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The objective of this study was to assess the association between postpartum insurance instability and access to postpartum mental health services.We used 2018-2019 Colorado Health eMoms survey data, which sampled mothers from the 2018 birth certificate files at 3-6 months and 12-14 months postpartum. Respondents were classified as stably insured or unstably insured based on postpartum insurance status at each time point. We examined postpartum insurance patterns and used logistic regression to assess the association between postpartum insurance instability and mental health care access.Insurance changes primarily occurred by 3-6 months postpartum. Of respondents with public coverage at childbirth, 33.2% experienced postpartum insurance changes compared with 9.5% with private coverage (p .001). Respondents who were younger, had incomes of less than $50,000, and were of Hispanic ethnicity were more likely to experience unstable postpartum insurance. Respondents who experienced postpartum insurance instability had a lower odds of reporting that they discussed mental health at a postpartum check-up (adjusted odds ratio, 0.4; 95% confidence interval, 0.2-0.7; p .01) and received postpartum mental health services (adjusted odds ratio, 0.4; 95% confidence interval, 0.2-0.9; p .05).The majority of postpartum insurance disruptions occurred among respondents with public coverage at childbirth and by 3-6 months postpartum. Respondents who experienced unstable coverage were more likely to have less access to postpartum mental health care. Policies that increase postpartum insurance stability, such as postpartum Medicaid extensions beyond 60 days, are needed to improve access to postpartum mental health services.

The Affordable Care Act takes a "patchwork" approach to expanding coverage: Medicaid covers individuals with incomes 138% of the federal poverty level (FPL) in expansion states, while subsidized Marketplace insurance is available to those above this income cutoff.To characterize the magnitude of churning between Medicaid and Marketplace coverage and to examine the impact of the 138% FPL income cutoff on stability of coverage.We measured the incidence of transitions between Medicaid and Marketplace coverage. Then, we used a differences-in-differences framework to compare insurance churning in Medicaid expansion and non-expansion states, before and after the ACA, among adults with incomes 100-200% of poverty.Non-elderly adult respondents of the Medical Expenditure Panel Survey 2010-2018 MAIN MEASURES: The annual proportion of adults who (1) transitioned between Medicaid and Marketplace coverage; (2) experienced any coverage disruption.One million U.S. adults transitioned between Medicaid and Marketplace coverage annually. The 138% FPL cutoff in expansion states was not associated with an increase in insurance churning among individuals with incomes close to the cutoff.Transitions between Medicaid and Marketplace insurance are uncommon-far lower than pre-ACA analyses predicted. The 138% income cutoff does not to contribute significantly to insurance disruptions.

Insurance disruptions before, during, and after pregnancy are common in the United States, but little is known about the enrollment patterns of pregnant people in the Affordable Care Act Marketplaces. Data from the Pregnancy Risk Assessment Monitoring System from the period 2016-18 show that among respondents enrolled in Marketplace coverage, approximately one-third reported continuous Marketplace enrollment from preconception through the postpartum period. Compared with respondents who were continuously enrolled in Marketplace coverage from preconception through postpartum, respondents who enrolled in Marketplace plans during pregnancy had a 10.8 percent lower rate of adequate prenatal care, a 6.4 percent lower rate of timely prenatal care initiation, and a 13.2 percent lower rate of having twelve or more prenatal care visits. Policies that promote continuity of coverage during pregnancy, such as designating pregnancy as a qualifying event for a Marketplace open enrollment period, may enable pregnant people to enroll in Marketplace coverage early in their pregnancies and thus enhance access to prenatal care.

To investigate the relationship between community care (CC) treatment and a postoperative surgical complication in elective hernia surgery among Veterans using multiple approaches to control for potential selection bias.Veterans Health Administration (VHA) data sources included Corporate Data Warehouse (VHA encounters and patient data), the Program Integrity Tool and Fee tables (CC encounters), the Planning Systems Support Group (geographic information), and the Paid file (VHA primary care providers).Prior works suggest patient outcomes are better in VHA than in CC settings; however, these studies may not have appropriately accounted for the selection of higher-risk cases into CC. We estimated (1) a naïve logistic regression model to calculate the effect of CC setting on the probability of a complication, controlling for facility fixed effects and patient and procedure characteristics, and (2) a 2-stage model using the hernia patient's primary care provider's 1-year prior CC referral rate as the instrument.We identified patients residing ≤40 miles from a VHA surgical facility with elective VHA or CC hernia surgery from 2018 to 2019.Of 7991 hernia surgeries, 772 (9.7%) were in CC. The overall complication rate was 4.2%; 286/7219 (4.0%) among VHA surgeries versus 51/5772 (6.6%, p 0.05) in CC. We observed a 2.8 percentage point increase in the probability of postoperative complication given CC surgery (95% confidence interval: 0.7, 4.8) in the naïve model. After accounting for the VHA provider's historical rate of CC referral, we no longer observed a relationship between surgery setting and risk of postoperative complication.After accounting for the selection of higher-risk patients to CC settings, we found no difference in hernia surgery postoperative complications between CC and VHA. Future VHA and non-VHA comparisons should account for unobserved as well as observed differences in patients seen in each setting.

Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors.This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care.Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06).With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.

Supplemental Digital Content is available in the text., Background: The 2014 Choice Act expanded the Veterans Health Administration’s (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans’ primary care use in community settings. Objectives: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. Data and Sample: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. Analysis: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. Results: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2–3 percentage point (pp) increase in CBPC penetration growth (P

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state officials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects.

Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Insurance disruptions before, during, and after pregnancy are common in the United States, but little is known about the enrollment patterns of pregnant people in the Affordable Care Act Marketplaces. Data from the Pregnancy Risk Assessment Monitoring System from the period 2016-18 show that among respondents enrolled in Marketplace coverage, approximately one-third reported continuous Marketplace enrollment from preconception through the postpartum period. Compared with respondents who were continuously enrolled in Marketplace coverage from preconception through postpartum, respondents who enrolled in Marketplace plans during pregnancy had a 10.8 percent lower rate of adequate prenatal care, a 6.4 percent lower rate of timely prenatal care initiation, and a 13.2 percent lower rate of having twelve or more prenatal care visits. Policies that promote continuity of coverage during pregnancy, such as designating pregnancy as a qualifying event for a Marketplace open enrollment period, may enable pregnant people to enroll in Marketplace coverage early in their pregnancies and thus enhance access to prenatal care.

Discontinuous Medicaid insurance erodes access to care, increases administrative costs, and exposes enrollees to substantial out-of-pocket spending. To assess the impact of Medicaid expansion under the Affordable Care Act on continuity of Medicaid coverage among those enrolled prior to expansion. Using a difference-in-differences framework, we compared Colorado, a state that expanded Medicaid, to Utah, a nonexpansion state, before and after Medicaid expansion implementation. Adults ages 18–62 who were enrolled in Medicaid coverage in Colorado and Utah prior to expansion, from the Utah and Colorado All Payer Claims Databases, 2013–2015. The primary outcomes were the duration of Medicaid enrollment and rates of disrupted coverage. Following Medicaid expansion, enrollees in Colorado gained an additional 2 months of coverage over two years of follow-up and were 16 percentage points less likely to experience a coverage disruption in a given year relative to enrollees in Utah. Increasing Medicaid eligibility levels under the Affordable Care Act appears to be an effective strategy to reduce churning in the Medicaid program, with important implications for other states that are considering Medicaid expansion.

BACKGROUND: Midyear disenrollment from Marketplace coverage may have detrimental effects on continuity of care and risk pool stability of individual health insurance markets. OBJECTIVE: The main objective of this study was to assess associations between insurance plan characteristics, individual and area-level demographics, and disenrollment from Marketplace coverage. DATA: All payer claims data from individual market enrollees, 2014–2016. STUDY DESIGN: We estimated Cox proportional hazards models to assess the relationship between plan actuarial value and Marketplace enrollment. The primary outcome was disenrollment from Marketplace coverage before the end of the year. We also calculated the proportion of enrollees who transitioned to other coverage after leaving the Marketplace, and identified demographic and area-level factors associated with early disenrollment. Finally, we compared monthly utilization rates between those who disenrolled early and those who maintained coverage. RESULTS: Nearly 1 in 4 Marketplace beneficiaries disenrolled midyear. The hazard rate of disenrollment was 30% lower for individuals in plans receiving cost-sharing reductions and 21% lower for those enrolled in gold plans, compared with silver plans without cost-sharing subsidies. Young adults had a 70% increased hazard of disenrollment compared with older adults. Those who disenrolled midyear had greater hospital and emergency department utilization before disenrollment compared with those who maintained continuous coverage. CONCLUSIONS: Plan generosity is significantly associated with lower disenrollment rates from Marketplace coverage. Reducing churning in Affordable Care Act Marketplaces may improve continuity of care and insurers’ ability to accurately forecast the health care costs of their enrollees.

Key Points Question How did health insurance enrollment rates compare for Medicaid vs subsidized marketplace coverage among low-income adults in Colorado 2014 to 2015? Findings In this cross-sectional study with a regression discontinuity analysis of 87 542 US adult enrollees in Medicaid and private insurance, marketplace enrollment was 81.3% lower than Medicaid enrollment in 2014 and 88.6% lower in 2015 among those close to the eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults. Meaning Substantial gaps in publicly subsidized private coverage may have existed for those with incomes just beyond the reach of Medicaid expansion, especially among younger adults., This cross-sectional study assesses the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among adults with low income in Colorado., Importance The Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option. Objective To assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado. Design, Setting, and Participants Using 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020. Main Outcome and Measures The main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace’s Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage. Results The primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, −86.0% to −75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, −90.8% to −86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off −88.7% (95% CI, −93.3% to −80.8%) and −87.8% (95% CI, −90.8% to −83.9%) in 2014, and relative drop off –91.9% (95% CI, −94.5% to −87.9%) and −93.0% (95% CI, −94.5% to −91.1%) in 2015, respectively. Conclusions and Relevance In this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical.To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance.This cross-sectional study used a propensity score-matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL.Health insurance through Colorado Medicaid or Colorado's state-based Marketplace.The primary analytical approach was a multivariate regression analysis of the propensity score-matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care-sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score-matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020.The propensity score-matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P .001). No differences in ambulatory care-sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid.In this cross-sectional propensity score-matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.

The fight over health insurance exchanges epitomizes the rapid evolution of health reform politics in the decade since the passage of the Affordable Care Act (ACA). The ACA's drafters did not expect the exchanges to be contentious because they would expand private insurance coverage to low- and middle-income individuals who were increasingly unable to obtain employer-sponsored health insurance. Instead, exchanges became one of the primary fronts in the war over Obamacare. Have the exchanges been successful? The answer is not straightforward and requires a historical perspective through a federalism lens. What the ACA has accomplished has depended largely on whether states were invested in or resistant to implementation, as well as individual decisions by state leaders working with federal officials. Our account demonstrates that the states that have engaged with the ACA most consistently appear to have experienced greater exchange-related success. But each aspect of states' engagement with or resistance to the ACA must be counted to fully paint this picture, with significant variation among states. This variation should give pause to those considering next steps in health reform, because state variation can mean innovation and improvement but also lack of coverage, disparities, and diminished access to care.

Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Objective To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. Data sources 2011-2016 Medicaid claims from a Northeastern state. Study design Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. Data collection We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. Principal findings Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. Conclusions Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.

Prior studies suggest that higher unemployment rates reduce mortality, but newer research suggests this relationship may have attenuated in recent decades. Moreover, individual-level evidence shows...

Sirt6 is a multifunctional enzyme that regulates numerous cellular processes connected to longevity. Overexpressing Sirt6 extends lifespan in mice, but the underlying cellular mechanisms are unclear. Here, we used the powerful genetic tools and short lifespan of Drosophila melanogaster to better understand the precise mechanisms by which Sirt6 regulates longevity. Sirt6 OE in flies produces robust extension of median lifespan in both sexes. Molecular and biochemical analyses reveal that Sirt6 OE reduces expression of genes involved in protein synthesis, including many Myc target genes, via epigenetic regulation. We will further discuss our findings on the connection between Sirt6, Myc, and the molecular regulation of protein synthesis and lifespan, as well as additional Sirt6 longevity mechanisms we identified, including autophagy and silencing of transposable elements.

Importance Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown. Objective To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan. Design, setting, and participants This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020. Interventions Assignment to a Medicaid-focused insurance plan or a commercial managed care plan. Main outcomes and measures Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations. Results A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching. Conclusions and relevance Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Background Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis. Methods We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes. Results Providers expressed challenges effectively meeting their patients’ needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice. Conclusions Underinvestment in primary care in Medicaid may detract from providers’ professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Integrating theory on close relationships and intergroup relations, we construct a manipulation of similarity that we demonstrate can improve interracial interactions across different settings. We find that manipulating perceptions of similarity on self-revealing attributes that are peripheral to the interaction improves interactions in cross-race dyads and racially diverse task groups. In a getting-acquainted context, we demonstrate that the belief that one’s different-race partner is similar to oneself on self-revealing, peripheral attributes leads to less anticipatory anxiety than the belief that one’s partner is similar on peripheral, nonself-revealing attributes. In another dyadic context, we explore the range of benefits that perceptions of peripheral, self-revealing similarity can bring to different-race interaction partners and find (a) less anxiety during interaction, (b) greater interest in sustained contact with one’s partner, and (c) stronger accuracy in perceptions of one’s partners’ relationship intentions. By contrast, participants in same-race interactions were largely unaffected by these manipulations of perceived similarity. Our final experiment shows that among small task groups composed of racially diverse individuals, those whose members perceive peripheral, self-revealing similarity perform superior to those who perceive dissimilarity. Implications for using this approach to improve interracial interactions across different goal-driven contexts are discussed.

As of January 2014, 26 states had chosen to expand Medicaid under the Affordable Care Act (ACA) to cover individuals with incomes up to 138% of the federal poverty level.1 In these states, Medicaid agencies are facing one of the largest implementation challenges in the program’s history. We undertook a survey of high-ranking Medicaid officials in these states to assess their priorities, expectations, and programmatic decisions related to the coming expansion. The Medicaid expansion poses major challenges in the domains of enrollment, management of health care costs, and providing adequate access to services for beneficiaries.2 Previous research has documented that millions of individuals eligible for Medicaid are currently not enrolled and remain uninsured,3 suggesting that state outreach strategies may underpin the success or failure of the ACA’s coverage expansion. With the problematic launch of the Federal Marketplace in October 2013, concerns have grown about the ability of states and the federal government to enroll eligible individuals.4 New enrollment among previously-eligible individuals (the so-called “woodwork effect” or “welcome-mat effect”) also may have major budget implications for states, since they will have to pay a larger share of costs for this group.5 More generally, with spending on Medicaid increasing significantly in recent years, cost projections and approaches to managing program costs are critical and have played a key role in states’ debates over whether to expand Medicaid in 2014.6 Lastly, recent studies have demonstrated Medicaid’s value in expanding access to needed services, with somewhat conflicting results regarding its impact on various health measures.7 At the same time, the program is faced with ongoing limitations in terms of the number of providers willing to care for Medicaid patients8 and potential disruptions in coverage over time under the ACA, as patients cycle in and out of Medicaid eligibility.9 While the Center for Medicare and Medicaid Services (CMS) has recently put out guidance to states on potential options to mitigate the impact of such coverage churning, as well as to increase enrollment more generally,10 it remains unclear how many states are pursuing various options along these lines. With major policy changes underway for nearly all aspects of the Medicaid program, understanding the perspectives of state leaders is critical. One recent article examined governors’ perspectives on the Medicaid expansion,11 but in this study, we targeted state Medicaid directors to focus on those officials actively supervising the details of implementation who may be closest to the everyday operational realities of the expansion. Two recent reports featuring surveys of Medicaid officials have focused on fiscal concerns and issues of integration of care.12 Our study aims to build on this body of knowledge in the context of the quickly changing political environments at the state and federal levels, while covering a more comprehensive set of policy issues. Furthermore, by focusing specifically on those experiences of officials in states expanding Medicaid for 2014, we were able to explore in more depth the specific policies states are pursuing in the areas of outreach and enrollment, cost control, and improving access to care for newly-eligible adults. Overall, our key findings—described in Part III below—show that Medicaid officials in expanding states were optimistic about the success of enrollment efforts, with community-based assistance predicted to play a large role in ensuring high enrollment rates.13 However, state officials expressed concerns regarding costs to the state budget and remaining barriers related to newly-eligible beneficiaries’ access to care.14 Officials unanimously reported a heavy reliance on delivery system and payment reform to help control costs, with managed care also playing a key role.15 Despite implementation challenges, Medicaid officials predicted that the expansion will deliver positive effects on health, access to care, and financial protection for those newly-eligible for Medicaid coverage.16

We used data from the mandatory statewide Rhode Island (RI) Health Information Technology (HIT) Survey to characterize office-based PCPs’ adoption and use of EHRs from 2009–2014. We found accelerated adoption of EHRs in the five years since state and federal incentive programs began targeting PCPs’ adoption of HIT. There was room for improvement, however; for example, when asked to indicate the proportion of patients with whom they used various functionalities, only 13.4% of office-based PCPs said they “almost always” communicated with patients using secure messaging and 22.3% “almost always” used secure clinical messaging with outside providers. Results suggest uneven use of EHR functionalities, with low rates and slower uptake in some areas. These findings highlight opportunities to increase use of functionalities related to improved patient care and quality-based payment models.

This study describes the rise of both national and international legal standards for the well‐being of merchant seamen. The early chapters describe both merchant seamen and sailors in the navy as e...

This book is a dramatic narrative that helps explain the rise and fall of the Philadelphia banker between 1861 and 1873. The early chapters describe his success in selling U.S. government bonds to ...

Laboratory dissolution experiments using the LL6 ordinary chondrite Bensour demonstrate that meteoritic minerals readily react with distilled water at low temperatures, liberating ions into solution and forming reaction products. Three experiments were performed, all for 68 days and at atmospheric fO2 but using a range of water/rock ratios and different temperatures. Experiments 1 and 2 were batch experiments and undertaken at room temperature, whereas in experiment 3, condensed boiling water was dripped onto meteorite subsamples within a Soxhlet extractor. Solutions from experiment 1 were chemically analyzed at the end of the experiment, whereas aliquots were extracted from experiments 2 and 3 for analysis at regular intervals. In all three experiments, a very significant proportion of the Na, Cl, and K within the Bensour subsamples entered solution, demonstrating that chlorapatite and feldspar were especially susceptible to dissolution. Concentrations of Mg, Al, Si, Ca, and Fe in solution were strongly affected by the precipitation of reaction products and Mg and Ca may also have been removed by sorption. Calculations predict saturation of experimental solutions with respect to Al hydroxides, Fe oxides, and Fe (oxy)hydroxides, which would have frequently been accompanied by hydrous aluminosilicates. Some reaction products were identified and include silica, a Mg-rich silicate, Fe oxides, and Fe (oxy)hydroxides. The implications of these results are that even very short periods of subaerial exposure of ordinary chondrites will lead to dissolution of primary minerals and crystallization of weathering products that are likely to include aluminosilicates and silicates, Mg-Ca carbonates, and sulfates in addition to the ubiquitous Fe oxides and (oxy)hydroxides.