American Indians travel great distances for obstetrical care: Examining rural and racial disparities

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans

Objective

To examine reported experiences of discrimination against lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults in the United States, which broadly contribute to poor health outcomes.

Data Source and Study Design

Data came from a national, probability‐based telephone survey of US adults, including 489 LGBTQ adults (282 non‐Hispanic whites and 201 racial/ethnic minorities), conducted January‐April 2017.

Methods

We calculated the percentages of LGBTQ adults reporting experiences of discrimination in health care and several other domains related to their sexual orientation and, for transgender adults, gender identity. We report these results overall, by race/ethnicity, and among transgender adults only. We used multivariable models to estimate adjusted odds of discrimination between racial/ethnic minority and white LGBTQ respondents.

Principal Findings

Experiences of interpersonal discrimination were common for LGBTQ adults, including slurs (57 percent), microaggressions (53 percent), sexual harassment (51 percent), violence (51 percent), and harassment regarding bathroom use (34 percent). More than one in six LGBTQ adults also reported avoiding health care due to anticipated discrimination (18 percent), including 22 percent of transgender adults, while 16 percent of LGBTQ adults reported discrimination in health care encounters. LGBTQ racial/ethnic minorities had statistically significantly higher odds than whites in reporting discrimination based on their LGBTQ identity when applying for jobs, when trying to vote or participate in politics, and interacting with the legal system

Conclusions

Discrimination is widely experienced by LGBTQ adults across health care and other domains, especially among racial/ethnic minorities. Policy and programmatic efforts are needed to reduce these negative experiences and their health impact on sexual and/or gender minority adults, particularly those who experience compounded forms of discrimination.

Supplemental Insurance and Racial Health Disparities under Medicare Part B

OBJECTIVE

To assess the impact of preferences, socioeconomic status (SES), and supplemental insurance (SI) on racial/ethnic disparities in the probability and use of services at physicians' offices, hospitals, and emergency departments among Medicare beneficiaries enrolled in Part B.

RESEARCH DESIGN AND SUBJECTS

This study includes black and white beneficiaries from the 2009-2011 panel of the Medicare Current Beneficiary Survey who were enrolled in Medicare Part B. Logit and negative binomial multivariate regression analysis were used in conjunction with rank-and-replace methods to determine factors influencing utilization and black-white utilization disparities.

PRINCIPAL FINDINGS

Among Part B beneficiaries, significant disparities exist for each studied service. Examining contributing factors, 12-19 percent of the black-white health-adjusted difference in the probability of use is explained by differences in SES, whereas differences in the distribution of SI accounts for 20 percent or more. For volume, SES is found to account for 2-11 percent of differences with SI making up another 9-10 percent.

CONCLUSIONS

A substantial portion of the difference in black-white beneficiary use of outpatient services is due to SI. Policies aimed at increasing coverage are likely to increase the probability of visits with modest increases in volume.