Joint effects of Medicaid eligibility and fees on recession-linked declines in healthcare access and health status.

Whether Medicaid can function as a safety net to offset health risks created by health insurance coverage losses due to job loss is conditional on (1) the eligibility guidelines shaping the pathway for households to access the program for temporary relief, and (2) Medicaid reimbursement policies affecting the value of the program for both the newly and previously enrolled. We find states with more expansive eligibility guidelines lowered the healthcare access and health risk of coverage loss associated with rising unemployment during the 2007-2009 Great Recession. Rises in cost-related barriers to care associated with unemployment were smallest in states with expansive eligibility guidelines and higher Medicaid-to-Medicare fee ratios. Similarly, states whose Medicaid programs had expansive eligibility guidelines and higher fees saw the smallest recession-linked declines in self-reported good health. Medicaid can work to stabilize access to health care during periods of joblessness. Our findings yield important insights into the alignment of at least two Medicaid policies (i.e., eligibility and payment) shaping Medicaid's viability as a safety net.

An extreme magneto-ionic environment associated with the fast radio burst source FRB 121102.

Fast radio bursts are millisecond-duration, extragalactic radio flashes of unknown physical origin. The only known repeating fast radio burst source-FRB 121102-has been localized to a star-forming region in a dwarf galaxy at redshift 0.193 and is spatially coincident with a compact, persistent radio source. The origin of the bursts, the nature of the persistent source and the properties of the local environment are still unclear. Here we report observations of FRB 121102 that show almost 100 per cent linearly polarized emission at a very high and variable Faraday rotation measure in the source frame (varying from +1.46 × 105 radians per square metre to +1.33 × 105 radians per square metre at epochs separated by seven months) and narrow (below 30 microseconds) temporal structure. The large and variable rotation measure demonstrates that FRB 121102 is in an extreme and dynamic magneto-ionic environment, and the short durations of the bursts suggest a neutron star origin. Such large rotation measures have hitherto been observed only in the vicinities of massive black holes (larger than about 10,000 solar masses). Indeed, the properties of the persistent radio source are compatible with those of a low-luminosity, accreting massive black hole. The bursts may therefore come from a neutron star in such an environment or could be explained by other models, such as a highly magnetized wind nebula or supernova remnant surrounding a young neutron star.

Childhood anhedonia symptoms and stressful life events predict the development of reward-related brain activity across adolescence.

The reward positivity (RewP) is an event-related potential that indexes reinforcement learning and reward system activation. The RewP has been shown to increase across adolescence; however, most studies have examined the RewP across two assessments, and no studies have examined within-person changes across adolescence into young adulthood. Moreover, the RewP has been identified as a neurobiological risk factor for adolescent-onset depression, but it is unclear whether childhood psychosocial risk factors might predict RewP development across adolescence. In a sample of 317 8- to 14-year-old girls (Mage = 12.4, SD = 1.8), the present study examined self-report measures of depression symptoms and stressful life events at baseline and the ΔRewP during the doors guessing task across three timepoints. Growth modeling indicated that, across all participants, the ΔRewP did not demonstrate linear change across adolescence. However, baseline anhedonia symptoms predicted within-person changes in the ΔRewP, such that individuals with low anhedonia symptoms demonstrated a linear increase in the ΔRewP, but individuals with high anhedonia symptoms had no change in the ΔRewP across adolescence. Similar patterns were observed for stressful life events. The present study suggests that childhood risk factors impact the development of reward-related brain activity, which might subsequently increase risk for psychopathology.

Severe Maternal Morbidity in Georgia, 2009-2020.

BACKGROUND: The increasing focus of population surveillance and research on maternal-and not only fetal and infant-health outcomes is long overdue. The United States maternal mortality rate is higher than any other high-income country, and Georgia is among the highest rates in the country. Severe maternal morbidity (SMM) is conceived of as a "near miss" for maternal mortality, is 50 times more common than maternal death, and efforts to systematically monitor SMM rates in populations have increased in recent years. Much of the current population-based research on SMM has occurred in coastal states or large cities, despite substantial geographical variation with higher maternal and infant health burdens in the Southeast and rural regions. METHODS: This population-based study uses hospital discharge records linked to vital statistics to describe the epidemiology of SMM in Georgia between 2009 and 2020. RESULTS: Georgia had a higher SMM rate than the United States overall (189.2 vs. 144 per 10,000 deliveries in Georgia in 2014, the most recent year with US estimates). SMM was higher among racially minoritized pregnant persons and those at the extremes of age, of lower socioeconomic status, and with comorbid chronic conditions. SMM rates were 5 to 6 times greater for pregnant people delivering infants <1500 grams or <32 weeks' gestation as compared with those delivering normal weight or term infants. Since 2015, SMM has increased in Georgia. CONCLUSION: SMM represents a collection of life-threatening emergencies that are unevenly distributed in the population and require increased attention. This descriptive analysis provides initial guidance for programmatic interventions intending to reduce the burden of SMM and, subsequently, maternal mortality in the US South.

A realist approach to understanding alliancing within Local Government public health and social care service provision.

BACKGROUND: Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services. METHODS: A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches. RESULTS: Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components. CONCLUSIONS: The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Leveraging the Full Continuum of Care to Prevent Opioid Use Disorder.

Substance use disorder prevention programs are most effective when matched appropriately to the baseline risk of the population. Individuals who misuse opioids often have unique risk profiles different from those who use other substances such as alcohol or cannabis. However, most substance use prevention programs are geared toward universal audiences, neglecting key inflection points along the continuum of care. The HEAL Prevention Cooperative (HPC) is a unique cohort of research projects that represents a continuum of care, from community-level universal prevention to indicated prevention among older adolescents and young adults who are currently misusing opioids or other substances. This paper describes the theoretical basis for addressing opioid misuse and opioid use disorder across the prevention continuum, using examples from research projects in the HPC.

End-to-end stapled technique for Kono-S anastomosis.

PURPOSE: Our aim was to develop a Kono-S anastomotic technique using surgical staplers. METHODS: Two patients underwent stapled Kono-S anastomosis, one via abdominal and one transanal approach. RESULTS: The approach for an abdominal and transanal stapled Kono-S anastomosis is detailed. CONCLUSION: The Kono-S anastomosis can be safely configured using common surgical staplers.

Prevalence of alloantibodies associated with haemolytic disease of the fetus and newborn in pregnant women at the Ekiti State University Teaching Hospital, Ado-Ekiti, Southwest Nigeria.

Haemolytic disease of the fetus and newborn (HDFN) is caused by maternal alloimmunization against red blood cell antigens, which could result in fetal anaemia, hyperbilirubinaemia, kernicterus, and death. This study was designed to determine the prevalence of alloantibodies against erythrocyte antigens in blood samples of pregnant women during the first trimester which may cause HDFN. A total of 123 consenting pregnant women attending the antenatal clinic of Ekiti state University Teaching Hospital, Ado Ekiti participated in the study which lasted three months. The participants were within the ages of 16 to 45 years old across the major ethnic group in Nigeria. ABO/Rh typing, screening and identification of red blood cell alloantibodies were carried out using standard protocols. 15 (12.2%) subjects had detectable antibodies known to cause haemolytic disease of the fetus and newborn (HDFN). The specificity of the antibodies was as follows: anti-K (5, 33%), anti-k (3, 20%), anti- Jsa (2, 13%), anti-C. (3, 20%), and anti-E (2, 13 %). Based on ethnicity, the prevalence of Kell antibodies was highly significant among the Yorubas as well as anti-C and anti-E. The observation was similar in the Igbo and Hausa groups. There is a need to determine these antibodies and monitor their titre in pregnant women to manage or prevent the morbidity and mortality associated with HDFN during routine antenatal care.

Is walking netball an effective, acceptable and feasible method to increase physical activity and improve health in middle- to older age women?: A RE-AIM evaluation.

BACKGROUND: Physical activity is a modifiable risk factor for health and wellbeing, all-cause mortality and healthy aging. However, for middle- to older-age females less is known about the benefits of sports participation on these outcomes. Further, the acceptability and feasibility of setting-up, implementing and maintaining sports-based programmes for an aging population is an understudied area of inquiry. The current study used the RE-AIM framework to investigate a nationwide Walking Netball (WN) programme. METHODS: The evaluation used a mixed-methods approach incorporating a multiple-baseline study, quasi-experimental study, programme monitoring data and qualitative studies to evaluate the programme in the Women's Institutes (WI) in England. Data were analysed using multilevel growth modelling, mixed-design ANOVAs, multilevel regression, t-testing, and thematic analysis. Data were triangulated to address each dimension of the RE-AIM framework. FINDINGS: The programme reached 1.4% (n = 3148) of the WI population across 82.0% of WI regions in England and attracted inactive members at risk of ill-health. WN contributed to adaptations in physical function, mental health and wellbeing, social isolation, quality of life and increased physical activity. The adoption of the programme was successful with 87.7% WN groups' maintaining participation beyond the 20-session initial delivery phase. Adoption was effective because of its set-up, peer-mentorship and long-term delivery; these factors likewise shaped implementation. Adapting and tailoring WN to the varying characteristics of participants within the WI and the facilities available, along with training delivery staff and providing resources are key programme components. The Walking Netball programme can be maintained through promotion within the local community, sustainable funding, inter-WI competitions, festivals and networks, multiple-hosts and continued host development. CONCLUSIONS: WN was found to be an acceptable, feasible and effective intervention to increase physical activity and improve health in middle- to older- aged women. Future programmes may consider adapted styles of set-up and delivery. These include adapting to people, places and spaces through personalised support and providing a range of resources. Future designs may seek to understand how participation can contribute to healthy aging through longitudinal research beyond 12-months. STUDY REGISTRATION: The evaluation protocol was published in Open Science Framework in December 2018 prior to follow-up data collection being collected ( https://www.osf.io/dcekz ). Date of registration: 17 December 2018.

Community interventions for improving adult mental health: mapping local policy and practice in England.

BACKGROUND: Public mental health (PMH) aims to improve wellbeing and prevent poor mental health at the population level. It is a global challenge and a UK priority area for action. Communities play an important role in the provision of PMH interventions. However, the evidence base concerning community-based PMH interventions is limited, meaning it is challenging to compare service provision to need. Without this, the efficient and equitable provision of services is hindered. Here, we sought to map the current range of community-based interventions for improving mental health and wellbeing currently provided in England to inform priority areas for policy and service intervention. METHOD: We adopted an established mapping exercise methodology, comparing service provision with demographic and deprivation statistics. Five local authority areas of England were selected based on differing demographics, mental health needs and wider challenging circumstances (i.e. high deprivation). Community-based interventions were identified through: 1) desk-based research 2) established professional networks 3) chain-referral sampling of individuals involved in local mental health promotion and prevention and 4) peer researchers' insight. We included all community-based, non-clinical interventions aimed at adult residents operating between July 2019 and May 2020. RESULTS: 407 interventions were identified across the five areas addressing 16 risk/protective factors for PMH. Interventions for social isolation and loneliness were most prevalent, most commonly through social activities and/or befriending services. The most common subpopulations targeted were older adults and people from minority ethnic backgrounds. Interventions focusing on broader structural and environmental determinants were uncommon. There was some evidence of service provision being tailored to local need, though this was inconsistent, meaning some at-risk groups such as men or LGBTQ+ people from minority ethnic backgrounds were missed. Interventions were not consistently evaluated. CONCLUSIONS: There was evidence of partial responsiveness to national and local prioritising. Provision was geared mainly towards addressing social and individual determinants of PMH, suggesting more integration is needed to engage wider service providers and policy-makers in PMH strategy and delivery at the community level. The lack of comprehensive evaluation of services to improve PMH needs to be urgently addressed to determine the extent of their effectiveness in communities they serve.

Medicaid Managed Care's Effects on Costs, Access, and Quality: An Update.

Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are currently enrolled in a health maintenance organization (HMO). Proponents of HMOs argue that they can lower costs while maintaining access and quality. We critically reviewed 32 studies on Medicaid managed care (2011-2019). Authors reported state-specific cost savings and instances of increased access or quality with implementation or redesign of Medicaid managed-care programs. Studies on high-risk populations (e.g., disabled) found improvements in quality specific to a state or a high-risk population. A unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state. New trends in the literature focused on analysis of auto-assignment algorithms, provider networks, and plan quality. More analysis of costs jointly with access/quality is needed, as is research on managing long-term care among elderly and disabled Medicaid recipients.

Diversity and antimicrobial resistance of Enterococcus from the Upper Oconee Watershed, Georgia.

AIM: It is well-known that enterococci are abundant in the environment; however, the role of surface water as a reservoir of antimicrobial-resistant enterococci remains largely undefined. In this study, surface water samples were collected over a 2-year period from the Upper Oconee watershed, Athens, GA to examine enterococci and their antimicrobial resistance. METHODS AND RESULTS: Approximately 97% (445/458) of the samples were positive for enterococci and a total of 637 enterococci were isolated. The predominant species were Enterococcus casseliflavus (33·6%) followed by Enterococcus faecalis (26·5%) and Enterococcus hirae (13·2%). Regardless of species, the highest levels of resistance were to lincomycin (88·5%) and tetracycline (13%); isolates also exhibited resistance to newer antimicrobials, daptomycin (8·9%) and tigecycline (6·4%). Multidrug resistance (resistance ≥3 antimicrobial classes) was observed to as many as five classes of antimicrobials. Resistant enterococci appeared to be randomly dispersed over the seasons rather than clustered by species or antimicrobial resistance. CONCLUSIONS: This study demonstrated that surface waters contain a large population of diverse species of antimicrobial-resistant enterococci, including resistance to new antimicrobials. SIGNIFICANCE AND IMPACT OF THE STUDY: These results may indicate the potential of human intestinal illness and/or colonization of the human gut with resistant enterococci as enterococci correlate with increased disease risk to humans during recreational exposure to water.

A preliminary assessment of mercury in the feathers of migratory songbirds breeding in the North American subarctic.

Passerines appear to have a greater sensitivity to mercury than other avian orders, and little data exists for mercury exposure in songbirds breeding at high latitudes. In this preliminary study, we examined mercury exposure in 12 migratory songbird species breeding in Denali National Park & Preserve, in subarctic interior Alaska. Overall, we analyzed 343 feather samples collected in 2015-2017 for their total mercury content. Mercury levels found in feathers indicates exposure during the period of feather growth, which we assume largely took place on the breeding ground. In this limited sample of songbird feathers, mercury concentrations ranged from near zero to 6.34 µg/g. Most species sampled showed relatively low mercury, but some individuals had high enough concentrations to be subject to adverse physiological and behavioral effects. There was an indication that mercury concentrations of breeding songbirds may vary by diet composition, with non-invertivorous species possibly tending towards lower mercury concentrations. Overall, however, the degree of mercury exposure observed was low for songbirds breeding in the subarctic. Further examination would prove useful in clarifying mercury exposure and ecological relationships in this under-studied region.

A synthesis of patterns of environmental mercury inputs, exposure and effects in New York State.

Mercury (Hg) pollution is an environmental problem that adversely affects human and ecosystem health at local, regional, and global scales-including within New York State. More than two-thirds of the Hg currently released to the environment originates, either directly or indirectly, from human activities. Since the early 1800s, global atmospheric Hg concentrations have increased by three- to eight-fold over natural levels. In the U.S., atmospheric emissions and point-source releases to waterways increased following industrialization into the mid-1980s. Since then, water discharges have largely been curtailed. As a result, Hg emissions, atmospheric concentrations, and deposition over the past few decades have declined across the eastern U.S. Despite these decreases, Hg pollution persists. To inform policy efforts and to advance public understanding, the New York State Energy Research and Development Authority (NYSERDA) sponsored a scientific synthesis of information on Hg in New York State. This effort includes 23 papers focused on Hg in atmospheric deposition, water, fish, and wildlife published in Ecotoxicology. New York State experiences Hg contamination largely due to atmospheric deposition. Some landscapes are inherently sensitive to Hg inputs driven by the transport of inorganic Hg to zones of methylation, the conversion of inorganic Hg to methylmercury, and the bioaccumulation and biomagnification along food webs. Mercury concentrations exceed human and ecological risk thresholds in many areas of New York State, particularly the Adirondacks, Catskills, and parts of Long Island. Mercury concentrations in some biota have declined in the Eastern Great Lakes Lowlands and the Northeastern Highlands over the last four decades, concurrent with decreases in water releases and air emissions from regional and U.S. sources. However, widespread changes have not occurred in other ecoregions of New York State. While the timing and magnitude of the response of Hg levels in biota varies, policies expected to further diminish Hg emissions should continue to decrease Hg concentrations in food webs, yielding benefits to the fish, wildlife, and people of New York State. Anticipated improvements in the Hg status of aquatic ecosystems are likely to be greatest for inland surface waters and should be roughly proportional to declines in atmospheric Hg deposition. Efforts that advance recovery from Hg pollution in recent years have yielded significant progress, but Hg remains a pollutant of concern. Indeed, due to this extensive compilation of Hg observations in biota, it appears that the extent and intensity of the contamination on the New York landscape and waterscape is greater than previously recognized. Understanding the extent of Hg contamination and recovery following decreases in atmospheric Hg deposition will require further study, underscoring the need to continue existing monitoring efforts.

Oiling of American white pelicans, common loons, and northern gannets in the winter following the Deepwater Horizon (MC252) oil spill.

The Natural Resource Damage Assessment and Restoration Trustees for the Deepwater Horizon oil spill assessed the external oiling of migratory bird species dependent on open water in the Gulf of Mexico following the aforementioned spill. The assessment was designed to evaluate birds that use open water during the winter within 40 km of the Gulf shoreline. We focused on the American white pelican (Pelecanus erythrorhynchos), common loon (Gavia immer), and northern gannet (Morus bassanus). Point counts (pelican, loon) or strip transects (gannet) were used and each target species was assessed for oiling (unoiled, trace, light, moderate, or heavy amounts) and photographed. Due to distance at sighting and/or poor visibility, not all visible birds were assessed. The percentage of birds oiled varied by species, with the common loon being the highest (23.6%), followed by American white pelican (16.9%), and northern gannet (6.9%). Most of the American white pelicans and common loons had trace (83% and 72%, respectively) or light levels (11% and 24%, respectively) of oiling. The northern gannet had just trace levels of oiling. Some pelicans (6%) and loons (4%) had moderate amounts of oiling. Based on expert derived-mortality estimates and our estimates of oil exposure, we used Monte Carlo simulations to predict expected decreases of 2.5%, 4%, and 11% in the observed population for the northern gannet, American white pelican, and common loon, respectively. While these values are underestimates of the true values given the long time lag (10-12 months) between the oil spill and the assessment, these data represent some of the few estimates of exposure for these species and describe minimum risk estimates to these species.

Characterization of synovial fluid metabolomic phenotypes of cartilage morphological changes associated with osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) is a multifactorial disease with etiological heterogeneity. The objective of this study was to classify OA subgroups by generating metabolomic phenotypes from human synovial fluid. DESIGN: Post mortem synovial fluids (n = 75) were analyzed by high performance-liquid chromatography mass spectrometry (LC-MS) to measure changes in the global metabolome. Comparisons of healthy (grade 0), early OA (grades I-II), and late OA (grades III-IV) donor populations were considered to reveal phenotypes throughout disease progression. RESULTS: Global metabolomic profiles in synovial fluid were distinct between healthy, early OA, and late OA donors. Pathways differentially activated among these groups included structural deterioration, glycerophospholipid metabolism, inflammation, central energy metabolism, oxidative stress, and vitamin metabolism. Within disease states (early and late OA), subgroups of donors revealed distinct phenotypes. Synovial fluid metabolomic phenotypes exhibited increased inflammation (early and late OA), oxidative stress (late OA), or structural deterioration (early and late OA) in the synovial fluid. CONCLUSION: These results revealed distinct metabolic phenotypes in human synovial fluid, provide insight into pathogenesis, represent novel biomarkers, and can move toward developing personalized interventions for subgroups of OA patients.

Emergence of carriage of CTX-M-15 in faecal Escherichia coli in horses at an equine hospital in the UK; increasing prevalence over a decade (2008-2017).

BACKGROUND: This study investigated changes over time in the epidemiology of extended-spectrum ß-lactamase (ESBL) producing Escherichia coli within a single equine referral hospital in the UK. Faecal samples were collected from hospitalised horses in 2008 and 2017, processed using selective media and standard susceptibility laboratory methods. A novel real-time PCR with high resolution melt analysis was used to distinguish blaCTX-M-1 and blaCTX-M-15 within CTX-M-1 group. RESULTS: In 2008, 457 faecal samples from 103 horses were collected, with ESBL-producing E. coli identified in 131 samples (28.7, 95% CI 24.6-33.1). In 2017, 314 faecal samples were collected from 74 horses with ESBL-producing E. coli identified in 157 samples (50.0, 95% CI 44.5-55.5). There were 135 and 187 non-duplicate ESBL-producing isolates from 2008 and 2017, respectively. In 2008, 12.6% of isolates belonged to CTX-M-1 group, all carrying blaCTX-M-1, whilst in 2017, 94.1% of isolates were CTX-M-1 group positive and of these 39.2 and 60.8% of isolates carried blaCTX-M-1 and blaCTX-M-15, respectively. In addition, the prevalence of doxycycline, gentamicin and 3rd generation cephalosporin resistance increased significantly from 2008 to 2017 while a decreased prevalence of phenotypic resistance to potentiated sulphonamides was observed. CONCLUSIONS: The real-time PCR proved a reliable and high throughput method to distinguish between blaCTX-M-1 and blaCTX-M-15. Furthermore, its use in this study demonstrated the emergence of faecal carriage of CTX-M-15 in hospitalised horses, with an increase in prevalence of ESBL-producing E. coli as well as increased antimicrobial resistance to frequently used antimicrobials.

Percentage of Deaths Associated With Inadequate Physical Activity in the United States.

INTRODUCTION: Current physical activity guidelines recommend that adults participate weekly in at least 150 minutes of moderate-intensity equivalent aerobic physical activity to achieve substantial health benefits. We used a nationally representative sample of data of US adults to estimate the percentage of deaths attributable to levels of physical activity that were inadequate to meet the aerobic guideline. METHODS: Data from the 1990 to 1991 National Health Interview Survey for adults aged 25 years or older were linked with mortality data up until December 31, 2011, from the National Death Index (N = 67,762 persons and 18,796 deaths). Results from fully adjusted Cox proportional hazards models were used to estimate hazard ratios and population attributable fractions for inadequate levels of physical activity (ie, less than 150 minutes per week of moderate-intensity equivalent aerobic activity). RESULTS: Overall, 8.3% (95% confidence interval [CI], 6.4-10.2) of deaths were attributed to inadequate levels of physical activity. The percentage of deaths attributed to inadequate levels was not significant for adults aged 25 to 39 years (-0.2%; 95% CI, -8.8% to 7.7%) but was significant for adults aged 40 to 69 years (9.9%; 95% CI, 7.2%-12.6%) and adults aged 70 years or older (7.8%; 95% CI, 4.9%-10.7%). CONCLUSIONS: A significant portion of deaths was attributed to inadequate levels of physical activity. Increasing adults' physical activity levels to meet current guidelines is likely one way to reduce the risk of premature death in the United States.

Investigation of the First Seven Reported Cases of Candida auris, a Globally Emerging Invasive, Multidrug-Resistant Fungus-United States, May 2013-August 2016.

November 11, 2016/65(44);1234-1237. What is already known about this topic? Candida auris is an emerging pathogenic fungus that has been reported from at least a dozen countries on four continents during 2009-2015. The organism is difficult to identify using traditional biochemical methods, some isolates have been found to be resistant to all three major classes of antifungal medications, and C. auris has caused health care-associated outbreaks. What is added by this report? This is the first description of C. auris cases in the United States. C. auris appears to have emerged in the United States only in the last few years, and U.S. isolates are related to isolates from South America and South Asia. Evidence from U.S. case investigations suggests likely transmission of the organism occurred in health care settings. What are the implications for public health practice? It is important that U.S. laboratories accurately identify C. auris and for health care facilities to implement recommended infection control practices to prevent the spread of C. auris. Local and state health departments and CDC should be notified of possible cases of C. auris and of isolates of C. haemulonii and Candida spp. that cannot be identified after routine testing.

The Role of Public and Private Insurance Expansions and Premiums for Low-income Parents: Lessons From State Experiences.

BACKGROUND: Numerous states have implemented policies expanding public insurance eligibility or subsidizing private insurance for parents. OBJECTIVES: To assess the impact of parental health insurance expansions from 1999 to 2012 on the likelihood that parents are insured; their children are insured; both the parent and child within a family unit are insured; and the type of insurance. DESIGN: Cross-sectional analysis of the 2000-2013 March supplements to the Current Population Survey, with data from the Medical Expenditure Panel Survey-Insurance Component and the Area Resource File. METHODS: Cross-state and within-state multivariable regression models estimated the effects of health insurance expansions targeting parents using 2-way fixed effect modeling and difference-in-difference modeling. All analyses controlled for household, parent, child, and local area characteristics that could affect insurance status. RESULTS: Expansions increased parental coverage by 2.5 percentage points, and increased the likelihood of both parent and child being insured by 2.1 percentage points. Substantial variation was observed by type of expansion. Public expansions without premiums and special subsidized plan expansions had the largest effects on parental coverage and increased the likelihood of jointly insuring both the parent and child. Higher premiums were a substantial deterrent to parents' insurance. CONCLUSIONS: Our findings suggest that premiums and the type of insurance expansion can have a substantial impact on the insurance status of the family. These findings can help inform states as they continue to make decisions about expanding Medicaid under the Affordable Care Act to cover all family members.