Hest, Robert
Stewart, Andrea

Survey Data Season Essentials: What Is the BRFSS and How Can Researchers Use It?

This post is a part of our Survey Data Season series where we examine data from various surveys that are released annually from the summer through early fall. Find all of the Survey Data Season series posts on our Survey Data Season 2024 page here.

Each year, SHADAC covers the data releases of multiple federal surveys from a variety of agencies, beginning with the National Health Interview Survey (NHIS) in June continuing through the release of American Community Survey (ACS) and Current Population Survey (CPS) data products in September through January. 

While our focus has traditionally been on the health insurance coverage data that found in these surveys, we have also looked at factors related to coverage, including ‘access to care’ via measures of adults without primary doctors, for example, and ‘cost of care’ via measures such as adults who forgo needed medical care (because of cost). Both of those measures come from the BRFSS, a survey that is both part of our overall Survey Data Season coverage and is used in our annual “Comparing Federal Surveys that Count the Uninsured” brief, but is not typically used as our main source of data when analyzing health insurance coverage.*

This blog post will provide an overview of the BRFSS, answer some common questions about this survey, walk through a few examples of how we at SHADAC use BRFSS data, and review how other researchers and analysts can use it, too.

What Does “BRFSS” Stand For?

BRFSS stands for Behavioral Risk Factor Surveillance System. “BRFSS” can be treated as either an acronym and pronounced “BUR-fiss” or an initialism with each letter read out individually.

Which Federal Agency Conducts the BRFSS?

Conducted since 1984, the BRFSS is a partnership between the Centers for Disease Control (CDC) and state health departments in U.S. states and territories, which are responsible for data collection in their area. 

How Are BRFSS Data Collected?

BRFSS is an annual, telephone-based survey of U.S. adults (18 years or older) that calls landlines and cell phones via random digit dialing. 

The survey questionnaire has three parts:

1. The core component, which includes demographic questions and asks about health-related perceptions, conditions, and behaviors. The core is composed of a “standard” core of questions that states ask every year, and also includes a “rotating” core of alternating and emerging content (e.g., questions related to COVID were added in 2021) that is asked in even and odd years. 
2. The optional modules, which focus on specific health conditions and additional risk factors and that states can optionally choose to ask.
3. The state-added questions, which are additional questions added by individual states to their own questionnaire that can be used to learn more about a specific topic, or can be used to oversample groups of interest.

All participating states and territories (50 states, District of Columbia, Guam, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands) are required to ask the survey questions contained in the core component, but are not required to ask anything from the optional or state-added question sections. This can make it difficult to compare data across all states or analyze trends over time, depending on the health topic area of interest.

What Kind of Information Is Found in the BRFSS? 

BRFSS collects state-level data about adult “health-related risk behaviors and events, chronic health conditions, and use of preventive services.” 

When Does the BRFSS Release Data?

Data from the BRFSS is released annually, but the exact timeframe can vary. Unlike the American Community Survey (ACS) and Current Population Survey (CPS) - which are scheduled to come out on September 10 and September 12 this year, respectively - the BRFSS does not release data on a specific date. Rather, data usually come out in August, but can be released anytime from July to September. Researchers can check the BRFSS Annual Survey Data page to see when the data becomes available.

This year's data released on August 29th - you can find that here.

Can You Pool or Combine Multiple Years of BRFSS Data?

BRFSS data can generally be pooled (i.e., combined) across multiple years of data. This is usually done to increase both sample sizes and the statistical reliability of estimates for small populations or uncommon events.

Survey questions, measures, and variable names can change across data years, though, so care should be taken to appropriately harmonize variables when pooling multiple years of BRFSS data. For example, BRFSS’ usual source of care measure changed substantially in 2021, creating a “break in series” in that year. Survey weights can generally be divided by the number of pooled data years to produce accurate weighted counts.

Important to note for combining multiple years of BRFSS data specifically: There was a break in the BRFSS series in 2011 when the survey began including cell phones in addition to landlines. Thus, data before 2011 should not be pooled with data from 2011 forward. 

How Does SHADAC Use BRFSS Data?

SHADAC draws on data from the BRFSS to produce key resources like our Comparing Federal Government Surveys That Count the Uninsured, which looks at trends in rates of uninsurance across time and across five different federal surveys, helping researchers understand how and when to most appropriately use each one.

The BRFSS is a rich source of 50-state data on health outcomes and behaviors, and thus offers researchers and analysts a venue for tracking the effects of health reforms for persons of varying income levels. Since the BRFSS income categories do not always match those set by the federal government for calculating poverty levels, SHADAC produced a helpful brief detailing Four Methods for Calculating Income as a Percent of the Federal Poverty Guidelines (FPG) in the Behavioral Risk Factor Surveillance System (BRFSS) in order to assist with this analytic process.

Choosing Between Federal Surveys That Measure Rent Affordability is another resource produced by SHADAC researchers that uses data from multiple federal surveys, including the BRFSS, to help researchers better understand ways to measure the effect of a rising housing affordability crisis across varying populations and across states in the U.S. We also use a variety of data from BRFSS measures on our State Health Compare tool.

Take a look at the BRFSS measures that are available on our State Health Compare site!

Access, Cost, and Quality of Care

Adults Who Forgo Needed Medical Care contains estimates of adults who could not get needed medical care due to cost. Uniquely for this measure, our demographic subgroups are organized not only by racial and ethnic categories and educational attainment, but also by chronic disease status. See more on this measure in this recent resource.

Adults Who Have No Personal Doctor is a measure of adults who do not have a doctor or care provider that they regularly interact with or schedule visits with for routine health care. SHADAC pulls this measure from the BRFSS and has used it in several past analyses, including this blog. 

Adult Cancer Screenings provides users with the rate of adults receiving recommended cancer screenings, including pap smears (cervical cancer screening), colorectal cancer screenings, and mammograms (breast cancer screening). Check out this recent SHADAC blog for more detail on this measure and analysis by available demographics.

Adult Flu Vaccinations are a gauge for adults in the United States who received their annual vaccine to protect against influenza. Tracking flu vaccination rates can help in estimating broader vaccination trends - such as in this analysis - and help detect gaps in vaccination coverage across different demographic groups.

Health Behaviors and Outcomes

Adult Excessive Alcohol Consumption is newer measure on state health compare that provides the rate of adult excessive alcohol consumption, which in turn is defined as binge drinking (4 or more drinks for women or 5 or more drinks for men on one occasion) and/or heavy drinking (7 or more drinks per week for women or 15 or more drinks per week for men).

Adult Smoking and Adult E-Cigarette Use are two related measures that track annual state-level rates of adults who smoke traditional tobacco cigarettes and those who smoke e-cigarettes, respectively. SHADAC researchers used this data from the BRFSS to produce a series of blogs on health behaviors, including this one. 

Chronic Disease Prevalence looks at the percent of the adult population who report having one or more of the following specific chronic disease types: diabetes, cardiovascular disease (CVD), heart attack, stroke and asthma.

Adult Unhealthy Days is a self-reported measure of the number of days within a month (30 days) that an individual does not have good health, either mentally or physically. Recently, SHADAC produced a 50-state resource which takes a closer look at this measure.

Activities Limited due to Health Difficulty provides a look at rates on the average number of days in the past 30 days that a person reports limited activity due to mental or physical health difficulties.

Stay Updated on the BRFSS Data Release and More with SHADAC’s Survey Data Season Series

We hope that this blog helps you to better understand what the BRFSS is, what kinds of information we can get from the data, and how SHADAC and other researchers can use BRFSS data to understand health care use, cost, quality, and access in each of the states and the nation as a whole.

But Survey Data Season doesn’t stop with the BRFSS. Through September, SHADAC will be covering the release of various major survey data from important federal survey sources, including the NHIS, MEPS, ACS, CPS, and, of course, the BRFSS. Stay up to date on our Survey Data Season series, with more Essentials blogs like this one along with other products analyzing newly released data, by signing up for our newsletter and following us on LinkedIn.

Want to see what we’ve already made for our Survey Data Season series? Check out the Survey Data Season archive page for a full list of everything we’ve created so far, including a blog on recently released 2023 NHIS data. Check back often for updates and new additions.

Notes

*The BRFSS has included a question about current health insurance coverage within the standard core component since 1991. However, the question simply asked whether the respondent had coverage, and not about the type of health insurance coverage a respondent might have. 

Question: “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?” 

Answers: Yes; No; Don’t Know/Not Sure; Refused

Recently, in 2021, the BRFSS added a primary source of coverage question, making it possible to understand what portions of the national and state populations have different types of coverage. 

Question: “What is the current primary source of your health insurance?” 

Answers: A plan purchased through an employer or union (including plans purchased through another person's employer); A private nongovernmental plan that you or another family member buys on your own; Medicare; Medigap; Medicaid; Children's Health Insurance Program (CHIP); Military related health care: TRICARE (CHAMPUS) / VA health care / CHAMP- VA; Indian Health Service; State sponsored health plan; Other government program; No coverage of any type; Don’t Know/Not Sure; Refused

BRFSS’ measure of health insurance coverage is substantially different from those found in other federal surveys (e.g., ACS, CPS or NHIS) that allow respondents to choose multiple sources of health insurance coverage, rather than requiring respondents to select one “primary” source of coverage. Though BRFSS coverage data are generally reliable, by preventing respondents from selecting multiple sources of coverage, they present a less nuanced picture of health insurance compared to other surveys. Further, because BRFSS only surveys adults and has lower response rates than other surveys, other surveys are typically better sources of information about health insurance coverage, per se.

Tatiana "Annie" Gowlovech
Research Assistant

Integrated Health Partnerships—Minnesota’s Medicaid Accountable Care Organization Model

Minnesota's Integrated Health Partnerships (IHPs) have pioneered a new approach to implementing accountable care organizations (ACOs) for the Medicaid population. Initially launched in 2013 by the Minnesota Department of Human Services (DHS), these partnerships are voluntary agreements between health provider groups and DHS. Health provider groups partner directly with DHS in multi-year contracts to both improve the quality of and reduce the total cost of care for specified patient populations using a shared savings/shared risk financing model. 

When IHPs were first established in Minnesota, there were six provider groups participating. A little more than 10 years later, the number of IHPs in Minnesota has more than tripled, with 25 total partnerships covering more than 505,000 beneficiaries, as of July 2024. 

DHS released the 2025 Request for Proposals (RFPs) (which recently closed) hoping to expand the program to more interested organizations and to allow current organizations to continue their partnership with the agency.  

In order to better understand potential expansions and changes that may be implemented through Minnesota’s IHPs, we must first understand the foundation, function, and purpose of these partnerships.

In this blog, SHADAC staff will explore:

• What is the purpose of an Accountable Care Organization (ACO)?
• How do IHPs relate to ACOs?
• How have IHPs been established in Minnesota and how have they evolved?
• How can IHPs advance health equity for included populations?
• What are some future considerations that could help in better understanding the effect of IHPs?

Keep reading to start learning about the IHP program and how it impacts communities in Minnesota.

ACOs in Medicaid

Accountable Care Organizations (ACOs) are groups of health care providers that agree to take financial responsibility for the quality and cost of care they deliver to a defined patient population. There are national, state, and regional ACO models, and they may support multiple insured populations, i.e., Medicare, Medicaid, commercial, and self-insured.

ACOs often operate alongside Managed Care Organizations (MCOs), offering additional avenues for health care reform and focusing increasingly on advancing health equity. ACOs are a pivotal tool in promoting access to care, investing in population health, and addressing social determinants of health that affect health equity.

Since the enactment of the Affordable Care Act (ACA) in 2010, the Center for Medicare and Medicaid Innovation (CMMI) has supported state initiatives like Minnesota's State Innovation Model (SIM) to test and expand ACO models within Medicaid, and Medicaid-specific ACOs have now been established in nearly a dozen states.*

These programs vary by state in terms of delivery system reform, payment expectations, and in the authorities needed to administer them, but all such Medicaid ACO alternative payment models (APMs) are standardized through classification under Categories 2, 3, and 4 of the Health Care Payment – Learning Access Network (HCP-LAN) APM framework.

IHPs are Minnesota’s Medicaid ACO model. In 2008, the Health Reform Law of Minnesota included recommendations for statewide quality reporting, payments for coordinated care services provided in health care homes (HCHs), and encouragement to participate in bundled payment demonstrations. The law was then amended in 2011 to require DHS to develop a program to “test alternative and innovative health care delivery systems, including ACOs that provide services to a specified patient population for an agreed-upon total cost of care or risk/gain sharing payment arrangement”, leading to the creation of IHPs.

In 2017, SHADAC had the opportunity to conduct an evaluation of early Minnesota IHP implementation as part of Minnesota’s SIM cooperative agreement with CMMI, which documented IHP expansion and evolution, helpful data analytics, and importance of ongoing monitoring of the effects of the IHP program on health care utilization, cost, and quality.

Minnesota's Integrated Health Partnerships Today

As noted earlier, Minnesota’s IHP program began over 10 years ago in 2013. In 2018, the program was updated with various enhancements and changes in order to place a stronger focus and effort on health equity, enhance the risk arrangement incentives, and provide a population-based payment. This led to the implementation of a new overall IHP model (Integrated Health Partnerships 2.0) with two possible tracks for Minnesota IHPs to operate under (see figure below). These two distinct organizational design tracks are tailored to both provider capabilities and population needs.

For full details and requirement on IHP design tracks, please reference the Minnesota Department of Human Services 2025 Request for Proposals for IHP Program

On top of improving care quality and reducing the total cost of care, IHPs on both tracks are also required to design interventions that address specific health disparities across their target population. IHPs in both tracks receive a quarterly risk-adjusted population-based payment (PBP) which is intended to contribute to care coordination and other investments for the population served. IHPs are also assessed based on quality, utilization, and health equity measures. This population-based payment is flexible, adjusting to reflect changing numbers of the included population specified by the IHP’s intervention plan, as well as changing risk factors due to medical and social complexities in the population makeup.**

IHPs are measured through quality and data metrics (e.g., comparing percent change between performance years), as well as a calculation of standards across five domains for those in the shared-risk model - Quality Core Set, Care for Children and Adolescents, Quality Improvement, Closing Gaps, and Equitable Care - a process which is described in further detail in the following section.

Ultimately, IHPs have proven quite successful in Minnesota, with significant savings and quality improvements. Since their inception, IHPs have yielded nearly $546 million in total savings through 2022.

Emphasis on Advancing Health Equity

In response to evolving health care needs and feedback suggesting that the timing was right to build on prior successes of the original IHP program, DHS introduced an improved program, IHP 2.0, enhancing its focus on health equity. The IHP 2.0 program, included modifications to allow the program to more directly address social determinants of health (SDOH) and incentivize partners to reduce racial, geographical, and/or other disparities.

The Minnesota Department of Health describes health equity as “addressing health disparities as part of a broad spectrum of public investments in housing, transportation, education, economic opportunity and criminal justice.” By implementing changes and integrating health equity goals into core operational frameworks, the hope with the IHP 2.0 program is to overcome the limitations of traditional health care approaches in addressing SDOH and health disparities that arise as a result. 

In fact, recent case studies on Medicaid payment reforms conducted by the Urban Institute directly referenced and cited Minnesota’s IHPs, describing their influence on health equity along with the overall changes made to the program in 2018 in order to continue to advance equity in Medicaid. 

The table below from the Urban Institute identifies and describes the core features of the IHP 2.0 program designed to both focus on and advance equity for beneficiaries.

Source: Allen & Willis, “Can Medicaid Payment and Purchasing Strategies Advance Health Equity?” The Urban Institute, December 2023, https://www.urban.org/sites/default/files/2023-12/Can%20Medicaid%20Payment%20and%20Purchasing%20Strategies%20Advance%20Health%20Equity_0.pdf

As described above, the success of IHPs is evaluated based on performance in health care quality, utilization, health equity, and total cost of care (TCOC). When monitoring quality for those in risk arrangements where quality has an impact on shared savings and losses, the quality-related assessments are organized into five domains.

As a reminder, those domains are as follows:

1. Quality Core Set
2. Care for Children and Adolescents
3. Quality Improvement
4. Closing Gaps
5. Equitable Care

Two of these domains, “Closing Gaps” and “Equitable Care,” specifically target health equity through tailored clinical and utilization measures aimed at reducing and eliminating disparities among specific Medicaid populations. IHPs can also receive ‘bonus points’ on their overall quality score for creating additional initiatives under the Quality Improvement, Closing Gaps, and Equitable Care domains.

Recent Health Equity Interventions

As a part of the enhanced focus on health equity, IHPs are encouraged to design interventions to address targeted populations’ health equity challenges. 

Target populations may differ among the IHPs, with some initiatives aimed at supporting the entire IHP patient population and some designed to serve a more specific sub-population. A summary list of common target populations of Minnesota’s 25 IHPs include:

• Children, adolescents, families, and new mothers
• Justice-involved individuals
• Patients with a mental illness or individuals living with a family member with a mental illness
• Patients that are food insecure
• Adults with substance use disorder
• Individuals experiencing challenges accessing care, including Black, Indigenous, and people of color

A summary list of common social risk factors across Minnesota’s 25 IHPs include:

• Housing instability
• Food insecurity
• Social isolation
• Transportation
• Difficulty paying bills
• Education
• Employment
• Mental health needs
• Access to care
• Language barriers
• Income
• Childcare

IHPs must first identify the population or populations that they are serving, and then they must design, develop, and implement targeted intervention efforts based on those populations, risk factors, and SDOH to advance equity for those groups. IHPs are encouraged to identify an intervention that will meet the needs of their specific population given their knowledge of their community. Examples of these efforts include community partnerships, screening initiatives, referrals to community resources or other needed programs, and care coordination for social needs. The following is a summary list of common interventions currently being used to address health equity across Minnesota’s 25 IHPs:

For a full list, the Health Equity Interventions Summary at this link provides the specific target population, social risk factors, interventions, and milestone components for each IHP in Minnesota.

Closing Thoughts

As DHS’ IHP Program continues to evolve, its focus on data analytics and population health management remains pivotal for achieving comprehensive care delivery and advancing health equity statewide. The IHP 2.0 Program exhibits the importance of translating equity-focused policy goals into actionable requirements and programs. DHS’ work to monitor and disseminate the outcomes of the health equity initiatives and interventions implemented by IHPs will continue to provide valuable insights into their effectiveness and impact on Minnesota's health care landscape. 
 
One potential dissemination method would be to make the Population Health Reports from IHPs publicly available. This would not only increase transparency around the data collected by IHPs and the lessons learned from putting interventions into practice, but also aid in our understanding of the effectiveness of IHPs in addressing SDOH, improving access to care, and eliminating health disparities. 
 
Continue learning about health equity in Medicaid and beyond with the following SHADAC products:

Notes

Reproductive Oppression in Health Care: Underlying Factors of Medicaid Inequities Annotated Bibliography

*Click here to jump to the 'Reproductive Oppression in Health Care' annotated bibliography*

The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.

During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).

While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.

These topics are complex and intersectional – the hope for the “Underlying Factors” section of a future equity monitoring tool is to break these topics down into clear, manageable, and understandable information. Researchers performed a data scan to find recent (2018 and onward) and relevant material, specifically selecting resources for inclusion that provide:

• Historical context of Medicaid inequities
• Information on how underlying factors perpetuate inequities in Medicaid
• Potential solutions for alleviating inequities within Medicaid

Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.

Sections of the full annotated bibliography include:

• Systemic Racism
• Systemic / Structural Ableism
• Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
• Reproductive Oppression in Health Care
• Impact on Vital Community Conditions

 

 

This page is dedicated to a single section from the full annotated bibliography:

Reproductive Oppression in Health Care

 

Find each of the sources and their summaries below. Resources are in chronological order with the most recent perspectives at the end - articles from the same year are ordered alphabetically by author, not by month of publication. 

 

Want to stay updated on the latest products and information released as a part of the Medicaid Equity Monitoring Tool project? Find the project page here, and sign up for SHADAC’s newsletters here to be notified of our latest releases.

Underlying Factors Annotated Bibliography: Reproductive Oppression in Health Care

Have a source you'd like to submit for inclusion in our annotated bibliography? Contact us here to propose a source for inclusion.

Click on the arrows to expand / collapse each source.

Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women's Health (2002), 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882  

Author(s): Joia Crear-Perry, National Birth Equity Collaborative, Washington D.C.; Rosaly Correa-deAraujo, Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health; Tamara Lewis Johnson, Office of Disparities Research and Workforce Diversity, National Institute of Mental Health, National Institutes of Health; Monica R. McLemore, Family Health Care Nursing Department & Advancing New Standards in Reproductive Health, University of California San Francisco; Elizabeth Neilson, Office of Disease Prevention, Office of the Director, National Institutes of Health; Maeve Wallace, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine 

Article Type: Peer-reviewed Journal 

The authors of this article make a distinction between structural and social determinants of health, describing structural determinants as the “cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)” of social determinants of health. The authors explore these concepts in the context of social determinants of maternal health. They present a theoretical framework of determinants of Black maternal health called “Restoring Our Own Through Transformation” (created by Jessica Roach, 2016) to illustrate a “web of causation” between structural and social determinants of health and wellness. Crear-Perry et al. explore structural determinants of maternal health that are features of the U.S. health care system including financial barriers to care, a shortage of primary care providers, and gaps in quality, while also considering policy levers that might improve structural factors to support better maternal health outcomes, like paid family leave, access to affordable and comprehensive health care (which could be measured using exposure to Medicaid expansion, having Medicaid coverage through 12 months postpartum, etc.), access to culturally appropriate care (e.g., with clinicians that have received education on structural determinants of health and health inequities—i.e. “structural competency” education), and investments in community-oriented primary care for diverse women of reproductive age (e.g., midwifery maternity centers, nurse practitioner practices, maternal and child clinics, etc.).

 

Morcelle, M.T. (2022). Reforming Medicaid Coverage Toward Reproductive Justice. American Journal of Law & Medicine, 48, 223–243. https://doi.org/10.1017/amj.2022.27   

Author(s): Madeline Morcelle, Senior Attorney in the National Health Law Program's (NHeLP) Washington, D.C. Office

Article Type: Peer-reviewed journal 

The author of this journal article argues that while Medicaid presents a powerful vehicle for reproductive justice, especially for Black people and people of color, its structure allows for discriminatory eligibility and coverage policies that worsen health inequities for adults and their children. Historically, women and people of color have been advocating against reproductive oppression and advocating for “...universal, comprehensive, and affordable health coverage and access, with strong nondiscrimination protections, for everyone.” However, the author describes how voices of those experiencing oppression need to be centered or part of an “open source” framework rather than a “bottom to the top” engagement to dismantle oppressive systems. The author explains how Medicaid was designed by whites in power to only provide access to health coverage for some, “...the ‘worthy poor’,” and that these discriminatory practices continue today through policy decisions, like making Medicaid expansion a choice, for example. The author also describes the lack of adequate benefits for certain populations. While advances have been made recently, namely the Medicaid postpartum coverage extension opportunity and options to cover some immigrant groups, reproductive justice voices and frameworks should be at the center of Medicaid reform efforts to stop reproductive oppression and advance health equity for all.

 

Thompson, T. M., Young, Y.-Y., Bass, T. M., Baker, S., Njoku, O., Norwood, J., & Simpson, M. (2022). Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South. Health Affairs, 41(2), 195–202. https://doi.org/10.1377/hlthaff.2021.01422  

Author(s): Terri-ann Monique Thompson & Yves-Yvette Young, Ibis Reproductive Health, Tanya M. Bass, North Carolina Central University, Stephanie Baker, Elon University, Oriaku Njoku, Access Reproductive Care–Southeast, Jessica Norwood, The Runway Project, Monica Simpson, SisterSong Women of Color Reproductive Justice Collective 

Article Type: Peer-reviewed journal 

This article details a community-based participatory research approach to focus groups with nearly 50 Black women living in both Georgia and North Carolina (states chosen for having relatively restrictive reproductive health policies) to understand their experiences interacting with reproductive health care. The research team focused on three aspects of the participants’ experiences: access to health care, use of health care, and experience in health care – and how these experiences were connected to structural (summarized here) and individual racism. In terms of structural factors and access to adequate care, findings include that reproductive health clinics were often located outside of participants’ communities, making accessing care difficult. Focus group participants covered by Medicaid experienced issues with copayment being too burdensome. Lack of abortion coverage in some states was also a major concern for participants. In terms of structural racism and service use, authors report inconsistencies in what services are covered by different plans (both private and Medicaid coverage are mentioned), which impacted utilization. Focus group participants also reported that being a Black woman or living in a predominately Black community and receiving public assistance (or being uninsured) negatively impacted their health care experiences. Further, there was a perception that facilities caring for primarily publicly-insured individuals were lower quality. The authors urge for policy actions that alleviate these structural barriers, such as expanding federally funded Medicaid coverage, requiring abortion coverage, increasing reimbursement for doulas and midwives, and investing in hospitals that provide uncompensated care.

 

Ogunwole, S. M., Karbeah, J., Bozzi, D. G., Bower, K. M., Cooper, L. A., Hardeman, R., & Kozhimannil, K. (2022). Health Equity Considerations in State Bills Related to Doula Care (2015-2020). Women's Health Issues: Official publication of the Jacobs Institute of Women's Health, 32(5), 440–449. https://doi.org/10.1016/j.whi.2022.04.004   

Author(s): S Michelle Ogunwole, Department of Medicine, Johns Hopkins University School of Medicine & John Hopkins Center for Health Equity; J’Mag Karbeah and Katy Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health; Rachel Hardeman, Center for Antiracism Research for Health Equity & Division of Health Policy and Management, School of Public Health, University of Minnesota; Debra G Bozzi, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Kelly M. Bower, Johns Hopkins University School of Nursing, & Johns Hopkins Center for Health Disparities Solutions; Lisa A. Cooper, Department of Medicine, Johns Hopkins University School of Medicine, Departments of Health Policy and Management, Health, Behavior, and Society, and Epidemiology, Johns Hopkins Bloomberg School of Public Health 

Article type: Peer-reviewed journal 

This article presents findings from a landscape analysis of state legislation related to doula care, including Medicaid coverage and reimbursement, with specific attention to whether legislation addresses racial health equity. It is well known that disparities in birth outcomes disproportionately affect Black and Indigenous birthing people. And evidence suggests that doula care is associated with improved birth outcomes. Authors draw on reproductive justice and public health critical race praxis frameworks in formulating study questions and methods. Reproductive justice refers to women having autonomy over their own bodes and the right to have and parent children safely and with access to community supports to realize optimal reproductive health. Public health critical care praxis theory acknowledges the legacy of white supremacy and racism as a root cause of health inequities in public health research. Authors draw on this theory to develop criteria for assessing whether doula care legislation is designed to address racial health equity. Criteria included reimbursement with plans to provide a living wage, collaboration with community-based doulas, training and certification requirements and funding, and emphasis on workforce diversity, promising practices, and metrics. Authors found that of the 73 bills introduced by 24 states between 2015 and 2020, just over half focused on Medicaid reimbursement for dual care. (Twelve bills in seven states became law.) However, only two states that passed Medicaid reimbursement for doulas also met some of the authors criteria for racial equity in their laws. Authors conclude that while proposals for increased access to doula care have increased over time, a racial equity lens is lacking. Authors suggest engaging doulas and considering racial equity policy assessments in the legislative drafting process. 

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[1] Women's Leadership and Resource Center. (2023). Reproductive Oppression Against Black Women | Women’s Leadership and Resource Center | University of Illinois Chicago. Wlrc.uic.edu; University of Illinois Chicago. https://wlrc.uic.edu/reproductive-oppression-against-black-women/  

New Brief from SHADAC and UMN Cannabis Research Center: Using the Minnesota Student Survey to understand cannabis use and perceptions among high school students

As of 2023, Minnesota legalized cannabis for non-medical use by adults, becoming one of the now 24 states with such policies. Minnesota’s cannabis legislation limits legal cannabis use to adults aged 21 and older, similar to other states’ legislation for cannabis, tobacco, and alcohol use as well. 

Despite the legislation prescribing this age restriction, many policymakers and other stakeholders are concerned with the impact legalized cannabis could have on public health in general and on youth populations, specifically. 

“As cannabis policy continues to develop in Minnesota, and once legal sales of cannabis begin, it will be crucial to study youth cannabis use and to use those findings to fine-tune the state’s approach to minimize public health risks for youth,” says SHADAC and Cannabis Research Center (CRC) researcher Colin Planalp.

Commercial sales of legal cannabis in Minnesota have not yet begun, and they are not expected until 2025. However, the Cannabis Research Center (CRC) and SHADAC — both centers housed at the University of Minnesota’s School of Public Health — have already begun work to understand potential effects this legislation could have on youth. In fact, researchers purposefully wanted to start research and use data from before the beginning of commercial sales in order to provide key baseline evidence on cannabis use and perceptions among youth.

Thus, in their newest brief, researchers from the CRC and SHADAC used data from the Minnesota Student Survey (MSS) to study youth experiences with and perceptions of cannabis and other substances prior to legalization. This brief specifically looks at:

• Self-reported cannabis use
• Differences between demographic groups’ cannabis use
• Perceived prevalence of cannabis use by peers

You can read the brief in full here or by clicking the image to the right.

Interested in Minnesota cannabis policy? Want to learn more about the potential public health implications of cannabis use and legalization? Check out some of SHADAC and the CRC’s other collaborative pieces:

• Accompanying Blog: Using the Minnesota Student Survey to understand cannabis use and perceptions among high school students
• Brief: Public Health Implications of Cannabis Policy in Minnesota
• Brief: Perceptions and Opinions Relating to Cannabis in Minnesota

Planalp, Colin
Research Fellow

p 612-624-4850
e cplanalp@umn.edu

Understanding cannabis use and perceptions among Minnesota high school students

Most 9th and 11th graders report never having tried cannabis, but rates of recent use vary by demographic groups

In 2023, Minnesota became one of a growing number of states that have legalized cannabis for non-medical use by adults. When lawmakers crafted Minnesota’s legislation, they established a minimum age of 21 to use and purchase cannabis, similar to policies in other states that have legalized, and consistent with alcohol and tobacco policies. 

The decision to limit legal access to cannabis to adults age 21 and older reflects common concerns about the potential for cannabis use to harm youth. While research on the public health implications of cannabis use is limited, studies have found associations between adolescent use of cannabis and a variety of negative outcomes, including lower educational attainment and worse school performance, as well as mental health and substance use disorders.^1,2,3,4

Other states that legalized cannabis earlier and have had time to examine impacts of that legislation have generally not found clear increases in underage use since policies changed and legal sales began.^5,6 Nevertheless, it will be important to monitor this issue in Minnesota, as experiences with alcohol and tobacco demonstrate that policies and enforcement matter when limiting substance use by youth. 

Though commercial sales of legal cannabis in Minnesota aren’t expected to begin until 2025, researchers at the University of Minnesota School of Public Health’s Cannabis Research Center and SHADAC sought to get a head-start in understanding potential effects on youth. To do this, researchers began by studying youth experiences with and perceptions of cannabis and other substances prior to legalization. Our aim is to provide researchers, policymakers, and community members with key baseline evidence that can illuminate the current cannabis landscape, so it may be compared to post-legalization data in the coming years.

Cannabis and Other Substance Use Has Been Declining Among Youth in Minnesota

Using data from the Minnesota Department of Education’s Minnesota Student Survey, we produced estimates of the experiences and perceptions of Minnesota 9th and 11th graders (i.e., high school students) pertaining to cannabis, alcohol and tobacco, as well as some measures on nicotine-vaping products — a newer phenomenon for which less data is available. 

Among the most important findings include:

• Almost 9 in 10 (86%) Minnesota high school students said in 2022 that they had never used cannabis, and the rate of students saying they had never used cannabis has been increasing over time.

• Less than 1 in 10 (8%) Minnesota high school students reported having used cannabis in the past month, but that percentage varied across demographic groups. For instance, only 3% of Asian students reported using cannabis in the past month, but 17% of American Indian and Alaska Native students reported they had used cannabis in the past month.

• Minnesota high school students appear to overestimate the prevalence of cannabis use by their peers. While half (50%) said they believed most of their peers use cannabis monthly, only 7% reported that they themselves use cannabis monthly — a similar pattern of apparent overestimation of substance use by peers as for alcohol and tobacco use.

More Research on Youth Use Necessary Once Legal Cannabis Sales Begin

The findings of our study are somewhat reassuring: despite the stereotype of teenagers experimenting with substances, most Minnesota high school students report they aren’t using cannabis — or alcohol, tobacco, and nicotine-vaping products. 

However, even with 8% of Minnesota high school students reporting cannabis use, that represents tens of thousands of youth in the state. That is concerning, based on research that suggests various risks related to underage cannabis use.

Research from other states suggesting that legalization doesn’t necessarily lead to an unavoidable increase in underage cannabis use is reassuring, but we shouldn’t take that for granted. As cannabis policy continues to develop in Minnesota, and once legal sales of cannabis begin, it will be crucial to study youth cannabis use and to use those findings to fine-tune the state’s approach to minimize public health risks for youth.

Click here to read the full brief on this subject.

[1] National Academies of Sciences, Engineering, and Medicine. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. The National Academies Press. https://doi.org/10.17226/24625.

[2] Volkow, ND, Swanson, JM, Evins, AE, et al. (2016). Effects of Cannabis Use on Human Behavior, Including Cognition, Motivation, and Psychosis: A Review. JAMA Psychiatry. 73(3), 292-297. doi:10.1001/jamapsychiatry.2015.3278

[3] Winters, KC, Lee, CY. (2008). Likelihood of developing an alcohol and cannabis use disorder during youth: association with recent use and age. Drug and Alcohol Dependence. 92(1-3), 239-247. https://doi.org/10.1016%2Fj.drugalcdep.2007.08.005

[4] Tervo-Clemmens, B, Gilman, J, Evins, E. (2024). Substance Use, Suicidal Thoughts, and Psychiatric Comorbidities Among High School Students. JAMA Pediatrics. 178(3), 310-313. doi:10.1001/jamapediatrics.2023.6263

[5] Esie P, Ta M. (2024). Cannabis Use Among Students in Grades 8, 10, and 12, by Sex — King County, Washington, 2008–2021. MMWR Morbidity and Mortality Weekly Report. 73:27–31. https://www.cdc.gov/mmwr/volumes/73/wr/mm7302a1.htm

[6] Colorado Department of Public Health and Environment. (2022). CDPHE releases latest Healthy Kids Colorado Survey data. https://cdphe.colorado.gov/press-release/cdphe-releases-latest-healthy-kids-colorado-survey-data-0