Health Divide: Money keeps people out of the ER, and America’s ongoing dental crisis

Giving people money cuts ER visits by about a quarter

Providing poor people with up to $400 a month in no-strings-attached cash resulted in fewer visits to the emergency department, according to a new study in JAMA. 

Since poverty and poor health are tightly correlated, the study tested the idea that giving people money would benefit health, rather than the common criticism that it would be wasted on items such as alcohol or drugs. 

City managers set up a lottery among 2,880 people in the low-income Boston suburb of Chelsea, Massachusetts, where many immigrants reside. Nearly 1,750 people won the lottery, and between November 2020 and August 2021, they received up to $400 each month.

It’s one of nearly 200 guaranteed income pilot programs taking place in the U.S. and around the world. Media coverage of the 2019 program in Stockton, California helped to kick off broader interest in such basic income pilots. (The Health Divide newsletter looked at a similar pilot program in Austin, Texas earlier this year.) 

Stockton’s experiment led to boosts in wellbeing and mental health among participants, according to one study. In general, people in such programs spend the extra funds on groceries, retail, transportation and housing costs, as well as education and health care.

In Chelsea, researchers from Boston and Cambridge examined participants’ health records, and discovered those who received the loaded debit cards visited the emergency room 27% less often than those who didn’t over the nine-month span. Specifically, they were less likely to seek emergency care for substance use and behavioral health issues.

The study’s authors say the decrease in ER visits could be linked to reduced stress due to better financial stability.

The money did not make a difference to regular doctor visits, but those who received the cash were more likely to access specialty care.

“We can trust the poor with money,” concluded study author Dr. Sumit Agarwal of Brigham and Women’s Hospital, speaking to AP’s Devna Bose. 

Not all studies find such health benefits. A large study of guaranteed income — $1,000 per month to each of 1,000 people for three years — found it made people slightly more likely to visit the ER or dentist than the 2,000 control subjects who received only $50 each month, without overall improving health, reports Chabeli Carrazana at The 19th.

But some past studies only considered one-time payments, included fewer people than the Chelsea study, or asked people to self-report their health care usage. In contrast, the JAMA study looked at the effects of ongoing payments in a large group of people and directly assessed health care via their medical records.

Former Chelsea city manager Tom Ambrosino said he was “pleasantly surprised” by the study results. “It supports that universal basic income programs do work and they aren’t wasteful. People spend money on the things that we want them to spend money on: essentials.”

Dental care crisis in America

The lack of dental coverage for Americans is a “crisis,” reports Ken Alltucker at USA Today.

“There’s a great divide for Americans who need dental care,” writes Alltucker, “with some forced to live with pain and shame while others flash five-figure veneers.”

Basic Medicare doesn’t usually cover routine dental services such as cleanings, and states are only required to cover dental care for people younger than 21 through Medicaid, though they have the option of adding coverage for older adults. But few dentists accept Medicaid payments, which are lower than those paid by commercial insurance or patients who pay out of pocket.

That leaves many of the nation’s poorest and most vulnerable individuals without good coverage.

“At least hospitals will work with you on costs and even waive some of the payments, but all the dental providers I’ve encountered never do,” Jackie Duda, a freelance health journalist facing $6,000 in charges for dental implants, told Alltucker.

The problem impacts her ability to earn money, Duda notes. “I’m trying to work and look like a professional,” she said. “I can’t be smiling and have holes in my mouth.”

Another patient in need of implants reported that clinic personnel criticized him “for being poor,” Alltucker reports.

Vermont Sen. Bernie Sanders is trying to improve the situation, Alltucker reports in a companion interview. He’s introduced a Senate bill to add “oral health” coverage to Medicare and Medicaid and to financially support training of dental professionals

“For many people, their coverage only pays a fraction of the cost,” Sanders said. “Clearly, we need fundamental changes in the way we do dental care in this country,” 

Sanders’ bill includes $4.5 million to support training of dental students in underserved areas and at historically Black colleges and universities.

“Any plan that significantly expands health and dental benefits would be pricey at a time of ballooning federal budget deficits and will likely face opposition from fiscal conservatives,” Alltucker writes.

Trans adults face double risk of liver disease

Transgender people have double the risk of severe liver disease, including cirrhosis associated with alcohol use, reports Isabella Cueto at STAT.  

The rate was “shocking,” said study co-author Dr. Brian P. Lee, a liver transplant doctor at Keck Medicine of USC. 

Lee and colleagues analyzed 15 years’ worth of health records from 330,000 cirrhosis patients and found transgender people had higher risk for both alcohol-driven and virus-associated disease, they report in the American Journal of Gastroenterology.

About two-thirds of the trans people in the study group had been diagnosed with anxiety or depression, a higher rate than among cisgender people with cirrhosis. Lee speculated that these mental health factors could underlie higher alcohol use.

Lee said trans individuals should be screened for cirrhosis and relevant risk factors.

“My hope is that, if we’re able to have interventions that are really tailored to transgender individuals but also the broader LGBTQ community — about education, awareness, access to treatments for alcohol use — we would be able to address the really alarming rates of liver disease,” he said.

Encouragingly, Cueto notes that trans individuals received liver transplants and survived at similar rates as cisgender individuals.

From the Center for Health Journalism

• July 31 is the deadline to apply for the Data Fellowship, which offers an extensive, hands-on data journalism training the week of Oct. 7–10, a $2,000 reporting stipend, and five months of professional membership so fellows can produce either a major investigative or explanatory health reporting project or a series of individual data-driven health stories. Apply here!

• July 31, 10–11 a.m. PDT, the Center hosts a free webinar, “Disappearing Options: Tracking the Story on Reproductive Health Care.” Abortion dominates the headlines, but the policy changes are far broader. Amid ongoing uncertainty, what do journalists need to know to smartly inform their audiences? Featuring Shefali Luthra of The 19th, Maya Manian of the American University Washington College of Law, and Eleanor Klibanoff of The Texas Tribune. Sign-up here!

What we’re reading

• “34 years after the passage of Americans with Disabilities Act, data sheds light on the disabled,” by Sara Chernikoff, USA Today
• “Mind the gap, the cost of mental health disparities,” by The Hill
• “Black Americans struggle with lack of mental health care access in communities,” by Fred de Sam Lazaro, PBS News Hour
• “Why Black women need Black doctors,” by Anissa Durham, Word In Black
• “Pay people, and they will go to cardiac rehab,” by Nicole Lou, MedPage Today
• “As doctors leave Puerto Rico in droves, a rapper tries to fill the gaps,” by Coral Murphy Marcos, AP News 
• “US infant mortality increased in 2022 for the first time in decades, CDC report shows,” by Dierdre McPhilliips, CNN
• “One baby at a time: Dakota midwife revitalizes Indigenous birth work, inspired to improve quality of rural health care,” by Adrianna Adame, Buffalo’s Fire