Utsha G. Khatri

People with criminal-legal involvement (CLI) face disproportionately high morbidity and mortality. Policies like the Affordable Care Act (ACA), Section 1115 waivers, and other state-level initiatives have extended Medicaid coverage to millions in this population, aiming to improve outcomes. Our objective was to map the literature for studies assessing the association of policies that increase Medicaid access with key health (e.g., utilization, mortality) and non-health (e.g., recidivism) outcomes among people with CLI. We searched eight academic databases for experimental or quasi-experimental studies published through April 1, 2025. Of the 4,845 studies identified, 62 met inclusion criteria. Policies expanding eligibility consistently increased insurance coverage, particularly when paired with prerelease enrollment assistance. However, impacts on healthcare utilization and health outcomes were mixed. While targeted enrollment efforts promoted greater use of outpatient and behavioral health services, Medicaid expansion alone did not consistently increase care utilization. Many quasi-experimental studies linked Medicaid expansion to reduced recidivism, though others found null or inconsistent results. Conversely, one study of a large-scale Medicaid disenrollment found that coverage loss was associated with increased crime, particularly non-violent offenses. Expanding Medicaid eligibility is an essential first step to increasing health care access for people with CLI, but its potential is only realized when policy changes are paired with targeted implementation strategies that bridge coverage to care. Critical gaps remain in the literature as few studies examined equity, long-term outcomes, or key subgroups like women and older adults. Future research is needed to determine how to operationalize insurance coverage into improved health and social outcomes for this population.

Importance: Despite expanded efforts to improve treatment access, inequities exist in the receipt of medications for opioid use disorder by race and ethnicity and insurance type.Objective: To examine inequities in access to medications for opioid use disorder (MOUD)—specifically buprenorphine and naltrexone—by race and ethnicity and insurance type after opioid-related health care events.Design, Setting, and Participants: This retrospective cohort study used data from the Institute for Health Equity Research Multi-Payor Claims Database, which includes more than 130 million individuals across commercial, Medicaid, and Medicare Advantage insurance plans. The cohort consisted of patients aged 18 years or older with an opioid use disorder (OUD)–related health care event (opioid-related overdose, infection, or treatment event) that occurred between January 1, 2017, and December 31, 2022. Statistical analysis was conducted from October 2023 to December 2024.Exposure: Race and ethnicity and insurance type, including commercial insurance, Medicaid, and Medicare Advantage, were the primary exposures.Main Outcomes and Measures: The primary outcome was receipt of MOUD (buprenorphine or naltrexone) within 180 days of an OUD-related health care event. Logistic regression models were used to assess the associations of MOUD receipt with race and ethnicity and with insurance type, adjusting for demographic, clinical, time, and geographical covariates.Results: Among 176 997 index events involving 164 728 patients between 2017 and 2022, the mean (SD) patient age was 40.0 (13.1) years; 104 005 (58.8%) involved men; 1083 events (0.6%) were among Asian patients, 23 424 (13.2%) were among Black patients, 10 302 (5.8%) were among Hispanic patients, 90 124 (50.9%) were among White patients, and 4697 (2.7%) were among patients of other race and ethnicity; and 147 257 (83.2%) were covered by Medicaid. Black (adjusted estimated probability, 17.1% [95% CI, 13.0%-21.1%]) and Hispanic (adjusted estimated probability, 16.2% [95% CI, 11.6%-20.8%]) patients were significantly less likely than White patients (adjusted estimated probability, 20.5% [95% CI, 16.4%-24.7%]) to receive buprenorphine (Black patients: adjusted odds ratio [AOR], 0.75 [95% CI, 0.63-0.90]; adjusted risk difference [ARD], −3.4 percentage points [pp] [95% CI, –6.5 to –0.4 pp]; Hispanic patients: AOR, 0.69 [95% CI, 0.51-0.92]; ARD, –4.4 pp [95% CI, –9.1 to 0.4 pp]) but received naltrexone at similar rates. Patients with Medicaid (AOR, 1.39 [95% CI, 1.14-1.69]; ARD, 3.5 pp [95% CI, 0.9-6.1 pp]) or Medicare Advantage (AOR, 1.40 [95% CI, 1.05-1.86]; ARD, 3.6 pp [95% CI, –0.6 to 7.7 pp]) were more likely to receive buprenorphine compared with those with commercial insurance. Buprenorphine access improved incrementally from 2017 to 2022, reflecting recent clinical and policy changes; however, disparities persisted.Conclusions and Relevance: In this cohort study of more than 176 000 opioid-related index health care events, race and ethnicity–based and insurance-based disparities in access to MOUD persisted despite efforts to expand treatment availability. These findings underscore the need for targeted interventions, including culturally tailored care, expanded access points, and policy reforms to address structural barriers and reduce inequities contributing to the overdose crisis.

Importance: The US has the highest incarceration rates in the developed world. The harms of incarceration have long-term health implications, including increased mortality. Existing studies of incarceration-related mortality are limited by data sources and design.Objective: To examine the associations between both individual- and area-level incarceration rates with all-cause and overdose mortality in the US.Design, Setting, and Participants: This cohort study used data from the Mortality Disparities in American Communities (MDAC) study, linking over 3 million 2008 American Community Survey (ACS) respondents to National Death Index data from the respondents’ 2008 interview date through December 31, 2019, or their date of death, and county incarceration data from the Vera Institute of Justice. The sample included US adults 18 years or older, representing individuals in group quarters such as prisons and jails but excluding those in counties lacking jail incarceration rate data. Data were analyzed from July 5, 2023, to November 10, 2024.Exposure: Individual incarceration status at the time of the ACS survey and county jail incarceration rates.Main Outcomes and Measures: The outcomes of interest were all-cause mortality and overdose mortality, assessed through time-to-event analyses. Cox proportional hazard models were used to estimate mortality risks, adjusting for individual- and county-level characteristics. ACS survey weights were applied so that the final sample represents the US adult population.Results: The study includes a total of 3 255 000 individuals (51.3% female), of whom 45 000 (0.93%) were incarcerated at the time of the 2008 ACS administration. The mean (SD) county jail incarceration rate was 372 (358) per 100 000 people. During the study period, 431 000 individuals (11.6%) died from any cause, and 5500 (0.2%) died from overdoses. Incarcerated individuals had a higher risk of all-cause mortality (hazard rate [HR], 1.39 [95% CI, 1.33-1.45]) and an increased risk of overdose mortality (HR, 3.08 [95% CI, 2.70-3.52]) compared with nonincarcerated individuals. A 10% increase in county jail incarceration rates was associated with 4.6 (95% CI, 3.8-5.5) additional all-cause deaths per 100 000 people.Conclusions and Relevance: In this cohort study of 3.26 million individuals in the US, results highlighted the dual burden of incarceration on health outcomes. Individuals who were incarcerated faced significantly higher risks of death, particularly from overdoses, and elevated county incarceration rates exacerbated individual-level mortality risks. These findings suggest the need for reforms in criminal justice and public health policies to address these elevated risks and their widespread implications.

As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures. A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile. There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region. Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

Introduction: Law enforcement officers (LEO) interact with patients and clinicians in the emergency department (ED) for many reasons. There is no current consensus on what should comprise, or how to best enact, guidelines that ideally balance LEO activities in the service of public safety with patient health, autonomy, and privacy. The purpose of this study was to explore how a national sample of emergency physicians (EP) perceives activities of LEOs during the delivery of emergency medical care. Methods: Members of the Emergency Medicine Practice Research Network (EMPRN) were recruited via an email-delivered, anonymous survey that elicited experiences, perceptions, and knowledge of policies that guide interactions with LEOs in the ED. The survey included multiple-choice items, which we analyzed descriptively, and open-ended questions, which we analyzed using qualitative content analysis. Results: Of 765 EPs in the EMPRN, 141 (18.4%) completed the survey. Respondents represented diverse locations and years in practice. A total of 113 (82%) respondents were White, and 114 (81%) were male. Over a third reported LEO presence in the ED on a daily basis. A majority (62%) perceived LEO presence as helpful for clinicians and clinical practice. When asked about the factors deemed highly important in allowing LEOs to access patients during care, 75% reported patients’ potential as a threat to public safety. A small minority of respondents (12%) considered the patients’ consent or preference to interact with LEOs. While 86% of EPs felt that information-gathering by LEO was appropriate in the ED setting, only 13% were aware of policy to guide these decisions. Perceived barriers to implementation of policy in this area included: issues of enforcement; leadership; education; operational challenges; and potential negative consequences. Conclusion: Future research is warranted to explore how policies and practices that guide intersections between emergency medical care and law enforcement impact patients, clinicians, and the communities that health systems serve.

Introduction: To address persistent gender inequities in academic medicine, women professional development groups (PDG) have been developed to support the advancement of women in medicine. While these programs have shown promising outcomes, long-term evaluative metrics do not currently exist. The objective of this study was to establish metrics to assess women’s PDGs. Methods: This was a modified Delphi study that included an expert panel of current and past emergency department (ED) chairs and Academy for Women in Academic Emergency Medicine (AWAEM) presidents. The panel completed three iterative surveys to develop and rank metrics to assess women PDGs. Metrics established by the expert panel were also distributed for member-checking to women EM faculty. Results: The expert panel ranked 11 metrics with high to moderate consensus ranking with three metrics receiving greater than 90% consensus: gender equity strategy and plan; recruitment; and compensation. Members ranked 12 metrics with high consensus with three metrics receiving greater than 90% consensus: gender equity strategy and plan; compensation; and gender equity in promotion rates among faculty. Participants emphasized that departments should be responsible for leading gender equity efforts with PDGs providing a supportive role. Conclusion: In this study, we identified metrics that can be used to assess academic EDs’ gender equity initiatives and the advisory efforts of a departmental women’s PDG. These metrics can be tailored to individual departmental/institutional needs, as well as to a PDG’s mission. Importantly, PDGs can use metrics to develop and assess programming, acknowledging that many metrics are the responsibility of the department rather than the PDG.

Background Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. Methods We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. Results Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI − 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI − 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01–1.09, standard arm difference .85 95% CI .34–1.37). Conclusions A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. Trial Registration ClinicalTrials.gov Identifier: NCT03821103.

Although a history of incarceration is associated with poor long-term health status, the experience of seeking health care access during reentry is complex. Semistructured open-ended interviews were conducted among individuals with a recent history of incarceration (N = 20). The majority of participants were male (90%) and African American (80%). The majority (55%) had one or more chronic medical conditions, 40% reported active substance addiction, and 75% reported having a chronic psychiatric condition. In qualitative analysis, participants described the three biggest facilitators to accessing health care as eligibility for Medicaid, support through reentry organizations, and online resources. Participants said the major barriers to accessing health care were multiple and competing priorities, limitations of Medicaid, and lack of access to health records. Ensuring individuals with a history of incarceration are connected to the public assistance programs for which they are eligible is an important public health initiative and may facilitate successful reintegration.