Health Affairs’ March Issue: Hospitals, Health Equity & More

The March issue of Health Affairs, a variety issue, covers a broad range of topics, including hospital finances and billing, equity in clinical trials and HIV prevention, considerations in covering cancer screening, and the effects of providing people with a transportation benefit.

Featured articles highlighted and described below:

Inadequate health equity representation in clinical trials continues.

For decades Black patients have been underrepresented in clinical trials of new treatments. In response, in 2015, the Food and Drug Administration (FDA) launched a plan aimed at improving the diversity of participants in clinical trials and the transparency of clinical trial results for newly approved drugs. To determine the program’s success, Angela Green and coauthors from Memorial Sloan Kettering Cancer Center analyzed trial data from the FDA’s Drug Trials Snapshots website for 2014–21. They report that the initiative did not improve clinical trial representation of Black participants relative to White participants, with a median of one-third the enrollment that would be required. According to the authors, only 20 percent of studies after the plan went into effect included race-specific reporting of benefits and adverse effects. They conclude that the FDA should consider a new approach to improving clinical trial representativeness, reaching beyond transparency-centered measures to implement representational requirements.

Effects of a nonemergency transportation benefit.

Nonemergency medical transportation benefits, often using smartphone application-based ridesharing services, are increasingly being offered as part of population health management programs. However, the impact of these programs on health care use and costs remains largely unknown. In one of the first studies of its kind, Seth Berkowitz of the University of North Carolina Chapel Hill and coauthors analyzed data of Medicare beneficiaries of one health accountable care organization for its members during 2017–19. They found that program participation was associated with 9.2 percent higher outpatient spending compared with spending for those not in the program (but there was no difference in inpatient admissions or emergency department visits), and that the program was not cost saving. However, additional qualitative data revealed that the program participants were highly satisfied with the program, reporting that it eased their financial burdens, reduced the likelihood of them missing medical appointments, and made them feel that they were better able to take control of their health management. The authors conclude that their findings suggest that although health transportation programs may not prove to be a way of controlling health care spending, they were successful in improving health care access for people facing financial difficulties.

Effects of tobacco surcharges on ACA Marketplace enrollment.

One Affordable Care Act (ACA) provision for the Marketplace allows insurers to charge tobacco users who have nongroup coverage up to 50 percent more than nonusers of tobacco. To gain a better understanding of whether these surcharges deterred tobacco users from choosing Marketplace insurance plans, Ernest Dorilas of Georgia State University and coauthors examined administrative data on enrollment from for the period 2014–19. They analyzed the number of individual Marketplace consumers in each county who selected a plan by county of residence, age, sex, and income. According to the authors, the tobacco surcharge rate averaged approximately 14 percent and was associated with lower total enrollment as well as a reduced share of total enrollees who reported any tobacco use. Their analysis also found that tobacco surcharges have a significantly larger effect on enrollment share in rural areas compared with urban areas, which may contribute to urban-rural health disparities. The authors conclude that their findings suggest that reducing surcharges may increase Marketplace enrollment, especially for rural residents.

Also of interest in the March issue:


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