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Azaroff LS, Woolhandler S, Dickman SL, Bor D, Himmelstein DU. Excess Infant and Child Deaths 2007-2020 in U.S. States With Abortion Bans. Am J Prev Med 2024; 66:917-920. [PMID: 38135198 DOI: 10.1016/j.amepre.2023.12.014] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Lenore S Azaroff
- Edward M. Kennedy Community Health Center, Worcester, Massachusetts.
| | - Steffie Woolhandler
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Hunter College, City University of New York, New York, New York
| | | | - David Bor
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
| | - David U Himmelstein
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Hunter College, City University of New York, New York, New York
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2
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Dickman SL, White K, Himmelstein DU, Lupez E, Schrier E, Woolhandler S. Rape-Related Pregnancies in the 14 US States With Total Abortion Bans. JAMA Intern Med 2024; 184:330-332. [PMID: 38265790 PMCID: PMC10809138 DOI: 10.1001/jamainternmed.2024.0014] [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: 10/02/2023] [Accepted: 12/23/2023] [Indexed: 01/25/2024]
Abstract
This cross-sectional study estimates the incidence of rape-related pregnancies in US states with abortion bans.
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Affiliation(s)
| | - Kari White
- Resound Research for Reproductive Health, Austin, Texas
| | | | - Emily Lupez
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
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Chatillon A, Vizcarra E, Kumar B, Dickman SL, Beasley AD, White K. Access to care following Planned Parenthood's termination from Texas' Medicaid network: A qualitative study. Contraception 2023; 128:110141. [PMID: 37597715 DOI: 10.1016/j.contraception.2023.110141] [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] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES This study aimed to explore Planned Parenthood Medicaid patients' experiences getting reproductive health care in Texas after the state terminated Planned Parenthood providers from its Medicaid program in 2021. STUDY DESIGN Between January and September 2021, we recruited Medicaid patients who obtained care at Planned Parenthood health centers prior to the state termination using direct mailers, electronic messages, community outreach, and flyers in health centers. We conducted baseline and 2-month follow-up semistructured phone interviews about patients' previous experiences using Medicaid at Planned Parenthood and other providers and how the termination affected their care. We qualitatively analyzed the data using the principles of grounded theory. RESULTS We interviewed 30 patients, 24 of whom completed follow-up interviews. Participants reported that Planned Parenthood reliably accepted different Medicaid plans, worked with patients to ameliorate the structural barriers they face to care, and referred them to other providers as needed. After Planned Parenthood's termination from the Texas Medicaid program, participants faced difficulties accessing care elsewhere, including same-day appointments and on-site medications. Consequences included delayed or forgone reproductive health care, including contraception, and emotional distress. CONCLUSIONS Planned Parenthood Medicaid patients found it difficult to connect with other providers for reproductive health care and to obtain evidence-based care following the organization's termination from Medicaid. Ensuring all Medicaid patients have freedom to choose providers would improve access to quality contraception and other reproductive health care. IMPLICATIONS Medicaid-funded reproductive health care access is restricted for people living on low incomes when providers do not reliably accept all Medicaid plans or cannot participate in Medicaid. This situation can lead to lower quality care, delayed or forgone care, and emotional distress.
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Affiliation(s)
- Anna Chatillon
- Population Research Center, University of Texas at Austin, Austin, TX, United States
| | | | - Bhavik Kumar
- Planned Parenthood Gulf Coast, Houston, TX, United States
| | | | - Anitra D Beasley
- Planned Parenthood Gulf Coast, Houston, TX, United States; Baylor College of Medicine, Houston, TX, United States
| | - Kari White
- Population Research Center, University of Texas at Austin, Austin, TX, United States; Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, United States.
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Himmelstein J, Cai C, Himmelstein DU, Woolhandler S, Bor DH, Dickman SL, McCormick D. Specialty Care Utilization Among Adults with Limited English Proficiency. J Gen Intern Med 2022; 37:4130-4136. [PMID: 35349026 PMCID: PMC9708984 DOI: 10.1007/s11606-022-07477-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/08/2021] [Accepted: 03/03/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS 149,611 survey respondents aged 18 and older. EXPOSURE LEP, defined as taking the survey in a language other than English. MAIN MEASURES Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.
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Affiliation(s)
- Jessica Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Christopher Cai
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- City University of New York at Hunter College, New York, NY, USA
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- City University of New York at Hunter College, New York, NY, USA
| | - David H Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Samuel L Dickman
- Planned Parenthood South Texas, San Antonio, TX, USA
- The University of Texas at Austin, Austin, TX, USA
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
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White K, Sierra G, Lerma K, Beasley A, Hofler LG, Tocce K, Goyal V, Ogburn T, Potter JE, Dickman SL. Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States. JAMA 2022; 328:2048-2055. [PMID: 36318197 PMCID: PMC9627516 DOI: 10.1001/jama.2022.20423] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 11/07/2022]
Abstract
IMPORTANCE Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade. OBJECTIVE To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022. EXPOSURES Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8. MAIN OUTCOMES AND MEASURES Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation. RESULTS Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend). CONCLUSIONS AND RELEVANCE Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.
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Affiliation(s)
- Kari White
- Steve Hicks School of Social Work, University of Texas at Austin
- Texas Policy Evaluation Project, Austin
| | - Gracia Sierra
- Texas Policy Evaluation Project, Austin
- Population Research Center, University of Texas at Austin
| | - Klaira Lerma
- Texas Policy Evaluation Project, Austin
- Population Research Center, University of Texas at Austin
| | - Anitra Beasley
- Texas Policy Evaluation Project, Austin
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Lisa G. Hofler
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, Colorado
| | - Vinita Goyal
- Texas Policy Evaluation Project, Austin
- Population Research Center, University of Texas at Austin
| | - Tony Ogburn
- Texas Policy Evaluation Project, Austin
- Department of Obstetrics and Gynecology, University of Texas Rio Grande Valley, Edinburg
| | - Joseph E. Potter
- Texas Policy Evaluation Project, Austin
- Population Research Center, University of Texas at Austin
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Cai C, Woolhandler S, McCormick D, Himmelstein DU, Himmelstein J, Schrier E, Dickman SL. Racial and Ethnic Inequities in Diabetes Pharmacotherapy: Black and Hispanic Patients Are Less Likely to Receive SGLT2is and GLP1as. J Gen Intern Med 2022; 37:3501-3503. [PMID: 35141853 PMCID: PMC9551144 DOI: 10.1007/s11606-022-07428-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Christopher Cai
- Department of Medicine, Internal Medicine Residency at Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York City, NY, USA
- Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - Danny McCormick
- Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - David U Himmelstein
- City University of New York at Hunter College, New York City, NY, USA
- Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | | | - Elizabeth Schrier
- University of California San Francisco (UCSF) School of Medicine, San Francisco, CA, USA
| | - Samuel L Dickman
- Planned Parenthood South Texas, San Antonio, TX, USA
- The University of Texas at Austin, Austin, TX, USA
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Dickman SL, Himmelstein G, Himmelstein DU, Strandberg K, McGregor A, McCormick D, Woolhandler S. Uncovered Medical Bills after Sexual Assault. N Engl J Med 2022; 387:1043-1044. [PMID: 36103420 DOI: 10.1056/nejmc2207644] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Himmelstein DU, Dickman SL, McCormick D, Bor DH, Gaffney A, Woolhandler S. Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US. JAMA Netw Open 2022; 5:e2231898. [PMID: 36112374 PMCID: PMC9482049 DOI: 10.1001/jamanetworkopen.2022.31898] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 12/03/2022] Open
Abstract
IMPORTANCE Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH). OBJECTIVE To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years. EXPOSURES Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs. MAIN OUTCOMES AND MEASURES Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity. RESULTS Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, 51.6% were female, 16.8% Hispanic, 6.0% were non-Hispanic Asian, 11.9% non-Hispanic Black, 62.6% non-Hispanic White, and 2.18% other non-Hispanic. A total of 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates: 15.3%; (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]). In cross-sectional analyses, hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness; residing in a Medicaid-expansion state was protective (2019 odds ratio [OR], 0.76; 95% CI, 0.70-0.83). Prospective findings were similar, eg, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019 (OR, 1.63; 95% CI, 1.23-2.14), as was becoming newly disabled (OR, 2.42; 95% CI, 1.95-3.00) or newly hospitalized (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening SDOHs, with ORs of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019. CONCLUSIONS AND RELEVANCE In this cross-sectional and cohort study, medical indebtedness was common, even among insured individuals. Acquiring such debt may worsen SDOHs. Expanded and improved health coverage could ameliorate financial distress, and improve housing and food security.
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Affiliation(s)
- David U. Himmelstein
- The City University of New York at Hunter College, New York, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Public Citizen Health Research Group, Washington, DC
| | | | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David H. Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- The City University of New York at Hunter College, New York, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Public Citizen Health Research Group, Washington, DC
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Abstract
IMPORTANCE In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking. OBJECTIVE To assess trends in Black-White disparities in health care use since 1963. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians. EXPOSURES Self-reported race and ethnicity. MAIN OUTCOMES AND MEASURES Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures. RESULTS Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods. CONCLUSIONS AND RELEVANCE This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.
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Affiliation(s)
- Samuel L. Dickman
- Texas Policy Evaluation Project, The University of Texas at Austin, Austin
- Planned Parenthood South Texas, San Antonio, Texas
| | - Adam Gaffney
- Division of Pulmonary and Critical Care Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
| | - Alecia McGregor
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David U. Himmelstein
- City University of New York at Hunter College, New York, New York
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
- Public Citizen Health Research Group, Washington, DC
| | - Danny McCormick
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
| | - David H. Bor
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, New York
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
- Public Citizen Health Research Group, Washington, DC
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Abstract
Objectives. To identify financial hardships related to costs of obtaining abortion care in Texas, which has the highest uninsured rate in the United States and restricts insurance coverage for abortions. Methods. We surveyed patients seeking abortion at 12 Texas clinics in 2018 regarding costs and financial hardships related to abortion care. We compared mean out-of-pocket costs and the percentage reporting hardships across income and insurance categories. Results. Of 603 respondents, 42% were Latinx, 25% White, and 21% Black or African American, and most (62.0%) reported having low incomes (< 200% federal poverty level). Mean out-of-pocket costs were $634, which varied little across insurance groups. Patients with low incomes were more likely to obtain financial assistance from an abortion fund than were wealthier patients (12.3% vs 1.6%, respectively; P < .05). Financial hardships related to abortion costs were more common among uninsured (57.6%) and publicly insured (55.1%) patients than those with private insurance (48.2%). One in 5 (19.8%) uninsured respondents delayed buying food to pay for abortion care. Conclusions. Restrictions on insurance coverage for abortions result in high out-of-pocket costs and major financial hardships for most patients with low incomes in Texas. (Am J Public Health. 2022;112(5):758-761. https://doi.org/10.2105/AJPH.2021.306701).
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Affiliation(s)
- Samuel L Dickman
- All authors are with the Texas Policy Evaluation Project, University of Texas at Austin. Samuel L. Dickman is also with Planned Parenthood South Texas, San Antonio. Kari White is also with the Steve Hicks School of Social Work, University of Texas at Austin. Daniel Grossman is also with the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Kari White
- All authors are with the Texas Policy Evaluation Project, University of Texas at Austin. Samuel L. Dickman is also with Planned Parenthood South Texas, San Antonio. Kari White is also with the Steve Hicks School of Social Work, University of Texas at Austin. Daniel Grossman is also with the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Gracia Sierra
- All authors are with the Texas Policy Evaluation Project, University of Texas at Austin. Samuel L. Dickman is also with Planned Parenthood South Texas, San Antonio. Kari White is also with the Steve Hicks School of Social Work, University of Texas at Austin. Daniel Grossman is also with the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Daniel Grossman
- All authors are with the Texas Policy Evaluation Project, University of Texas at Austin. Samuel L. Dickman is also with Planned Parenthood South Texas, San Antonio. Kari White is also with the Steve Hicks School of Social Work, University of Texas at Austin. Daniel Grossman is also with the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
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Cai C, Gaffney A, McGregor A, Woolhandler S, Himmelstein DU, McCormick D, Dickman SL. Racial and Ethnic Disparities in Outpatient Visit Rates Across 29 Specialties. JAMA Intern Med 2021; 181:1525-1527. [PMID: 34279566 PMCID: PMC8290333 DOI: 10.1001/jamainternmed.2021.3771] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cross-sectional study examines US racial/ethnic disparities in outpatient visit rates to 29 physician specialties.
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Affiliation(s)
- Christopher Cai
- Department of Medicine, Internal Medicine Residency Program at Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Adam Gaffney
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
| | - Alecia McGregor
- Department of Community Health, Tufts University, Medford, Massachusetts
| | - Steffie Woolhandler
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts.,City University of New York at Hunter College, New York City
| | - David U Himmelstein
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts.,City University of New York at Hunter College, New York City
| | - Danny McCormick
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
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12
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Affiliation(s)
- Samuel L Dickman
- Planned Parenthood South Texas, San Antonio.,Texas Policy Evaluation Project, The University of Texas at Austin
| | - Kari White
- Texas Policy Evaluation Project, The University of Texas at Austin.,Steve Hicks School of Social Work, The University of Texas at Austin
| | - Daniel Grossman
- Texas Policy Evaluation Project, The University of Texas at Austin.,Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland
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13
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Woolhandler S, Himmelstein DU, Ahmed S, Bailey Z, Bassett MT, Bird M, Bor J, Bor D, Carrasquillo O, Chowkwanyun M, Dickman SL, Fisher S, Gaffney A, Galea S, Gottfried RN, Grumbach K, Guyatt G, Hansen H, Landrigan PJ, Lighty M, McKee M, McCormick D, McGregor A, Mirza R, Morris JE, Mukherjee JS, Nestle M, Prine L, Saadi A, Schiff D, Shapiro M, Tesema L, Venkataramani A. Public policy and health in the Trump era. Lancet 2021; 397:705-753. [PMID: 33581802 DOI: 10.1016/s0140-6736(20)32545-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/22/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Steffie Woolhandler
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - David U Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York, NY, USA; Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Sameer Ahmed
- Harvard Immigration and Refugee Clinical Program, Harvard Law School, Harvard University, Boston, MA, USA
| | - Zinzi Bailey
- Medical Oncology Division, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mary T Bassett
- Francois-Xavier Bagnoud Center for Health and Human Rights, Harvard University, Boston, MA, USA
| | | | - Jacob Bor
- School of Public Health, Boston University, Boston, MA, USA
| | - David Bor
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olveen Carrasquillo
- Division of General Internal Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Samantha Fisher
- Program for Global Public Health and the Common Good, Boston College, Chestnut Hill, MA, USA
| | - Adam Gaffney
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Sandro Galea
- School of Public Health, Boston University, Boston, MA, USA
| | | | - Kevin Grumbach
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact and Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Helena Hansen
- Research Theme in Translational Social Science and Health Equity, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Philip J Landrigan
- Program for Global Public Health and the Common Good, Boston College, Chestnut Hill, MA, USA
| | | | - Martin McKee
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Danny McCormick
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Alecia McGregor
- Department of Community Health, Tufts University, Medford, MA, USA
| | - Reza Mirza
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juliana E Morris
- Harvard Medical School, Harvard University, Boston, MA, USA; Department of Medicine and Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Joia S Mukherjee
- Harvard Medical School, Harvard University, Boston, MA, USA; Partners in Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marion Nestle
- Department of Nutrition and Food Studies, New York University, New York, NY, USA
| | - Linda Prine
- Department of Family and Community Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Altaf Saadi
- Harvard Medical School, Harvard University, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Davida Schiff
- Harvard Medical School, Harvard University, Boston, MA, USA; Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA
| | - Martin Shapiro
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Lello Tesema
- Department of Public Health, Los Angeles County, Los Angeles, CA, USA
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10-15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.
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Affiliation(s)
- Samuel L Dickman
- Department of Medicine, University of California, San Francisco, CA, USA
| | - David U Himmelstein
- City University of New York School of Urban Public Health at Hunter College, New York, NY, USA; Harvard Medical School, Boston, MA, USA.
| | - Steffie Woolhandler
- City University of New York School of Urban Public Health at Hunter College, New York, NY, USA; Harvard Medical School, Boston, MA, USA
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Dickman SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU. Health Spending For Low-, Middle-, And High-Income Americans, 1963–2012. Health Aff (Millwood) 2016; 35:1189-96. [DOI: 10.1377/hlthaff.2015.1024] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Samuel L. Dickman
- Samuel L. Dickman ( ) was a student at Harvard Medical School, in Boston, Massachusetts, at the time this work was carried out. He is currently a medical intern at the University of California, San Francisco
| | - Steffie Woolhandler
- Steffie Woolhandler is a professor of health policy at Hunter College, City University of New York, in New York City, and a lecturer in medicine at Harvard Medical School
| | - Jacob Bor
- Jacob Bor is an assistant professor in the Departments of Global Health and Epidemiology at the Boston University School of Public Health, in Massachusetts
| | - Danny McCormick
- Danny McCormick is an associate professor of medicine at Harvard Medical School and chief of the Division of Social and Community Medicine in the Department of Medicine at the Cambridge Health Alliance, in Cambridge, Massachusetts
| | - David H. Bor
- David H. Bor is an associate professor of medicine at Harvard Medical School and chief of the Department of Medicine at the Cambridge Health Alliance
| | - David U. Himmelstein
- David U. Himmelstein is a professor of health policy at Hunter College, City University of New York, and a lecturer in medicine at Harvard Medical School
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Dickman SL, Himmelstein DU, McCormick D, Woolhandler S. Health and Financial Consequences of 24 States' Decision to Opt Out of Medicaid Expansion. Int J Health Serv 2015; 45:133-142. [PMID: 26460452 DOI: 10.2190/hs.45.1.j] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Twenty-four states have opted out of expanding Medicaid coverage under the Affordable Care Act. We projected the number of persons who will remain uninsured because of the Medicaid opt-outs and used data from three prior studies to predict the health and financial impacts of the opt-outs. We estimate that as a result of the opt-outs, 7.74 million people who would have gained coverage will remain uninsured. This will result in between 7,076 and 16,945 more deaths than had all states opted-in, as well as 708,195 more persons screening positive for depression, 239,557 more persons suffering catastrophic medical expenditures, 420,273 fewer diabetics receiving medication, 193,735 fewer mammograms, and 441,260 fewer Pap smears. Many low-income adults will suffer health and financial harms because of their state's refusal to expand Medicaid coverage.
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McKenzie M, Zaller N, Dickman SL, Green TC, Parihk A, Friedmann PD, Rich JD. A randomized trial of methadone initiation prior to release from incarceration. Subst Abus 2012; 33:19-29. [PMID: 22263710 DOI: 10.1080/08897077.2011.609446] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Individuals who use heroin and illicit opioids are at high risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens, as well as incarceration. The purpose of the randomized trial reported here is to compare outcomes between participants who initiated methadone maintenance treatment (MMT) prior to release from incarceration, with those who were referred to treatment at the time of release. Participants who initiated MMT prior to release were significantly more likely to enter treatment postrelease (P < .001) and for participants who did enter treatment, those who received MMT prerelease did so within fewer days (P = .03). They also reported less heroin use (P = .008), other opiate use (P = .09), and injection drug use (P = .06) at 6 months. Initiating MMT in the weeks prior to release from incarceration is a feasible and effective way to improve MMT access postrelease and to decrease relapse to opioid use.
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Trigg BG, Dickman SL. Medication-assisted therapy for opioid-dependent incarcerated populations in New Mexico: statewide efforts to increase access. Subst Abus 2012; 33:76-84. [PMID: 22263716 DOI: 10.1080/08897077.2011.611455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
An acute awareness of the profound social and medical costs associated with heroin and opiate addiction in New Mexico has led a group of advocates from public health, state and local governments, corrections, academia, and community activists to collaborate for the purpose of increasing access to medication-assisted therapy (MAT) with buprenorphine and methadone in New Mexico. This paper describes these collaborations, with a focus on the evolution of harm reduction approaches to substance abuse disorders and successful efforts to make MAT available to incarcerated persons.
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Affiliation(s)
- Josiah D Rich
- Division of Infectious Diseases, Department of Medicine, Miriam Hospital and Brown Medical School, and the Center for Prisoner Health and Human Rights, Providence, RI, USA
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