The effect of the socioeconomic status on the measurement of asthma control

Background: The Asthma Control Test (ACT) is a commonly used scoring system for evaluation of asthma control in the pediatric and adult populations. Asthma control has been deemed poor in those economically disadvantaged. Objective: To study whether the ACT is affected by socioeconomic status (SES) as evaluated by the percentage of the federal poverty level and the education level. Methods: This was a cross-sectional study (N = 307), in which the patients were surveyed for demographics data and underwent ACT scoring, spirometry (forced expiratory volume in the first second of expiration) and fractional concentration of exhaled nitric oxide testing. Results: There was a positive correlation of improved mean score on the ACT (p < 0.001) with higher education status and higher federal poverty level status. Conclusion: SES plays a factor in the way patients perceived their asthma control, and therefore affected how they scored on the ACT.

Defining Poverty as an Eligibility Requirement for Supportive Services

Deciding which individuals qualify as “poor” often depends on how each country or municipality defines the term ‘poverty’. In the United States, program eligibility is often tied to the Federal Poverty Level (FPL), using 100% of the FPL as a cut-off for receipt of services. However, research has shown that incomes of 200% of the FPL and higher are often needed to establish even minimum levels of economic security. Using data from an omnibus health study conducted in 2018 that included 1,581 persons ages 60+ who were asked about their health and service needs, we compared persons making 100% of the FPL or less to persons making 101%-199% and 200%+, respectively. Results show that poor health status and need for services among persons in the 101%-199% are similar to those with incomes less than 100% FPL, and significantly higher than persons with incomes at 200%+ of the FPL.

Census tract socioeconomic indicators and COVID-19-associated hospitalization rates—COVID-NET surveillance areas in 14 states, March 1–April 30, 2020

Objectives Some studies suggested more COVID-19-associated hospitalizations among racial and ethnic minorities. To inform public health practice, the COVID-19-associated Hospitalization Surveillance Network (COVID-NET) quantified associations between race/ethnicity, census tract socioeconomic indicators, and COVID-19-associated hospitalization rates. Methods Using data from COVID-NET population-based surveillance reported during March 1–April 30, 2020 along with socioeconomic and denominator data from the US Census Bureau, we calculated COVID-19-associated hospitalization rates by racial/ethnic and census tract-level socioeconomic strata. Results Among 16,000 COVID-19-associated hospitalizations, 34.8% occurred among non-Hispanic White (White) persons, 36.3% among non-Hispanic Black (Black) persons, and 18.2% among Hispanic or Latino (Hispanic) persons. Age-adjusted COVID-19-associated hospitalization rate were 151.6 (95% Confidence Interval (CI): 147.1–156.1) in census tracts with >15.2%–83.2% of persons living below the federal poverty level (high-poverty census tracts) and 75.5 (95% CI: 72.9–78.1) in census tracts with 0%–4.9% of persons living below the federal poverty level (low-poverty census tracts). Among White, Black, and Hispanic persons living in high-poverty census tracts, age-adjusted hospitalization rates were 120.3 (95% CI: 112.3–128.2), 252.2 (95% CI: 241.4–263.0), and 341.1 (95% CI: 317.3–365.0), respectively, compared with 58.2 (95% CI: 55.4–61.1), 304.0 (95%: 282.4–325.6), and 540.3 (95% CI: 477.0–603.6), respectively, in low-poverty census tracts. Conclusions Overall, COVID-19-associated hospitalization rates were highest in high-poverty census tracts, but rates among Black and Hispanic persons were high regardless of poverty level. Public health practitioners must ensure mitigation measures and vaccination campaigns address needs of racial/ethnic minority groups and people living in high-poverty census tracts.

Effects of medicaid expansion on poverty disparities in health insurance coverage

Background More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level. Method American Community Survey (2012–2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) < 138 %, (2) 138–400 % and (3) > 400 % federal poverty level (FPL). Results Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for < 138 %, 138–400 %, and > 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and < 138 % FPL group had the highest uninsured rate. Compared with ≥ 138 % FPL groups, there was a 2.54 % reduction in uninsured risk after Medicaid expansion among < 138 % FPL group in Medicaid expansion states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18 % decrease was estimated. Conclusion Poverty disparity in uninsured rates improved with Medicaid expansion. However, < 138 % FPL population are still at a higher risk for being uninsured.

Comparison of Reduced-Fare Programs for Low-Income Transit Riders

Means-based reduced-fare programs can help address transit rider fare equity. The objective of this study is to synthesize the current state of reduced-fare programs for low-income transit riders. The reduced-fare programs of the 50 largest transit agencies in the United States were examined and agencies with programs for low-income riders were compared based on three dimensions: eligibility and enrollment, fare media and discount pricing, and estimated transit expenditure by eligible riders. The results reveal that 17 of the 50 largest transit agencies have low-income reduced-fare programs. Of these, 14 agencies administer the programs themselves, while three use partnerships with social service organizations to administer them. Additionally, nine of the 14 agencies that administer their own programs provide a 50% discount on fares and require participants to have an income at or below 125% to 200% of the federal poverty level for eligibility. Using a method developed to evaluate the “fare burden” of transit riders with different income levels, it was determined that low-income reduced-fare program participants at the income eligibility threshold typically spend an estimated 2% to 6% of their annual income on transit, although very-low-income people may need to spend much higher shares of their incomes on transit fares. These results indicate that agencies may need to reevaluate the structure of their existing low-income reduced-fare programs and implement tiers of discounts to ensure that fare equity is being extended to all riders.

Neighborhood Inequities in Tobacco Retailer Density and the Presence of Tobacco-Selling Pharmacies and Tobacco Shops

Studies document inequitable tobacco retailer density by neighborhood sociodemographics, but these findings may not be robust to different density measures. Policies to reduce density may be less equitable depending on how the presence of store types differs by neighborhood characteristics. We built a 2018 list of probable tobacco retailers in the United States and calculated four measures of density for all census tracts ( N = 71,495), including total count, and number of retailers per 1,000 people, square mile, and kilometers of roadway. We fit multivariable regression models testing associations between each density measure and tract-level sociodemographics. We fit logistic regression models testing associations between sociodemographics and the presence of a tobacco-selling pharmacy or tobacco shop. Across all measures, tracts with a greater percentage of residents living below 150% of the federal poverty level (FPL) had higher density. A higher percentage of Black residents, Hispanic or Latino residents, and vacant housing was inconsistently associated with density across measures. Neighborhoods with a greater percentage of Black residents had a lower odds of having a pharmacy (adjusted odds ratio [a OR] = 0.96, 95% confidence interval [CI; 0.95, 0.97]) and tobacco shop (a OR = 0.87, CI [0.86, 0.89]), while those with a greater percentage of residents living below 150% FPL had greater odds of having a tobacco shop (a OR = 1.18, CI [1.16, 1.20]). Researchers and policymakers should consider how various measures of retailer density may capture different aspects of the environment. Furthermore, there may be an inequitable impact of retailer-specific policies on tobacco availability.

Effects of Medicaid Expansion on Poverty Disparities in Health Insurance Coverage

Background: More than 30 States have either expanded Medicaid or considering expansion. The coverage gains from this policy is well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at national level.Method: American Community Survey (2012-2018) was used to examine the effects of Medicaid expansion (ME) on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze the trends in uninsured rates (UR) by different poverty levels: <138%, 138–400% and >400% federal poverty level (FPL).Results: Compared with UR in 2012, UR in 2018 decreased by 10.75%, 6.42%, and 1.11% for <138%, 138-400%, and >400% FPL. From 2012-2018, >400% FPL group continuously had the lowest UR and <138% FPL group had the highest UR. Compared with ≥ 138% FPL groups, there was a 2.54% reduction in uninsured risk after ME among <138% FPL group in ME states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18% decrease was estimated. Conclusion: Poverty disparity in UR improved with ME. However, <138% FPL population are still at a higher risk for being uninsured.

Geographic Differences in Social Determinants of Health Among US-Born and Non–US-Born Hispanic/Latino Adults With Diagnosed HIV Infection, United States and Puerto Rico, 2017

Objective HIV disproportionately affects Hispanic/Latino people in the United States, and factors other than individual attributes may be contributing to these differences. We examined differences in the distribution of HIV diagnosis and social determinants of health (SDH) among US-born and non–US-born Hispanic/Latino adults in the United States and Puerto Rico. Methods We used data reported to the Centers for Disease Control and Prevention’s National HIV Surveillance System (NHSS) to determine US census tract–level HIV diagnosis rates and percentages among US-born and non–US-born Hispanic/Latino adults aged ≥18 for 2017. We merged data from the US Census Bureau’s American Community Survey with NHSS data to examine regional differences in federal poverty level, education, median household income, employment, and health insurance coverage among 8648 US-born (n = 3328) and non–US-born (n = 5320) Hispanic/Latino adults. Results A comparison of US-born and non–US-born men by region showed similar distributions of HIV diagnoses. The largest percentages occurred in census tracts where ≥19% of residents lived below the federal poverty level, ≥18% did not finish high school, the median household income was <$40 000 per year, ≥6% were unemployed, and ≥16% did not have health insurance. A comparison of US-born and non–US-born women by region showed similar distributions. Conclusion The findings of higher numbers of HIV diagnoses among non–US-born Hispanic/Latino adults than among US-born Hispanic/Latino adults, regional similarities in patterns of SDH and HIV percentages and rates, and Hispanic/Latino adults faring poorly in each SDH category are important for understanding SDH barriers that may be affecting Hispanic/Latino adults with HIV in the United States.

974. The Effects of Changes in State-Level Policies Affecting Eligibility for the Supplemental Nutrition Assistance Program (SNAP) on Annual HIV Diagnoses in the United States

Background The connection between food insecurity and HIV outcomes is well-established. The Supplementary Nutrition Assistance Program (SNAP), the primary program in the United States that addresses food insecurity, may have collateral impacts on HIV incidence, but the extent to which it does is unknown. “Broad-based categorical eligibility” for SNAP is a federal policy that provides a mechanism for states to increase the income or asset limits for SNAP eligibility. The Department of Agriculture under the Trump Administration has proposed eliminating this policy. Methods We estimated the association between the number of new HIV diagnoses from 2010 to 2014 for each state and (1) state income limits for SNAP eligibility as a percentage of the federal poverty level and (2) state asset limits for SNAP eligibility (increased/eliminated vs. unchanged). We fitted multivariable negative binomial regression models with annual incidence of HIV diagnoses specified as the outcome; SNAP policies as the primary explanatory variable of interest; state and year fixed effects; and time-varying covariates related to the costs of food, health care, housing, employment, SNAP outreach, and total spending on Temporary Assistance for Needy Families (TANF) programs. Results From 2010 to 2014, 204,034 new HIV diagnoses occurred in the United States. HIV diagnoses within states had a statistically significant inverse association with state income limits for SNAP eligibility (IRR 0.94 per increase in the income limit by 35% of federal poverty level, 95% CI 0.91-0.98), but no statistically significant association with state asset limits (increased asset limit vs. no change, IRR 1.02, 95% CI 0.94-1.10; eliminated asset limit vs. no change, IRR 1.04, 95% CI 0.99-1.10) (Table). Table Conclusion State income limits for SNAP eligibility were inversely associated with the number of new HIV diagnoses for states between 2010-2014. Proposals to eliminate the use of broad-based categorical eligibility to increase the income limit for SNAP may undercut efforts to end the HIV epidemic in the United States. Disclosures All Authors: No reported disclosures