Hannah Cohen-Cline

Housing insecurity and substance use disorder (SUD) are critical public health issues in the USA, with significant implications for health outcomes. This study evaluated the intersection of housing insecurity, SUD, and psychosis among Medicaid enrollees in an urban center in Oregon. Using data from Health Share of Oregon, we identified three distinct cohorts—individuals with housing insecurity, those with SUD/psychosis, and those with both conditions. Key outcomes included inpatient admission rates, average lengths of stay, and 30-day readmissions. The findings indicate that housing-insecure individuals with SUD/psychosis show greater acute care utilization than the other two cohorts. Inpatient admissions for housing-insecure individuals with SUD/psychosis were over twice as high as those without housing insecurity (29.7% vs. 12.4%), nearly three times as high as those without SUD/psychosis (29.7% vs. 9.5%), and almost ten times higher than those without either (29.7% vs. 3.0%). There were likewise corresponding increases in ambulatory-sensitive hospitalizations, 30-day readmissions, and longer hospital stays. Effective interventions should address both housing and healthcare needs, including comprehensive case management and improved access to physical, behavioral, and mental health services integrated with housing programs and services. These strategies could mitigate acute care utilization and improve overall health outcomes for these vulnerable populations.

Housing insecurity and substance use disorder (SUD) are critical public health issues in the United States with significant implications for health outcomes. This study evaluated the intersection of housing insecurity, SUD, and serious mental illness (SMI) among Medicaid enrollees in an urban center in Oregon. Using data from Health Share of Oregon, we identified three distinct cohorts—individuals with housing insecurity, those with SUD/Psychotic Disorders, and those with both conditions. Key outcomes included inpatient admission rates, average lengths of stay, and 30-day readmissions. The findings indicate that housing insecure individuals show greater acute care utilization. Inpatient admissions for housing insecure individuals with SUD/Psychotic Disorders were nearly three times higher than those without housing insecurity (29.2% vs. 12.2%), with corresponding increases in ambulatory-sensitive hospitalizations and 30-day readmissions. The length of stay also significantly increased with housing insecurity, indicating compounding health challenges. Effective interventions should address both housing and healthcare needs, including comprehensive case management and low-barrier access to physical, behavioral, and mental health services. These strategies could mitigate acute care utilization and improve overall health outcomes for these vulnerable populations.

Adverse childhood experiences (ACEs) increase the risk of poor health and wellbeing in adulthood. In this study, we tested whether experiences in early adulthood—intimate partner violence (IPV), substance use, social isolation, and work instability—mediate the relationship between ACEs and poor physical health in later adulthood. Using data from a large-scale survey of Medicaid enrollees in the Portland metropolitan area, four separate mediation models were constructed to assess the indirect effects of each early adulthood experience and the proportion of the total effect on physical health accounted for by the pathway. Experiencing four or more ACEs increased the risk of poor adult physical health by 50% (RR 1.50). Considered in separate models, mediation by IPV accounted for 14.4% of the total effect; substance use mediated a similar proportion (14.0%). Social isolation was a less substantial mediator (7.6%). Work instability did not mediate the relationship between ACEs and adult physical health in our population. These findings provide evidence that IPV, substance use, and social isolation in early adulthood are part of the pathway between high ACEs and poor adult physical health. Intervening to prevent negative early adult experiences may mitigate some of the long-term effects of childhood trauma on health.

Adverse childhood experiences (ACEs) are widely prevalent but unevenly distributed in the United States, with disadvantaged groups, especially those with low socioeconomic status, being more likely to experience them. ACEs have been linked to poor health outcomes in adulthood. In this study, we examined the association between ACEs and emergency department (ED) utilization using a cross-sectional life-course survey of low-income adults matched to Medicaid enrollment and claims data. Surveys were obtained from 2348 Medicaid-enrolled adults in the Portland, OR metropolitan area; 1133 were used in this analysis. We used a two-part regression model to estimate the association between ACE score and both ever using the ED and frequency of ED use in the year after survey completion. We also evaluated a set of potentially protective factors to see if they impacted the relationship between ED use and ACE score. We found that participants with a higher ACE score were more likely to obtain any emergency services care (odds ratio (OR) = 1.11, p = 0.011), but ACE score did not predict how frequently they would utilize those services. Close social relationships were found to be protective against high ED utilization for those with high ACE scores. Upstream prevention efforts that identify places to intervene in childhood and incorporate trauma-informed strategies into ED care in adulthood have the potential to decrease ED use.

While associations between obtaining affordable housing and improved health care are well documented, insufficient funding often forces housing authorities to prioritize limited housing vouchers to specific populations. We assessed the impact of obtaining housing on health care utilization at two urban housing authorities with different distribution policies: Housing Authority A prioritized seniors and people with disabilities, while Housing Authority B prioritized medically complex individuals and families with school-aged children. Both housing authorities used random selection to distribute vouchers, allowing us to conduct a randomized natural experiment of cases and waitlisted controls. No significant demographic differences were present between those receiving vouchers and waitlisted controls. Housing Authority A vouchers were associated with increased outpatient visits (OR = 1.19; P = 0.051). Housing Authority B vouchers decreased the likelihood of emergency department visits (OR = 0.61; P = 0.042). This study provides evidence that, while obtaining housing can result in better health care outcomes overall, local prioritization policies can influence that impact.

Ensuring access to high-quality outpatient care is an important strategy to improve COVID-19 outcomes, reduce social inequities, and prevent potentially expensive complications of disease. This study assesses the equity of health care response to COVID-19 by examining outpatient care utilization by factors at the individual and community levels in the 12 months prior to and following COVID-19 diagnosis. Employing a retrospective, observational cohort design, we analyzed electronic health record data from a sample of 11,326 adults diagnosed with COVID-19 between March and July 2020. We used two-part models to estimate changes in use of primary and specialty care by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our findings showed that while overall probability and counts of primary and specialty care visits increased following a positive COVID-19 diagnosis, disparities in care utilization by race/ethnicity and living in a socially vulnerable community persisted in the year that followed. These findings reiterate the need for strategic approaches to improve access to and utilization of care among those diagnosed with COVID-19, especially for individuals who are traditionally undeserved by the health system. Our findings also highlight the importance of systematic approaches for addressing social inequity in health care.

Background: Data on the characteristics of COVID-19 patients disaggregated by race/ethnicity remain limited. We evaluated the sociodemographic and clinical characteristics of patients across racial/ethnic groups and assessed their associations with COVID-19 outcomes. Methods: This retrospective cohort study examined 629,953 patients tested for SARS-CoV-2 in a large health system spanning California, Oregon, and Washington between March 1 and December 31, 2020. Sociodemographic and clinical characteristics were obtained from electronic health records. Odds of SARS-CoV-2 infection, COVID-19 hospitalization, and in-hospital death were assessed with multivariate logistic regression. Results: 570,298 patients with known race/ethnicity were tested for SARS-CoV-2, of whom 27.8% were non-White minorities. 54,645 individuals tested positive, with minorities representing 50.1%. Hispanics represented 34.3% of infections but only 13.4% of tests. While generally younger than White patients, Hispanics had higher rates of diabetes but fewer other comorbidities. 8,536 patients were hospitalized and 1,246 died, of whom 56.1% and 54.4% were non-White, respectively. Racial/ethnic distributions of outcomes across the health system tracked with state-level statistics. Increased odds of testing positive and hospitalization were associated with all minority races/ethnicities. Hispanic patients also exhibited increased morbidity, and Hispanic race/ethnicity was associated with in-hospital mortality (OR: 1.39 [95% CI: 1.14-1.70]). Conclusion: Major healthcare disparities were evident, especially among Hispanics who tested positive at a higher rate, required excess hospitalization and mechanical ventilation, and had higher odds of in-hospital mortality despite younger age. Targeted, culturally-responsive interventions and equitable vaccine development and distribution are needed to address the increased risk of poorer COVID-19 outcomes among minority populations. Key points: Racial/ethnic disparities are evident in the disaggregated characteristics of COVID-19 patients. Minority patients experience increased odds of SARS-CoV-2 infection and COVID-19 hospitalization. Hospitalized Hispanic patients presented with more severe illness, experienced increased morbidity, and faced increased mortality.

Background: This study assessed whether several adult life experiences, including loss of support, loss of food security, loss of housing, and substance use cessation, are associated with change in domestic violence (DV) perpetration from early to later adulthood. Using 2015 to 2016 cross-sectional, self-report survey data from Medicaid enrollees in Oregon (N = 1620), we assessed change in DV perpetration from early adulthood (19–30 years) to later adulthood (≥ 31 years of age), cut points determined by existing survey questions. Multinomial logistic regression models were constructed to estimate the association between life experiences and physical DV perpetration using odds ratios (OR), adjusting for sociodemographic characteristics, DV victimization, and childhood abuse, bullying, and social support. Findings: Of the 20% of participants who perpetrated DV, 36% perpetrated DV in both early and later adulthood (persisters), 42% discontinued (desisters) and 22% began (late-onsetters) perpetration in later adulthood. Loss of support and loss of food security were both associated with change in DV perpetration (i.e., desistance or late onset of perpetration or both). Loss of support was associated with 9.5 times higher odds of being a desister (OR = 9.5, 95% CI = 1.1, 84.1) and 54.2 times higher odds of being a late-onsetter (OR = 54.2, 95% CI = 6.5, 450.8) of DV perpetration compared to persisters. Loss of food security was associated with 10.3 times higher odds of being a late-onsetter (OR = 10.3, 95% CI = 1.9, 55.4) of DV perpetration compared to persisters. In addition, substance use cessation was associated with 10.3 times higher odds of being a desister (OR = 10.3, 95% CI = 1.9, 56.2) compared to persisters. Conclusions: Findings suggest that specific life experiences in adulthood, including loss of support, loss of food security, and substance use cessation, are associated with changes in DV perpetration.