Post-expansion Period Research Articles

Sex differences in the impact of Affordable Care Act Medicaid expansion on colorectal cancer screening

Access to care varies by sex such that interactions with insurance status result in mixed patterns of preventive services utilization. We examined sex-specific effects of ACA Medicaid expansions on receipt of CRC screening. We used Behavioral Risk Factor Surveillance System data (2008–2016) for adults aged 50–64 years with household income ≤138% of federal poverty level to examine self-reported lifetime use of guideline-recommended CRC screening services overall and by screening modality. We employed difference-in-difference models comparing changes in CRC screening in 20 Medicaid expansion states before and after the ACA to changes in 18 states that did not expand Medicaid during our study period. We divided the expansion period into implementation (2014) and post-expansion (2016) periods to account for possible lagged effects. We observed time-varying effects of Medicaid expansion that revealed relative increases in CRC screening occurring during the post-expansion period. Heterogeneous effects by sex and by screening modality were also observed: there was a significant relative increase of 16.2 percentage points (95% CI [2.2, 30.2]; p-value = 0.023) in lifetime colonoscopy use among women in expansion states relative to non-expansion states in the post-expansion period. There were no significant effects of Medicaid expansion among men. Health insurance expansion had a lagged but significant effect on CRC screening among low-income non-elderly women in Medicaid expansion states, but no effect for men. The observed increase in CRC screening among women suggests that barriers to CRC screening may differ by sex, and tailored interventions to increase CRC screening improve outcomes.

Impact of Medicaid expansion on access and healthcare among individuals with sickle cell disease.

Sickle cell disease (SCD) is associated with high acute healthcare utilization. The purpose of this study was to examine whether Medicaid expansion in California increased Medicaid enrollment, increased hydroxyurea prescriptions filled, and decreased acute healthcare utilization in SCD. Individuals with SCD (≤65 years and enrolled in Medicaid for ≥6 total calendar months any year between 2011 and 2016) were identified in a multisource database maintained by the California Sickle Cell Data Collection Program. We describe trends and changes in Medicaid enrollment, hydroxyurea prescriptions filled, and emergency department (ED) visits and hospital admissions before (2011-2013) and after (2014-2016) Medicaid expansion in California. The cohort included 3635 individuals. Enrollment was highest in 2014 and lowest in 2016 with a 2.8% annual decease postexpansion. Although<20% of the cohort had a hydroxyurea prescription filled, the percentage increased by 5.2% annually after 2014. The ED visit rate was highest in 2014 and decreased slightly in 2016, decreasing by 1.1% annually postexpansion. Hospital admission rates were similar during the pre- and postexpansion periods. Young adults and adults had higher ED and hospital admission rates than children and adolescents. Medicaid expansion does not appear to have improved enrollment or acute healthcare utilization among individuals with SCD in California. Future studies should explore whether individuals with SCD transitioned to other insurance plans or became uninsured postexpansion, the underlying reasons for low hydroxyurea utilization, and the lack of effect on hospital admissions despite a modest effect on ED visits.

Economic impacts of Papahānaumokuākea Marine National Monument expansion on the Hawaii longline fishery

This study examines the economic impacts of the Papahānaumokuākea Marine National Monument (PMNM) expansion on the Hawaii longline fishery, using difference-in-differences (DID) models with fixed effects. It evaluates the impacts of the PMNM expansion on catch per unit effort (CPUE) and fishing revenue for the group of vessels that had a high portion of their fishing effort inside the Monument Expanded Area (MEA) prior to the expansion in August 2016. The results show that the PMNM expansion caused the CPUE of this group of vessels to decrease by 7%. Revenue per trip decreased by 9%, $3.5 million, during the first 16 months of post-expansion period. One likely reason for the negative impacts is that longline fishers who used to fish inside the MEA have been displaced from their traditional fishing grounds are still in the process of becoming more efficient in finding areas with comparable productivity.

The Effects on Hospital Utilization of the 1966 and 2014 Health Insurance Coverage Expansions in the United States

Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth. To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use. Repeated cross-sectional study. Nationally representative surveys. Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015). Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression. Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, -0.1 to 0.4 discharges] per 100 persons; P= 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P< 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA's implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, -0.6 discharges [CI, -1.3 to 0.2 discharges] per 100 persons; P= 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health. Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited. Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained. None.

Impact of Medicaid coverage expansion under the Affordable Care Act on mammography and pap tests utilization among low-income women.

IntroductionThe Affordable Care Act (ACA) expanded the coverage of Medicaid to include entire population with income below 138% of federal poverty line. It remains unclear whether this policy change has improved access to and utilization of health care, particularly use of mammography and Pap tests among poor women.MethodsWe used a difference-in-difference (DID) design to estimate the impact of Medicaid expansion on mammography and Pap tests utilization among low-income women. Expansion states are the treatment group and non-expansion states are the control group. The years 2012–13 are the pre-expansion period and 2015–16 are the post-expansion period for the purpose of estimating the DID parameters.ResultsThe difference-in-difference estimate show that likelihood of utilizing mammograms did not change significantly among low-income women after the implementation of Medicaid expansion (DID coefficient -0.0476 with t-statistics at -1.26), Pap test decreased (coefficient -0.0615, t-statistics -2.76), and Medicaid enrollment has increased significantly among low-income women living in expansion states (coefficient 0.0889 with t-value of 3.68).ConclusionExpansion of Medicaid was associated with increased Medicaid enrollment but did not yield near-term improvement in use of mammography and Pap tests among low-income women. Factors beyond health insurance coverage may be important in determining the likelihood of obtaining these screenings. Policy makers should try to identify other barriers to cancer screenings among low-income women in the USA.

Increased Utilization of Ambulatory Occupational Therapy and Physical Therapy After Medicaid Expansion

ObjectiveTo determine if Medicaid expansion in 2014 improved utilization of ambulatory physical therapy and occupational therapy. DesignSecondary data, pre-post analysis study using a difference in differences approach. The study compared utilization rates and likelihood of an ambulatory therapy visit for Medicaid ambulatory therapy patients in the pre-expansion (2012-2013) period and postexpansion (2014-2015) period. A descriptive analysis of utilization and logistic regression with a difference in differences approach of the odds of a therapy visit was conducted. SettingNot applicable. ParticipantsThe 2012-2015 public use data files of the Medical Expenditure Panel Survey- Household Component. Main Outcome MeasuresDescriptive results and the odds ratio of an ambulatory therapy visit were determined. ResultsAbout 788,233 more Medicaid beneficiaries had an ambulatory therapy visit after Medicaid expansion. By subpopulation, the increases in utilization were greatest for beneficiaries from low-income households and beneficiaries living in the west census region. Policy change increased the odds of a therapy visit for a Medicaid beneficiary by 27%. ConclusionsUtilization of ambulatory therapy by Medicaid beneficiaries increased after Medicaid expansion.

Medicaid Expansion and Breast Cancer Screening in Appalachia and Non-Appalachia, United States, BRFSS 2003 to 2015.

Background:Prior data suggests that breast cancer screening rates are lower among women in the Appalachian region of the United States. This study examined the changes in breast cancer screening before and after the implementation of the Affordable Care Act Medicaid expansion, in Appalachia and non-Appalachia states.Methods:Data from the Behavioral Risk Factor Surveillance System between 2003 and 2015 were analyzed to evaluate changes in breast cancer screening in the past 2 years among US women aged 50-74 years. Multivariable adjusted logistic regression and generalized estimating equation models were utilized, adjusting for sociodemographic, socioeconomic, and health-care characteristics. Data were analyzed for 2 periods: 2003 to 2009 (pre-expansion) and 2011 to 2015 (post-expansion) comparing Appalachia and non-Appalachia states.Results:The prevalence for of self-reported breast cancer screening in Appalachia and non-Appalachia states were 83% and 82% (P < .001), respectively. In Appalachian states, breast cancer screening was marginally higher in non-expanded versus expanded states in both the pre-expansion (relative risk [RR]: 1.002, 95% confidence interval [CI]: 1.002-1.003) and post-expansion period (RR: 1.001, 95% CI: 1.001-1.002). In non-Appalachian states, screening was lower in non-expanded states versus expanded states in both the pre-expansion (RR: 0.98, 95% CI: 0.97-0.98) and post-expansion period (RR: 0.95, 95% CI: 0.95-0.96). There were modest 3% to 4% declines in breast cancer screening rates in the pos-texpansion period regardless of expansion and Appalachia status.Conclusions:Breast cancer screening rates were higher in Appalachia versus non-Appalachia US states and higher in expanded versus nonexpanded non-Appalachia states. There were modest declines in breast cancer screening rates in the post-expansion period regardless of expansion and Appalachia status, suggesting that more work may be needed to reduce administrative, logistical, and structural barriers to breast cancer screening services.

Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure.

Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the Affordable Care Act expanded Medicaid eligibility, and millions of low-income adults gained insurance. Little is known about Medicaid expansion's effect on inpatient HF care. We used the American Heart Association's Get With The Guidelines-Heart Failure registry to assess changes in inpatient care quality and outcomes among low-income patients (<65 years old) hospitalized for HF after Medicaid expansion, in expansion, and nonexpansion states. Patients were classified as low-income if covered by Medicaid, uninsured, or missing insurance. Expansion states were those that implemented expansion in 2014. Piecewise logistic multivariable regression models were constructed to track quarterly trends of quality and outcome measures in the pre (January 1, 2010-December 31, 2013) and postexpansion (January 1, 2014-June 30, 2017) periods. These measures were compared between expansion versus nonexpansion states during the postexpansion period. The cohort included 58 804 patients hospitalized across 391 sites. In states that expanded Medicaid, uninsured HF hospitalizations declined from 7.9% to 4.4%, and Medicaid HF hospitalizations increased from 18.3% to 34.6%. Defect-free HF care was increasing during the preexpansion period (adjusted odds ratio/quarter, 1.06; 95% confidence interval, 1.03-1.08) but did not change after expansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.02). Patterns were similar for other quality measures. There were no quality measures for which the rate of improvement sped up after expansion. In-hospital mortality rates remained similar during the preexpansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.96-1.02) and postexpansion periods (adjusted odds ratio, 1.00; 95% confidence interval, 0.97-1.03). Among nonexpansion states, uninsured HF hospitalizations increased (11.6% to 16.7%) as did Medicaid HF hospitalizations (17.9% to 26.6%), and no quarterly improvement was observed for most quality measures in the post compared with preexpansion period. During the postexpansion period, defect-free care and mortality did not differ between expansion and nonexpansion states. Medicaid expansion was associated with a significant decline in uninsured HF hospitalizations but not improvements in quality of care or in-hospital mortality among sites participating in a national quality improvement initiative. Efforts beyond insurance expansion are needed to improve in-hospital outcomes for low-income patients with HF.

Abstract 1: The Impact of State Medicaid Expansions on Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure

Background: Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite considerable advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the ACA expanded Medicaid eligibility, and millions of low-income, non-elderly adults gained insurance coverage in 32 states. Little is known about Medicaid expansion’s effect on quality and outcomes of inpatient care for HF. Methods: We used the American Heart Association’s Get With The Guidelines-HF registry to assess changes in inpatient care quality and outcomes among low income, non-elderly patients hospitalized for HF prior to and following Medicaid expansion, in expansion and non-expansion states. Patients were classified as low income if covered by Medicaid, uninsured, or missing insurance. We considered expansion states to be those that implemented expansions in 2014. We constructed piecewise logistic multivariable regression models to track quarterly trends over time of quality and outcome measures in the pre-expansion (1/1/2010-12/31/2013) and post-expansion (1/1/14 - 6/30/17) periods, by state expansion status. Results: The cohort included 58,804 patients hospitalized across 391 sites - 53% were covered by Medicaid, 21.3% uninsured, and 25.6% missing insurance. Among expansion states, defect-free HF care increased significantly during the pre-expansion period (aOR 1.06, 95% CI 1.03-1.08) but did not change after expansion (aOR 0.99, 95% CI 0.97-1.02). Similarly, other quality measures, such as use of aldosterone antagonists, evidence-based beta blockers, and ICD implantation significantly increased prior to expansion, but did not change following expansion (Table). In-hospital mortality rates remained similar during the pre-expansion (aOR 0.99, 95% CI 0.96-1.02) and post-expansion periods (aOR 1.00, 95% CI 0.97-1.03). Trends in quality and outcome measures for non-expansion states are also shown in the table. Conclusion: The ACA Medicaid state expansions were not associated with improvements in quality of care or in-hospital mortality in expansion states among sites participating in a national quality improvement initiative. Future investigation should evaluate the long-term impact of expansion on HF care during the post-discharge period.

Abstract 282: The Effect of State Medicaid Expansions on Acute Myocardial Infarction Care Quality and Outcomes

Background: Despite considerable progress in the treatment of acute myocardial infarction (AMI), major disparities in care remain for the uninsured. Lack of insurance is associated with delays in seeking emergency care for AMI, and uninsured patients are less likely to receive guideline-directed medical therapy, invasive cardiac procedures, and have higher mortality rates than their insured counterparts. In 2014, Medicaid eligibility was expanded under the ACA, and millions of low-income adults gained insurance coverage in over 30 states. However, little is known about Medicaid expansions’ impact on the quality and outcomes of inpatient care for AMI. Methods: We studied 325,343 MI patients under 65 years of age treated at 860 hospitals in the ACTION-GWTG Registry between 2012 and 2016. Expansion states were those that implemented ACA Medicaid expansion during 2014. Our pre-expansion period included the two years prior to expansion (1/1/2012 to 12/31/2013) and our post-expansion period included the two years following expansion (1/1/2015 to 12/31/2016). We first characterized trends in AMI hospitalizations by insurance status during the study period in expansion and non-expansion states. We then identified a low-income cohort, defined as being covered by Medicaid or uninsured, and assessed the association between state expansion status and quality and outcome measures stratified by time periods using hierarchical logistic regression models. Results: In our overall cohort, from 2012 to 2016, the proportion of hospitalized AMI patients insured by Medicaid increased by 6.9% in expansion states (7.5% to 14.4%) and 0.4% in non-expansion states (6.2% to 6.6%). Uninsured hospitalizations also declined more in expansion states (18% to 8.4%) than in non-expansion states (25.6% to 21.1%). Our low-income cohort included 55,737 patients - 38,786 were uninsured and 16,951 were insured with Medicaid. Prior to expansion, states that eventually expanded Medicaid were more likely to provide defect free AMI care (all performance measures followed for eligible patients) compared with non-expansion states (aOR 1.26, 95% CI 1.10-1.45, p&lt;0.001). In the post-expansion period, there was no significant difference in defect free AMI care (aOR 1.02, 95% CI 0.89-1.16, p=0.83, p for interaction&lt;0.001). In addition, patients in expansion and non-expansion states had similar rates of in-hospital death both during the pre-expansion period (aOR 0.95, 95% CI 0.79-1.13, p=0.56) and the post-expansion period (aOR 1.03, 95% CI 0.87-1.24, p=0.71, p for interaction=0.48). Conclusions: States that elected to expand Medicaid did not experience significant improvements in AMI care quality or in-hospital mortality compared with non-expansion states.

Effects of EU Expansion on Migrants Employment and Income: A Natural Experiment

With the European Union expansion in 2004 providing a unique form of natural experiment, this paper uses the European Values Study data and the difference-in-differences estimation to identify causal effects of the EU expansion on migrants&#8217; employment chances and income. Estimation results suggest that the expansion has increased migrants&#8217; employment chances and income. The probability of having a full-time employment for a male migrant in the postexpansion period increases by about 7.7 percentage points. The increase in income for male migrants is higher than that of their female counterparts after the expansion. When the income distribution is broken down into quantiles, estimation results show that male migrants at lower ends of the income distribution experience higher increase in income. At the highest end of the income distribution, there is no evidence that the expansion has any significant effect on either male or female migrants´ income.

Medicaid Participation among Liver Transplant Candidates after the Affordable Care Act Medicaid Expansion

The 2014 Medicaid expansion in participating states increased insurance coverage among people with chronic health conditions, but its implications for access to surgical care remain unclear. We investigated how Medicaid expansion influenced the insurance status of candidates for liver transplantation (LT) and transplant center payor mix. Data on LT candidates aged 18 to 64 years, in 2012 to 2013 (pre-expansion) and 2014 to 2015 (post-expansion), were obtained from the United Network for Organ Sharing registry. Change between the 2 periods in the percent of LT candidates using Medicaid was compared between expansion and nonexpansion states. Multivariable logistic regression was used to determine how Medicaid expansion influenced individual LT candidates' likelihood of using Medicaid insurance. The study included 33,017 LT candidates, of whom 29,666 had complete data for multivariable analysis. Medicaid enrollment increased by 4% after Medicaid expansion in participating states. One-quarter of the transplant centers in these states experienced ≥10% increase in the proportion of LT candidates using Medicaid insurance. Multivariable analysis confirmed that Medicaid expansion was associated with increased odds of LT candidates using Medicaid insurance (odds ratio 1.49; 95% CI 1.34, 1.66; p < 0.001). However, the absolute number and demographic characteristics of patients listed for LT did not change in Medicaid expansion states during the post-expansion period. Candidates for LT became more likely to use Medicaid after the 2014 Medicaid expansion policy came into effect. Enactment of this policy did not appear to increase access to LT or address socioeconomic and demographic disparities in access to the LT wait list.

Prescription Drug Utilization and Reimbursement Increased Following State Medicaid Expansion in 2014.

The Affordable Care Act (ACA) expanded health care and medication insurance coverage through Medicaid expansion in select states. Expansion has the potential to increase the availability of health services to patients, including prescription medications. However, limited studies have examined how expansion affected prescription drug utilization and reimbursement. To compare prescription drug utilization (number of prescriptions filled) and reimbursement trends between states that did and did not expand Medicaid coverage in 2014, while accounting for known effects of expansion on Medicaid enrollment. We conducted a comparative interrupted time series using retrospective Medicaid state drug utilization data from 2011 to 2014. After inclusion/exclusion criteria, 8 states that expanded Medicaid in 2014 and 10 states that did not expand Medicaid were studied. Primary outcomes were changes in quarterly prescription drug utilization and quarterly total prescription drug reimbursement before and after expansion. To account for increases in enrollment in expansion states, secondary outcomes were per-member-per-quarter (PMPQ) utilization and reimbursement before and after expansion. Expansion states experienced a 1.4 million prescriptions per quarter and $163 million per quarter increase in utilization and reimbursement above the change in rates observed in nonexpansion states after expansion (P < 0.001). Specifically, 1 year after ACA implementation, expansion states used 17.0% more prescriptions and spent 36.1% more in reimbursement than the quarter preceding expansion. Expansion and nonexpansion states experienced significant drops in PMPQ prescriptions immediately after expansion (P < 0.001), but PMPQ prescriptions and reimbursement trends increased by the end of the postexpansion period in expansion states (P < 0.029 and P < 0.001, respectively). Study results suggest that Medicaid expansion offers vulnerable patients who were previously uninsured increased access to health care resources, specifically prescription drugs. Although this hypothesis would benefit from further testing, it aligns with previous studies that have shown that Medicaid expansion has led to increased access to coverage and care. While enrollment contributes to the increase in prescription utilization and reimbursement, the drop in PMPQ utilization suggests that the patients entering the program are healthier than existing patients. This shows that risk pooling is working. However, the increase in PMPQ reimbursement suggests that new enrollment may not be the only factor driving reimbursement changes. Factors such as changes in product mix, risk pool composition, and drug pricing and their effects on total and per-member reimbursement should be evaluated in future studies. No outside funding supported this study. Mahendraratnam is currently a Worldwide Health Economics and Outcomes Research Pre-doctoral Fellow at Bristol-Myers Squibb and previously provided advisory services to public and private sector clients while employed at Avalere Health, an Inovalon Company, as well as completed an internship at Genentech, a member of the Roche Group. Farley and Dusetzina have no conflicts of interest to report. Preliminary results of this study were presented at the 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 21st Annual Meeting in Washington, DC, on May 21-25, 2016, and the 2016 AcademyHealth Annual Research Meeting (ARM) in Boston, Massachusetts, on June 26-28, 2016. Study concept and design were contributed by Farley, Mahendraratnam, and Dusetzina. Mahendraratnam, Farley, and Dusetzina collected the data, and data interpretation was performed by all the authors. The manuscript was written by Mahendraratnam, Farley, and Dusetzina and revised by Farley, Dusetzina, and Mahendraratnam.

How did medicaid expansions affect labor supply and welfare enrollment? Evidence from the early 2000s.

In the early 2000s, Arizona, Maine, New Mexico, New York, Oregon, and Vermont expanded Medicaid to cover more low-income individuals, primarily childless adults. This change provides the researcher with an opportunity to analyze the effects of these expansions on labor supply and welfare enrollment. I use a large data set of 176 counties over 7 years, including 3 years of pre-expansion period, 1 year of implementation year, and 3 years of post-expansion period. Using a difference-in-differences approach, I find the most-affected counties had a 1.4 percentage-point more decline in labor force participation rate in comparison to other counties. Furthermore, I observe a 0.32 h decrease in average weekly hours and a 1.1 % increase in average weekly wages. This indicates labor supply was affected more than labor demand. I also observe a 0.49 % increase in Supplemental Nutrition Assistance Program (SNAP) enrollment after the Medicaid expansions. These results are robust to an alternative identification of the most-affected counties, inclusion of counties from comparison states, limiting the control group to only high-poverty counties from comparison states, exclusion of county-specific time trends, and different configuration of clustered errors. My findings provide early insights on the potential effects of new Medicaid expansions of the Affordable Care Act (ACA), since 82 % of those newly eligible are expected to be childless adults.

An early look at rates of uninsured safety net clinic visits after the Affordable Care Act.

The Affordable Care Act of 2010 supports marked expansions in Medicaid coverage in the United States. As of January 1, 2014, a total of 25 states and the District of Columbia expanded their Medicaid programs. We tested the hypothesis that rates of uninsured safety net clinic visits would significantly decrease in states that implemented Medicaid expansion, compared with states that did not. We undertook a longitudinal observational study of coverage status for adult visits in community health centers, from 12 months before Medicaid expansion (January 1, 2013 to December 31, 2013) through 6 months after expansion (January 1, 2014 to June 30, 2014). We analyzed data from 156 clinics in the OCHIN practice-based research network, with a shared electronic health record, located in 9 states (5 expanded Medicaid coverage and 4 did not). Analyses were based on 333,655 nonpregnant adult patients and their 1,276,298 in-person billed encounters. Overall, clinics in the expansion states had a 40% decrease in the rate of uninsured visits in the postexpansion period and a 36% increase in the rate of Medicaid-covered visits. In contrast, clinics in the nonexpansion states had a significant 16% decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits. There was a substantial decrease in uninsured community health center visits and a significant increase in Medicaid-covered visits in study clinics in states that expanded Medicaid in 2014, whereas study clinics in states opting out of the expansion continued to have a high rate of uninsured visits. These findings suggest that Affordable Care Act-related Medicaid expansions have successfully decreased the number of uninsured safety net patients in the United States.

Photographic assessment of nasal morphology following rapid maxillary expansion in children

ObjectiveThe aim of the present study was to use facial analysis to determine the effects of rapid maxillary expansion (RME) on nasal morphology in children in the stages of primary and mixed dentition, with posterior cross-bite. Material and MethodsFacial photographs (front view and profile) of 60 patients in the pre-expansion period, immediate post-expansion period and one year following rapid maxillary expansion with a Haas appliance were evaluated on 2 occasions by 3 experienced orthodontists independently, with a 2-week interval between evaluations. The examiners were instructed to assess nasal morphology and had no knowledge regarding the content of the study. Intraexaminer and interexaminer agreement (assessed using the Kappa statistic) was acceptable. ResultsFrom the analysis of the mode of the examiners' findings, no alterations in nasal morphology occurred regarding the following aspects: dorsum of nose, alar base, nasal width of middle third and nasal base. Alterations were only detected in the nasolabial angle in 1.64% of the patients between the pre-expansion and immediate post-expansion photographs. In 4.92% of the patients between the immediate post-expansion period and 1 year following expansion; and in 6.56% of the patients between the pre-expansion period and one year following expansion. ConclusionRME performed on children in stages of primary and mixed dentition did not have any impact on nasal morphology, as assessed using facial analysis.

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center. This was a pre-post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a five-month pre-expansion period (November 1, 2004, to March 1, 2005) and a five-month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders. From pre-expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI = -74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI = -4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI = -4.0 to 3.5). Mean (+/-SD) total LOS increased from 4.6 (+/-1.9) to 5.6(+/-2.3) hours, and mean (+/-SD) admission hold LOS also increased from 3.0 (+/-0.2) to 4.1 (+/-0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre-expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode. An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital.

Multivariate analysis of the impacts of NAS investments: A case study of a capacity expansion at Dallas-Fort Worth Airport

Multivariate statistical analysis is used to estimate the impacts of a major capacity expansion at Dallas-Fort Worth International Airport. The model relates the Daily Flight Time Index (DFTI) to demand, weather, origin airport congestion, and the expansion itself. The effect of the capacity expansion on DFTI is found to depend strongly on visibility. On average, the index in the post-expansion period is 1.3 min less as a consequence of investment. This change includes a larger reduction in departure delay that is offset by an increase in taxi time. Moreover, the reduction caused by the expansion has been more than offset by increases in the DFTI resulting from other factors, notably increased demand and worse weather.

MH1: THE IMPACT OF SECOND-GENERATION ANTIPSYCHOTIC MEDICATIONS ON AMBULATORY PATIENTS WITH SCHIZOPHRENIA

BACKGROUND: The Medi-Cal program in California added second-generation antipsychotic medications to its formulary in October 1997. OBJECTIVE: Investigate the impact of the formulary expansion on patient outcomes for olanzapine and risperidone patients before and after the formulary expansion. STUDY POPULATION: The study population consisted of 13,106 olanzapine and 15,718 risperidone ambulatory patients from the 100% Medi-Cal dataset, who were classified into 3 groups. New: no previous antipsychotic drug therapy history. Restarters: re-started antipsychotic drug therapy while not on active therapy. Switcher: who switched to one of these products while on active drug therapy. METHODS: Models of one-year treatment costs were estimated using both OLS regression and propensity score methods. Models included over 85 covariates for patient demographics, prior use of services, prior antipsychotic drug profile and diagnostic profile. Separate models were estimated for the 3 patient populations. Outcomes include total costs over one year broken down into component costs and days of uninterrupted drug therapy achieved after re-starting therapy. RESULTS: The formulary expansion immediately increased the number of new, switcher, restarter patients starting therapy with risperidone and olanzapine. Olanzapine patients were more likely to be male, between the ages of 30 and 60, urban residents and AFDC recipients. For restarters and switchers, Olanzapine patients also appear to be more compliant with their prior antipsychotic drug regimen. Once these differences were accounted for, Risperidone and olanzapine patients exhibited similar treatment cost profiles in the post-expansion period. CONCLUSIONS: More research is needed to determine if the formulary expansion reduced the cost of treating patients with schizophrenia. Furthermore, future comparison across drugs must take into account potential treatment selection bias and formulary expansion effects on the decision to start drug therapy.

Maxillary adaptation to expansion in the mixed dentition.

This study presents the findings of 162 patients who underwent rapid maxillary expansion during the early mixed dentition. Maxillary changes were evaluated through the analysis of serial dental casts. Arch dimensions were measured pre-expansion, immediately post-expansion, and at yearly intervals until the eruption of the first premolars. The expansion was effected with an acrylic rapid maxillary expansion appliance bonded to the posterior teeth for 5 to 6 months. A simple retention protocol was used post-expansion. The average increase in transpalatal width was 5 to 6 mm. During the post-expansion period, most of the arch width increases were maintained. For example, 90.5% of the original expansion at the first permanent molars remained after the first year, with slightly less overall expansion (80.4%) evident at the end of the observation period (2.4 years postexpansion). Maxillary dental arches that initially were narrow tended to retain a greater percentage of the achieved expansion than those with initially wider arch dimensions. In addition, maxillae with initially more lingually-inclined molars tended to retain more expansion than maxillae with initially more facially-inclined molars. Palatal vault height decreased very slightly during treatment, but returned to pretreatment values one year after expansion and increased slightly during subsequent time intervals. The results of this study indicate that the majority of increased arch dimensions in patients produced by early orthopedic expansion of the maxilla are maintained at the end of the transitional dentition.