COVID-19 Admission Rates and Changes in Care Quality in US Hospitals.

Importance: Unprecedented increases in hospital occupancy rates during COVID-19 surges in 2020 caused concern over hospital care quality for patients without COVID-19. Objective: To examine changes in hospital nonsurgical care quality for patients without COVID-19 during periods of high and low COVID-19 admissions. Design, Setting, and Participants: This cross-sectional study used data from the 2019 and 2020 Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Inpatient Databases. Data were obtained for all nonfederal, acute care hospitals in 36 states with admissions in 2019 and 2020, and patients without a diagnosis of COVID-19 or pneumonia who were at risk for selected quality indicators were included. The data analysis was performed between January 1, 2023, and March 15, 2024. Exposure: Each hospital and week in 2020 was categorized based on the number of COVID-19 admissions per 100 beds: less than 1.0, 1.0 to 4.9, 5.0 to 9.9, 10.0 to 14.9, and 15.0 or greater. Main Outcomes and Measures: The main outcomes were rates of adverse outcomes for selected quality indicators, including pressure ulcers and in-hospital mortality for acute myocardial infarction, heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and percutaneous coronary intervention. Changes in 2020 compared with 2019 were calculated for each level of the weekly COVID-19 admission rate, adjusting for case-mix and hospital-month fixed effects. Changes during weeks with high COVID-19 admissions (≥15 per 100 beds) were compared with changes during weeks with low COVID-19 admissions (<1 per 100 beds). Results: The analysis included 19 111 629 discharges (50.3% female; mean [SD] age, 63.0 [18.0] years) from 3283 hospitals in 36 states. In weeks 18 to 48 of 2020, 35 851 hospital-weeks (36.7%) had low COVID-19 admission rates, and 8094 (8.3%) had high rates. Quality indicators for patients without COVID-19 significantly worsened in 2020 during weeks with high vs low COVID-19 admissions. Pressure ulcer rates increased by 0.09 per 1000 admissions (95% CI, 0.01-0.17 per 1000 admissions; relative change, 24.3%), heart failure mortality increased by 0.40 per 100 admissions (95% CI, 0.18-0.63 per 100 admissions; relative change, 21.1%), hip fracture mortality increased by 0.40 per 100 admissions (95% CI, 0.04-0.77 per 100 admissions; relative change, 29.4%), and a weighted mean of mortality for the selected indicators increased by 0.30 per 100 admissions (95% CI, 0.14-0.45 per 100 admissions; relative change, 10.6%). Conclusions and Relevance: In this cross-sectional study, COVID-19 surges were associated with declines in hospital quality, highlighting the importance of identifying and implementing strategies to maintain care quality during periods of high hospital use.

A Nationally Representative Summary of 2020 Changes in the Use of Health Care in the United States.

The COVID-19 pandemic produced an unprecedented shock to the U.S. health care system. Prior literature documenting 2020 changes has been limited to certain types of care or subsets of patients. We use the nationally representative Medical Expenditure Panel Survey to summarize changes in all types of health care from 2018 through 2020. Outpatient visits, emergency department visits, and inpatient admissions each fell about 35% in April 2020. Dental visits fell over 80%. Ophthalmology visits declined 71% and mammograms 82%. Psychiatric visits rose slightly (1.6%). By the end of 2020, specialist physician visits recovered, though primary care and dental visits remained 12% lower than 2019.

COVID-19 Admission Rates and Changes in US Hospital Inpatient and Intensive Care Unit Occupancy.

Importance: The COVID-19 pandemic had unprecedented effects on hospital occupancy, with consequences for hospital operations and patient care. Previous studies of occupancy during COVID-19 have been limited to small samples of hospitals. Objective: To measure the association between COVID-19 admission rates and hospital occupancy in different US areas and at different time periods during 2020. Design, Setting, and Participants: This cross-sectional study used data from the Healthcare Cost and Utilization Project State Inpatient Databases (2019-2020) for patients in nonfederal acute care hospitals in 45 US states, including the District of Columbia. Data analysis was performed between September 1, 2022, and April 30, 2023. Exposures: Each hospital and week in 2020 was categorized based on the number of COVID-19 admissions per 100 beds (<1 [low], 1-4.9, 5-9.9, 10-14.9, or ≥15 [high]). Main Outcomes and Measures: The main outcomes were inpatient and intensive care unit (ICU) occupancy. We used regression analysis to estimate the average change in occupancy for each hospital-week in 2020 relative to the same hospital week in 2019. Results: This study included 3960 hospitals and 54 355 916 admissions. Of the admissions in the 40 states used for race and ethnicity analyses, 15.7% were for Black patients, 12.9% were for Hispanic patients, 62.5% were for White patients, and 7.2% were for patients of other race or ethnicity; 1.7% of patients were missing these data. Weekly COVID-19 admission rates in 2020 were less than 4 per 100 beds for 63.9% of hospital-weeks and at least 10 in only 15.9% of hospital-weeks. Inpatient occupancy decreased by 12.7% (95% CI, 12.1% to 13.4%) during weeks with low COVID-19 admission rates and increased by 7.9% (95% CI, 6.8% to 9.0%) during weeks with high COVID-19 admission rates. Intensive care unit occupancy rates increased by 67.8% (95% CI, 60.5% to 75.3%) during weeks with high COVID-19 admissions. Increases in ICU occupancy were greatest when weighted to reflect the experience of Hispanic patients. Changes in occupancy were most pronounced early in the pandemic. During weeks with high COVID-19 admissions, occupancy decreased for many service lines, with occupancy by surgical patients declining by 43.1% (95% CI, 38.6% to 47.2%) early in the pandemic. Conclusions and Relevance: In this cross-sectional study of US hospital discharges in 45 states in 2020, hospital occupancy decreased during weeks with low COVID-19 admissions and increased during weeks with high COVID-19 admissions, with the largest changes occurring early in the pandemic. These findings suggest that surges in COVID-19 strained ICUs and were associated with large decreases in the number of surgical patients. These occupancy fluctuations may have affected quality of care and hospital finances.

Primary Care Spending in the US Population.

This survey study assesses the 2019 spending estimates on checkups, well-child visits, and diagnosis or treatment provided by primary care physicians, nurses, nurse practitioners, and physician's assistants.

Association Between Medicaid Dental Payment Policies and Children's Dental Visits, Oral Health, and School Absences.

Importance: Although all state Medicaid programs cover children's dental services, less than half of publicly insured children receive recommended care. Objective: To evaluate the association between the ratio of Medicaid payment rates to dentist charges for an index of services (fee ratio) and children's preventive dental visits, oral health, and school absences. Design, Setting, and Participants: In this cross-sectional study, a difference-in-differences analysis was conducted between September 2021 and April 2022 of 15 738 Medicaid-enrolled children and a control group of 16 867 privately insured children aged 6 to 17 years who participated in the 2016-2019 National Survey of Children's Health. Exploratory subgroup analyses by sex and race and ethnicity were also performed. A 2-sided P < .05 was considered significant. Main Outcomes and Measures: Past-year preventive dental visits (at least 1 and at least 2), parent-reported excellent oral health, and number of days absent from school (at least 4 days and at least 7 days). Results: The Medicaid-enrolled sample included a weighted estimate of 51.20% boys and 48.80% girls (mean age, 11.24 years; Black, 21.65%; Hispanic, 37.75%; White, 31.45%). By weighted baseline estimates, 87% and 48% of Medicaid-enrolled children had at least 1 and at least 2 past-year dental visits, respectively, and 29% had parent-reported excellent oral health. Increasing the fee ratio by 1 percentage point was associated with percentage point increases of 0.18 in at least 1 dental visit (95% CI, 0.07-0.30), 0.27 in at least 2 visits (95% CI, 0.04-0.51), and 0.19 in excellent oral health (95% CI, 0.01-0.36). Increases in at least 2 visits were larger for Hispanic children than for White children. By weighted baseline estimates, 28% and 15% of Medicaid-enrolled children had at least 4 and at least 7 past-year school absences, respectively. Regression estimates for school absences were not statistically significant for the full sample but were estimated to be significantly reduced among girls. Conclusions and Relevance: This cross-sectional study found that more generous Medicaid payment policies were associated with significant but modest increases in children's preventive dental visits and excellent oral health. Further research is needed to understand the potential association between policies that improve access to dental care and children's academic success.

Eligibility for and Enrollment in Medicaid Among Nonelderly Adults After Implementation of the Affordable Care Act.

The Affordable Care Act's (ACA) Medicaid expansion resulted in substantial gains in coverage. However, little research has documented eligibility or participation rates among eligible adults in the post-ACA period in part because of the complexities involved in assigning eligibility status. We used simulation modeling to examine Medicaid eligibility and participation during 2014 to 2017. More than one in five adults were Medicaid eligible in expansion states in the post-ACA period. In contrast, about one in 30 adults were Medicaid eligible in nonexpansion states. While eligibility rates differed substantially by expansion status, participation rates among Medicaid-eligible adults were similar in both sets of states (44% to 46%). These estimates indicate that differences in eligibility rather than in participation rates explained differences in enrollment between expansion and nonexpansion states during the study period. Participation in Medicaid is expected to grow during the coronavirus pandemic. Our study provides baseline estimates for future analyses of enrollment trends.

The Association Between Medicaid Adult Dental Coverage And Children's Oral Health.

Although all state Medicaid programs cover children's dental care, Medicaid-eligible children are more likely to experience tooth decay than children in higher-income families. Using data from the 1999-2016 National Health and Nutrition Examination Survey and the 2003, 2007, and 2011-12 waves of the National Survey of Children's Health, we examined the association between Medicaid adult dental coverage (an optional benefit) and children's oral health. Adult dental coverage was associated with a statistically significant 5-percentage-point reduction in the prevalence of untreated caries among children after Medicaid-enrolled adults had access to coverage for at least one year. These policies were also associated with a reduction in parent-reported fair or poor child oral health with a two-year lag between the onset of the policy and the effect. Effects were concentrated among children younger than age twelve. We estimated declines in poor oral health among all racial and ethnic subgroups, although there was some evidence that non-Hispanic Black children experienced larger and more persistent effects than non-Hispanic White children. Future assessments of the costs and benefits of offering adult dental coverage may consider potential effects on the children of adult Medicaid enrollees.

The Affordable Care Act Appears to Have Narrowed Racial and Ethnic Disparities in Insurance Coverage and Access to Care Among Young Adults.

Prior to the Affordable Care Act, one in three young adults aged 19 to 25 years were uninsured, with substantial racial/ethnic disparities in coverage. We analyzed the separate and cumulative changes in racial/ethnic disparities in coverage and access to care among young adults after implementation of the Affordable Care Act's 2010 dependent coverage provision and 2014 Medicaid and Marketplace expansions. We find that the dependent coverage provision was associated with similar gains across racial/ethnic groups, but the 2014 expansion was associated with larger gains in coverage among Hispanics and Blacks relative to Whites. After the 2014 expansion, coverage increased by 11.0 and 10.1 percentage points among Hispanics and Blacks, respectively, compared with a 5.6 percentage point increase among Whites. The percentage with a usual source of care and a recent doctor's visit also increased more for Blacks relative to Whites. Increases in coverage were larger in Medicaid expansion compared with nonexpansion states for most racial/ethnic groups.

Association between Medicaid adult nonemergency dental benefits and dental services use and expenditures.

BACKGROUND: Only some states provide coverage of nonemergency dental services for adult Medicaid enrollees. This study examined the association between coverage of Medicaid adult nonemergency dental services and dental services use and expenditures. METHODS: The authors analyzed data from the 2000 through 2015 Medical Expenditure Panel Survey Household Component for adults 21 years or older enrolled in Medicaid. The authors examined a range of outcomes such as dental visits, preventive and 5 other types of dental services, and total and out-of-pocket dental expenditures. Multivariate regression models were used to estimate the differences in outcomes for Medicaid enrollees between states that provided coverage of nonemergency dental services and states that did not, controlling for potentially confounding factors. RESULTS: Compared with Medicaid enrollees in states that did not provide coverage, enrollees in states that provided coverage of nonemergency dental services were approximately 9 percentage points more likely to have a dental visit, approximately 7 percentage points more likely to have any preventive dental service, and more likely to have all other types of dental services except oral surgery services. Among enrollees with any visit, out-of-pocket share of dental expenditures was approximately 19 percentage points lower among those in covered states than those in uncovered states. CONCLUSIONS: Medicaid adult nonemergency dental benefits were associated with higher use of preventive and other types of dental services and lower out-of-pocket share of dental costs. PRACTICAL IMPLICATIONS: Our results may help inform policy makers as they consider ways of improving dental health of adults through Medicaid.

Coverage For Self-Employed And Others Without Employer Offers Increased After 2014.

Little is known about how the Affordable Care Act might have differentially affected insurance coverage for self-employed workers, wage earners with and without offers of employer-sponsored insurance, and people not employed. We found that the self-employed and wage earners without employer coverage offers had coverage gains equal to or greater than those of people not employed.

No Association Found Between The Medicaid Primary Care Fee Bump And Physician-Reported Participation In Medicaid.

On average, state Medicaid programs paid 59 percent of what Medicare paid for primary care services in 2012. The Affordable Care Act required states in 2013 and 2014 to raise Medicaid payment rates to primary care physicians for certain services to the level of Medicare rates. The result was an average 73 percent increase in primary care Medicaid payments for qualifying physicians. This study used nationally representative data to examine the association between this Medicaid "fee bump" and physician-reported measures of participation in Medicaid. No such association was found. For example, about 65 percent of primary care physicians reported accepting new Medicaid patients in both 2012 and 2013, whereas about 67 percent reported doing so in 2014-a difference that is not significant. Multivariate results were similar. The lack of a sizable change in measures of physician participation in Medicaid may have been due to the temporary nature of the fee bump.

Has inpatient hospital treatment before and after age 65 changed as the difference between private and Medicare payment rates has widened?

The past decade witnessed a dramatic increase in inpatient hospital payment rates for patients with private insurance relative to payment rates for those covered by Medicare. A natural question is whether the widening private-Medicare payment rate difference had implications for the hospital care received by patients just before and after turning 65-the age at which there is a substantial shift from private to Medicare coverage. Using a large discharge dataset covering the period 2001-2011, we tracked changes at age 65 in the following dimensions of hospital care: overall hospitalization rates, case mix, referral-sensitive surgeries, length of stay, full established charges, number of procedures, mortality, and composite measures of inpatient quality and patient safety. In all cases we found either no change or a change that was small and inconsistent with payment rate changes during the study period.

Protein corona-mediated targeting of nanocarriers to B cells allows redirection of allergic immune responses.

BACKGROUND: Nanoparticle (NP)-based vaccines are attractive immunotherapy tools because of their capability to codeliver antigen and adjuvant to antigen-presenting cells. Their cellular distribution and serum protein interaction ("protein corona") after systemic administration and their effect on the functional properties of NPs is poorly understood. OBJECTIVES: We analyzed the relevance of the protein corona on cell type-selective uptake of dextran-coated NPs and determined the outcome of vaccination with NPs that codeliver antigen and adjuvant in disease models of allergy. METHODS: The role of protein corona constituents for cellular binding/uptake of dextran-coated ferrous nanoparticles (DEX-NPs) was analyzed both in vitro and in vivo. DEX-NPs conjugated with the model antigen ovalbumin (OVA) and immunostimulatory CpG-rich oligodeoxynucleotides were administered to monitor the induction of cellular and humoral immune responses. Therapeutic effects of this DEX-NP vaccine in mouse models of OVA-induced anaphylaxis and allergic asthma were assessed. RESULTS: DEX-NPs triggered lectin-induced complement activation, yielding deposition of activated complement factor 3 on the DEX-NP surface. In the spleen DEX-NPs targeted predominantly B cells through complement receptors 1 and 2. The DEX-NP vaccine elicited much stronger OVA-specific IgG2a production than coadministered soluble OVA plus CpG oligodeoxynucleotides. B-cell binding of the DEX-NP vaccine was critical for IgG2a production. Treatment of OVA-sensitized mice with the DEX-NP vaccine prevented induction of anaphylactic shock and allergic asthma accompanied by IgE inhibition. CONCLUSIONS: Opsonization of lectin-coated NPs by activated complement components results in selective B-cell targeting. The intrinsic B-cell targeting property of lectin-coated NPs can be exploited for treatment of allergic immune responses.

Medicaid Expansion And Marketplace Eligibility Both Increased Coverage, With Trade-Offs In Access, Affordability.

Affordable Care Act (ACA) provisions implemented in 2014 provide a valuable case study regarding the merits of using public versus subsidized private insurance to help low-income people obtain and finance health care. In particular, nonelderly adults with incomes of 100-138 percent of the federal poverty level gained Medicaid eligibility if they lived in states that implemented the ACA's Medicaid expansion, whereas those in nonexpansion states became eligible for subsidized Marketplace coverage. Using data for 2008-15 from the National Health Interview Survey, we found that as of 2015, adults with family incomes in this range had experienced large declines in uninsurance rates in both expansion and nonexpansion states (the adjusted declines were 22 percentage points and 18 percentage points, respectively). Adults in expansion and nonexpansion states also experienced similar increases in having a usual source of care and primary care visits, and similar reductions in delayed receipt of medical care due to cost. There were, however, important differences: Adults in expansion states experienced larger reductions in out-of-pocket spending but also faced greater difficulty accessing physician care relative to adults in nonexpansion states.

Medicaid Expansion Coverage Effects Grew In 2015 With Continued Improvements In Coverage Quality.

Previous research has demonstrated large gains in insurance coverage associated with the Affordable Care Act's (ACA's) Medicaid expansion in 2014. We used detailed federal survey data through 2015 to analyze more recent changes in coverage for low-income adults after the expansion. We found that the uninsurance rate fell in both expansion and nonexpansion states but that it fell significantly more in expansion states. By 2015 the post-ACA uninsurance rate for low-income adults had fallen by 7.5 percentage points more in expansion than in nonexpansion states, a difference that was similar (about 6.8 percentage points) in adjusted regression models. Private coverage increased in nonexpansion states, but significantly less than Medicaid coverage increased in expansion states. Rates of private coverage did not appear to decline in expansion states. Finally, Medicaid expansion was associated with significantly improved quality of health coverage, as reported by low-income adults.