; Department of Medical Ethics and Health Policy (AS Venkataramani), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Calif.
| | - Chén C Kenyon
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
| | - Alexander G Fiks
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
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Underhill K, Bair EF, Dixon EL, Ferrell WJ, Linn KA, Volpp KG, Venkataramani AS. Public Views on Medicaid Work Requirements and Mandatory Premiums in Kentucky. JAMA Health Forum 2023; 4:e233656. [PMID: 37862033 PMCID: PMC10589806 DOI: 10.1001/jamahealthforum.2023.3656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/22/2023] [Indexed: 10/21/2023] Open
Abstract
Importance Federal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements. Objective To identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums. Design, Setting, and Participant A cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023. Main Outcomes and Measures Agreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an internet panel to recruit residents aged 18 years or older. Findings were weighted to reflect state demographics. Of 39 110 landlines called, 209 reached an eligible person (of whom 150 participated), 8654 were of unknown eligibility, and 30 247 were ineligible. Of 55 305 cell phone lines called, 617 reached an eligible person (of whom 451 participated), 29 951 were of unknown eligibility, and 24 737 were ineligible. Internet recruitment (602 participants) used a panel of adult Kentucky residents maintained by an external data collector. Results Percentages were weighted to resemble the adult population of Kentucky residents. Of the participants in the study, 52% (95% CI, 48%-55%) were women, 80% (95% CI, 77%-82%) were younger than 65 years, 41% (95% CI, 38%-45%) were enrolled in Medicaid, 36% (95% CI, 32%-39%) were Republican voters, 32% (95% CI, 29%-36%) were Democratic voters, 14% (95% CI, 11%-16%) were members of racial and ethnic minority groups (including but not limited to American Indian or Alaska Native, Asian, Black, Hispanic or Latinx, and Native Hawaiian or Pacific Islander), and 48% (95% CI, 44%-52%) were employed. Most participants supported work requirements generally (69% [95% CI, 66%-72%]) but did not support terminating benefits due to noncompliance (43% [95% CI, 39%-46%]) or requiring quotas of 20 or more hours per week (34% [95% CI, 31%-38%]). Support for monthly premiums (34% [95% CI, 31%-38%]) and exclusion penalties for premium nonpayment (22% [95% CI, 19%-25%]) was limited. Medicaid enrollees were significantly less supportive of these policies than nonenrollees. For instance, regarding work requirements, agreement was lower (64% [95% CI, 59%-69%] vs 72% [95% CI, 68%-77%]) and disagreement higher (26% [95% CI, 21%-31%] vs 20% [95% CI, 16%-24%]) among current Medicaid enrollees compared with nonenrollees (P = .04). Among Medicaid enrollees, some beliefs about work requirements varied significantly by employment status but not by political affiliation. Among nonenrollees, beliefs about work requirements, premiums, and Medicaid varied significantly by political affiliation but not by employment. Conclusions and Relevance This study suggests that even when public constituencies express general support for Medicaid work requirements or premiums, they may oppose central design features, such as quotas and termination of benefits. Program participants may also hold significantly different beliefs than nonparticipants, which should be understood before policies are changed.
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Affiliation(s)
- Kristen Underhill
- Cornell Law School, Ithaca, New York
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Elizabeth F. Bair
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania. Philadelphia
| | - Erica L. Dixon
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania. Philadelphia
| | - William J. Ferrell
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania. Philadelphia
| | - Kristin A. Linn
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania. Philadelphia
| | - Kevin G. Volpp
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania. Philadelphia
- Wharton School, University of Pennsylvania, Philadelphia
- Corporal Michael J. Cresencz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania. Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Venkataramani AS. Affirmative Action, Population Health, and the Importance of Opportunity and Hope. N Engl J Med 2023; 389:1157-1159. [PMID: 37672691 DOI: 10.1056/nejmp2307766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Atheendar S Venkataramani
- From the Department of Medical Ethics and Health Policy, Perelman School of Medicine, the Leonard Davis Institute of Health Economics, and the Opportunity for Health Lab, University of Pennsylvania, Philadelphia
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Venkataramani AS. Moving Beyond Intent and Realizing Health Equity. JAMA Health Forum 2023; 4:e232525. [PMID: 37656474 DOI: 10.1001/jamahealthforum.2023.2525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Berkowitz SA, Dave G, Venkataramani AS. Potential gaps in income support policies for those in poor health: The case of the earned income tax credit-A cross sectional analysis. SSM Popul Health 2023; 23:101429. [PMID: 37252288 PMCID: PMC10209707 DOI: 10.1016/j.ssmph.2023.101429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/01/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023] Open
Abstract
Background The federal Earned Income Tax Credit (EITC) is the primary income support program for low-income workers in the U.S., but its design may hinder its effectiveness when poor health limits, but does not preclude, work. Methods Cross-sectional analysis of nationally-representative U.S. Census Current Population Survey (CPS) data covering 2019. Working-age adults eligible to receive federal EITC were included in this study. Poor health, as indicated by self-report of at least one problem with hearing, vision, cognitive function, mobility, dressing and bathing, or independence, was the exposure. The main outcome was federal EITC benefit category, categorized as no benefit, phase-in (income too low for the maximum benefit), plateau (maximum benefit), phase-out (income above threshold for maximum benefit), or earnings too high to receive any benefit. We estimated EITC benefit category probabilities by health status using multinomial logistic regression. We further examined whether other government benefits provided additional income support to those in poor health. Results 41,659 participants (representing 87.1 million individuals) were included. 2,724 participants (representing 5.6 million individuals) reported poor health. In analyses standardized over age, gender, race, and ethnicity, those in poor health, compared with those not in poor health, were more likely to be in the no benefit (2.40% vs. 0.30%, risk difference 2.10 percentage points [95%CI 1.75 to 2.46 percentage points]), and phase-in (9.28% vs. 2.74%, risk difference 6.54 percentage points [95%CI 5.82 to 7.26 percentage points]) categories. Differences in resources by health status persisted even after accounting for other government benefits. Conclusions EITC program design creates an important gap in income support for those for whom poor health limits work, which is not closed by other programs. Filling this gap is an important public health goal.
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Affiliation(s)
- Seth A. Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gaurav Dave
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
- Center for Health Equity Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Atheendar S. Venkataramani
- Division of Health Policy, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
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Dean A, McCallum J, Venkataramani AS, Michaels D. The Effect Of Labor Unions On Nursing Home Compliance With OSHA's Workplace Injury And Illness Reporting Requirement. Health Aff (Millwood) 2023; 42:1260-1265. [PMID: 37669485 DOI: 10.1377/hlthaff.2023.00255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
All US nursing homes are required to report workplace injury and illness data to the Occupational Safety And Health Administration (OSHA). Nevertheless, the compliance rate for US nursing homes during the period 2016-21 was only 40 percent. We examined whether unionization increases the probability that nursing homes will comply with that requirement. Using a difference-in-differences design and proprietary data on union status from the Service Employees International Union for all forty-eight continental US states from the period 2016-21, we found that two years after unionization, nursing homes were 31.1 percentage points more likely than nonunion nursing homes to report workplace injury and illness data to OSHA. Data on injuries occurring in specific workplaces play a central role in injury prevention. Further unionization could help improve workplace safety in nursing homes, a sector with one of the highest occupational injury and illness rates in the US.
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Affiliation(s)
- Adam Dean
- Adam Dean , George Washington University, Washington, D.C
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Manski CF, Mullahy J, Venkataramani AS. Using measures of race to make clinical predictions: Decision making, patient health, and fairness. Proc Natl Acad Sci U S A 2023; 120:e2303370120. [PMID: 37607231 PMCID: PMC10469015 DOI: 10.1073/pnas.2303370120] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/24/2023] [Indexed: 08/24/2023] Open
Abstract
The use of race measures in clinical prediction models is contentious. We seek to inform the discourse by evaluating the inclusion of race in probabilistic predictions of illness that support clinical decision making. Adopting a static utilitarian framework to formalize social welfare, we show that patients of all races benefit when clinical decisions are jointly guided by patient race and other observable covariates. Similar conclusions emerge when the model is extended to a two-period setting where prevention activities target systemic drivers of disease. We also discuss non-utilitarian concepts that have been proposed to guide allocation of health care resources.
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Affiliation(s)
- Charles F. Manski
- Department of Economics, Northwestern University, Evanston, IL60208
- Institute for Policy Research, Northwestern University, Evanston, IL60208
| | - John Mullahy
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI53726
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Vasan A, Kenyon CC, Fiks AG, Venkataramani AS. Continuous Eligibility And Coverage Policies Expanded Children's Medicaid Enrollment. Health Aff (Millwood) 2023; 42:753-758. [PMID: 37276479 DOI: 10.1377/hlthaff.2022.01465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We examined children's Medicaid participation during 2019-21 and found that as of March 2021, states newly adopting continuous Medicaid coverage for children during the COVID-19 pandemic experienced a 4.62 percent relative increase in children's Medicaid participation compared to states with previous continuous eligibility policies.
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Affiliation(s)
- Aditi Vasan
- Aditi Vasan , University of Pennsylvania, Philadelphia, Pennsylvania
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Himmelstein KEW, Lawrence JA, Jahn JL, Ceasar JN, Morse M, Bassett MT, Wispelwey BP, Darity WA, Venkataramani AS. Association Between Racial Wealth Inequities and Racial Disparities in Longevity Among US Adults and Role of Reparations Payments, 1992 to 2018. JAMA Netw Open 2022; 5:e2240519. [PMID: 36342718 PMCID: PMC9641537 DOI: 10.1001/jamanetworkopen.2022.40519] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
IMPORTANCE In the US, Black individuals die younger than White individuals and have less household wealth, a legacy of slavery, ongoing discrimination, and discriminatory public policies. The role of wealth inequality in mediating racial health inequities is unclear. OBJECTIVE To assess the contribution of wealth inequities to the longevity gap that exists between Black and White individuals in the US and to model the potential effects of reparations payments on this gap. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study, a nationally representative panel study of community-dwelling noninstitutionalized US adults 50 years or older that assessed data collected from April 1992 to July 2019. Participants included 7339 non-Hispanic Black (hereinafter Black) and 26 162 non-Hispanic White (hereinafter White) respondents. Data were analyzed from January 1 to September 17, 2022. EXPOSURES Household wealth, the sum of all assets (including real estate, vehicles, and investments), minus the value of debts. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality by the end of survey follow-up in 2018. Using parametric survival models, the associations among household wealth, race, and survival were evaluated, adjusting for age, sex, number of household members, and marital status. Additional models controlled for educational level and income. The survival effects of eliminating the current mean wealth gap with reparations payments ($828 055 per household) were simulated. RESULTS Of the 33 501 individuals in the sample, a weighted 50.1% were women, and weighted mean (SD) age at study entry was 59.3 (11.1) years. Black participants' median life expectancy was 77.5 (95% CI, 77.0-78.2) years, 4 years shorter than the median life expectancy for White participants (81.5 [95% CI, 81.2-81.8] years). Adjusting for demographic variables, Black participants had a hazard ratio for death of 1.26 (95% CI, 1.18-1.34) compared with White participants. After adjusting for differences in wealth, survival did not differ significantly by race (hazard ratio, 1.00 [95% CI, 0.92-1.08]). In simulations, reparations to close the mean racial wealth gap were associated with reductions in the longevity gap by 65.0% to 102.5%. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that differences in wealth are associated with the longevity gap that exists between Black and White individuals in the US. Reparations payments to eliminate the racial wealth gap might substantially narrow racial inequities in mortality.
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Affiliation(s)
- Kathryn E. W. Himmelstein
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jourdyn A. Lawrence
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- François-Xavier Bagnoud Center for Health and Human Rights, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jaquelyn L. Jahn
- The Ubuntu Center on Racism, Global Movements, and Population Health Equity, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Joniqua N. Ceasar
- Department of Medicine, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Morse
- Center for Health Equity and Community Wellness, New York City Department of Health and Mental Hygiene, New York, New York
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Bram P. Wispelwey
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - William A. Darity
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Atheendar S. Venkataramani
- Leonard Davis Institute of Health Economics, Division of Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Chatterjee P, Lin Y, Venkataramani AS. Changes in economic outcomes before and after rural hospital closures in the United States: A difference-in-differences study. Health Serv Res 2022; 57:1020-1028. [PMID: 35426125 PMCID: PMC9441283 DOI: 10.1111/1475-6773.13988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The objective of this study is to assess changes in local economic outcomes before and after rural hospital closures. DATA SOURCES Rural hospital closures from January 1, 2005, to December 31, 2018, were obtained from the Sheps Center for Health Services Research. Economic outcomes from this same period were obtained from the Bureau of Labor Statistics, Bureau of Economic Analysis, Quarterly Workforce Indicators, U.S. Federal Reserve Economic Data, RAND Corporation state statistics database, U.S. Social Security Administration, and U.S. Census Bureau. DESIGN Difference-in-differences study of 2094 rural counties. DATA COLLECTION/EXTRACTION The primary exposure was county-level rural hospital closures. The primary outcomes were county-level unemployment rates; employment-population ratios; labor force participation-population ratios; per capita income; total jobs; health care sector jobs; disability program participation-population ratios; percent of the population with subprime credit scores; total filings for bankruptcies per 1000 population; and population size. PRINCIPAL FINDINGS A total of 104 rural counties experienced a hospital closure, compared to 1990 rural counties that did not. Rural hospital closures were associated with significant reductions in health care sector employment (-13.8%; 95% CI: -22%, -5.6%; p < 0.001), but not with changes in any other economic measure. For unemployment rates, employment-population ratios, per capita income, disability program participation-population ratios, and total jobs, we found evidence of adverse trends preceding hospital closures. Findings were robust to adjusting for county-specific time trends, specifying exposure at the commuting zone-level, and using alternate definitions of rurality to define sample counties. CONCLUSION With the exception of a decline in jobs within the health care sector, there was no association between rural hospital closures and county-level economic outcomes. Instead, economic conditions were already declining in counties experiencing closures compared to those that did not.
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Affiliation(s)
- Paula Chatterjee
- Department of Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yuqing Lin
- Department of Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Atheendar S. Venkataramani
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Ethics & Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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15
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Dean A, McCallum J, Kimmel SD, Venkataramani AS. Resident Mortality And Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020-21. Health Aff (Millwood) 2022; 41:751-759. [PMID: 35442760 DOI: 10.1377/hlthaff.2021.01687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since the start of the COVID-19 pandemic, nursing home residents have accounted for roughly one of every six COVID-19 deaths in the United States. Nursing homes have also been very dangerous places for workers, with more than one million nursing home workers testing positive for COVID-19 as of April 2022. Labor unions may play an important role in improving workplace safety, with potential benefits for both nursing home workers and residents. We examined whether unions for nursing home staff were associated with lower resident COVID-19 mortality rates and worker COVID-19 infection rates compared with rates in nonunion nursing homes, using proprietary data on nursing home-level union status from the Service Employees International Union for all forty-eight continental US states from June 8, 2020, through March 21, 2021. Using negative binomial regression and adjusting for potential confounders, we found that unions were associated with 10.8 percent lower resident COVID-19 mortality rates, as well as 6.8 percent lower worker COVID-19 infection rates. Substantive results were similar, although sometimes smaller and less precisely estimated, in sensitivity analyses.
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Affiliation(s)
- Adam Dean
- Adam Dean , George Washington University, Washington, D.C
| | | | - Simeon D Kimmel
- Simeon D. Kimmel, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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16
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Abstract
The decline of manufacturing employment is frequently invoked as a key cause of worsening U.S. population health trends, including rising mortality due to "deaths of despair." Increasing automation-the use of industrial robots to perform tasks previously done by human workers-is one structural force driving the decline of manufacturing jobs and wages. In this study, we examine the impact of automation on age- and sex-specific mortality. Using exogenous variation in automation to support causal inference, we find that increases in automation over the period 1993-2007 led to substantive increases in all-cause mortality for both men and women aged 45-54. Disaggregating by cause, we find evidence that automation is associated with increases in drug overdose deaths, suicide, homicide, and cardiovascular mortality, although patterns differ by age and sex. We further examine heterogeneity in effects by safety net program generosity, labor market policies, and the supply of prescription opioids.
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Affiliation(s)
- Rourke O'Brien
- Department of Sociology and Institution for Social and Policy Studies, Yale University, New Haven, CT, USA
| | - Elizabeth F Bair
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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17
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Affiliation(s)
- Tiffany Green
- From the Departments of Population Health Sciences and Obstetrics and Gynecology, University of Wisconsin-Madison, Madison (T.G.); and the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (A.S.V.)
| | - Atheendar S Venkataramani
- From the Departments of Population Health Sciences and Obstetrics and Gynecology, University of Wisconsin-Madison, Madison (T.G.); and the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (A.S.V.)
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18
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Fink G, Venkataramani AS, Zanolini A. Early life adversity, biological adaptation, and human capital: evidence from an interrupted malaria control program in Zambia. J Health Econ 2021; 80:102532. [PMID: 34600186 DOI: 10.1016/j.jhealeco.2021.102532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/25/2021] [Accepted: 09/06/2021] [Indexed: 06/13/2023]
Abstract
Growing evidence from evolutionary biology demonstrates how early life shocks trigger physiological changes designed to be adaptive in challenging environments. We examine the implications of one type of physiological adaptation - immunity formation - for human capital accumulation. Using variation in early life malaria risk generated by an interrupted disease control program in Zambia, we show that exposure to infectious diseases during the first two years of life can reduce the harmful effects of malaria exposure on cognitive development during the preschool years. These findings suggest a non-linear and trajectory-dependent relationship between early life adversity and human capital formation.
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Affiliation(s)
- Günther Fink
- Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland.
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19
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Abstract
This study assesses whether participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) differed before and during the COVID-19 pandemic in states with offline vs online electronic benefits transfer debit cards.
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Affiliation(s)
- Aditi Vasan
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chén C. Kenyon
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina A. Roberto
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Alexander G. Fiks
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
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20
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Bruch JD, Barin O, Venkataramani AS, Song Z. Mortality Before and After Border Wall Construction Along the US-Mexico Border, 1990-2017. Am J Public Health 2021; 111:1636-1644. [PMID: 34197717 PMCID: PMC8589061 DOI: 10.2105/ajph.2021.306329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/04/2022]
Abstract
Objectives. To evaluate changes in mortality in US counties along the US-Mexico border in which there was substantial new border wall construction after the Secure Fence Act of 2006 relative to border counties in which there was no such border wall construction. Methods. Using complete 1990 to 2017 mortality microdata and a quasi-experimental difference-in-differences design, we evaluated changes in overall (all-cause) mortality, mortality from drug overdose, and mortality from homicide in the 10 counties with substantial new border wall construction and 11 counties with no such construction. We fit a linear model, adjusting for population characteristics and county and year fixed effects, with Bonferroni adjustments for multiple comparisons. Sensitivity analyses included the addition of adjacent inland counties and modifications to the statistical model. Results. Relative to counties without substantial new border wall construction, counties in which a substantial amount of new border wall was constructed exhibited a nonsignificant 0.02-percentage-point increase (95% confidence interval [CI] = -0.06, 0.10; P > .99) in overall mortality after construction. Border wall construction was not associated with changes in either deaths from overdose or deaths from homicide. Conclusions. Wall construction along the US-Mexico border after the Secure Fence Act of 2006 was not associated with discernible changes in mortality.
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Affiliation(s)
- Joseph Dov Bruch
- Joseph Dov Bruch is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Ozlem Barin is with the Department of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada. Atheendar S. Venkataramani is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA. Zirui Song is with the Department of Health Care Policy, Harvard Medical School, Harvard University, and the Department of Medicine, Massachusetts General Hospital, Boston
| | - Ozlem Barin
- Joseph Dov Bruch is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Ozlem Barin is with the Department of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada. Atheendar S. Venkataramani is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA. Zirui Song is with the Department of Health Care Policy, Harvard Medical School, Harvard University, and the Department of Medicine, Massachusetts General Hospital, Boston
| | - Atheendar S Venkataramani
- Joseph Dov Bruch is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Ozlem Barin is with the Department of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada. Atheendar S. Venkataramani is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA. Zirui Song is with the Department of Health Care Policy, Harvard Medical School, Harvard University, and the Department of Medicine, Massachusetts General Hospital, Boston
| | - Zirui Song
- Joseph Dov Bruch is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA. Ozlem Barin is with the Department of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada. Atheendar S. Venkataramani is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA. Zirui Song is with the Department of Health Care Policy, Harvard Medical School, Harvard University, and the Department of Medicine, Massachusetts General Hospital, Boston
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21
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Matta S, Chatterjee P, Venkataramani AS. The Income-Based Mortality Gradient Among US Health Care Workers: Cohort Study. J Gen Intern Med 2021; 36:2870-2872. [PMID: 32607931 PMCID: PMC7325834 DOI: 10.1007/s11606-020-05989-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sasmira Matta
- Department of Health Care Management, Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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22
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Wang TT, Dixon EL, Bair EF, Ferrell W, Linn KA, Volpp KG, Underhill K, Venkataramani AS. Oral health and oral health care use among able-bodied adults enrolled in Medicaid in Kentucky after Medicaid expansion: A mixed methods study. J Am Dent Assoc 2021; 152:747-755. [PMID: 34454649 DOI: 10.1016/j.adaj.2021.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oral health care use remains low among adult Medicaid recipients, despite the Patient Protection and Affordable Care Act's expansion increasing access to care in many states. It remains unclear the extent to which low use reflects either low demand for care or barriers to accessing care. The authors aimed to examine factors associated with low oral health care use among adults enrolled in Medicaid. METHODS The authors conducted a survey from May through September 2018 among able-bodied (n = 9,363) Medicaid recipients who were aged 19 through 65 years and nondisabled childless adults in Kentucky. The survey included questions on perceived oral health care use. Semistructured interviews were also conducted from May through November 2018 among a subset of participants (n = 127). RESULTS More than one-third (37.8%) of respondents reported fair or poor oral health, compared with 26.2% who reported fair or poor physical health. Although 47.6% of respondents indicated needing oral health care in the past 6 months, only one-half of this group reported receiving all of the care they needed. Self-reported barriers included lack of coverage for needed services and lack of access to care (for example, low provider availability and transportation difficulties). CONCLUSIONS Low rates of oral health care use can be attributed to a subset of the study population having low demand and another subset facing barriers to accessing care. Although Medicaid-covered services might be adequate for beneficiaries with good oral health, those with advanced dental diseases and a history of irregular care might benefit from coverage for more extensive restorative services. PRACTICAL IMPLICATIONS These results can inform dentists and policy makers about how to design effective interventions and policies to improve oral health care use and oral health outcomes.
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Abstract
Aggressive deportation policy enforcement in the US may make undocumented immigrants and those close to them reluctant to seek medical care. With 68 percent of undocumented immigrants coming from Mexico or Central America, US deportation policies particularly affect Hispanic residents. To examine how deportation enforcement relates to health care use in the Hispanic population in general, we matched survey data from the 2011-16 Behavioral Risk Factor Surveillance System to measures of Immigration and Customs Enforcement (ICE) activity. Quasi-experimental analyses demonstrated that Hispanic respondents were less likely to report having had a regular provider or annual checkup following increased ICE activity in their state. In contrast, these behaviors were unchanged among non-Hispanic adults, a group less likely to be affected by deportation enforcement. Parallel results were found among Hispanic and non-Hispanic adults with diabetes, for whom lapses in care may confer significant health risks.
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Affiliation(s)
- Abigail S Friedman
- Abigail S. Friedman is an assistant professor in the Department of Health Policy and Management at the Yale School of Public Health, in New Haven, Connecticut
| | - Atheendar S Venkataramani
- Atheendar S. Venkataramani is an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
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24
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Ortiz R, Farrell-Bryan D, Gutierrez G, Boen C, Tam V, Yun K, Venkataramani AS, Montoya-Williams D. A Content Analysis Of US Sanctuary Immigration Policies: Implications For Research In Social Determinants Of Health. Health Aff (Millwood) 2021; 40:1145-1153. [PMID: 34228526 DOI: 10.1377/hlthaff.2021.00097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Restrictive immigration policies are important social determinants of health, but less is known about the health implications and health-related content of protective immigration policies, which may also represent critical determinants of health. We conducted a content analysis of types, themes, and health-related language in 328 "sanctuary" policies enacted between 2009 and 2017 in the United States. Sanctuary policies were introduced in thirty-two states and Washington, D.C., most frequently in 2014 and 2017. More than two-thirds of policies (67.6 percent) contained language related to health, including direct references to access to services. Health-related themes commonly co-occurred with language related to supporting immigrants in communities, including themes of antidiscrimination, inclusion, trust, and privacy. Our work provides foundational, nuanced data about the scope and nature of sanctuary policies that can inform future research exploring the impacts of these policies on health and health care.
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Affiliation(s)
- Robin Ortiz
- Robin Ortiz is a National Clinician Scholar at the Perelman School of Medicine, University of Pennsylvania, and the Children's Hospital of Philadelphia, in Philadelphia, Pennsylvania
| | - Dylan Farrell-Bryan
- Dylan Farrell-Bryan is a PhD candidate in the Department of Sociology, University of Pennsylvania
| | - Gabriel Gutierrez
- Gabriel Gutierrez is a BA candidate in the Department of Anthropology, University of Pennsylvania
| | - Courtney Boen
- Courtney Boen is an assistant professor in the Department of Sociology, University of Pennsylvania
| | - Vicky Tam
- Vicky Tam is a data scientist in the Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia
| | - Katherine Yun
- Katherine Yun is an assistant professor in the Division of General Pediatrics, Children's Hospital of Philadelphia
| | - Atheendar S Venkataramani
- Atheendar S. Venkataramani is an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Diana Montoya-Williams
- Diana Montoya-Williams is an instructor in the Division of Neonatology, Children's Hospital of Philadelphia
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Sandoval-Olascoaga S, Venkataramani AS, Arcaya MC. Eviction Moratoria Expiration and COVID-19 Infection Risk Across Strata of Health and Socioeconomic Status in the United States. JAMA Netw Open 2021; 4:e2129041. [PMID: 34459904 PMCID: PMC8406080 DOI: 10.1001/jamanetworkopen.2021.29041] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Housing insecurity induced by evictions may increase the risk of contracting COVID-19. OBJECTIVE To estimate the association of lifting state-level eviction moratoria, which increased housing insecurity during the COVID-19 pandemic, with the risk of being diagnosed with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included individuals with commercial insurance or Medicare Advantage who lived in a state that issued an eviction moratorium and were diagnosed with COVID-19 as well as a control group comprising an equal number of randomly selected individuals in these states who were not diagnosed with COVID-19. Data were collected from OptumLabs Data Warehouse, a database of deidentified administrative claims. The study used a difference-in-differences analysis among states that implemented an eviction moratorium between March 13, 2020, and September 4, 2020. EXPOSURES Time since state-level eviction moratoria were lifted. MAIN OUTCOMES AND MEASURES The primary outcome measure was a binary variable indicating whether an individual was diagnosed with COVID-19 for the first time in a given week with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code U07.1. The study analyzed changes in COVID-19 diagnosis before vs after a state lifted its moratorium compared with changes in states that did not lift it. For sensitivity analyses, models were reestimated on a 2% random sample of all individuals in the claims database during this period in these states. RESULTS The cohort consisted of 509 694 individuals (254 847 [50.0%] diagnosed with COVID-19; mean [SD] age, 47.0 [23.6] years; 239 056 [53.3%] men). During the study period, 43 states and the District of Columbia implemented an eviction moratorium and 7 did not. Among the states that implemented a moratorium, 26 (59.1%) lifted their moratorium before the US Centers for Disease Control and Prevention issued their national moratorium, while 18 (40.1%) maintained theirs. In a Cox difference-in-differences regression model, individuals living in a state that lifted its eviction moratorium experienced higher hazards of a COVID-19 diagnosis beginning 5 weeks after the moratorium was lifted (hazard ratio [HR], 1.39; 95% CI, 1.11-1.76; P = .004), reaching an HR of 1.83 (95% CI, 1.36-2.46; P < .001) 12 weeks after. Hazards increased in magnitude among individuals with preexisting comorbidities and those living in nonaffluent and rent-burdened areas. Individuals with a Charlson Comorbidity Index score of 3 or greater had an HR of 2.37 (95% CI, 1.67-3.36; P < .001) at the end of the study period. Those living in nonaffluent areas had an HR of 2.14 (95% CI, 1.51-3.05; P < .001), while those living in areas with a high rent burden had an HR of 2.31 (95% CI, 1.64-3.26; P < .001). CONCLUSIONS AND RELEVANCE The findings of this difference-in-differences analysis suggest that eviction-led housing insecurity may have exacerbated the COVID-19 pandemic.
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Affiliation(s)
- Sebastian Sandoval-Olascoaga
- Department of Urban Studies and Planning, Massachusetts Institute of Technology, Cambridge
- OptumLabs Visiting Fellow, Eden Prairie, Minnesota
| | - Atheendar S. Venkataramani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Mariana C. Arcaya
- Department of Urban Studies and Planning, Massachusetts Institute of Technology, Cambridge
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26
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Kavanagh NM, Goel RR, Venkataramani AS. County-Level Socioeconomic and Political Predictors of Distancing for COVID-19. Am J Prev Med 2021; 61:13-19. [PMID: 33947527 PMCID: PMC7988444 DOI: 10.1016/j.amepre.2021.01.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In response to the COVID-19 pandemic, governments have implemented social distancing measures to slow viral transmission. This work aims to determine the extent to which socioeconomic and political conditions have shaped community-level distancing behaviors during the COVID-19 pandemic, especially how these dynamics have evolved over time. METHODS This study used daily data on physical distancing from 15‒17 million cell phone users in 3,037 U.S. counties. County-level changes in the average distance traveled per person were estimated relative to prepandemic weeks as a proxy for physical distancing. Pooled ordinary least squares regressions estimated the association between physical distancing and a variety of county-level demographic, socioeconomic, and political characteristics by week from March 9, 2020 to January 17, 2021. Data were collected until January 2021, at which point the analyses were finalized. RESULTS Lower per capita income and greater Republican orientation were associated with significantly reduced physical distancing throughout nearly all the study period. These associations persisted after adjusting for a variety of county-level demographic and socioeconomic characteristics. Other county-level characteristics, such as the shares of Black and Hispanic residents, were associated with reduced distancing at various points during the study period. CONCLUSIONS These results highlight the importance of dynamic socioeconomic and political gradients in preventive behavior and imply the need for nimble policy responses.
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Affiliation(s)
- Nolan M Kavanagh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Rishi R Goel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Atheendar S Venkataramani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Vasan A, Kenyon CC, Feudtner C, Fiks AG, Venkataramani AS. Association of WIC Participation and Electronic Benefits Transfer Implementation. JAMA Pediatr 2021; 175:609-616. [PMID: 33779712 PMCID: PMC8008428 DOI: 10.1001/jamapediatrics.2020.6973] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/20/2020] [Indexed: 11/14/2022]
Abstract
Importance The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an important source of nutritional support and education for women and children living in poverty; although WIC participation confers clear health benefits, only 50% of eligible women and children currently receive WIC. In 2010, Congress mandated that states transition WIC benefits by 2020 from paper vouchers to electronic benefits transfer (EBT) cards, which are more convenient to use, are potentially less stigmatizing, and may improve WIC participation. Objective To estimate the state-level association between transition from paper vouchers to EBT and subsequent WIC participation. Design, Setting, and Participants This economic evaluation of state-level WIC monthly benefit summary administrative data regarding participation between October 1, 2014, and November 30, 2019, compared states that did and did not implement WIC EBT during this time period. Difference-in-differences regression modeling allowed associations to vary by time since policy implementation and included stratified analyses for key subgroups (pregnant and postpartum women, infants younger than 1 year, and children aged 1-4 years). All models included dummy variables denoting state, year, and month as covariates. Data analyses were performed between March 1 and June 15, 2020. Exposures Statewide transition from WIC paper vouchers to WIC EBT cards, specified by month and year. Main Outcomes and Measures Monthly number of state residents enrolled in WIC. Results A total of 36 states implemented WIC EBT before or during the study period. EBT and non-EBT states had similar baseline rates of poverty and food insecurity. Three years after statewide WIC EBT implementation, WIC participation increased by 7.78% (95% CI, 3.58%-12.15%) in exposed states compared with unexposed states. In stratified analyses, WIC participation increased by 7.22% among pregnant and postpartum women (95% CI, 2.54%-12.12%), 4.96% among infants younger than 1 year (95% CI, 0.95%-9.12%), and 9.12% among children aged 1 to 4 years (95% CI, 3.19%-15.39%; P for interaction = .20). Results were robust to adjustment for state unemployment and poverty rates, population, and Medicaid expansion status. Conclusions and Relevance In this study, the transition from paper vouchers to WIC EBT was associated with a significant and sustained increase in enrollment. Interventions that simplify the process of redeeming benefits may be critical for addressing low rates of enrollment in WIC and other government benefit programs.
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Affiliation(s)
- Aditi Vasan
- National Clinician Scholars Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chén C. Kenyon
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chris Feudtner
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander G. Fiks
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Affiliation(s)
- Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Rourke O'Brien
- Department of Sociology, Yale University, New Haven, Connecticut
- Institution for Social and Policy Studies, Yale University, New Haven, Connecticut
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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Khatana SAM, Venkataramani AS, Nathan AS, Dayoub EJ, Eberly LA, Kazi DS, Yeh RW, Mitra N, Subramanian SV, Groeneveld PW. Association Between County-Level Change in Economic Prosperity and Change in Cardiovascular Mortality Among Middle-aged US Adults. JAMA 2021; 325:445-453. [PMID: 33528535 PMCID: PMC7856543 DOI: 10.1001/jama.2020.26141] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE After a decline in cardiovascular mortality for nonelderly US adults, recent stagnation has occurred alongside rising income inequality. Whether this is associated with underlying economic trends is unclear. OBJECTIVE To assess the association between changes in economic prosperity and trends in cardiovascular mortality in middle-aged US adults. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the association between change in 7 markers of economic prosperity in 3123 US counties and county-level cardiovascular mortality among 40- to 64-year-old adults (102 660 852 individuals in 2010). EXPOSURES Mean rank for change in 7 markers of economic prosperity between 2 time periods (baseline: 2007-2011 and follow-up: 2012-2016). A higher mean rank indicates a greater relative increase or lower relative decrease in prosperity (range, 5 to 92; mean [SD], 50 [14]). MAIN OUTCOMES AND MEASURES Mean annual percentage change (APC) in age-adjusted cardiovascular mortality rates. Generalized linear mixed-effects models were used to estimate the additional APC associated with a change in prosperity. RESULTS Among 102 660 852 residents aged 40 to 64 years living in these counties in 2010 (51% women), 979 228 cardiovascular deaths occurred between 2010 and 2017. Age-adjusted cardiovascular mortality rates did not change significantly between 2010 and 2017 in counties in the lowest tertile for change in economic prosperity (mean [SD], 114.1 [47.9] to 116.1 [52.7] deaths per 100 000 individuals; APC, 0.2% [95% CI, -0.3% to 0.7%]). Mortality decreased significantly in the intermediate tertile (mean [SD], 104.7 [38.8] to 101.9 [41.5] deaths per 100 000 individuals; APC, -0.4% [95% CI, -0.8% to -0.1%]) and highest tertile for change in prosperity (100.0 [37.9] to 95.1 [39.1] deaths per 100 000 individuals; APC, -0.5% [95% CI, -0.9% to -0.1%]). After accounting for baseline prosperity and demographic and health care-related variables, a 10-point higher mean rank for change in economic prosperity was associated with 0.4% (95% CI, 0.2% to 0.6%) additional decrease in mortality per year. CONCLUSIONS AND RELEVANCE In this retrospective study of US county-level mortality data from 2010 to 2017, a relative increase in county-level economic prosperity was significantly associated with a small relative decrease in cardiovascular mortality among middle-aged adults. Individual-level inferences are limited by the ecological nature of the study.
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Affiliation(s)
- Sameed Ahmed M. Khatana
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ashwin S. Nathan
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elias J. Dayoub
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Lauren A. Eberly
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Nandita Mitra
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Tsai AC, Venkataramani AS. US elections: treating the acute-on-chronic decompensation. Lancet Public Health 2020; 5:e519-e520. [PMID: 33007207 PMCID: PMC7524534 DOI: 10.1016/s2468-2667(20)30212-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA.
| | - Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Wang SY, Eberly LA, Roberto CA, Venkataramani AS, Groeneveld PW, Khatana SAM. Food Insecurity and Cardiovascular Mortality for Nonelderly Adults in the United States From 2011 to 2017: A County-Level Longitudinal Analysis. Circ Cardiovasc Qual Outcomes 2020; 14:e007473. [PMID: 33164557 DOI: 10.1161/circoutcomes.120.007473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen Y Wang
- Department of Internal Medicine, Yale-New Haven Hospital, CT (S.Y.W.)
| | - Lauren A Eberly
- Division of Cardiovascular Medicine (L.A.E., S.A.M.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Christina A Roberto
- Department of Medical Ethics and Health Policy (C.A.R., A.S.V.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy (C.A.R., A.S.V.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Peter W Groeneveld
- Division of General Internal Medicine (P.W.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine (L.A.E., S.A.M.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Linn KA, Underhill K, Dixon EL, Bair EF, Ferrell WJ, Montgomery ME, Volpp KG, Venkataramani AS. The design of a randomized controlled trial to evaluate multi-dimensional effects of a section 1115 Medicaid demonstration waiver with community engagement requirements. Contemp Clin Trials 2020; 98:106173. [PMID: 33038505 PMCID: PMC7538873 DOI: 10.1016/j.cct.2020.106173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 10/26/2022]
Abstract
Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization - the gold standard for assessing causality - has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of beneficiaries deemed able-bodied to maintain eligibility for benefits. Beneficiaries were randomized 9:1 to the new waiver program or a control group who would retain their current benefits as part of the existing Medicaid expansion program. To address potential bias from differential attrition from the Medicaid program that would accrue from solely analyzing administrative data, our team designed a rich, prospective, longitudinal survey to collect primary and secondary outcomes from six categories of interest to policymakers: insurance coverage, health care utilization and quality, health behaviors, socioeconomic measures, personal finances, and health outcomes. At baseline, a subset of survey participants was invited to participate in the collection of biometric samples via in-person follow-up visits, and a cross-section were also invited to participate in qualitative interviews. While the demonstration waiver was terminated before the program began, our study design illustrates that it is possible for other researchers and state agencies seeking to evaluate Medicaid demonstration waivers and other demonstration policies to work together to implement high quality randomized trials - even for controversial policies.
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Affiliation(s)
- Kristin A Linn
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA
| | - Kristen Underhill
- Columbia Law School, New York, NY, USA; Department of Population and Family Health, Mailman School of Public Heath, Columbia University, New York, NY, USA
| | - Erica L Dixon
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA
| | - Elizabeth F Bair
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA
| | - William J Ferrell
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA
| | - Margrethe E Montgomery
- National Opinion Research Center at the University of Chicago, Bethesda MD and Chicago, IL, USA
| | - Kevin G Volpp
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Center for Health Equity Research and Promotion, Cresencz VA Medical Center, Philadelphia, USA
| | - Atheendar S Venkataramani
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, USA.
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Siedner MJ, Harling G, Reynolds Z, Gilbert RF, Haneuse S, Venkataramani AS, Tsai AC. Correction: Social distancing to slow the US COVID-19 epidemic: Longitudinal pretest-posttest comparison group study. PLoS Med 2020; 17:e1003376. [PMID: 33022016 PMCID: PMC7537852 DOI: 10.1371/journal.pmed.1003376] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pmed.1003244.].
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Abstract
Atheendar S. Venkataramani and colleagues discuss economic factors and population health in the United States.
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Rourke O’Brien
- Department of Sociology, Yale University, New Haven, Connecticut, United States of America
| | - Gregory L. Whitehorn
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Alexander C. Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
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Siedner MJ, Harling G, Reynolds Z, Gilbert RF, Haneuse S, Venkataramani AS, Tsai AC. Social distancing to slow the US COVID-19 epidemic: Longitudinal pretest-posttest comparison group study. PLoS Med 2020; 17:e1003244. [PMID: 32780772 PMCID: PMC7418951 DOI: 10.1371/journal.pmed.1003244] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/02/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Social distancing measures to address the US coronavirus disease 2019 (COVID-19) epidemic may have notable health and social impacts. METHODS AND FINDINGS We conducted a longitudinal pretest-posttest comparison group study to estimate the change in COVID-19 case growth before versus after implementation of statewide social distancing measures in the US. The primary exposure was time before (14 days prior to, and through 3 days after) versus after (beginning 4 days after, to up to 21 days after) implementation of the first statewide social distancing measures. Statewide restrictions on internal movement were examined as a secondary exposure. The primary outcome was the COVID-19 case growth rate. The secondary outcome was the COVID-19-attributed mortality growth rate. All states initiated social distancing measures between March 10 and March 25, 2020. The mean daily COVID-19 case growth rate decreased beginning 4 days after implementation of the first statewide social distancing measures, by 0.9% per day (95% CI -1.4% to -0.4%; P < 0.001). We did not observe a statistically significant difference in the mean daily case growth rate before versus after implementation of statewide restrictions on internal movement (0.1% per day; 95% CI -0.04% to 0.3%; P = 0.14), but there is substantial difficulty in disentangling the unique associations with statewide restrictions on internal movement from the unique associations with the first social distancing measures. Beginning 7 days after social distancing, the COVID-19-attributed mortality growth rate decreased by 2.0% per day (95% CI -3.0% to -0.9%; P < 0.001). Our analysis is susceptible to potential bias resulting from the aggregate nature of the ecological data, potential confounding by contemporaneous changes (e.g., increases in testing), and potential underestimation of social distancing due to spillover effects from neighboring states. CONCLUSIONS Statewide social distancing measures were associated with a decrease in the COVID-19 case growth rate that was statistically significant. Statewide social distancing measures were also associated with a decrease in the COVID-19-attributed mortality growth rate beginning 7 days after implementation, although this decrease was no longer statistically significant by 10 days.
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Affiliation(s)
- Mark J. Siedner
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, London, United Kingdom
- MRC/Wits Agincourt Unit, Rural Public Health and Health Transitions Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, United States of America
| | - Zahra Reynolds
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Rebecca F. Gilbert
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Alexander C. Tsai
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, United States of America
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Venkataramani AS, Bair EF, Dixon E, Linn KA, Ferrell WJ, Volpp KG, Underhill K. Association Between State Policies Using Medicaid Exclusions to Sanction Noncompliance With Welfare Work Requirements and Medicaid Participation Among Low-Income Adults. JAMA Netw Open 2020; 3:e204579. [PMID: 32391890 PMCID: PMC7215259 DOI: 10.1001/jamanetworkopen.2020.4579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study examines the association of implementation of Medicaid sanctions in the Temporary Assistance for Needy Families program with Medicaid coverage rates among low-income adults.
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Elizabeth F. Bair
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Erica Dixon
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kristin A. Linn
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - William J. Ferrell
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kristen Underhill
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Columbia Law School, New York, New York
- Mailman School of Public Heath, Department of Population and Family Health, Columbia University, New York, New York
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Alexander C. Tsai
- Center for Global HealthMassachusetts General HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
- Mbarara University of Science and TechnologyMbararaUganda
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Venkataramani AS, Bair EF, O'Brien RL, Tsai AC. Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis. JAMA Intern Med 2020; 180:254-262. [PMID: 31886844 PMCID: PMC6990761 DOI: 10.1001/jamainternmed.2019.5686] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Fading economic opportunity has been hypothesized to be an important factor associated with the US opioid overdose crisis. Automotive assembly plant closures are culturally significant events that substantially erode local economic opportunities. OBJECTIVE To estimate the extent to which automotive assembly plant closures were associated with increasing opioid overdose mortality rates among working-age adults. DESIGN, SETTING, AND PARTICIPANTS A county-level difference-in-differences study was conducted among adults aged 18 to 65 years in 112 manufacturing counties located in 30 commuting zones (primarily in the US South and Midwest) with at least 1 operational automotive assembly plant as of 1999. The study analyzed county-level changes from January 1, 1999, to December 31, 2016, in age-adjusted, county-level opioid overdose mortality rates before vs after automotive assembly plant closures in manufacturing counties affected by plant closures compared with changes in manufacturing counties unaffected by plant closures. Data analyses were performed between April 1, 2018, and July 20, 2019. EXPOSURE Closure of automotive assembly plants in the commuting zone of residence. MAIN OUTCOMES AND MEASURES The primary outcome was the county-level age-adjusted opioid overdose mortality rate. Secondary outcomes included the overall drug overdose mortality rate and prescription vs illicit drug overdose mortality rates. RESULTS During the study period, 29 manufacturing counties in 10 commuting zones were exposed to an automotive assembly plant closure, while 83 manufacturing counties in 20 commuting zones remained unexposed. Mean (SD) baseline opioid overdose rates per 100 000 were similar in exposed (0.9 [1.4]) and unexposed (1.0 [2.1]) counties. Automotive assembly plant closures were associated with statistically significant increases in opioid overdose mortality. Five years after a plant closure, mortality rates had increased by 8.6 opioid overdose deaths per 100 000 individuals (95% CI, 2.6-14.6; P = .006) in exposed counties compared with unexposed counties, an 85% higher increase relative to the mortality rate that would have been expected had exposed counties followed the same outcome trends as unexposed counties. In analyses stratified by age, sex, and race/ethnicity, the largest increases in opioid overdose mortality were observed among non-Hispanic white men aged 18 to 34 years (20.1 deaths per 100 000; 95% CI, 8.8-31.3; P = .001) and aged 35 to 65 years (12.8 deaths per 100 000; 95% CI, 5.7-20.0; P = .001). We observed similar patterns of prescription vs illicit drug overdose mortality. Estimates for opioid overdose mortality in nonmanufacturing counties were not statistically significant. CONCLUSIONS AND RELEVANCE From 1999 to 2016, automotive assembly plant closures were associated with increases in opioid overdose mortality. These findings highlight the potential importance of eroding economic opportunity as a factor in the US opioid overdose crisis.
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Affiliation(s)
- Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elizabeth F Bair
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rourke L O'Brien
- Department of Sociology, Yale University, New Haven, Connecticut
| | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Atheendar S Venkataramani
- Perelman School of Medicine, Department of Medical Ethics and Health Policy and Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Kristen Underhill
- Columbia Law School, New York, New York
- Mailman School of Public Health, Department of Population and Family Health, Columbia University, New York, New York
| | - Kevin G Volpp
- Perelman School of Medicine, Department of Medical Ethics and Health Policy and Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
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Navathe AS, Emanuel EJ, Venkataramani AS, Huang Q, Gupta A, Dinh CT, Shan EZ, Small D, Coe NB, Wang E, Ma X, Zhu J, Cousins DS, Liao JM. Spending And Quality After Three Years Of Medicare’s Voluntary Bundled Payment For Joint Replacement Surgery. Health Aff (Millwood) 2020; 39:58-66. [DOI: 10.1377/hlthaff.2019.00466] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Amol S. Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center, in Philadelphia, and an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and a senior fellow at the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
| | - Ezekiel J. Emanuel
- Ezekiel J. Emanuel is the Diane V. S. Levy and Robert M. Levy University Professor, chair of the Department of Medical Ethics and Health Policy, and vice provost for global initiatives, all at the University of Pennsylvania
| | - Atheendar S. Venkataramani
- Atheendar S. Venkataramani is an assistant professor of medical ethics and of health policy at the Perelman School of Medicine, University of Pennsylvania
| | - Qian Huang
- Qian Huang is a statistical analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Atul Gupta
- Atul Gupta is an assistant professor in the Department of Health Care Management, Wharton School, University of Pennsylvania
| | - Claire T. Dinh
- Claire T. Dinh is a medical student at Harvard Medical School, in Boston, Massachusetts. She was a research coordinator in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, when this work was completed
| | - Eric Z. Shan
- Eric Z. Shan is a research assistant in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Dylan Small
- Dylan Small is a professor in the Department of Statistics, University of Pennsylvania
| | - Norma B. Coe
- Norma B. Coe is an associate professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Erkuan Wang
- Erkuan Wang is a data analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Xinshuo Ma
- Xinshuo Ma is a data analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Jingsan Zhu
- Jingsan Zhu is associate director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Deborah S. Cousins
- Deborah S. Cousins is a project manager in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Joshua M. Liao
- Joshua M. Liao is medical director of payment strategy, director of the Value and Systems Science Lab, and an assistant professor in the Department of Medicine, all at the University of Washington, in Seattle, and an adjunct senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania
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Tsai AC, Kiang MV, Barnett ML, Beletsky L, Keyes KM, McGinty EE, Smith LR, Strathdee SA, Wakeman SE, Venkataramani AS. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019; 16:e1002969. [PMID: 31770387 PMCID: PMC6957118 DOI: 10.1371/journal.pmed.1002969] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.
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Affiliation(s)
- Alexander C. Tsai
- Center for Global Health, Massachusetts General Hospital, Boston,
Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of
America
- Mbarara University of Science and Technology, Mbarara,
Uganda
| | - Mathew V. Kiang
- Center for Population Health Sciences, Stanford University School of
Medicine, Stanford, California, United States of America
| | - Michael L. Barnett
- Harvard Medical School, Boston, Massachusetts, United States of
America
- Department of Health Policy and Management, Harvard T. H. Chan School of
Public Health, Boston, Massachusetts, United States of America
- Division of General Internal Medicine and Primary Care, Brigham and
Women’s Hospital, Boston, Massachusetts, United States of
America
| | - Leo Beletsky
- Northeastern University School of Law, Boston, Massachusetts, United
States of America
- Bouvé College of Health Sciences, Northeastern University, Boston,
Massachusetts, United States of America
- Division of Infectious Diseases and Global Public Health, University of
California at San Diego School of Medicine, San Diego, California, United States
of America
| | - Katherine M. Keyes
- Mailman School of Public Health, Columbia University, New York City, New
York, United States of America
| | - Emma E. McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, Baltimore, Maryland, United States of
America
| | - Laramie R. Smith
- Division of Infectious Diseases and Global Public Health, University of
California at San Diego School of Medicine, San Diego, California, United States
of America
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, University of
California at San Diego School of Medicine, San Diego, California, United States
of America
| | - Sarah E. Wakeman
- Harvard Medical School, Boston, Massachusetts, United States of
America
- Department of Medicine, Massachusetts General Hospital, Boston,
Massachusetts, United States of America
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania,
Philadelphia, Pennsylvania, United States of America
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Liao JM, Emanuel EJ, Venkataramani AS, Huang Q, Dinh CT, Shan EZ, Wang E, Zhu J, Cousins DS, Navathe AS. Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations. JAMA Netw Open 2019; 2:e1912270. [PMID: 31560389 PMCID: PMC6777392 DOI: 10.1001/jamanetworkopen.2019.12270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/11/2019] [Indexed: 11/14/2022] Open
Abstract
Importance An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models. Objective To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. Design, Setting, and Participants This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States. Exposures Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants). Main Outcomes and Measures Changes in clinical outcomes and mean LEJR episode spending. Results A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants. Conclusions and Relevance Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Claire T. Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric Z. Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Smith ML, Kakuhikire B, Baguma C, Rasmussen JD, Perkins JM, Cooper-Vince C, Venkataramani AS, Ashaba S, Bangsberg DR, Tsai AC. Relative wealth, subjective social status, and their associations with depression: Cross-sectional, population-based study in rural Uganda. SSM Popul Health 2019; 8:100448. [PMID: 31338411 PMCID: PMC6626875 DOI: 10.1016/j.ssmph.2019.100448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/13/2019] [Accepted: 07/06/2019] [Indexed: 01/24/2023] Open
Abstract
Depression is a leading cause of disability worldwide, and has been found to be a consistent correlate of socioeconomic status (SES). The relative deprivation hypothesis proposes that one mechanism linking SES to health involves social comparisons, suggesting that relative SES rather than absolute SES is of primary importance in determining health status. Using data from a whole-population sample of 1,620 participants residing in rural southwestern Uganda, we estimated the independent associations between objective and subjective relative wealth and probable depression, as measured by the depression subscale of the Hopkins Symptom Checklist (HSCLD). Objective relative wealth was measured by an asset index based on information about housing characteristics and household possessions, which was used to rank study participants into quintiles (within each village) of relative household asset wealth. Subjective relative wealth was measured by a single question asking participants to rate their wealth, on a 5-point Likert scale, relative to others in their village. Within the population, 460 study participants (28.4%) screened positive for probable depression. Using Poisson regression with cluster-robust error variance, we found that subjective relative wealth was associated with probable depression, adjusting for objective relative wealth and other covariates (adjusted relative risk [aRR] comparing lowest vs. highest level of subjective relative wealth = 1.90, 95% confidence interval [CI]: 1.18, 3.06). Objective relative wealth was not associated with probable depression (aRR comparing lowest vs. highest quintile of objective relative wealth = 1.09, 95% CI: 0.77, 1.55). These results suggest that, in this context, subjective relative wealth is a stronger correlate of mental health status compared with objective relative wealth. Our findings are potentially consistent with the relative deprivation hypothesis, but more research is needed to explain how relative differences in wealth are (accurately or inaccurately) perceived and to elucidate the implications of these perceptions for health outcomes.
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Affiliation(s)
- Meghan L. Smith
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | | | | | - David R. Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Alexander C. Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Venkataramani AS, Bair EF, Dixon E, Linn KA, Ferrell W, Montgomery M, Strollo MK, Volpp KG, Underhill K. Assessment of Medicaid Beneficiaries Included in Community Engagement Requirements in Kentucky. JAMA Netw Open 2019; 2:e197209. [PMID: 31314117 PMCID: PMC6647552 DOI: 10.1001/jamanetworkopen.2019.7209] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/27/2019] [Indexed: 11/14/2022] Open
Abstract
Importance States are pursuing Section 1115 Medicaid demonstration waiver authority to apply community engagement (CE) requirements (eg, participation in work, volunteer activities, or training) to beneficiaries deemed able-bodied as a condition of coverage. Understanding the size and characteristics of the populations included in these requirements can help inform policy initiatives and anticipate effects. Objective To estimate the number and characteristics of Kentucky Medicaid beneficiaries who would have to meet CE requirements. Design, Setting, and Participants Cross-sectional study in which administrative records for the entire population of Medicaid beneficiaries in Kentucky as of February 2018 and original survey data, based on responses from 9396 Medicaid beneficiaries included in the waiver program, were analyzed. Exposures Eligibility for Kentucky's Medicaid demonstration waiver as of the originally planned implementation date (July 2018). Main Outcomes and Measures Number of beneficiaries included in CE requirements, including those already meeting vs not meeting hour quotas and those who may qualify for medical frailty exemptions. Results Among the 9396 individuals included in the Section 1115 waiver program who participated in the survey, the mean weighted (SD) age was 36.1 (11.9) years; a weighted 47.2% of respondents were female, and most beneficiaries (weighted percentage, 78.2%) were non-Hispanic white participants. We estimated that 132 790 (95% CI, 129 132-136 449) beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver. Of this group, 25 422 (95% CI, 23 135-27 710) beneficiaries may have qualified for a medical frailty exemption either by self-attestation (after confirmation by their Medicaid insurer) or by being identified as eligible by physicians or their insurer. Another 58 943 (95% CI, 55 687-62 196) beneficiaries likely would have met CE hour requirements and been required to report compliance. Ultimately, 48 427 (95% CI, 45 281-51 574) individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver. Beneficiaries in the potentially medically frail group reported worse socioeconomic status, poorer health outcomes, and higher rates of hospital admission and emergency department use than those meeting CE requirements. Similarly, the group currently not meeting and not exempt from CE hour requirements reported worse socioeconomic status than those meeting the CE requirements, although magnitudes of the differences were smaller. Conclusions and Relevance Findings suggest that most beneficiaries who would be included in CE programs either already meet activity requirements, which they will be required to proactively report, or may qualify for a medical frailty exemption. Consequently, the outcomes of CE programs will depend on states' processes for addressing health-related, socioeconomic, and administrative barriers to participating in and reporting CE activities and identifying medical frailty.
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Affiliation(s)
- Atheendar S. Venkataramani
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth F. Bair
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erica Dixon
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristin A. Linn
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Will Ferrell
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Margrethe Montgomery
- National Opinion Research Center (NORC) at the University of Chicago, Chicago, Illinois
| | - Michelle K. Strollo
- National Opinion Research Center (NORC) at the University of Chicago, Bethesda, Maryland
| | - Kevin G. Volpp
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristen Underhill
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Columbia Law School, New York, New York
- Department of Population and Family Health, Mailman School of Public Heath, Columbia University, New York, New York
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Venkataramani AS, Cook E, O’Brien RL, Kawachi I, Jena AB, Tsai AC. College affirmative action bans and smoking and alcohol use among underrepresented minority adolescents in the United States: A difference-in-differences study. PLoS Med 2019; 16:e1002821. [PMID: 31211777 PMCID: PMC6581254 DOI: 10.1371/journal.pmed.1002821] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 05/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND College affirmative action programs seek to expand socioeconomic opportunities for underrepresented minorities. Between 1996 and 2013, 9 US states-including California, Texas, and Michigan-banned race-based affirmative action in college admissions. Because economic opportunity is known to motivate health behavior, banning affirmative action policies may have important adverse spillover effects on health risk behaviors. We used a quasi-experimental research design to evaluate the association between college affirmative action bans and health risk behaviors among underrepresented minority (Black, Hispanic, and Native American) adolescents. METHODS AND FINDINGS We conducted a difference-in-differences analysis using data from the 1991-2015 US national Youth Risk Behavior Survey (YRBS). We compared changes in self-reported cigarette smoking and alcohol use in the 30 days prior to survey among underrepresented minority 11th and 12th graders in states implementing college affirmative action bans (Arizona, California, Florida, Michigan, Nebraska, New Hampshire, Oklahoma, Texas, and Washington) versus outcomes among those residing in states not implementing bans (n = 35 control states). We also assessed whether underrepresented minority adults surveyed in the 1992-2015 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) who were exposed to affirmative action bans during their late high school years continued to smoke cigarettes between the ages of 19 and 30 years. Models adjusted for individual demographic characteristics, state and year fixed effects, and state-specific secular trends. In the YRBS (n = 34,988 to 36,268, depending on the outcome), cigarette smoking in the past 30 days among underrepresented minority 11th-12th graders increased by 3.8 percentage points after exposure to an affirmative action ban (95% CI: 2.0, 5.7; p < 0.001). In addition, there were also apparent increases in past-30-day alcohol use, by 5.9 percentage points (95% CI: 0.3, 12.2; p = 0.041), and past-30-day binge drinking, by 3.5 percentage points (95% CI: -0.1, 7.2, p = 0.058), among underrepresented minority 11th-12th graders, though in both cases adjustment for multiple comparisons resulted in failure to reject the null hypothesis (adjusted p = 0.083 for both outcomes). Underrepresented minority adults in the TUS-CPS (n = 71,575) exposed to bans during their late high school years were also 1.8 percentage points more likely to report current smoking (95% CI: 0.1, 3.6; p = 0.037). Event study analyses revealed a discrete break for all health behaviors timed with policy discussion and implementation. No substantive or statistically significant effects were found for non-Hispanic White adolescents, and the findings were robust to a number of additional specification checks. The limitations of the study include the continued potential for residual confounding from unmeasured time-varying factors and the potential for recall bias due to the self-reported nature of the health risk behavior outcomes. CONCLUSIONS In this study, we found evidence that some health risk behaviors increased among underrepresented minority adolescents after exposure to state-level college affirmative action bans. These findings suggest that social policies that shift socioeconomic opportunities could have meaningful population health consequences.
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Erin Cook
- Analysis Group, Boston, Massachusetts, United States of America
| | - Rourke L. O’Brien
- La Follette School of Public Affairs, University of Wisconsin–Madison, Madison, Wisconsin, United States of America
| | - Ichiro Kawachi
- Department of Social and Behavioral Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alexander C. Tsai
- Chester M. Pierce, M.D. Division of Global Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Affiliation(s)
- Jacob Bor
- Department of Global Health and Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - David R Williams
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health and Department of African and African American Studies, Harvard University, Boston, MA, USA
| | - Alexander C Tsai
- Chester M Pierce MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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47
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Affiliation(s)
- Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Himmelstein KEW, Venkataramani AS. Economic Vulnerability Among US Female Health Care Workers: Potential Impact of a $15-per-Hour Minimum Wage. Am J Public Health 2018; 109:198-205. [PMID: 30571300 DOI: 10.2105/ajph.2018.304801] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate racial/ethnic and gender inequities in the compensation and benefits of US health care workers and assess the potential impact of a $15-per-hour minimum wage on their economic well-being. METHODS Using the 2017 Annual Social and Economic Supplement to the Current Population Survey, we compared earnings, insurance coverage, public benefits usage, and occupational distribution of male and female health care workers of different races/ethnicities. We modeled the impact of raising the minimum wage to $15 per hour with different scenarios for labor demand. RESULTS Of female health care workers, 34.9% of earned less than $15 per hour. Nearly half of Black and Latina female health care workers earned less than $15 per hour, and more than 10% lacked health insurance. A total of 1.7 million female health care workers and their children lived in poverty. Raising the minimum wage to $15 per hour would reduce poverty rates among female health care workers by 27.1% to 50.3%. CONCLUSIONS Many US female health care workers, particularly women of color, suffer economic privation and lack health insurance. Achieving economic, gender, and racial/ethnic justice will require significant changes to the compensation structure of health care.
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Affiliation(s)
- Kathryn E W Himmelstein
- At the time of the study, Kathryn E. W. Himmelstein was a medical student at the Perelman School of Medicine, University of Pennsylvania, Philadelphia. Atheendar S. Venkataramani is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and the Leonard Davis Institute for Health Economics, University of Pennsylvania
| | - Atheendar S Venkataramani
- At the time of the study, Kathryn E. W. Himmelstein was a medical student at the Perelman School of Medicine, University of Pennsylvania, Philadelphia. Atheendar S. Venkataramani is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and the Leonard Davis Institute for Health Economics, University of Pennsylvania
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Cook EE, Venkataramani AS, Kim JJ, Tamimi RM, Holmes MD. Legislation to Increase Uptake of HPV Vaccination and Adolescent Sexual Behaviors. Pediatrics 2018; 142:e20180458. [PMID: 30104422 PMCID: PMC6317562 DOI: 10.1542/peds.2018-0458] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite preventive health benefits of the human papillomavirus (HPV) vaccination, uptake in the United States remains low. Twenty-four states have enacted legislation regarding HPV vaccination and education. One reason these policies have been controversial is because of concerns that they encourage risky adolescent sexual behaviors. Our aim in this study is to determine if state HPV legislation is associated with changes in adolescent sexual behaviors. METHODS This is a difference-in-difference study in which we use data on adolescent sexual behaviors from the school-based state Youth Risk Behavior Surveillance System from 2001 to 2015. Sexual behaviors included ever having sexual intercourse in the last 3 months and condom use during last sexual intercourse. We compared changes in sexual behaviors among high school students before and after HPV legislation to changes among high school students in states without legislation. RESULTS A total of 715 338 participants reported ever having sexual intercourse in the last 3 months, and 217 077 sexually active participants reported recent condom use. We found no substantive or statistically significant associations between HPV legislation and adolescent sexual behaviors. Recent sexual intercourse decreased by 0.90 percentage points (P = .21), and recent condom use increased by 0.96 percentage points (P = .32) among adolescents in states that enacted legislation compared with states that did not. Results were robust to a number of sensitivity analyses. CONCLUSIONS Implementation of HPV legislation was not associated with changes in adolescent sexual behaviors in the United States. Concern that legislation will increase risky adolescent sexual behaviors should not be used when deciding to pass HPV legislation.
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Affiliation(s)
| | - Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania; and
| | - Jane J Kim
- Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Rulla M Tamimi
- Departments of Epidemiology and
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michelle D Holmes
- Departments of Epidemiology and
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Bor J, Venkataramani AS, Williams DR, Tsai AC. Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. Lancet 2018; 392:302-310. [PMID: 29937193 PMCID: PMC6376989 DOI: 10.1016/s0140-6736(18)31130-9] [Citation(s) in RCA: 343] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 04/07/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Police kill more than 300 black Americans-at least a quarter of them unarmed-each year in the USA. These events might have spillover effects on the mental health of people not directly affected. METHODS In this population-based, quasi-experimental study, we combined novel data on police killings with individual-level data from the nationally representative 2013-15 US Behavioral Risk Factor Surveillance System (BRFSS) to estimate the causal impact of police killings of unarmed black Americans on self-reported mental health of other black American adults in the US general population. The primary exposure was the number of police killings of unarmed black Americans occurring in the 3 months prior to the BRFSS interview within the same state. The primary outcome was the number of days in the previous month in which the respondent's mental health was reported as "not good". We estimated difference-in-differences regression models-adjusting for state-month, month-year, and interview-day fixed effects, as well as age, sex, and educational attainment. We additionally assessed the timing of effects, the specificity of the effects to black Americans, and the robustness of our findings. FINDINGS 38 993 (weighted sample share 49%) of 103 710 black American respondents were exposed to one or more police killings of unarmed black Americans in their state of residence in the 3 months prior to the survey. Each additional police killing of an unarmed black American was associated with 0·14 additional poor mental health days (95% CI 0·07-0·22; p=0·00047) among black American respondents. The largest effects on mental health occurred in the 1-2 months after exposure, with no significant effects estimated for respondents interviewed before police killings (falsification test). Mental health impacts were not observed among white respondents and resulted only from police killings of unarmed black Americans (not unarmed white Americans or armed black Americans). INTERPRETATION Police killings of unarmed black Americans have adverse effects on mental health among black American adults in the general population. Programmes should be implemented to decrease the frequency of police killings and to mitigate adverse mental health effects within communities when such killings do occur. FUNDING Robert Wood Johnson Foundation and National Institutes of Health.
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Affiliation(s)
- Jacob Bor
- Department of Global Health and Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Atheendar S Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine and Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - David R Williams
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health and Department of African and African American Studies, Harvard University, Boston, MA, USA
| | - Alexander C Tsai
- Chester M Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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