David U. Himmelstein

Background Many healthcare workers, particularly women of color, are poorly paid, and even among physicians, women and some minoritized groups earn less. Earnings inequalities are generally smaller in the public sector and might be attenuated in the Veterans Health Administration (VHA). Objective To compare earnings and earnings disparities among VHA and non-VHA healthcare workers. Design Cross-sectional analysis of 2018–2022 American Community Survey data. Participants Personnel in hospitals or outpatient care settings (n=591,265; weighted n=12,717,305/year, including n=358,118 VHA employees). Main Measures Annual earnings overall and for individual occupation groups among VHA and non-VHA personnel; and gender-based or race/ethnicity-based earnings disparities assessed using linear regressions controlled for annual work hours and occupation. Key Results Mean earnings were higher in VHA than non-VHA settings; $88,964 (95% CI $86,373–89,754) vs. $81,125 ($80,718–$81,532), and pay inequalities were smaller in the VHA. Earnings in the VHA were lower for a few higher-income occupations, including physicians, whose earnings averaged $255,158 [95% CI 244,733–265,583] in the VHA vs. $286,090 [95% CI 283,613–288,567] in non-VHA settings, a difference (after control for annual work hours) of $26,702 [95% CI 15,691–37,713]. Gender- and race-based disparities were present but smaller in VHA than non-VHA settings. Adjusted for work hours and occupation, the pay disparity between women and men was $12,215 [$9151–$15,279] in the VHA and $26,859 [$25,981–$27,737] in non-VHA settings (p for interaction p for interaction = 0.015). Hispanic personnel earned less than non-Hispanic white personnel in both settings, and disparities were similar. Conclusions Although physicians earn somewhat less in the VHA than in other settings, overall VHA personnel earn about 10% more on average, overall earnings inequalities are smaller, as are earnings disparities for women and Black personnel.

Background and ObjectivesLimited English proficiency (LEP) impairs health access—including outpatient specialty care—and quality care, i.e., inappropriate use of diagnostic tests. At least in some ...

We assessed how many US deaths would have been averted each year, 1933–2021, if US age-specific mortality rates had equaled the average of 21 other wealthy nations. We refer to these excess US deaths as “missing Americans.” The United States had lower mortality rates than peer countries in the 1930s–1950s and similar mortality in the 1960s and 1970s. Beginning in the 1980s, however, the United States began experiencing a steady increase in the number of missing Americans, reaching 622,534 in 2019 alone. Excess US deaths surged during the COVID-19 pandemic, reaching 1,009,467 in 2020 and 1,090,103 in 2021. Excess US mortality was particularly pronounced for persons under 65 years. In 2020 and 2021, half of all US deaths under 65 years and 90% of the increase in under-65 mortality from 2019 to 2021 would have been avoided if the United States had the mortality rates of its peers. In 2021, there were 26.4 million years of life lost due to excess US mortality relative to peer nations, and 49% of all missing Americans died before age 65. Black and Native Americans made up a disproportionate share of excess US deaths, although the majority of missing Americans were White.

Although immigrants use fewer health care services than US-born citizens,¹ some worry that immigrants are a burden to the US economy and particularly to the health care system.² Previous studies have found that immigrants,³ particularly undocumented immigrants,⁴ contribute more to the Medicare program (mostly through payroll taxes) than Medicare pays for their health care, thereby prolonging the life of the Medicare Trust Fund. Similarly, private health insurance premiums paid by immigrants (and by employers on their behalf) exceed the amounts private insurance plans pay for their care (ie, immigrants with private insurance effectively subsidize US-born private insurance enrollees).⁵ However, to our knowledge, no studies have examined the balance between immigrants’ financial contributions and costs to Medicaid, the third major pillar of the US health care economy, or provided an overall accounting of whether immigrants consume more health care than the care for which they pay.

Background Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. Objective To assess the association of Veterans’ Health Administration (VA) coverage with influenza vaccine uptake and disparities. Design Cross-sectional. Participants Adult respondents to the 2019–2020 National Health Interview Survey. Main Measures We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. Key Results Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI −14.3, −8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI −10.3, −3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. Conclusions VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.

Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. Although uninsured individuals are most often harmed, persons with coverage are also at risk. One-fifth of insured adults aged 18 to 64 years incurred unaffordable out-of-pocket costs in 2020, and insurance deductibles left another 7% financially vulnerable.¹ Among Medicare beneficiaries, out-of-pocket costs averaged $5460 in 2016; half spent at least 12% of their income on such costs, and one-quarter spent at least 23%.²