Millions of Americans have medical debt and/or defer care due to cost. Few studies have examined the association of such health-related financial problems with sexual orientation or gender identity, and whether state-level policies protecting sexual and gender minority (SGM) people affect disparities in such problems. To examine the relationships between SGM status, state-level SGM protections, and health-related financial problems. Cross-sectional analysis. Nationally-representative sample of U.S. adults in the 2021 National Financial Capability Study. Prevalence of medical debt and/or deferred care; adjusted odds ratios (aORs) by SGM status and residence in a state with fewer SGM protections. Of 25,170 survey respondents, 3.7

Importance Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access. Objective To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state's standard prison co-payment and care receipt in 2016. Design, Setting, and Participants This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics' 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey. Exposures The state's standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison's minimum wage. Main Outcomes and Measures Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level. Results Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week's prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay <= 1 week's wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week's wage: aOR, 2.17; 95% CI, 1.61-2.93). Conclusions and Relevance This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.

This cross-sectional study examines Medicare Advantage and traditional Medicare beneficiaries' use of and spending for dental services.

Private equity (PE) acquisitions in health care delivery nearly tripled from 2010 to 2020. Despite concerns around clinical and economic implications, policy responses have remained limited. We discuss the US policy landscape around PE ownership, using policies in the European Union for comparison. We present four domains in which policy can be strengthened. First, to improve oversight of acquisitions, policy makers should lower reporting thresholds, review sequential acquisitions that together affect market power, automate reviews with potential denials based on market concentration effects, consider new regulatory mechanisms such as attorney general veto, and increase funding for this work. Second, policy makers should increase the longer-run transparency of PE ownership, including the health care prices garnered by acquired entities. Third, policy makers should protect patients and providers by establishing minimum staffing ratios, spending floors for direct patient care, and limits on layoffs and the sale of real estate after acquisition (forms of "asset stripping"). Finally, policy makers should mitigate risky financial behavior by limiting the amount or proportion of debt used to finance PE acquisitions in health care.

This Viewpoint details how and why improved oversight of private equity acquisition of physician practices and hospitals is needed to mitigate the effects on health care costs, clinicians' jobs, and patients' access to care.

Living with family and friends is a common strategy to prevent or exit homelessness, but little is known about structural barriers that impede family and friends' ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported staying with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived these stays as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.

Letters26 October 2021COVID-19–Related Care for Hispanic Elderly Adults With Limited English ProficiencyFREEJessica Himmelstein, MD, MPH, David U. Himmelstein, MD, Steffie Woolhandler, MD, MPH, Samuel Dickman, MD, Chris Cai, MD, Danny McCormick, MD, MPHJessica Himmelstein, MD, MPHDepartment of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, MassachusettsSearch for more papers by this author, David U. Himmelstein, MDCity University of New York at Hunter College, New York, New York, and Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, MassachusettsSearch for more papers by this author, Steffie Woolhandler, MD, MPHCity University of New York at Hunter College, New York, New York, and Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, MassachusettsSearch for more papers by this author, Samuel Dickman, MDPlanned Parenthood South Texas, San Antonio, and The University of Texas at Austin, Austin, TexasSearch for more papers by this author, Chris Cai, MDDepartment of Medicine, Internal Medicine Residency Program at Brigham and Women's Hospital and Harvard Medical School, Boston, MassachusettsSearch for more papers by this author, Danny McCormick, MD, MPHDepartment of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, MassachusettsSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-2900 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Hispanic persons with limited English proficiency (LEP) have low rates of COVID-19 testing and high rates of COVID-19 infection and death (1). About 8% of Medicare enrollees have LEP, and the Centers for Medicare & Medicaid Services has identified improving their care as a priority (2). Anecdotal reports suggest that LEP may pose a barrier to COVID-19 vaccination (3, 4), a safe and effective preventive measure, but little is known about the willingness of older persons with LEP to be vaccinated or about factors that might impede vaccination acceptance.Objective: To assess language-based differences in concerns about and willingness to receive COVID-19 vaccination among Medicare enrollees and differences in COVID-19 testing, symptom severity, whether medical care has been sought, and perceptions regarding COVID-19's contagiousness and lethality.Methods and Findings: We analyzed data from the Medicare Current Beneficiary Survey COVID-19 Fall Supplement, a nationally representative, cross-sectional telephone survey of Medicare beneficiaries. We classified respondents taking the survey in Spanish as LEP and those taking the survey in English as English proficient (EP). On the basis of self-reported ethnicity, we compared Hispanic beneficiaries with LEP to both Hispanic and non-Hispanic beneficiaries with EP. The survey, which was conducted before the roll-out of COVID-19 vaccines, asked respondents how likely they were to get vaccinated when vaccination became available. We categorized respondents answering “definitely” or “probably” as likely and those answering “probably not,” “definitely not,” or “not sure” as hesitant. Among vaccine-hesitant respondents, we report the prevalence of the 2 most common concerns about the vaccine.Testing for COVID-19 was self-reported. Among respondents who tested positive, we report severity of symptoms (moderate/severe vs. none/mild), and whether medical care was sought (yes/no). Respondents were considered to agree that COVID-19 is more contagious or deadly than influenza (referred to as “the flu” in the survey) if they answered “agree” or “strongly agree” and to disagree if they answered otherwise. We assessed COVID-19 precautions on the basis of responses to questions about 2 precautions that are the most practicable, effective, and widely advocated by public health experts. For all of these variables, we categorized “don't know,” “refused,” or “inapplicable” responses as missing.We used logistic regression with marginal standardization to compare Hispanic respondents with LEP with both comparison groups and report unadjusted risk differences (RDs) and RDs adjusted for sex, income, census region, Medicare–Medicaid dual eligibility, and Medicare Advantage enrollment. We used Stata/MP V16.1 (StataCorp), procedures that account for the complex sample design and weights to generate national estimates. Cambridge Health Alliance's Institutional Review Board exempted this study from review.Results: The sample included 438 Hispanic adults with LEP, 533 Hispanic adults with EP, and 8713 non-Hispanic adults with EP. Hispanic adults with LEP were more often female, older (≥75 years), lower-income, residents of the South or West, enrolled in Medicare Advantage, and lacking a source of care (Table 1).Table 1. Characteristics of Medicare Beneficiaries With and Without LEP, by Hispanic Ethnicity, Fall 2020Hispanic Medicare enrollees with LEP were less likely to anticipate getting vaccinated (unadjusted RD, −12.6 [95% CI, −19.4 to −5.9]) than non-Hispanic adults with EP (Table 2), a difference that was attenuated in the adjusted analysis (RD, −5.8 [CI, −13.6 to 2.0]), primarily due to income differences. Among vaccine-hesitant older respondents, those who were Hispanic with LEP were more likely to be worried about vaccine side effects than non-Hispanic adults with EP (62.6% vs. 41.2%; adjusted RD, 22.4 [CI, 7.7 to 37.1]).Table 2. COVID-19 Care Among Medicare Beneficiaries With and Without LEP, by Hispanic Ethnicity, Fall 2020Hispanic adults with LEP reported high rates of COVID-19 test positivity (17.9% of those tested [CI, 12.4% to 25.2%] and 5.3% overall [CI, 3.6% to 7.8%]) and, in adjusted analyses, were more likely than non-Hispanic adults with EP to recognize that COVID-19 is more contagious and deadly than influenza and to report avoiding large gatherings (Table 2).Discussion: Among Medicare enrollees, persons with LEP were less likely to intend to get vaccinated, despite being insured and having higher test positivity rates and knowledge of the seriousness of COVID-19. Concern about side effects was a major driver of vaccine hesitancy. Although reduced health literacy, which is more common among persons with LEP, may influence vaccine hesitancy, we lacked data to explore this. Adjustment for sociodemographic differences (most importantly, income) attenuated the language-based disparity in vaccine hesitancy, suggesting that lower income among adults with LEP (which LEP may cause) explains at least some of this disparity.Our findings support efforts by Medicare and Medicare Advantage plans to communicate the risks and benefits of COVID-19 vaccines to this high-risk group through linguistically and culturally appropriate outreach and engagement in care (5). Clinicians, public health officials, and Spanish-language news media also have roles to play in overcoming vaccine hesitancy in the older population with LEP.References1. Reitsma MB, Claypool AL, Vargo J, et al. Racial/Ethnic disparities in COVID-19 exposure risk, testing, and cases at the subcounty level in California. Health Aff (Millwood). 2021;40:870-878. [PMID: 33979192] doi:10.1377/hlthaff.2021.00098 CrossrefMedlineGoogle Scholar2. The CMS Equity Plan for Improving Quality in Medicare. Centers for Medicare & Medicaid Services Office of Minority Health; 2015:19. Accessed at www.cms.gov/about-cms/agency-information/omh/omh_dwnld-cms_equityplanformedicare_090615.pdf on 7 September 2021. Google Scholar3. Salame R. Limited English skills can mean limited access to the COVID-19 vaccine. Slate. 30 April 2021. Accessed at https://slate.com/news-and-politics/2021/04/covid-19-vaccine-for-non-english-speakers.html on 7 September 2021. Google Scholar4. Fuchs JR, Fuchs JW, Tietz SE, et al. Older adults with limited English proficiency need equitable COVID-19 vaccine access. J Am Geriatr Soc. 2021;69:888-891. [PMID: 33555042] doi:10.1111/jgs.17069 CrossrefMedlineGoogle Scholar5. Fernandez A. We need to get more Latinx people vaccinated. Here's how. AAMC. 11 February 2021. Accessed at www.aamc.org/news-insights/we-need-get-more-latinx-people-vaccinated-heres-how on 7 September 2021. Google Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Jessica Himmelstein, MD, MPH; David U. Himmelstein, MD; Steffie Woolhandler, MD, MPH; Samuel Dickman, MD; Chris Cai, MD; Danny McCormick, MD, MPHAffiliations: Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, MassachusettsCity University of New York at Hunter College, New York, New York, and Department of Medicine, Cambridge Health Alliance, Cambridge, and Harvard Medical School, Boston, MassachusettsPlanned Parenthood South Texas, San Antonio, and The University of Texas at Austin, Austin, TexasDepartment of Medicine, Internal Medicine Residency Program at Brigham and Women's Hospital and Harvard Medical School, Boston, MassachusettsCorresponding Author: Jessica Himmelstein, MD, MPH, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139; e-mail,jhimmelstein@challiance.org.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-2900.This article was published at Annals.org on 26 October 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byDocumented barriers to health care access among Latinx older adults: A scoping reviewLessons Learned from Health Disparities in Coronavirus Disease-2019 in the United StatesThe association between non-English primary language and COVID-19 clinical trial eligibility and enrollment: A retrospective cohort studySpanish-Language Communication of COVID-19 Information Across US Local Health Department WebsitesUsing Community Engagement and Geographic Information Systems to Address COVID-19 Vaccination Disparities January 2022Volume 175, Issue 1 Page: 143-145 Keywords COVID-19 Elderly Health care providers Hispanic people Hospital medicine Medicare Risk management Risk ratio Vaccine hesitancy Vaccines ePublished: 26 October 2021 Issue Published: January 2022 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

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. To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. Repeated cross-sectional. National Ambulatory Medical Care Survey, 1979–1981, 1985, 1989–2016, 2018. Office-based physicians. 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. 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. Self-reported visit length. 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.

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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