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Gaffney A, McCormick D, Bor D, Woolhandler S, Himmelstein DU. Hospital Capital Assets, Community Health, and the Utilization and Cost of Inpatient Care: A Population-Based Study of US Counties. Med Care 2024; 62:396-403. [PMID: 38598671 DOI: 10.1097/mlr.0000000000001999] [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: 04/12/2024]
Abstract
BACKGROUND The provision of high-quality hospital care requires adequate space, buildings, and equipment, although redundant infrastructure could also drive service overprovision. OBJECTIVE To explore the distribution of physical hospital resources-that is, capital assets-in the United States; its correlation with indicators of community health and nonhealth factors; and the association between hospital capital density and regional hospital utilization and costs. RESEARCH DESIGN We created a dataset of n=1733 US counties by analyzing the 2019 Medicare Cost Reports; 2019 State Inpatient Database Community Inpatient Statistics; 2020-2021 Area Health Resource File; 2016-2020 American Community Survey; 2022 PLACES; and 2019 CDC WONDER. We first calculated aggregate hospital capital assets and investment at the county level. Next, we examined the correlation between community's medical need (eg, chronic disease prevalence), ability to pay (eg, insurance), and supply factors with 4 metrics of capital availability. Finally, we examined the association between capital assets and hospital utilization/costs, adjusted for confounders. RESULTS Counties with older and sicker populations generally had less aggregate hospital capital per capita, per hospital day, and per hospital discharge, while counties with higher income or insurance coverage had more hospital capital. In linear regressions controlling for medical need and ability to pay, capital assets were associated with greater hospital utilization and costs, for example, an additional $1000 in capital assets per capita was associated with 73 additional discharges per 100,000 population (95% CI: 45-102) and $19 in spending per bed day (95% CI: 12-26). CONCLUSIONS The level of investment in hospitals is linked to community wealth but not population health needs, and may drive use and costs.
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Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Harvard Medical School, Boston, MA
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Harvard Medical School, Boston, MA
| | - David Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Harvard Medical School, Boston, MA
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Harvard Medical School, Boston, MA
- Hunter College, City University of New York, New York, NY
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Harvard Medical School, Boston, MA
- Hunter College, City University of New York, New York, NY
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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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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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Woolhandler S, Toporek A, Gao J, Moran E, Wilper A, Himmelstein DU. Administration's Share of Personnel in Veterans Health Administration and Private Sector Care. JAMA Netw Open 2024; 7:e2352104. [PMID: 38236601 PMCID: PMC10797450 DOI: 10.1001/jamanetworkopen.2023.52104] [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: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024] Open
Abstract
Importance Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). Objective To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. Design, Setting, and Participants This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. Exposure VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. Main Outcome and Measure The proportion of staff working in administrative occupations. Results Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. Conclusions and Relevance In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.
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Affiliation(s)
- Steffie Woolhandler
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
- Harvard Medical School, Boston, Massachusetts
| | - Andrew Toporek
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs
| | - Jian Gao
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs
| | - Eileen Moran
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs
| | - Andrew Wilper
- Office of the Chief of Staff, Boise Veterans Affairs Medical Center, Boise, Idaho
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - David U. Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
- Harvard Medical School, Boston, Massachusetts
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Gaffney A, Himmelstein DU, Woolhandler S. Asthma Disparities in the United States Narrowed During the COVID-19 Pandemic: Findings From a National Survey, 2019 to 2022. Ann Intern Med 2024; 177:103-106. [PMID: 38109736 PMCID: PMC10732267 DOI: 10.7326/m23-2100] [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: 12/20/2023] Open
Affiliation(s)
- Adam Gaffney
- Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - David U Himmelstein
- Hunter College, City University of New York, New York, New York; Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- Hunter College, City University of New York, New York, New York; Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts
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Kassavin D, Mota L, Ostertag-Hill CA, Kassavin M, Himmelstein DU, Woolhandler S, Wang SX, Liang P, Schermerhorn ML, Vithiananthan S, Kwoun M. Amputation Rates and Associated Social Determinants of Health in the Most Populous US Counties. JAMA Surg 2024; 159:69-76. [PMID: 37910120 PMCID: PMC10620677 DOI: 10.1001/jamasurg.2023.5517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/07/2023] [Indexed: 11/03/2023]
Abstract
Importance Social Determinants of Health (SDOH) have been found to be associated with health outcome disparities in patients with peripheral artery disease (PAD). However, the association of specific components of SDOH and amputation has not been well described. Objective To evaluate whether individual components of SDOH and race are associated with amputation rates in the most populous counties of the US. Design, Setting, and Participants In this population-based cross-sectional study of the 100 most populous US counties, hospital discharge rates for lower extremity amputation in 2017 were assessed using the Healthcare Cost and Utilization Project State Inpatient Database. Those data were matched with publicly available demographic, hospital, and SDOH data. Data were analyzed July 3, 2022, to March 5, 2023. Main outcome and Measures Amputation rates were assessed across all counties. Counties were divided into quartiles based on amputation rates, and baseline characteristics were described. Unadjusted linear regression and multivariable regression analyses were performed to assess associations between county-level amputation and SDOH and demographic factors. Results Amputation discharge data were available for 76 of the 100 most populous counties in the United States. Within these counties, 15.3% were African American, 8.6% were Asian, 24.0% were Hispanic, and 49.6% were non-Hispanic White; 13.4% of patients were 65 years or older. Amputation rates varied widely, from 5.5 per 100 000 in quartile 1 to 14.5 per 100 000 in quartile 4. Residents of quartile 4 (vs 1) counties were more likely to be African American (27.0% vs 7.9%, P < .001), have diabetes (10.6% vs 7.9%, P < .001), smoke (16.5% vs 12.5%, P < .001), be unemployed (5.8% vs 4.6%, P = .01), be in poverty (15.8% vs 10.0%, P < .001), be in a single-parent household (41.9% vs 28.6%, P < .001), experience food insecurity (16.6% vs 12.9%, P = .04), or be physically inactive (23.1% vs 17.1%, P < .001). In unadjusted linear regression, higher amputation rates were associated with the prevalence of several health problems, including mental distress (β, 5.25 [95% CI, 3.66-6.85]; P < .001), diabetes (β, 1.73 [95% CI, 1.33-2.15], P < .001), and physical distress (β, 1.23 [95% CI, 0.86-1.61]; P < .001) and SDOHs, including unemployment (β, 1.16 [95% CI, 0.59-1.73]; P = .03), physical inactivity (β, 0.74 [95% CI, 0.57-0.90]; P < .001), smoking, (β, 0.69 [95% CI, 0.46-0.92]; P = .002), higher homicide rate (β, 0.61 [95% CI, 0.45-0.77]; P < .001), food insecurity (β, 0.51 [95% CI, 0.30-0.72]; P = .04), and poverty (β, 0.46 [95% CI, 0.32-0.60]; P < .001). Multivariable regression analysis found that county-level rates of physical distress (β, 0.84 [95% CI, 0.16-1.53]; P = .03), Black and White racial segregation (β, 0.12 [95% CI, 0.06-0.17]; P < .001), and population percentage of African American race (β, 0.06 [95% CI, 0.00-0.12]; P = .03) were associated with amputation rate. Conclusions and Relevance Social determinants of health provide a framework by which the associations of environmental factors with amputation rates can be quantified and potentially used to guide interventions at the local level.
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Affiliation(s)
- Daniel Kassavin
- Division of Vascular Surgery, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Monica Kassavin
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
| | - David U. Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
| | - Sophie X. Wang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Moon Kwoun
- Division of Vascular Surgery, Cambridge Health Alliance, Cambridge, Massachusetts
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Gaffney A, Himmelstein DU, Woolhandler S. Population-level trends in asthma and chronic obstructive pulmonary disease emergency department visits and hospitalizations before and during the coronavirus disease 2019 pandemic in the United States. Ann Allergy Asthma Immunol 2023; 131:737-744.e8. [PMID: 37619778 DOI: 10.1016/j.anai.2023.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Previous studies have identified reductions in exacerbations of chronic lung disease in many locales after onset of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE To evaluate the population-level impacts of COVID-19 on asthma and chronic obstructive pulmonary disease (COPD) exacerbations-with a focus on disadvantaged communities-in the United States. METHODS We analyzed 2016 to 2020 county-level data on asthma and COPD acute care use, with myocardial infarction hospitalizations as a comparator condition. We linked this with county-level lower respiratory disease mortality data. We calculated rates of emergency department (ED) visits, hospitalizations, and deaths and evaluated changes using linear regressions adjusted for year and county-fixed effects. For a supplementary analysis, we calculated ED visit rates nationwide for asthma, COPD, or any diagnosis using the 2016 to 2020 National Hospital Ambulatory Medical Care Survey. RESULTS Our county-level data included 685 counties in 13 states. Rates of each outcome fell in 2020. In adjusted analyses, we found large reductions in asthma and COPD ED visit rates (eg, a 21.5 per 10,000-person reduction in COPD ED visits; 95% confidence interval, -23.8 to -19.1), with smaller reductions in hospitalizations and chronic lower respiratory mortality. Disadvantaged communities had mostly higher baseline rates of respiratory morbidity and larger absolute reductions in some outcomes. Among 90,808 ED visits in the National Hospital Ambulatory Medical Care Survey, asthma ED visits/y fell 33% during the pandemic and COPD visits by 51%; overall ED visits fell by only 7%. CONCLUSION Onset of the COVID-19 pandemic coincided with reductions in acute care utilization for asthma and COPD. Understanding the mechanism of this reduction might inform future efforts to prevent exacerbations.
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Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Hunter College, City University of New York, New York, New York; Public Citizen Health Research Group, Washington, District of Columbia
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Hunter College, City University of New York, New York, New York; Public Citizen Health Research Group, Washington, District of Columbia
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Gaffney AW, Himmelstein DU, Woolhandler S, Kahn JG. Hospital Expenditures Under Global Budgeting and Single-Payer Financing: An Economic Analysis, 2021-2030. Int J Soc Determinants Health Health Serv 2023; 53:548-556. [PMID: 36714974 DOI: 10.1177/27551938231152750] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
U.S. hospitals provide large amounts of low-value care and devote inordinate resources to administration, while some hospitals leverage market power to realize large profits. Meanwhile, many rural and safety net hospitals are financially distressed. The coexistence of waste and want suggests that U.S. hospital financing is neither efficient nor equitable. We model the economic consequences of adopting the mode of hospital payment used in Canada and the U.S. Veterans Health Administration and proposed in the leading congressional single-payer Medicare-for-All bill: global budgeting. Our models assume increased utilization due to expanded and upgraded coverage; gradual reductions in administrative costs from simplified payment; and the elimination of hospital profits, with hospital capital expenditures funded by explicit grants rather than from profits or borrowing. We estimate that non-federal hospital operating budgets will total $17.2 trillion between 2021 and 2030 under current law versus $14.7 trillion under single-payer with global budgeting. This difference reflects $520 billion in foregone profits and $1,984 billion in reduced expenditures on hospital administration; expenditures on clinical operating budgets, however, would be higher than under current law, funded out of profits.
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Affiliation(s)
- Adam W Gaffney
- Cambridge Health Alliance/Harvard Medical School, Boston, Massachusetts, USA
| | - David U Himmelstein
- Cambridge Health Alliance/Harvard Medical School, Boston, Massachusetts, USA
- City University of New York at Hunter College, New York, New York, USA
| | - Steffie Woolhandler
- Cambridge Health Alliance/Harvard Medical School, Boston, Massachusetts, USA
- City University of New York at Hunter College, New York, New York, USA
| | - James G Kahn
- University of California San Francisco School of Medicine, San Francisco, California, USA
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Affiliation(s)
- Nishant Uppal
- From the Department of Medicine, Brigham and Women's Hospital (N.U.), and Harvard Medical School (N.U., S.W., D.U.H.), Boston, and Cambridge Health Alliance, Cambridge (S.W., D.U.H.) - all in Massachusetts; and City University of New York at Hunter College, New York (S.W., D.U.H.)
| | - Steffie Woolhandler
- From the Department of Medicine, Brigham and Women's Hospital (N.U.), and Harvard Medical School (N.U., S.W., D.U.H.), Boston, and Cambridge Health Alliance, Cambridge (S.W., D.U.H.) - all in Massachusetts; and City University of New York at Hunter College, New York (S.W., D.U.H.)
| | - David U Himmelstein
- From the Department of Medicine, Brigham and Women's Hospital (N.U.), and Harvard Medical School (N.U., S.W., D.U.H.), Boston, and Cambridge Health Alliance, Cambridge (S.W., D.U.H.) - all in Massachusetts; and City University of New York at Hunter College, New York (S.W., D.U.H.)
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Gaffney A, Himmelstein DU, Dickman S, Myers C, Hemenway D, McCormick D, Woolhandler S. Projected Health Outcomes Associated With 3 US Supreme Court Decisions in 2022 on COVID-19 Workplace Protections, Handgun-Carry Restrictions, and Abortion Rights. JAMA Netw Open 2023; 6:e2315578. [PMID: 37289459 PMCID: PMC10251209 DOI: 10.1001/jamanetworkopen.2023.15578] [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: 01/23/2023] [Accepted: 04/12/2023] [Indexed: 06/09/2023] Open
Abstract
Importance Several recent US Supreme Court rulings have drawn criticism from the medical community, but their health consequences have not been quantitatively evaluated. Objective To model health outcomes associated with 3 Supreme Court rulings in 2022 that invalidated workplace COVID-19 vaccine or mask-and-test requirements, voided state handgun-carry restrictions, and revoked the constitutional right to abortion. Design, Setting, and Participants This decision analytical modeling study estimated outcomes associated with 3 Supreme Court rulings in 2022: (1) National Federation of Independent Business v Department of Labor, Occupational Safety and Health Administration (OSHA), which invalidated COVID-19 workplace protections; (2) New York State Rifle and Pistol Association Inc v Bruen, Superintendent of New York State Police (Bruen), which voided state laws restricting handgun carry; and (3) Dobbs v Jackson Women's Health Organization (Dobbs), which revoked the constitutional right to abortion. Data analysis was performed from July 1, 2022, to April 7, 2023. Main Outcomes and Measures For the OSHA ruling, multiple data sources were used to calculate deaths attributable to COVID-19 among unvaccinated workers from January 4 to May 28, 2022, and the share of these deaths that would have been prevented by the voided protections. To model the Bruen decision, published estimates of the consequences of right-to-carry laws were applied to 2020 firearm-related deaths (and injuries) in 7 affected jurisdictions. For the Dobbs ruling, the model assessed unwanted pregnancy continuations, resulting from the change in distance to the closest abortion facility, and then excess deaths (and peripartum complications) from forcing these unwanted pregnancies to term. Results The decision model projected that the OSHA decision was associated with 1402 additional COVID-19 deaths (and 22 830 hospitalizations) in early 2022. In addition, the model projected that 152 additional firearm-related deaths (and 377 nonfatal injuries) annually will result from the Bruen decision. Finally, the model projected that 30 440 fewer abortions will occur annually due to current abortion bans stemming from Dobbs, with 76 612 fewer abortions if states at high risk for such bans also were to ban the procedure; these bans will be associated with an estimated 6 to 15 additional pregnancy-related deaths each year, respectively, and hundreds of additional cases of peripartum morbidity. Conclusions and Relevance These findings suggest that outcomes from 3 Supreme Court decisions in 2022 could lead to substantial harms to public health, including nearly 3000 excess deaths (and possibly many more) over a decade.
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Affiliation(s)
- Adam Gaffney
- 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
- Public Citizen Health Research Group, Washington, DC
| | | | | | - David Hemenway
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Danny McCormick
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Cambridge Health Alliance, Cambridge, 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
- Public Citizen Health Research Group, Washington, DC
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Gaffney A, Woolhandler S, Himmelstein DU. Century-Long Trends in the Financing and Ownership of American Health Care. Milbank Q 2023. [PMID: 37093703 DOI: 10.1111/1468-0009.12647] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/28/2022] [Accepted: 02/08/2023] [Indexed: 04/25/2023] Open
Abstract
Policy Points Over the past century, the tax-financed share of health care spending has risen from 9% in 1923 to 69% in 2020; a large part of this tax financing is now the subsidization of private health insurance. For-profit ownership of health care facilities has also increased in recent decades and now predominates for many health subsectors. A rising share of physicians are now employees. US health care is, increasingly, publicly financed yet investor owned, a trend that has been accompanied by rising medical costs and, in recent years, stagnating or even worsening population health. A reconsideration of US health care financing and ownership appears warranted. CONTEXT Who pays for health care-and who owns it-determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century. METHODS We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for-profit), and private (not-for-profit). We used US Census data to classify physicians' employers as public, not-for-profit, or for-profit entities or "self-employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees. FINDINGS For-profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not-for-profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth. CONCLUSIONS American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted.
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Affiliation(s)
| | - Steffie Woolhandler
- Cambridge Health Alliance
- Harvard Medical School
- Hunter College, City University of New York
- Public Citizen Health Research Group
| | - David U Himmelstein
- Cambridge Health Alliance
- Harvard Medical School
- Hunter College, City University of New York
- Public Citizen Health Research Group
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Gaffney A, Himmelstein DU, McCormick D, Woolhandler S. COVID-19 Risk by Workers' Occupation and Industry in the United States, 2020‒2021. Am J Public Health 2023; 113:647-656. [PMID: 37053525 DOI: 10.2105/ajph.2023.307249] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Objectives. To assess the risk of COVID-19 by occupation and industry in the United States. Methods. Using the 2020-2021 National Health Interview Survey, we estimated the risk of having had a diagnosis of COVID-19 by workers' industry and occupation, with and without adjustment for confounders. We also examined COVID-19 period prevalence by the number of workers in a household. Results. Relative to workers in other industries and occupations, those in the industry "health care and social assistance" (adjusted prevalence ratio = 1.23; 95% confidence interval = 1.11, 1.37), or in the occupations "health practitioners and technical," "health care support," or "protective services" had elevated risks of COVID-19. However, compared with nonworkers, workers in 12 of 21 industries and 11 of 23 occupations (e.g., manufacturing, food preparation, and sales) were at elevated risk. COVID-19 prevalence rose with each additional worker in a household. Conclusions. Workers in several industries and occupations with public-facing roles and adults in households with multiple workers had elevated risk of COVID-19. Public Health Implications. Stronger workplace protections, paid sick leave, and better health care access might mitigate working families' risks from this and future pandemics. (Am J Public Health. Published online ahead of print April 13, 2023:e1-e10. https://doi.org/10.2105/AJPH.2023.307249).
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Affiliation(s)
- Adam Gaffney
- Adam Gaffney and Danny McCormick are with the Department of Medicine, Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School, Boston, MA. David Himmelstein and Steffie Woolhandler are with City University of New York at Hunter College, New York, NY; Department of Medicine, Cambridge Health Alliance; Harvard Medical School; and Public Citizen Health Research Group, Washington, DC
| | - David U Himmelstein
- Adam Gaffney and Danny McCormick are with the Department of Medicine, Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School, Boston, MA. David Himmelstein and Steffie Woolhandler are with City University of New York at Hunter College, New York, NY; Department of Medicine, Cambridge Health Alliance; Harvard Medical School; and Public Citizen Health Research Group, Washington, DC
| | - Danny McCormick
- Adam Gaffney and Danny McCormick are with the Department of Medicine, Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School, Boston, MA. David Himmelstein and Steffie Woolhandler are with City University of New York at Hunter College, New York, NY; Department of Medicine, Cambridge Health Alliance; Harvard Medical School; and Public Citizen Health Research Group, Washington, DC
| | - Steffie Woolhandler
- Adam Gaffney and Danny McCormick are with the Department of Medicine, Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School, Boston, MA. David Himmelstein and Steffie Woolhandler are with City University of New York at Hunter College, New York, NY; Department of Medicine, Cambridge Health Alliance; Harvard Medical School; and Public Citizen Health Research Group, Washington, DC
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Narm KE, Wen J, Sung L, Dar S, Kim P, Olson B, Schrager A, Tsay A, Himmelstein DU, Woolhandler S, Shure N, McCormick D, Gaffney A. Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study. Med Care 2023; 61:185-191. [PMID: 36730827 DOI: 10.1097/mlr.0000000000001791] [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: 02/04/2023]
Abstract
BACKGROUND Childhood chronic illness imposes financial burdens that may affect the entire family. OBJECTIVE The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses. RESEARCH DESIGN 2009-2018 National Health Interview Survey. SUBJECTS Adult-child dyads, consisting of one randomly sampled child and adult in each family. MEASURES The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders. RESULTS The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64). CONCLUSIONS Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.
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Affiliation(s)
- Koh Eun Narm
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Jenny Wen
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Lily Sung
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Sofia Dar
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Paul Kim
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Brady Olson
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Alix Schrager
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Annie Tsay
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - David U Himmelstein
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
- City University of New York at Hunter College, New York, NY
| | - Steffie Woolhandler
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
- City University of New York at Hunter College, New York, NY
| | | | - Danny McCormick
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
| | - Adam Gaffney
- Cambridge Health Alliance, Cambridge
- Harvard Medical School, Boston, MA
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Himmelstein DU, Woolhandler S. Corporate Efforts to Adopt and Distort the Social Determinants of Health Framework. Int J Soc Determinants Health Health Serv 2023:27551938231162573. [PMID: 36890714 DOI: 10.1177/27551938231162573] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Over the past two centuries, progressive scholars have highlighted the health-harming effects of oppressive living and working conditions. Early studies delineated the roots of inequities in these social determinants of health in capitalist exploitation. Analyses in the 1970s and 1980s that adopted the social determinants of health framework emphasized the deleterious effects of poverty but rarely explored its origins in capitalist exploitation. Recently, major U.S. corporations have adopted and distorted the social determinants of health framework, implementing trivial interventions that serve as rhetorical cover for their myriad health-harming behaviors, and the Trump administration cited social determinants to justify imposing work requirements for persons seeking health insurance through Medicaid. Progressives should raise the alarm against the use of social determinants of health rhetoric to bolster corporate power and undermine health.
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Affiliation(s)
- David U Himmelstein
- City University of New York at Hunter College, New York, NY, USA.,Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, NY, USA.,Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
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15
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Gaffney A, Himmelstein DU, Dickman S, McCormick D, Cai C, Woolhandler S. Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018. J Gen Intern Med 2023; 38:434-441. [PMID: 35668239 PMCID: PMC9905461 DOI: 10.1007/s11606-022-07688-x] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear. OBJECTIVE To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. DESIGN Repeated cross-sectional. SETTING National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018. PARTICIPANTS Office-based physicians. MEASURES Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration. RESULTS Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care. LIMITATION Self-reported visit length. CONCLUSION Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.
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Affiliation(s)
- Adam Gaffney
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
| | - David U. Himmelstein
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
- Hunter College, City University of New York, New York, NY USA
- Public Citizen Health Research Group, Washington, DC USA
| | | | - Danny McCormick
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
| | | | - Steffie Woolhandler
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
- Hunter College, City University of New York, New York, NY USA
- Public Citizen Health Research Group, Washington, DC USA
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16
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Gaffney A, Woolhandler S, Bor J, McCormick D, Himmelstein DU. Community Health, Health Care Access, And COVID-19 Booster Uptake In Massachusetts. Health Aff (Millwood) 2023; 42:268-276. [PMID: 36745834 DOI: 10.1377/hlthaff.2022.00835] [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: 02/08/2023]
Abstract
Booster vaccination offers vital protection against COVID-19, particularly for communities in which many people have chronic conditions. Although vaccination has been widely and freely available, people who have experienced barriers to care might be deterred from being vaccinated. We examined the relationship between COVID-19 booster uptake and small area-level demographics, chronic disease prevalence, and measures of health care access in 462 Massachusetts communities during the period September 2021-April 2022. Unadjusted analyses found that booster uptake was higher in older and wealthier areas, lower in areas with more Hispanic and Black residents, and lower in areas with a high prevalence of chronic conditions. In both unadjusted and adjusted analyses, uptake was lower in communities with more uninsured residents and those in which fewer residents received routine medical check-ups. Adjusted analyses found that areas with more vaccine providers and primary care physicians had higher booster uptake, but this association was not significant in unadjusted analyses. Results suggest a need for innovative outreach efforts, as well as structural changes such as expansion of health care coverage and universal access to care to mitigate the inequitable burden of COVID-19.
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Affiliation(s)
- Adam Gaffney
- Adam Gaffney , Harvard University and Cambridge Health Alliance, Cambridge, Massachusetts
| | - Steffie Woolhandler
- Steffie Woolhandler, City University of New York, New York, New York; Harvard University; and Cambridge Health Alliance
| | - Jacob Bor
- Jacob Bor, Boston University, Boston, Massachusetts
| | - Danny McCormick
- Danny McCormick, Harvard University and Cambridge Health Alliance
| | - David U Himmelstein
- David U. Himmelstein, City University of New York, Harvard University, and Cambridge Health Alliance
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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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18
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Robertson C, Woolhandler S, Himmelstein DU. Arizona's debt collection reform-a small step towards health justice. BMJ 2022; 379:o2822. [PMID: 36418037 DOI: 10.1136/bmj.o2822] [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: 11/24/2022]
Affiliation(s)
- Christopher Robertson
- Boston University School of Law and School of Public Health, Boston, Massachusetts, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
| | - David U Himmelstein
- City University of New York at Hunter College, New York
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
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Ommerborn MJ, Ranker LR, Touw S, Himmelstein DU, Himmelstein J, Woolhandler S. Assessment of Immigrants' Premium and Tax Payments for Health Care and the Costs of Their Care. JAMA Netw Open 2022; 5:e2241166. [PMID: 36350650 PMCID: PMC9647478 DOI: 10.1001/jamanetworkopen.2022.41166] [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: 11/11/2022] Open
Abstract
IMPORTANCE Some worry that immigrants burden the US economy and particularly the health care system. However, no analyses to date have assessed whether immigrants' payments for premiums and taxes that fund health care programs exceed third-party payers' expenditures on their behalf. OBJECTIVE To assess immigrants' net financial contributions to US health care programs. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis used 2017 data from the Medical Expenditure Panel Survey (MEPS) and the Current Population Survey (CPS) and 2014 to 2018 data from the American Community Survey. The main analyses used data from the calendar year 2017. Data from the calendar years 2012 to 2016 were also reported. Data were analyzed from June 15, 2020, to August 14, 2022. Participants comprised 210 669 community-dwelling respondents to the MEPS and CPS (main analysis) and nursing home residents who were included in the American Community Survey (additional analysis). EXPOSURES Citizenship and immigration status. MAIN OUTCOMES AND MEASURES Total and per capita payments for premiums and taxes that fund health care as well as third-party payers' expenditures for health care in 2018 US dollars. RESULTS Among 210 669 participants, 51.0% were female, 18.3% were Hispanic, 12.3% were non-Hispanic Black, 60.3% were non-Hispanic White, and 9.2% were of other races and/or ethnicities. A total of 180 084 participants were respondents to the 2018 CPS, and 30 585 were respondents to the 2017 MEPS. Among the 180 084 CPS respondents, immigrants accounted for 14.1% (weighted to be nationally representative), with the subgroup of citizen immigrants accounting for 6.8%, documented noncitizen immigrants accounting for 3.7%, and undocumented immigrants accounting for 3.6%; US-born citizens constituted 85.9% of the population. Relative to US-born citizens, immigrants were more often age 18 to 64 years (79.6% vs 58.3%), of Hispanic ethnicity (45.0% vs 14.0%), and uninsured (16.8% vs 7.4%); similar percentages (51.4% vs 50.9%) were female. US-born citizens vs immigrants paid similar amounts in premiums and taxes ($6269 per capita [95% CI, $6185-$6353 per capita] vs $6345 per capita [95% CI, $6220-$6470 per capita]). However, third-party expenditures for immigrants' health care ($5061 per capita; 95% CI, $4673-$5448 per capita) were lower than their expenditures for the care of US-born citizens ($6511 per capita; 95% CI, $6275-$6747 per capita). Immigrants, in general, paid significantly more per person (net contribution, $1284; 95% CI, $876-$1691) than was paid on their behalf. Most of this surplus was accounted for by undocumented immigrants, whose contributions exceeded their expenditures by $4418 per person (95% CI, $4047-$4789 per person). US-born citizens collectively paid $67.2 billion (95% CI, -$2.3 to $136.3 billion) less in premiums and taxes than third-party payers paid for their care. This deficit was mostly offset by the $58.3 billion (95% CI, $39.8-$76.8 billion) net surplus of payments from immigrants, 89% of which ($51.9 billion; 95% CI, $47.5-$56.3 billion) was attributable to undocumented immigrants. CONCLUSIONS AND RELEVANCE In this study, immigrants appeared to subsidize the health care of other US residents, suggesting that concerns that immigrants deplete health care resources may be unfounded.
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Affiliation(s)
| | - Lynsie R. Ranker
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Sharon Touw
- Institute for Community Health, Malden, Massachusetts
| | - David U. Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jessica Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- School of Urban Public Health, City University of New York at Hunter College, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Gaffney A, Himmelstein DU, Woolhandler S. Prevalence and Correlates of Patient Rationing of Insulin in the United States: A National Survey. Ann Intern Med 2022; 175:1623-1626. [PMID: 36252243 DOI: 10.7326/m22-2477] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/22/2022] Open
Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, and Harvard Medical School, Cambridge, Massachusetts
| | - David U Himmelstein
- Hunter College, City University of New York, Department of Medicine, Cambridge Health Alliance, Harvard Medical School, and Public Citizen Health Research Group, New York, New York
| | - Steffie Woolhandler
- Hunter College, City University of New York, Department of Medicine, Cambridge Health Alliance, Harvard Medical School, and Public Citizen Health Research Group, New York, New York
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21
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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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22
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Gao J, Moran E, Woolhandler S, Toporek A, Wilper AP, Himmelstein DU. Primary Care's Effects on Costs in the US Veterans Health Administration, 2016-2019: an Observational Cohort Study. J Gen Intern Med 2022; 37:3289-3294. [PMID: 34608563 PMCID: PMC9550907 DOI: 10.1007/s11606-021-07140-6] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care's effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. OBJECTIVE To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). DESIGN Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. PARTICIPANTS In total, 6,009,973 VHA patients in fiscal year (FY) 2019-5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP-and similar numbers in FYs 2016-2018. MAIN MEASURES Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients' demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. KEY RESULTS Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare's spending for VHA patients yielded similar results. CONCLUSIONS In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.
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Affiliation(s)
- Jian Gao
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Eileen Moran
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, NY, USA
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - Andrew Toporek
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Andrew P Wilper
- Boise Veterans Affairs Medical Center, Boise, ID, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - David U Himmelstein
- City University of New York at Hunter College, New York, NY, USA.
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA.
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23
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Gaffney A, Himmelstein DU, Dickman S, McCormick D, Woolhandler S. Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020. J Gen Intern Med 2022; 38:1152-1159. [PMID: 36163527 PMCID: PMC9512990 DOI: 10.1007/s11606-022-07797-7] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN Cross-sectional. PARTICIPANTS Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. CONCLUSIONS VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.
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Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, 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.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
| | | | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Stephanie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, 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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Gaffney A, Himmelstein DU, McCormick D, Woolhandler S. Disparities in COVID-19 Vaccine Booster Uptake in the USA: December 2021-February 2022. J Gen Intern Med 2022; 37:2918-2921. [PMID: 35610470 PMCID: PMC9128769 DOI: 10.1007/s11606-022-07648-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/30/2022] [Accepted: 04/28/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, 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.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Steffie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
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Gaffney A, Himmelstein DU, Woolhandler S. Reply: Trends in Smoking Prevalence and the Continuing Imperative of Tobacco Control. Ann Am Thorac Soc 2022; 19:1441-1442. [PMID: 35533311 PMCID: PMC9353966 DOI: 10.1513/annalsats.202204-354le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Adam Gaffney
- Cambridge Health AllianceCambridge, Massachusetts
- Harvard Medical SchoolBoston, Massachusetts
| | - David U. Himmelstein
- Cambridge Health AllianceCambridge, Massachusetts
- Harvard Medical SchoolBoston, Massachusetts
- City University of New YorkNew York, New York
| | - Steffie Woolhandler
- Cambridge Health AllianceCambridge, Massachusetts
- Harvard Medical SchoolBoston, Massachusetts
- City University of New YorkNew York, New York
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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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Gaffney A, Woolhandler S, Cai C, Bor D, Himmelstein J, McCormick D, Himmelstein DU. Medical Documentation Burden Among US Office-Based Physicians in 2019: A National Study. JAMA Intern Med 2022; 182:564-566. [PMID: 35344006 PMCID: PMC8961402 DOI: 10.1001/jamainternmed.2022.0372] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 01/03/2023]
Abstract
This cross-sectional study uses data from the 2019 National Electronic Health Records Survey to assess the burden and time spent on medical documentation outside office hours among US physicians.
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Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Stephanie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York.,Public Citizen Health Research Group, Washington, District of Columbia
| | - Christopher Cai
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jessica Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Hunter College, City University of New York, New York.,Public Citizen Health Research Group, Washington, District of Columbia
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Gaffney A, Himmelstein DU, Woolhandler S. A Potential Path to Universal Coverage With Medicare Advantage for All. JAMA 2022; 327:1615. [PMID: 35471522 DOI: 10.1001/jama.2022.3146] [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: 11/14/2022]
Affiliation(s)
- Adam Gaffney
- Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts
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Gaffney A, Woolhandler S, Himmelstein DU. COVID-19 Testing and Incidence Among Uninsured and Insured Individuals in 2020: a National Study. J Gen Intern Med 2022; 37:1344-1347. [PMID: 35141855 PMCID: PMC8971243 DOI: 10.1007/s11606-022-07429-0] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/19/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Adam Gaffney
- Cambridge Health Alliance, Cambridge, MA USA
- Harvard Medical School, Boston, MA USA
| | - Steffie Woolhandler
- 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 U. Himmelstein
- Cambridge Health Alliance, Cambridge, MA USA
- Harvard Medical School, Boston, MA USA
- City University of New York at Hunter College, New York, NY USA
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Gaffney AW, Woolhandler S, Himmelstein DU. Association of Uninsurance and VA Coverage with the Uptake and Equity of COVID-19 Vaccination: January-March 2021. J Gen Intern Med 2022; 37:1008-1011. [PMID: 35015259 PMCID: PMC8751452 DOI: 10.1007/s11606-021-07332-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Adam W Gaffney
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139 USA
- Harvard Medical School, Boston, USA
| | - Steffie Woolhandler
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139 USA
- Harvard Medical School, Boston, USA
- City University of New York at Hunter College, New York, USA
| | - David U. Himmelstein
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139 USA
- Harvard Medical School, Boston, USA
- City University of New York at Hunter College, New York, USA
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Himmelstein J, Himmelstein DU, Woolhandler S, Dickman S, Cai C, McCormick D. COVID-19-Related Care for Hispanic Elderly Adults With Limited English Proficiency. Ann Intern Med 2022; 175:143-145. [PMID: 34698514 PMCID: PMC8697484 DOI: 10.7326/m21-2900] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jessica Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, Massachusetts
| | - David U Himmelstein
- City University of New York at Hunter College, New York, New York, and Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, New York, and Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, Massachusetts
| | - Samuel Dickman
- Planned Parenthood South Texas, San Antonio, and The University of Texas at Austin, Austin, Texas
| | - Chris Cai
- Department of Medicine, Internal Medicine Residency Program at Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, Massachusetts
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Gaffney A, Dickman S, Cai C, McCormick D, Himmelstein DU, Woolhandler S. Medical Uninsurance and Underinsurance Among US Children: Findings From the National Survey of Children's Health, 2016-2019. JAMA Pediatr 2021; 175:1279-1281. [PMID: 34424273 PMCID: PMC8383158 DOI: 10.1001/jamapediatrics.2021.2822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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 uses data from the 2016 to 2019 National Survey of Children’s Health to examine trends in both medical uninsurnace and underinsurance among US children.
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Affiliation(s)
- Adam Gaffney
- Division of Pulmonary and Critical Care, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
| | | | - Christopher Cai
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
| | - David U. Himmelstein
- School of Urban Public Health, Hunter College, City University of New York, New York
| | - Steffie Woolhandler
- School of Urban Public Health, Hunter College, City University of New York, New York
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Affiliation(s)
- Laura Hawks
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
| | - Emily A Wang
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
| | - Benjamin Howell
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
| | - Steffie Woolhandler
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
| | - David U Himmelstein
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
| | - David Bor
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
| | - Danny McCormick
- Laura Hawks is with the Medical College of Wisconsin, Milwaukee. Emily A. Wang and Benjamin Howell are with the Yale School of Medicine, New Haven, CT. Steffie Woolhandler and David U. Himmelstein are with Hunter College, City University of New York, New York, NY, and Harvard Medical School, Boston, MA. David Bor and Danny McCormick are with the Cambridge Health Alliance, Cambridge, MA, and Harvard Medical School
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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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Gaffney AW, McCormick D, Woolhandler S, Christiani DC, Himmelstein DU. Prognostic implications of differences in forced vital capacity in black and white US adults: Findings from NHANES III with long-term mortality follow-up. EClinicalMedicine 2021; 39:101073. [PMID: 34458707 PMCID: PMC8379634 DOI: 10.1016/j.eclinm.2021.101073] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Because Forced Vital Capacity (FVC) is reduced in Black relative to White Americans of the same age, sex, and height, standard lung function prediction equations assign a lower "normal" range for Black patients. The prognostic implications of this race correction are uncertain. METHODS We analyzed 5,294 White and 3,743 Black participants age 20-80 in NHANES III, a nationally-representative US survey conducted 1988-94, which we linked to the National Death Index to assess mortality through December 31, 2015. We calculated the FVC-percent predicted among Black and White participants, first applying NHANES III White prediction equations to all persons, and then using standard race-specific prediction equations. We used Cox proportional hazard models to calculate the association between race and all-cause mortality without and with adjustment for FVC (using each FVC metric), smoking, socioeconomic factors, and comorbidities. FINDINGS Black participants' age- and sex-adjusted mortality was greater than White participants (HR 1.46; 95%CI:1.29, 1.65). With adjustment for FVC in liters (mean 3.7 L for Black participants, 4.3 L for White participants) or FVC percent-predicted using White equations for everyone, Black race was no longer independently predictive of higher mortality (HR∼1.0). When FVC-percent predicted was "corrected" for race, Black individuals again showed increased mortality hazard. Deaths attributed to chronic respiratory disease were infrequent for both Black and White individuals. INTERPRETATION Lower FVC in Black people is associated with elevated risk of all-cause mortality, challenging the standard assumption about race-based normal limits. Black-White disparities in FVC may reflect deleterious social/environmental exposures, not innate differences. FUNDING No funding.
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Affiliation(s)
- Adam W Gaffney
- Cambridge Health Alliance, Cambridge, USA
- Harvard Medical School, Boston, USA
- Corresponding author.
| | - Danny McCormick
- Cambridge Health Alliance, Cambridge, USA
- Harvard Medical School, Boston, USA
| | - Steffie Woolhandler
- Cambridge Health Alliance, Cambridge, USA
- Harvard Medical School, Boston, USA
- City University of New York at Hunter College, New York, USA
| | - David C. Christiani
- Harvard Medical School, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - David U. Himmelstein
- Cambridge Health Alliance, Cambridge, USA
- Harvard Medical School, Boston, USA
- City University of New York at Hunter College, New York, USA
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Himmelstein J, Himmelstein DU, Woolhandler S, Bor DH, Gaffney A, Zallman L, Dickman S, McCormick D. Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999-2018. Health Aff (Millwood) 2021; 40:1126-1134. [PMID: 34228521 DOI: 10.1377/hlthaff.2020.02510] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
One in seven people in the US speak Spanish at home, and twenty-five million people in the US have limited English proficiency. Using nationally representative data from the Medical Expenditure Panel Survey, we compare health care spending for and health care use by Hispanics adults with limited English proficiency with spending for and use by English-proficient Hispanic and non-Hispanic adults. During 2014-18 mean annual per capita expenditures were $1,463 (35 percent) lower for Hispanic adults with limited English proficiency than for Hispanic adults who were English proficient, after adjustment for respondents' characteristics. Hispanic adults with limited English proficiency also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient. Health care spending gaps between Hispanic adults with limited English proficiency and non-Hispanic adults with English proficiency widened between 1999 and 2018. These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency.
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Affiliation(s)
- Jessica Himmelstein
- Jessica Himmelstein is a fellow in internal medicine, Cambridge Health Alliance, in Cambridge, Massachusetts
| | - David U Himmelstein
- David U. Himmelstein is a distinguished professor of public health at Hunter College, City University of New York, in New York, New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
| | - Steffie Woolhandler
- Steffie Woolhandler is a distinguished professor of public health at Hunter College, City University of New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
| | - David H Bor
- David H. Bor is a professor of medicine at Harvard Medical School, in Boston, Massachusetts, and chief academic officer at Cambridge Health Alliance
| | - Adam Gaffney
- Adam Gaffney is an assistant professor of medicine at Harvard Medical School and is in the Division of Pulmonary and Critical Care Medicine at Cambridge Health Alliance
| | - Leah Zallman
- Leah Zallman, who died in November 2020, was director of research at the Institute for Community Health, an assistant professor of medicine at Harvard Medical School, and a primary care physician at Cambridge Health Alliance, when this research was conducted
| | - Samuel Dickman
- Samuel Dickman is the medical director for primary care at Planned Parenthood South Texas, in San Antonio, Texas
| | - Danny McCormick
- Danny McCormick is an associate professor of medicine at Harvard Medical School and director of the Division of Social and Community Medicine in the Department of Medicine, Cambridge Health Alliance
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Woolhandler S, Himmelstein DU. COVID-19’s Lessons: Scientific and Social. Am J Public Health 2021. [DOI: 10.2105/ajph.2021.306369] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Steffie Woolhandler
- The authors are with the City University of New York at Hunter College, New York, NY, and the Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA
| | - David U. Himmelstein
- The authors are with the City University of New York at Hunter College, New York, NY, and the Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA
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Touw S, McCormack G, Himmelstein DU, Woolhandler S, Zallman L. Immigrant Essential Workers Likely Avoided Medicaid And SNAP Because Of A Change To The Public Charge Rule. Health Aff (Millwood) 2021; 40:1090-1098. [PMID: 34228520 DOI: 10.1377/hlthaff.2021.00059] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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
During the COVID-19 pandemic in the US, essential workers have provided health care, food, and other necessities, often incurring considerable risk. At the pandemic's start, the federal government was in the process of tightening the "public charge" rule by adding nutrition and health benefits to the cash benefits that, if drawn, could subject immigrants to sanctions (for example, green card denial). Census Bureau data indicate that immigrants accounted for 13.6 percent of the population but 17.8 percent of essential workers in 2019. About 20.0 million immigrants held essential jobs, and more than one-third of these immigrants resided in US states bordering Mexico. Nationwide, 12.3 million essential workers and 18.9 million of their household members were at risk because of the new sanctions. The rule change (which was subsequently revoked) likely caused 2.1 million essential workers and household members to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance on the eve of the pandemic, highlighting the potential of immigration policy changes to exacerbate health risks.
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Affiliation(s)
- Sharon Touw
- Sharon Touw is a researcher at the Institute for Community Health, in Malden, Massachusetts
| | - Grace McCormack
- Grace McCormack is a PhD candidate in the Harvard Kennedy School, Harvard University, in Cambridge, Massachusetts
| | - David U Himmelstein
- David U. Himmelstein is a distinguished professor of public health at Hunter College, City University of New York, in New York, New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School, in Cambridge, Massachusetts
| | - Steffie Woolhandler
- Steffie Woolhandler is a distinguished professor of public health at Hunter College, City University of New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
| | - Leah Zallman
- Leah Zallman, who died in November 2020, was director of research at the Institute for Community Health, an assistant professor of medicine at Harvard Medical School, and a primary care physician at Cambridge Health Alliance, when this research was conducted
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Gaffney AW, Himmelstein DU, Christiani DC, Woolhandler S. Socioeconomic Inequality in Respiratory Health in the US From 1959 to 2018. JAMA Intern Med 2021; 181:968-976. [PMID: 34047754 PMCID: PMC8261605 DOI: 10.1001/jamainternmed.2021.2441] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 01/25/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
Abstract
Importance Air quality has improved and smoking rates have declined over the past half-century in the US. It is unknown whether such secular improvements, and other policies, have helped close socioeconomic gaps in respiratory health. Objective To describe long-term trends in socioeconomic disparities in respiratory disease prevalence, pulmonary symptoms, and pulmonary function. Design, Setting, and Participants This repeated cross-sectional analysis of the nationally representative National Health and Nutrition Examination Surveys (NHANES) and predecessor surveys, conducted from 1959 to 2018. included 160 495 participants aged 6 to 74 years. Exposures Family income quintile defined using year-specific thresholds; educational attainment. Main Outcomes and Measures Trends in socioeconomic disparities in prevalence of current/former smoking among adults aged 25 to 74 years; 3 respiratory symptoms (dyspnea on exertion, cough, and wheezing) among adults aged 40 to 74 years; asthma stratified by age (6-11, 12-17, and 18-74 years); chronic obstructive pulmonary disease ([COPD] adults aged 40-74 years); and 3 measures of pulmonary function (forced expiratory volume in 1 second [FEV1], forced vital capacity [FVC], and FEV1/FVC<0.70) among adults aged 24 to 74 years. Results Our sample included 160 495 individuals surveyed between 1959 and 2018: 27 948 children aged 6 to 11 years; 26 956 children aged 12 to 17 years; and 105 591 adults aged 18 to 74 years. Income- and education-based disparities in smoking prevalence widened from 1971 to 2018. Socioeconomic disparities in respiratory symptoms persisted or worsened from 1959 to 2018. For instance, from 1971 to 1975, 44.5% of those in the lowest income quintile reported dyspnea on exertion vs 26.4% of those in the highest quintile, whereas from 2017 to 2018 the corresponding proportions were 48.3% and 27.9%. Disparities in cough and wheezing rose over time. Asthma prevalence rose for all children after 1980, but more sharply among poorer children. Income-based disparities in diagnosed COPD also widened over time, from 4.5 percentage points (age- and sex-adjusted) in 1971 to 11.3 percentage points from 2013 to 2018. Socioeconomic disparities in FEV1 and FVC also increased. For instance, from 1971 to 1975, the age- and height-adjusted FEV1 of men in the lowest income quintile was 203.6 mL lower than men in the highest quintile, a difference that widened to 248.5 mL from 2007 to 2012 (95% CI, -328.0 to -169.0). However, disparities in rates of FEV1/FVC lower than 0.70 changed little. Conclusions and Relevance Socioeconomic disparities in pulmonary health persisted and potentially worsened over the past 6 decades, suggesting that the benefits of improved air quality and smoking reductions have not been equally distributed. Socioeconomic position may function as an independent determinant of pulmonary health.
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Affiliation(s)
- Adam W. Gaffney
- Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David U. Himmelstein
- Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- City University of New York at Hunter College, New York
| | - David C. Christiani
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Steffie Woolhandler
- Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- City University of New York at Hunter College, New York
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Cai C, Woolhandler S, Himmelstein DU, Gaffney A. Trends in Anxiety and Depression Symptoms During the COVID-19 Pandemic: Results from the US Census Bureau's Household Pulse Survey. J Gen Intern Med 2021; 36:1841-1843. [PMID: 33852142 PMCID: PMC8045436 DOI: 10.1007/s11606-021-06759-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/23/2021] [Indexed: 10/31/2022]
Affiliation(s)
- Christopher Cai
- University of California San Francisco (UCSF) School of Medicine, San Francisco, CA, USA.
| | - Steffie Woolhandler
- Harvard Medical School, Cambridge Health Alliance, Cambridge, MA, USA
- City University of New York at Hunter College, New York, USA
| | - David U Himmelstein
- Harvard Medical School, Cambridge Health Alliance, Cambridge, MA, USA
- City University of New York at Hunter College, New York, USA
| | - Adam Gaffney
- Harvard Medical School, Cambridge Health Alliance, Cambridge, MA, USA
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Himmelstein DU, Woolhandler S. Recovering from Trump: Biden's first 100 days. Lancet 2021; 397:1787-1791. [PMID: 33933187 PMCID: PMC8084352 DOI: 10.1016/s0140-6736(21)00979-x] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/01/2022]
Affiliation(s)
- David U Himmelstein
- City University of New York at Hunter College, New York, NY 10035, USA; Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA.
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, NY 10035, USA; Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA
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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
The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic-induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints-for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7-10 percent and hospital use by 0-3 percent. Modest administrative savings could offset the costs of such increases.
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Affiliation(s)
- Adam Gaffney
- Adam Gaffney is an instructor in medicine at Harvard Medical School, in Boston, and is in the Division of Pulmonary and Critical Care Medicine at Cambridge Health Alliance, in Cambridge, both in Massachusetts
| | - David U Himmelstein
- David U. Himmelstein is a distinguished professor of public health at Hunter College, City University of New York, in New York, New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
| | - Steffie Woolhandler
- Steffie Woolhandler is a distinguished professor of public health at Hunter College, City University of New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
| | - James G Kahn
- James G. Kahn is an emeritus professor in the Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco, in San Francisco, California
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Gaffney AW, Hawks L, Bor D, White AC, Woolhandler S, McCormick D, Himmelstein DU. National Trends and Disparities in Health Care Access and Coverage Among Adults With Asthma and COPD: 1997-2018. Chest 2021; 159:2173-2182. [PMID: 33497651 DOI: 10.1016/j.chest.2021.01.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/31/2020] [Accepted: 01/09/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Racial and ethnic as well as economic disparities in access to care among persons with asthma and COPD have been described, but long-term access trends are unclear. RESEARCH QUESTION Have health coverage and access to care and medications among adults with airways disease improved, and have disparities narrowed? STUDY DESIGN AND METHODS Using the 1997 through 2018 National Health Interview Survey, we examined time trends in health coverage and the affordability of medical care and prescription drugs for adults with asthma and COPD, overall and by income and by race and ethnicity. We performed multivariate linear probability regressions comparing coverage and access in 2018 with that in 1997. RESULTS Our sample included 76,843 adults with asthma and 30,548 adults with COPD. Among adults with asthma, lack of insurance rose in the first decade of the twenty-first century, peaking with the Great Recession, but fell after implementation of the Affordable Care Act (ACA). From 1997 through 2018, the uninsured rate among adults with asthma decreased from 19.4% to 9.6% (adjusted 9.27 percentage points; 95% CI, 7.1%-11.5%). However, the proportions delaying or foregoing medical care because of cost or going without medications did not improve. Racial and ethnic as well as economic disparities present in 1997 persisted over the study period. Trends and disparities among those with COPD were similar, although the proportion going without needed medications worsened, rising by an adjusted 7.8 percentage points. INTERPRETATION Coverage losses among persons with airways disease in the first decade of the twenty-first century were reversed by the ACA, but neither care affordability nor disparities improved. Further reform is needed to close these gaps.
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Affiliation(s)
- Adam W Gaffney
- Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA.
| | - Laura Hawks
- Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA
| | - David Bor
- Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alexander C White
- Cambridge Health Alliance, Cambridge, MA; Tufts Medical School, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Steffie Woolhandler
- Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA; City University of New York at Hunter College, New York, NY
| | - Danny McCormick
- Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA
| | - David U Himmelstein
- Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA; City University of New York at Hunter College, New York, NY
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Wong CJ, Woolhandler S, Himmelstein DU, McCormick D. SGIM's Endorsement of ACP's Better Is Possible: Aligning Policy with Values. J Gen Intern Med 2021; 36:203-204. [PMID: 33105002 PMCID: PMC7586867 DOI: 10.1007/s11606-020-06312-0] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Christopher J Wong
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
| | | | | | - Danny McCormick
- Department of Medicine, Harvard Medical School, Cambridge, MA, USA
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Jeurissen PPT, Kruse FM, Busse R, Himmelstein DU, Mossialos E, Woolhandler S. For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study. Int J Health Serv 2021; 51:67-89. [PMID: 33107779 PMCID: PMC7756069 DOI: 10.1177/0020731420966976] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
For-profit hospitals' market share has increased in many nations over recent decades. Previous studies suggest that their growth is not attributable to superior performance on access, quality of care, or efficiency. We analyzed other factors that we hypothesized may contribute to the increasing role of for-profit hospitals. We studied the historical development of the for-profit hospital sector across 4 nations with contrasting trends in for-profit hospital market share: the United States, the United Kingdom, Germany, and the Netherlands. We focused on 3 factors that we believed might help explain why the role of for-profits grew in some nations but not in others: (1) the treatment of for-profits by public reimbursement plans, (2) physicians' financial interests, and (3) the effect of the political environment. We conclude that access to subsidies and reimbursement under favorable terms from public health care payors is an important factor in the rise of for-profit hospitals. Arrangements that aligned financial incentives of physicians with the interests of for-profit hospitals were important in stimulating for-profit growth in an earlier era, but they play little role at present. Remarkably, the environment for for-profit ownership seems to have been largely immune to political shifts.
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Affiliation(s)
- Patrick P. T. Jeurissen
- IQ Healthcare Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
- Ministry of Health, Welfare and Sport, The Hague, the Netherlands
| | - Florien M. Kruse
- IQ Healthcare Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Reinhard Busse
- Department of Health Care Management, Berlin University of Technology, Berlin, Germany
| | - David U. Himmelstein
- City University of New York at Hunter College, New York, New York, USA
- Harvard Medical School, Cambridge, Massachusetts, USA
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Sciences, London, UK
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, New York, USA
- Harvard Medical School, Cambridge, Massachusetts, USA
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49
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Affiliation(s)
| | - David U Himmelstein
- City University of New York at Hunter College, New York, New York (D.U.H., S.W.)
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, New York (D.U.H., S.W.)
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50
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Abstract
We review recently published studies of US health policy and the nation's health care system. Even prior to the COVID-19 pandemic, health inequalities were widening and care was inequitably distributed. Although the Affordable Care Act's coverage expansion improved access to care and timely cancer diagnoses, a large proportion of US residents continued to avoid medical care due to concerns about costs, and access to mental health services remains particularly inadequate. Yet more evidence of private insurers' profit-driven misbehaviors and of corruption among medical leaders continues to emerge. Misguided incentives and lax regulation encourages nominally nonprofit health care providers to mimic for-profits' misconduct, and rapacious investors own and control an increasing share of physicians' practices. Pharmaceutical firms wield outsize political influence and devote far more funds to rewarding investors than to research and development effort. Yet despite vigorous efforts by pharma and other commercial interests to denigrate national health insurance, polls indicate that the COVID-19 pandemic has led to increasing support for such reform.
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Affiliation(s)
- David U Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York, NY, USA
| | - Steffie Woolhandler
- School of Urban Public Health, City University of New York at Hunter College, New York, NY, USA
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