Long non-coding RNA H19 suppresses retinoblastoma progression via counteracting miR-17-92 cluster.

Long non-coding RNAs (lncRNAs) are frequently dysregulated and play important roles in many cancers. lncRNA H19 is one of the earliest discovered lncRNAs which has diverse roles in different cancers. However, the expression, roles, and action mechanisms of H19 in retinoblastoma are still largely unknown. In this study, we found that H19 is downregulated in retinoblastoma tissues and cell lines. Gain-of-function and loss-of-function assays showed that H19 inhibits retinoblastoma cell proliferation, induces retinoblastoma cell cycle arrest and cell apoptosis. Mechanistically, we identified seven miR-17-92 cluster binding sites on H19, and found that H19 directly bound to miR-17-92 cluster via these seven binding sites. Through binding to miR-17-92 cluster, H19 relieves the suppressing roles of miR-17-92 cluster on p21. Furthermore, H19 represses STAT3 activation induced by miR-17-92 cluster. Hence, our results revealed that H19 upregulates p21 expression, inhibits STAT3 phosphorylation, and downregulates the expression of STAT3 target genes BCL2, BCL2L1, and BIRC5. In addition, functional assays demonstrated that the mutation of miR-17-92 cluster binding sites on H19 abolished the proliferation inhibiting, cell cycle arrest and cell apoptosis inducing roles of H19 in retinoblastoma. In conclusion, our data suggested that H19 inhibits retinoblastoma progression via counteracting the roles of miR-17-92 cluster, and implied that enhancing the action of H19 may be a promising therapeutic strategy for retinoblastoma.

Clinical nonlicensed personnel in U.S. hospitals: Job trends from 2010 to 2015.

BACKGROUND: Despite the large numbers in health care industry, little is known about the clinical nonlicensed personnel (CNLP) in U.S. hospitals and how their staffing has changed over time. PURPOSE: The purpose of this analysis is to better understand the conformation and recent trends in CNLP staffing in U.S. hospitals from 2010 to 2015. METHODS: Using Premier's OperationsAdvisor database, we examined trends in staffing of 25 CNLP jobs and graduate nurses (GNs) in U.S. hospitals and by hospital units, including medical-surgical units, outpatient units, and emergency departments, from 2010 to 2015, based on their skill levels. We measured CNLP and graduate nurse staffing using the average number of full-time equivalents (FTEs) in each hospital. We performed statistical analysis to compare the changes in the number of FTEs between 2010 and 2015. DISCUSSION: Over the 6-year period from 2010 to 2015, we observed declining trends in the average number of high-skill and middle-skill CNLP FTEs by 22% and 7%, respectively, and increases in the average number of low-skill and graduate nurse FTEs by 38% and 117%, respectively. This skill mix shift appears to be most pronounced in emergency departments. CONCLUSION: Changes in staffing levels and the skill mix of the hospital workforce warrant further study to understand both the reasons behind the observed changes and their effects on health outcomes. Although labor efficiency is an important goal, it is also critically important to assess whether reductions and/or the skill mix shifts among support staff impact nurse workload and, by extension, patient safety.

Evidence-Based Policy Making: Assessment of the American Heart Association's Strategic Policy Portfolio: A Policy Statement From the American Heart Association.

BACKGROUND: American Heart Association (AHA) public policy advocacy strategies are based on its Strategic Impact Goals. The writing group appraised the evidence behind AHA's policies to determine how well they address the association's 2020 cardiovascular health (CVH) metrics and cardiovascular disease (CVD) management indicators and identified research needed to fill gaps in policy and support further policy development. METHODS AND RESULTS: The AHA policy research department first identified current AHA policies specific to each CVH metric and CVD management indicator and the evidence underlying each policy. Writing group members then reviewed each policy and the related metrics and indicators. The results of each review were summarized, and topic-specific priorities and overarching themes for future policy research were proposed. There was generally close alignment between current AHA policies and the 2020 CVH metrics and CVD management indicators; however, certain specific policies still lack a robust evidence base. For CVH metrics, the distinction between policies for adults (age ≥20 years) and children (<20 years) was often not considered, although policy approaches may differ importantly by age. Inclusion of all those <20 years of age as a single group also ignores important differences in policy needs for infants, children, adolescents, and young adults. For CVD management indicators, specific quantitative targets analogous to criteria for ideal, intermediate, and poor CVH are lacking but needed to assess progress toward the 2020 goal to reduce deaths from CVDs and stroke. New research in support of current policies needs to focus on the evaluation of their translation and implementation through expanded application of implementation science. Focused basic, clinical, and population research is required to expand and strengthen the evidence base for the development of new policies. Evaluation of the impact of targeted improvements in population health through strengthened surveillance of CVD and stroke events, determination of the cost-effectiveness of policy interventions, and measurement of the extent to which vulnerable populations are reached must be assessed for all policies. Additional attention should be paid to the social determinants of health outcomes. CONCLUSIONS: AHA's public policies are generally robust and well aligned with its 2020 CVH metrics and CVD indicators. Areas for further policy development to fill gaps, overarching research strategies, and topic-specific priority areas are proposed.

The relative contribution of provider and ED-level factors to variation among the top 15 reasons for ED admission.

STUDY OBJECTIVE: We examine adult emergency department (ED) admission rates for the top 15 most frequently admitted conditions, and assess the relative contribution in admission rate variation attributable to the provider and hospital. METHODS: This was a retrospective, cross-sectional study of ED encounters (≥18years) from 19 EDs and 603 providers (January 2012-December 2013), linked to the Area Health Resources File for county-level information on healthcare resources. "Hospital admission" was the outcome, a composite of inpatient, observation, or intra-hospital transfer. We studied the 15 most commonly admitted conditions, and calculated condition-specific risk-standardized hospital admission rates (RSARs) using multi-level hierarchical generalized linear models. We then decomposed the relative contribution of provider-level and hospital-level variation for each condition. RESULTS: The top 15 conditions made up 34% of encounters and 49% of admissions. After adjustment, the eight conditions with the highest hospital-level variation were: 1) injuries, 2) extremity fracture (except hip fracture), 3) skin infection, 4) lower respiratory disease, 5) asthma/chronic obstructive pulmonary disease (A&C), 6) abdominal pain, 7) fluid/electrolyte disorders, and 8) chest pain. Hospital-level intra-class correlation coefficients (ICC) ranged from 0.042 for A&C to 0.167 for extremity fractures. Provider-level ICCs ranged from 0.026 for abdominal pain to 0.104 for chest pain. Several patient, hospital, and community factors were associated with admission rates, but these varied across conditions. CONCLUSION: For different conditions, there were different contributions to variation at the hospital- and provider-level. These findings deserve consideration when designing interventions to optimize admission decisions and in value-based payment programs.

How Do Hospitals Respond to Market Entry? Evidence from a Deregulated Market for Cardiac Revascularization.

Regulatory entry barriers to hospital service markets, namely Certificate of Need (CON) regulations, are enforced in many US states. Policy makers in other states are considering reinstating CON policies in tandem with service expansions mandated under the Affordable Care Act. Although previous studies examined the volume effects of CON, demand responses to actual entry into local hospital markets are not well understood. In this paper, we empirically examine the demand-augmenting, demand-redistribution, and risk-allocation effects of hospital entry by studying the cardiac revascularization markets in Pennsylvania, a state in which dynamic market entry occurred after repeal of CON in 1996. Results from interrupted time-series analyses indicate demand-augmenting effects for coronary artery bypass graft (CABG) and business-stealing effects for percutaneous coronary intervention (PCI) procedures: high entrant market share mitigated the declining incidence of CABG, but it had no significant effect on the rising trend in PCI use, among patients with coronary artery disease. We further find evidence that entry by new cardiac surgery centers tended to sort high-severity patients into the more invasive CABG procedure and low-severity patients into the less invasive PCI procedures. These findings underscore the importance of considering market-level strategic responses by hospitals when regulatory barriers are rescinded.

Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension.

INTRODUCTION: Hypertension is a risk factor for cardiovascular disease (CVD), the leading cause of death in the United States. The treatment and control of hypertension is inadequate, especially among patients without health insurance coverage. The Affordable Care Act offered an opportunity to improve hypertension management by increasing the number of people covered by insurance. This study predicts the long-term effects of improved hypertension treatment rates due to insurance expansions on the prevalence and mortality rates of CVD of nonelderly Americans with hypertension. METHODS: We developed a state-transition model to simulate the lifetime health events of the population aged 25 to 64 years. We modeled the effects of insurance coverage expansions on the basis of published findings on the relationship between insurance coverage, use of antihypertensive medications, and CVD-related events and deaths. RESULTS: The model projected that currently anticipated health insurance expansions would lead to a 5.1% increase in treatment rate among hypertensive patients. Such an increase in treatment rate is estimated to lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and 95,000 fewer CVD-related deaths by 2050. The estimated benefits were slightly greater for men than for women and were greater among nonwhite populations. CONCLUSION: Federal and state efforts to expand insurance coverage among nonelderly adults could yield significant health benefits in terms of CVD prevalence and mortality rates and narrow the racial/ethnic disparities in health outcomes for patients with hypertension.

Travel distance and health outcomes for scheduled surgery.

BACKGROUND: Changes in the location and availability of surgical services change the distances that patients must travel for surgery. Identifying health effects related to travel distance is therefore crucial to evaluating policies that affect the geographic distribution of these services. We examine the health outcomes of coronary artery bypass graft (CABG) patients in Pennsylvania for evidence that traveling further to a hospital for a one-time, scheduled surgical procedure causes harm. METHODS: We perform instrumental-variable regressions to test for the effect of distance to the admitting hospital on the in-hospital mortality and readmission rates of 102,858 CABG patients in Pennsylvania during 1995-2005, where the instrumental variables are constructed based on the quality of and distance to nearby CABG hospitals. RESULTS: We found that patients living near a CABG hospital with acceptable quality traveled significantly less and if they were high-risk, had lower in-hospital mortality rates. Readmission rates in general are not affected by patients' travel distance. DISCUSSION: The positive correlation between travel distance and health outcomes observed by previous studies may reflect the confounding effects of behavioral factors and patient health risks. We found instead that living further from the admitting hospital increases in-hospital mortality for high-risk CABG patients. More research on the possible causes of these effects is necessary to identify optimal policy responses.

Sertraline Hydrochloride Overdose Resulting in Diabetes Insipidus: A Case Report.

Sertraline hydrochloride belongs to the selective serotonin reuptake inhibitor class of antidepressants, which can cause respiratory depression, hypotension, malignant vomiting, liver function impairment, and other symptoms when taken in excess. To our knowledge, reports of sertraline hydrochloride overdose causing diabetes insipidus in patients are rare. This report describes a unique case of a 17-year-old female patient who developed diabetes insipidus after a one-time oral intake of 20 sertraline hydrochloride tablets (50 mg/tablet) during the later course of treatment. Her symptoms were effectively relieved after treatment with pituitrin.

MGFmiRNAloc: Predicting miRNA Subcellular Localization Using Molecular Graph Feature and Convolutional Block Attention Module.

MiRNA has distinct physiological functions at various cellular locations. However, few effective computational methods for predicting the subcellular location of miRNA exist, thereby leaving considerable room for improvement. Accordingly, our study proposes the MGFmiRNAloc simplified molecular input line entry system (SMILES) format as a new approach for predicting the subcellular localization of miRNA. Additionally, the graphical convolutional network (GCN) technique was employed to extract the atomic nodes and topological structure of a single base, thereby constructing RNA sequence molecular map features. Subsequently, the channel attention and spatial attention mechanisms (CBAM) were designed to mine deeper for more efficient information. Finally, the prediction module was used to detect the subcellular localization of miRNA. The 10-fold cross-validation and independent test set experiments demonstrate that MGFmiRNAloc outperforms the most sophisticated methods. The results indicate that the new atomic level feature representation proposed in this study could overcome the limitations of small samples and short miRNA sequences, accurately predict the subcellular localization of miRNAs, and be extended to the subcellular localization of other sequences.

Effects of a nursing home telehealth program on spending and utilization for Medicare residents.

OBJECTIVE: To assess the effects of eLongTermCare (eLTC), a telehealth program implemented by an integrated health system in 45 nursing homes across the Midwest, on the use of acute hospital services and total expenditures for Medicare residents. DATA SOURCES: Minimum Data Set, Medicare fee-for-service claims, and enrollment data from 2013 to 2018. STUDY DESIGN: We used a longitudinal difference-in-differences design to estimate the changes in outcomes for treatment beneficiaries before and after participating in the eLTC program, relative to changes for the matched comparison beneficiaries over the same period. We measured outcomes over a 24-month follow-up period, including total Medicare spending, emergency department (ED) visits, hospitalizations, and the likelihood of readmission. DATA COLLECTION/EXTRACTION METHODS: Using administrative data, we identified treatment beneficiaries who stayed at participating nursing facilities during the program period and matched comparison beneficiaries with similar baseline characteristics from non-participating facilities in the same geographic locations. PRINCIPAL FINDINGS: For long-term care residents, the eLTC program led to an estimated reduction of 73 ED visits per 1000 beneficiaries (p < 0.01, 8.6% effect) over the two-year follow-up period. The estimated effects for this group were concentrated among beneficiaries who entered the nursing home after program startup, with sizable reductions in hospitalizations, ED visits, and spending. For skilled care residents, the program was associated with an estimated reduction of 85 ED visits per 1000 beneficiaries (p = 0.03, 9.7% effect), but had no discernible effect on their hospitalizations or total Medicare spending. CONCLUSIONS: Telehealth can be a valuable tool for nursing homes to enhance care coordination and provide timely access to care, leading to lower spending for nursing home residents. Future research needs to explore payment methods that encourage telehealth expansion in nursing homes.

Ultrasonic Image Features under the Intelligent Algorithm in the Diagnosis of Severe Sepsis Complicated with Renal Injury.

This research was aimed at analyzing the diagnosis of severe sepsis complicated with acute kidney injury (AKI) by ultrasonic image information based on the artificial intelligence pulse-coupled neural network (PCNN) algorithm and at improving the diagnostic accuracy and efficiency of clinical severe sepsis complicated with AKI. In this research, 50 patients with sepsis complicated with AKI were collected as the observation group and 50 patients with sepsis as the control group. All patients underwent ultrasound examination. The clinical data of the two groups were collected, and the scores of acute physiology and chronic health assessment (APACHE II) and sequential organ failure assessment (SOFA) were compared. The ultrasonic image information enhancement algorithm based on artificial intelligence PCNN is constructed and simulated and is compared with the maximum between-class variance (OSTU) algorithm and the maximum entropy algorithm. The results showed that the PCNN algorithm was superior to the OSTU algorithm and maximum entropy algorithm in the segmentation results of severe sepsis combined with AKI in terms of regional consistency (UM), regional contrast (CM), and shape measure (SM). The acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores in the observation group were substantially higher than those in the control group (P < 0.05). The interlobular artery resistance index (RI) in the observation group was substantially higher than that in the control group (P < 0.05). Moreover, the mean transit time (mTT) in the observation group was significantly higher than that in the control group (4.85 ± 1.27 vs. 3.42 ± 1.04), and the perfusion index (PI) was significantly lower than that in the control group (134.46 ± 17.29 vs. 168.37 ± 19.28), with statistical significance (P < 0.05). In summary, it can substantially increase ultrasonic image information based on the artificial intelligence PCNN algorithm. The RI, mTT, and PI of the renal interlobular artery level in ultrasound images can be used as indexes for the diagnosis of severe sepsis complicated with AKI.

Soil Moisture Determines Horizontal and Vertical Root Extension in the Perennial Grass Lolium perenne L. Growing in Karst Soil.

Karst regions are characterized by heterogeneous soil habitats, with shallow wide soil (SW) on hilly slopes and deep narrow soil (DN) in rocky trenches. To make full use of limited water and nutrients, plants have therefore developed a number of root extension strategies. This study investigated the effect of soil moisture on horizontal root extension in SW and vertical root extension in DN by assessing root growth responses, biomass allocation, and root distribution. A full two-way factorial blocked design of soil dimensions by water availability was followed. The perennial grass Lolium perenne L. was grown in SW and DN under high (W100%), moderate (W50%), and low (W30%) water availability, respectively. The main results were as follows: (1) The total biomass of L. perenne was not influenced either by soil habitat or by water application. Root length, root surface area, root biomass and root to shoot ratio all decreased with decreasing water application in SW, but not in DN soil. (2) With decreasing water application, the cumulative percentage of root length, root surface area and root biomass in 4 rings from the center out to 12 cm of SW soil showed a trend of W50% > W30% > W100% in SW, however, the cumulative percentage of root biomass in 4 layers from the surface to a depth of 36 cm was not significantly different between different water treatments in DN. (3) Under all three water treatments, specific root length showed an increase but root length density showed a decreasing trend from the center outward in SW soil or from the surface to bottom in DN soil. Overall, these results suggest that in SW habitat, soil moisture determines horizontal expansion of the roots in L. perenne, although the overall expansion ability was limited in severe drought. However, due to the relatively strong water retention ability, soil moisture changes were less obvious in DN, resulting in no significant vertical extension of the root system. The root response of L. perenne helps our understanding of how herbaceous plants can adjust their belowground morphology to support their growth in harsh karst soil environments.

The Impact of State Tort Reforms on Imaging Utilization.

PURPOSE: Defensive medicine, broadly defined as medical practices that protect physicians from malpractice lawsuits without providing benefits to patients, can lead to wasteful use of health care resources and higher cost. Although physicians cite malpractice liability as an important factor driving their decisions to order imaging tests, little research has been done to examine the systematic impact of liability pressure on overall imaging. The authors examined the extent to which radiography use is influenced by malpractice liability pressure among office-based physicians. METHODS: Using National Ambulatory Medical Care Survey data from 1999 to 2010, the authors used multivariate difference-in-difference logistic regression to examine the effects of different types of state tort reforms on the probability of radiography orders by primary care physicians (PCPs) and specialists. RESULTS: The probability that a PCP ordered radiography decreased when states enacted permanent caps on noneconomic damages (-1.0%, P < .01), periodic payment reforms (-1.6%, P < .05), and the total number of tort reforms (-0.5%, P < .05). Specialist physicians were responsive to two reforms: caps on punitive damages (-6.1%, P < .01) and the total number of medical tort laws (-1.2%, P < .01). The passage of new indirect reforms was found to reduce radiography orders for PCPs (-1.8%, P < .05), and the repeal of indirect reforms was found to increase radiography orders for specialists (+3.4%, P < .01). CONCLUSIONS: State tort reform seems to reduce physicians' ordering of radiography. This analysis also suggests that reforms that make it harder to sue physicians have a stronger impact than reforms that directly reduce physicians' malpractice claim payments.

Nurse-Related Clinical Nonlicensed Personnel in U.S. Hospitals and Their Relationship with Nurse Staffing Levels.

OBJECTIVE: This study examines nurse-related clinical nonlicensed personnel (CNLP) in U.S. hospitals between 2010 and 2014, including job categories, trends in staffing levels, and the possible relationship of substitution between this group of workers and registered nurses (RNs) and/or licensed practical nurses (LPNs). DATA SOURCE: We used 5 years of data (2010-2014) from an operational database maintained by Premier, Inc. that tracks labor hours, hospital units, and facility characteristics. STUDY DESIGN: We assessed changes over time in the average number of total hours worked by RNs, LPNs, and CNLP, adjusted by total patient days. We then conducted linear regressions to estimate the relationships between nurse and CNLP staffing, controlling for patient acuity, volume, and hospital fixed effects. PRINCIPAL FINDINGS: The overall use of CNLP and LPN hours per patient day declined from 2010 to 2014, while RN hours per patient day remained stable. We found no evidence of substitution between CNLP and nurses during the study period: Nurse-related CNLP hours were positively associated with RN hours and not significantly related to LPN hours, holding other factors constant. CONCLUSIONS: Findings point to the importance of examining where and why CNLP hours per patient day have declined and to understanding of the effects of these changes on outcomes.

The Relationship of Financial Pressures and Community Characteristics to Closure of Private Safety Net Clinics.

In order to better understand what threatens vulnerable populations' access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic's financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics.

Malpractice Liability Risk and Use of Diagnostic Imaging Services: A Systematic Review of the Literature.

PURPOSE: A widespread concern among physicians is that fear of medical malpractice liability may affect their decisions for diagnostic imaging orders. The purpose of this article is to synthesize evidence regarding the defensive use of imaging services. METHODS: A literature search was conducted using a number of databases. The review included peer-reviewed publications that studied the link between physician orders of imaging tests and malpractice liability pressure. RESULTS: We identified 13 peer-reviewed studies conducted in the United States. Five of the studies reported physician assessments of the role of defensive medicine in imaging-order decisions; five assessed the association between physicians' liability risk and imaging ordering, and three assessed the impact of liability risk on imaging ordering at the state level. Although the belief that medical liability risk could influence decisions is highly prevalent among physicians, findings are mixed regarding the impact of liability risk on imaging orders at both the state and physician level. CONCLUSIONS: Inconclusive evidence suggests that physician ordering of imaging tests is affected by malpractice liability risk. Further research is needed to disentangle defensive medicine from other reasons for inefficient use of imaging.

[Therapeutic effect of acupuncture treatment on ischemic hypoxic neonate rats with cerebral palsy].

OBJECTIVE: To explore the mechanisms of acupuncture treatment promoting the motor function recovery of neonate rats with cerebral palsy. METHODS: The improved hypoxic-ischemic encephalopathy (HIE) means was performed to establish the model of neonate rats with cerebral palsy. All neonate rats were randomly divided into 3 groups: sham group, model group and acupuncture group (n = 20). We observed and scored motor function of rats, measured the levels of superoxide dismutase (SOD) and malondialdehyde (MDA) in serum, and also measured the expression of synaptophysin (SYP) and growth associated protein-43 (GAP-43) in the diseased region of cerebral tissue. RESULTS: The motor function scores (11.3 +/- 0.29) and the serum level of SOD (147.1 +/- 12.7) U/ml in acupuncture treatment group were higher than those of model group ( P < 0.05). The serum level of MDA was lower in acupuncture treatment group than that of model group (P < 0.05). The expression of SYP and GAP-43 in the diseased region of cerebral tissue of acupuncture treatment group were higher than those of model group ( P < 0.05) . CONCLUSION: Acupuncture-therapy could improve the motor function of neonate rats with cerebral palsy by decreasing the content of MDA in serum, increasing the contents of SOD in serum, and prolonging the upregulation of SYP and GAP-43 expressions in hmin tissue.

The Development of Intermediate Clinical Endpoints in Cancer of the Prostate (ICECaP).

New systemic therapies have prolonged the lives of men with metastatic castration-resistant prostate cancer (mCRPC). Use of these therapies in the adjuvant setting when the disease may be micrometastatic and potentially more sensitive to therapies may decrease mortality from prostate cancer. However, the conduct of adjuvant prostate cancer clinical trials is hampered by taking longer than a decade to reach the meaningful endpoint of overall survival (OS) and the fact that many men never die from prostate cancer, even if they relapse. A validated intermediate clinical endpoint (ICE) in prostate cancer that is a robust surrogate for OS has yet to be defined. This paper details the plans, process, and progress of the international Intermediate Clinical Endpoints in Cancer of the Prostate (ICECaP) working group to pool individual patient data from all available clinical trials of radiation or prostatectomy for localized disease and conduct the requisite analyses to determine whether an ICE can be identified. This paper further details the challenges and the a priori statistical analytical plans and strategies to define an ICE for adjuvant prostate cancer clinical trials. In addition, a brief review of the health economic analyses to model the benefits to patients, society and manufacturers is detailed. If successful, the results from this work will provide a robust surrogate for OS that will expedite the design and conduct of future adjuvant therapy trials using new agents that have proven activity in mCRPC. Moreover, it will also define the health economic benefits to patients and societies.

The cost savings of expanding Medicaid eligibility to include currently uninsured homeless adults with substance use disorders.

Following the June 2012 Supreme Court ruling that states are no longer mandated to expand their Medicaid programs in 2014 as part of the Affordable Care Act, many states plan to opt out of the expansion, citing affordability as their primary concern. In response to this controversy, the present study evaluated the cost savings of expanding Medicaid coverage to include currently ineligible homeless adults with substance use disorders, a subset of the population that incurs some of the greatest societal costs and is disproportionately impacted by uninsurance. Using a time horizon of 7 years, separate analyses were conducted for state and federal governments, and then a final analysis evaluated the combined costs for the other two models. Results of the study demonstrate that, although the expansion will be associated with a net cost when combining state and federal expenses and savings, states will experience tremendous savings if they choose to participate.