Importance:Cross-sectional studies indicate that out-of-pocket (OOP) health care costs strain household finances, but few studies have examined the risk of incurring burdensome health care spending longitudinally among individuals in the US. Objective:To assess burdensome OOP health care costs (and care foregone due to cost) over a 4-year period. Design, Setting, and Participants:In this cohort study, data were analyzed on respondents to the 4-year longitudinal Medical Expenditure Panel Surveys (MEPS), a nationally representative household survey of the US noninstitutionalized population conducted from 2018 to 2022. Analyses were performed from November 2024 to October 2025. Main Outcomes and Measures:Primary outcomes included 4 cost-related outcomes: cost burden, defined as individual annual OOP medical spending greater than 10% of family income (>5% for low-income individuals); catastrophic cost burden (CCB) defined as OOP spending greater than 40% of postsubsistence income; foregone care due to cost; and family-level cost burden. Risk was assessed using time-to-event analyses, overall and among subgroups, eg, baseline chronic disease, hospitalization, and uninsurance, and death during the study period. Results:Among 12 645 MEPS respondents, 74.6% (95% CI, 73.4%-75.8%) were aged 18 years or older and 50.6% (95% CI, 49.7%-51.6%) were female individuals (weighted); among adults, 50.3% (95% CI, 48.6%-52.0%) had a chronic disease, 7.9% (95% CI, 7.2%-8.7%) were hospitalized, and 2.3% (95% CI, 2.0%-2.6%) died. During year 1, 6.5% of adults experienced cost burdens (and 3.5% CCB); 17.4% (and 9.9% CCB) experienced these outcomes (respectively) at least once over 4 years. Overall, 24.7% of US individuals lived in families experiencing cost burdens over 4 years, and 11.2% lived in families experiencing CCBs. Overall, 26.7% of adults experienced either foregone care due to cost or cost burden over 4 years. Lower income, having no insurance, hospitalizations, and chronic disease were each associated with higher cost burden. Overall, 53.2% of decedents experienced cost burdens in 1 to 4 years before death. Conclusions and Relevance:This cohort study found that the US health care system imposes cost burdens on a larger share of the population than suggested by cross-sectional analyses, and most individuals in the US will experience such burdens during their lifetimes. Policies that reduce OOP costs might improve the well-being of individuals in the US.

Policy Points The One Big Beautiful Bill Act (OBBBA) may impose the largest coverage losses in US history, causing the number uninsured to rise by 55% in the coming decade. We examined four prior coverage contractions-Reagan-era Medicaid cuts, the 2005 TennCare disenrollment, 2019 Arkansas work requirements, and the Medicaid Unwinding-to shed light on the OBBBA's impacts. These suggest that most who lose Medicaid do not find alternative coverage, and that states are unlikely to compensate for federal cuts, findings that run counter to some assumptions adopted by the Congressional Budget Office in predicting the impacts of Medicaid cuts. Studies of coverage contractions complement data from coverage expansions in predicting worse health care access, household finances, and health for needy individuals due to the OBBBA. Studies also suggest that the magnitude of harms from contractions may exceed that suggested by expansions. CONTEXT:The so-called One Big Beautiful Bill Act signed into law by President Trump on July 4, 2025 will cut $1 trillion from federal health care programs over the coming decade and cause 10 million individuals to become uninsured according to the Congressional Budget Office. Most analyses of the bill's impacts have assumed they would be the inverse of those documented from previous coverage expansions. An examination of past coverage cuts might yield additional insights into the probable impacts of this legislation on the medical care and health of the needy. METHODS:We reviewed studies of four prior large scale coverage contractions: Reagan-era Medicaid cuts, the 2005 Tenncare Disenrollment, the 2019 implementation of work requirements in Arkansas, and the postpandemic "Unwinding" of Medicaid. FINDINGS:The experience of these prior coverage contractions complements evidence from analyses of coverage expansions in predicting that widespread insurance loss will lead to a reduction in care utilization, an increase in household financial strain, and worsened physical and mental health for low-income individuals. These coverage contractions additionally suggest that most who lose Medicaid coverage will not find alternative coverage; that work requirements will impose burdensome administrative costs on states; that states are unlikely to offset reductions in federal Medicaid funding with internal funds; and that the second-order effects of coverage losses may, in some instances, be greater (in magnitude) than the benefits seen after coverage expansions. CONCLUSIONS:Cuts to federal health care programs will produce sharp contractions in public coverage that will worsen existing problems in US health care such as insurance churn, degrading care, and worsening health inequality. While states may take some steps to mitigate harmful impacts, better protection of the medically needy would require repeal of the legislation, while full protection would require universal, seamless coverage.

This cross-sectional study examined whether parental job lock and other financial and employment factors are associated with access to care for children with cystic fibrosis.

Rationale: Early-life exposures may precipitate asthma, but their contribution to disparities in asthma is less clear. Objective: To elucidate racial, ethnic, and socioeconomic status (SES) disparities in the age trajectory of asthma burden among U.S. children. Methods: We analyzed three datasets: 1) 2016-2021 National Children's Health Survey (n = 223,551), 2) 2015-2017 Child Asthma Call-Back Survey (n = 4,289), and 3) 2018-2019 National Inpatient Sample (n = 23,713 children with asthma). We examined cumulative asthma prevalence by individual year of age and children's race and ethnicity or SES (National Children's Health Survey); mean age at asthma diagnosis by race and ethnicity and SES, unadjusted and adjusted for confounders (Asthma Call-Back Survey); and asthma hospitalization rates overall and per child with asthma by individual year of age and race and ethnicity (National Inpatient Sample). Results: Among White children, cumulative asthma prevalence increases gradually through childhood to 6.6% at age 5 years and 16.1% by age 17 years. Prevalence increases more sharply in early childhood among Black children, reaching 17.6% at age 5 years (risk ratio, 2.6; 95% confidence interval, 1.9-3.8), but plateaus after age 9 years, with a consequent decrease in Black-White relative disparities into adolescence. Disparities according to SES follow a similar trajectory, emerging early and subsequently narrowing. Similarly, Black, Hispanic, and low-income children with asthma are diagnosed at an earlier age than White (or high-income) children. The asthma hospitalization rate increases in the first years of life among all children, but most rapidly among Black children, with a peak absolute Black-White gap at age 4 years; the relative gap remains wide throughout childhood and peaks at age 10 years. However, per child with asthma, relative White-Black disparities in hospitalizations increase through age 15 years. Conclusions: Disparities in asthma prevalence emerge in early childhood and then narrow, suggesting that reducing early-life adverse environmental exposures may be key to asthma prevention. Policies to improve the social determinants of health during gestation and childhood, e.g., environmental equity and family income support, are needed.

This study explores the potential for health care staffing shortages in the US by estimating the number of immigrants employed in health care who could be affected by deportation or immigration restrictions.

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.

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.

Political leaders in several states have passed measures restricting abortion access, often citing their commitment to preserving children's lives. This study sought to assess whether child survival outcomes in those states are consonant with such a commitment.

Objectives Convenience sampling is an imperfect but important tool for seroprevalence studies. For COVID-19, local geographic variation in cases or vaccination can confound studies that rely on the geographically skewed recruitment inherent to convenience sampling. The objectives of this study were: (1) quantifying how geographically skewed recruitment influences SARS-CoV-2 seroprevalence estimates obtained via convenience sampling and (2) developing new methods that employ Global Positioning System (GPS)-derived foot traffic data to measure and minimise bias and uncertainty due to geographically skewed recruitment. Design We used data from a local convenience-sampled seroprevalence study to map the geographic distribution of study participants’ reported home locations and compared this to the geographic distribution of reported COVID-19 cases across the study catchment area. Using a numerical simulation, we quantified bias and uncertainty in SARS-CoV-2 seroprevalence estimates obtained using different geographically skewed recruitment scenarios. We employed GPS-derived foot traffic data to estimate the geographic distribution of participants for different recruitment locations and used this data to identify recruitment locations that minimise bias and uncertainty in resulting seroprevalence estimates. Results The geographic distribution of participants in convenience-sampled seroprevalence surveys can be strongly skewed towards individuals living near the study recruitment location. Uncertainty in seroprevalence estimates increased when neighbourhoods with higher disease burden or larger populations were undersampled. Failure to account for undersampling or oversampling across neighbourhoods also resulted in biased seroprevalence estimates. GPS-derived foot traffic data correlated with the geographic distribution of serosurveillance study participants. Conclusions Local geographic variation in seropositivity is an important concern in SARS-CoV-2 serosurveillance studies that rely on geographically skewed recruitment strategies. Using GPS-derived foot traffic data to select recruitment sites and recording participants’ home locations can improve study design and interpretation.

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.

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% Cl. 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 WhiteBlack 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.

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue

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 51872 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 $21687/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.

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.

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.

The initial phase of the COVID-19 pandemic in the US was marked by limited diagnostic testing, resulting in the need for seroprevalence studies to estimate cumulative incidence and define epidemic dynamics. In lieu of systematic representational surveillance, venue-based sampling was often used to rapidly estimate a community's seroprevalence. However, biases and uncertainty due to site selection and use of convenience samples are poorly understood. Using data from a SARS-CoV-2 serosurveillance study we performed in Somerville, Massachusetts, we found that the uncertainty in seroprevalence estimates depends on how well sampling intensity matches the known or expected geographic distribution of seropositive individuals in the study area. We use GPS-estimated foot traffic to measure and account for these sources of bias. Our results demonstrated that study-site selection informed by mobility patterns can markedly improve seroprevalence estimates. Such data should be used in the design and interpretation of venue-based serosurveillance studies.

This report by the Lancet Commission on Public Policy and Health in the Trump Era assesses the repercussions of President Donald Trump's health-related policies and examines the failures and social schisms that enabled his election. Trump exploited low and middle-income white people's anger over their deteriorating life prospects to mobilise racial animus and xenophobia and enlist their support for policies that benefit high-income people and corporations and threaten health. His signature legislative achievement, a trillion-dollar tax cut for corporations and high-income individuals, opened a budget hole that he used to justify cutting food subsidies and health care.