Medicare Skilled Nursing Facility Use and Spending Before and After Introduction of the Public Health Emergency Waiver During the COVID-19 Pandemic.

Importance: In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits. Objective: To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries. Design, Setting, and Participants: This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs. Exposures: The prepandemic period (January 2018-February 2020) vs the PHE period (March 2020-September 2021). Main Outcomes and Measures: The main outcomes were SNF episode volume, characteristics, and costs. Episodes were defined as standard (with a preceding 3-day hospitalization) or waiver (with other or no acute care use). Results: Skilled nursing facility care was provided to 4 299 863 Medicare fee-for-service beneficiaries. Medicare beneficiaries had on average 130 400 monthly SNF episodes in the prepandemic period (mean [SD] age of beneficiaries, 78.9 [11.0] years; 59% female) and 108 575 monthly episodes in the PHE period (mean [SD] age of beneficiaries, 79.0 [11.1] years; 59% female). All waiver episodes increased from 6% to 32%, and waiver episodes without preceding acute care increased from 3% to 18% (from 4% to 49% among LTC residents). Skilled nursing facility episodes provided for LTC residents increased by 77% (from 15 538 to 27 537 monthly episodes), primarily due to waiver episodes provided for residents with COVID-19 in 2020 and early 2021 (62% of waiver episodes without preceding acute care). Skilled nursing facilities in the top quartile of waiver episodes were more often for-profit (80% vs 68%) and had lower quality ratings (mean [SD] overall star rating, 2.7 [1.4] vs 3.2 [1.4]; mean [SD] staffing star rating, 2.5 [1.1] vs 3.0 [1.2]) compared with SNFs in the other quartiles. Monthly Medicare spending on SNF care was $2.1 billion before the pandemic and $2.0 billion during the PHE. For LTC residents, monthly SNF spending increased from $301 million to $585 million while spending on hospitalizations remained relatively stable. Conclusions and Relevance: This cohort study found that the PHE waiver for SNF care was associated with a marked increase in the prevalence of SNF episodes without a preceding hospitalization, especially in the first year of the COVID-19 pandemic. The waiver was used primarily among certain types of facilities and for LTC residents with COVID-19. Although the effect of the waiver cannot be differentiated from that of the pandemic, overall SNF care costs did not increase substantially; for LTC residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation.

Care Disruption During COVID-19: a National Survey of Hospital Leaders.

BACKGROUND: The COVID-19 pandemic caused massive disruption in usual care delivery patterns in hospitals across the USA, and highlighted long-standing inequities in health care delivery and outcomes. Its effect on hospital operations, and whether the magnitude of the effect differed for hospitals serving historically marginalized populations, is unknown. OBJECTIVE: To investigate the perspectives of hospital leaders on the effects of COVID-19 on their facilities' operations and patient outcomes. METHODS: A survey was administered via print and electronic means to hospital leaders at 588 randomly sampled acute-care hospitals participating in Medicare's Inpatient Prospective Payment System, fielded from November 2020 to June 2021. Summary statistics were tabulated, and responses were adjusted for sampling strategy and non-response. RESULTS: There were 203 responses to the survey (41.6%), with 20.7% of respondents representing safety-net hospitals and 19.7% representing high-minority hospitals. Over three-quarters of hospitals reported COVID testing shortages, about two-thirds reported staffing shortages, and 78.8% repurposed hospital spaces to intensive care units, with a slightly higher proportion of high-minority hospitals reporting these effects. About half of respondents felt that non-COVID inpatients received worsened quality or outcomes during peak COVID surges, and almost two-thirds reported worsened quality or outcomes for outpatient non-COVID patients as well, with few differences by hospital safety-net or minority status. Over 80% of hospitals participated in alternative payment models prior to COVID, and a third of these reported decreasing these efforts due to the pandemic, with no differences between safety-net and high-minority hospitals. CONCLUSIONS: COVID-19 significantly disrupted the operations of hospitals across the USA, with hospitals serving patients in poverty and racial and ethnic minorities reporting relatively similar care disruption as non-safety-net and lower-minority hospitals.

Supplier Risk Tower: The Vigilant Eye on Supply Chains

The disruptions in international supply chains caused by the COVID-19 pandemic highlight the importance of considering risk in supply chain management. Using an action research approach, we examine supply chain risk management at a tier-1 automotive supplier. We focus on the inbound supply risk of this supplier and introduce the new Supplier Risk Tower risk assessment. The Supplier Risk Tower combines vulnerability indices specific to the supply chain, supplier feedback on the current risk situation, and impact assessment from the tier-1's perspective. What is novel about this approach is that risk is calculated as an absolute number which provides guidance, especially for rare but severe disruptions. This approach also expands the understanding of lean management regarding the raison d'être of buffer stocks in supply chains. Because risks materialize. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Brain autopsies of critically ill COVID-19 patients demonstrate heterogeneous profile of acute vascular injury, inflammation and age-linked chronic brain diseases.

BACKGROUND: This study examined neuropathological findings of patients who died following hospitalization in an intensive care unit with SARS-CoV-2. METHODS: Data originate from 20 decedents who underwent brain autopsy followed by ex-vivo imaging and dissection. Systematic neuropathologic examinations were performed to assess histopathologic changes including cerebrovascular disease and tissue injury, neurodegenerative diseases, and inflammatory response. Cerebrospinal fluid (CSF) and fixed tissues were evaluated for the presence of viral RNA and protein. RESULTS: The mean age-at-death was 66.2 years (range: 26-97 years) and 14 were male. The patient's medical history included cardiovascular risk factors or diseases (n = 11, 55%) and dementia (n = 5, 25%). Brain examination revealed a range of acute and chronic pathologies. Acute vascular pathologic changes were common in 16 (80%) subjects and included infarctions (n = 11, 55%) followed by acute hypoxic/ischemic injury (n = 9, 45%) and hemorrhages (n = 7, 35%). These acute pathologic changes were identified in both younger and older groups and those with and without vascular risk factors or diseases. Moderate-to-severe microglial activation were noted in 16 (80%) brains, while moderate-to-severe T lymphocyte accumulation was present in 5 (25%) brains. Encephalitis-like changes included lymphocytic cuffing (n = 6, 30%) and neuronophagia or microglial nodule (most prominent in the brainstem, n = 6, 30%) were also observed. A single brain showed vasculitis-like changes and one other exhibited foci of necrosis with ball-ring hemorrhages reminiscent of acute hemorrhagic leukoencephalopathy changes. Chronic pathologies were identified in only older decedents: 7 brains exhibited neurodegenerative diseases and 8 brains showed vascular disease pathologies. CSF and brain samples did not show evidence of viral RNA or protein. CONCLUSIONS: Acute tissue injuries and microglial activation were the most common abnormalities in COVID-19 brains. Focal evidence of encephalitis-like changes was noted despite the lack of detectable virus. The majority of older subjects showed age-related brain pathologies even in the absence of known neurologic disease. Findings of this study suggest that acute brain injury superimposed on common pre-existing brain disease may put older subjects at higher risk of post-COVID neurologic sequelae.

Supplier Risk Tower: The Vigilant Eye on Supply Chains

The disruptions in international supply chains caused by the COVID-19 pandemic highlight the importance of considering risk in supply chain management. Using an action research approach, we examine supply chain risk management at a tier-1 automotive supplier. We focus on the inbound supply risk of this supplier and introduce the new Supplier Risk Tower risk assessment. The Supplier Risk Tower combines vulnerability indices specific to the supply chain, supplier feedback on the current risk situation, and impact assessment from the tier-1’s perspective. What is novel about this approach is that risk is calculated as an absolute number which provides guidance, especially for rare but severe disruptions. This approach also expands the understanding of lean management regarding the raison d’être of buffer stocks in supply chains. Because risks materialize. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Life-Writing and Virtual Exchange: An Exploration of the Impact on Students’ Learning Experiences

While we find ourselves immersed in a virtual society, the opportunity to use digital technologies for dialogue and understanding is still not well represented at third-level, despite the dramatic move towards teaching online during the Covid-19 pandemic. This paper presents a web-based Virtual Exchange (VE) between Cork (UCC) and the Fachhochschule Dresden (FHD) with a focus on life-writing and biography, developing qualitative research skills and speaking the foreign language (FL). Each student was tasked with conducting three interviews with their designated peer in the FL and producing a website (blog) or e-portfolio to present and reflect on findings. The first iteration of the module took place in 2020-21. This paper discusses students’ learning experiences during the updated, follow-up course in 2021-22. Findings show that they learned most in the interaction with their peers, learning through self-disclosure, sharing meaningful experiences, negotiating (difficult) life experiences and expanding their FL skills. The findings also point to evidence of transformational learning in the sample group. We conclude with some insights regarding the future development of the VE and include important limitations of the study. © 2022, The Irish Association for Applied Linguistics. All rights reserved.

LONG-TERM OUTCOME OF CEREBRAL VENOUS THROMBOSIS DUE TO SARS-COV-2 VACCINE-INDUCED IMMUNE THROMBOTIC THROMBOCYTOPENIA

Background and aims: Since initiation of COVID-19 vaccination, cases of cerebral venous thrombosis (CVT) due to vaccine-induced immune thrombotic thrombocytopenia (VITT) have been reported. Reported in-hospital mortality varies between 20-50%, but data on longterm outcome of surviving patients with CVT-VITT are not available. Methods: We report follow-up data of CVT-VITT cases after COVID- 19 vaccination from an international registry. VITT was classified according to the Pavord criteria. Outcomes were mortality, functional dependency, relapse of VITT, new thrombosis, and new bleeding events. Results: Of 62 patients with CVT-VITT who survived initial hospital admission, follow-up data were available for 48/62 (77%) cases (32 (67%) definite VITT, 7 (15%) probable VITT, 9 (19%) possible VITT). Median time from diagnosis to last follow-up was 110 days (IQR 86-174). There were no new venous or arterial thrombotic events reported in any case. Among 35/44 (80%) cases that achieved clinical remission, 0/29 cases had a relapse of VITT. Major bleeding was reported in 1/45 (2%) cases (intracranial bleed). Mortality at follow-up was 1/48 (2%, 95%CI 0-11%). 44/48 (92%) cases had a modified Rankin Scale score of 0-2 at follow-up, compared to 32/46 (70%) at hospital discharge. 16/34 (47%) of cases had returned to work or school. Conclusions: In patients who survive the acute phase of CVT-VITT, long-term mortality is low and thrombotic and bleeding events are rare. Approximately half of the CVT-VITT patients at follow-up could resume all daily activities.

CHANGE IN MANAGEMENT AND DECREASE IN MORTALITY OF CEREBRAL VENOUS SINUS THROMBOSIS WITH THROMBOCYTOPENIA AFTER SARS-COV-2 VACCINATION

Background and aims: Cerebral venous sinus thrombosis with thrombocytopenia syndrome (CVST-TTS) is a rare adverse effect of adenovirus- based SARS-CoV-2 vaccines. After the autoimmune pathogenesis of TTS was discovered, treatment recommendations were issued. The aim of this study was to evaluate if adherence to treatment recommendations was associated with lower mortality. Methods: TTS was defined according to the Brighton criteria. Cases from a prospective international CVT registry with symptom onset within 28 days of adenovirus-based SARS-CoV-2 vaccination were analysed. Treatment recommendations, following the International Society of Thrombosis and Haemostasis, included use of immunomodulation, non-heparin anticoagulants, and avoidance of platelet transfusions, unless needed for surgery. Results: Out of 178 CVT cases from 117 centres in 19 countries reported between March 29 and September 3, 2021, 95 patients fulfilled inclusion criteria. Five of 37 (14%), 13/25 (52%), and 29/33 (88%) of patients diagnosed in March, April, and from May onwards, respectively, were treated according to recommendations. Proportion of patients diagnosed in March, April, and from May onwards who received immunomodulation increased from 19/37 (51%) over 15/25 (60%) to 30/33 (90%), and the percentage of patients who were treated with heparins [26/37 (70%), 4/25 (16%), 1/33 (3%)] and platelet transfusion [15/37 (41%), 4/25 (16%), 7/33 (21%), respectively] decreased accordingly. Mortality of patients treated according to recommendations was 14/47 (30%, 95%CI 19-44%) compared to 28/48 (58%, 95%CI 44-71%) in patients not treated according to recommendations (OR 3.30, 95%CI 1.41-7.71). Conclusions: Over time, adherence to treatment recommendations improved, and mortality rate of patients with CVST-TTS decreased.

CEREBRAL VENOUS THROMBOSIS DUE TO VACCINE-INDUCED IMMUNE THROMBOTIC THROMBOCYTOPENIA AFTER A SECOND CHADOX1 NCOV-19 VACCINE DOSE

Background and aims: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare side effect of the ChAdOx1 nCoV-19 COVID- 19 vaccine (AstraZeneca/Oxford) and often manifests as cerebral venous thrombosis (CVT). So far, CVT-VITT has only been reported after a first ChAdOx1 nCoV-19 dose. Methods: We report cases (March-December 2021) of CVT-VITT after a second ChAdOx1 nCoV-19 vaccine dose from an international CVTVITT registry. We classified certainty of VITT diagnosis using criteria of the United Kingdom Expert Haematology Panel. Results: Out of 124 CVT cases that developed after ChAdOx1 nCoV- 19 vaccination, 120 were after a first dose (61 definite, 20 probable, 10 possible and 29 unlikely VITT), and 4 after a second dose (1 definite, 1 probable, 1 possible and 1 unlikely VITT). None of the four patients had any symptoms after the first ChAdOx1 nCoV-19 dose. All cases had symptom onset between 1 and 6 days after the second vaccination, thrombocytopenia, and increased D-dimer levels. Anti-PF4 antibodies were positive in 2/3 tested cases. Two patients presented in a coma and died during admission. Conclusion: CVT-VITT can occur after a second dose of ChAdOx1 nCoV-19 vaccine, but was reported substantially less often after a second than after a first vaccine dose. In some cases, symptom onset of VITT may be more rapid after a second than after the first dose, although the small number of cases precludes firm conclusions.

DECOMPRESSIVE SURGERY IN CEREBRAL VENOUS SINUS THROMBOSIS WITH VACCINE-INDUCED IMMUNE THROMBOTIC THROMBOCYTOPENIA

Background and aims: Cerebral venous sinus thrombosis with thrombosis with thrombocytopenia syndrome (CVST-TTS) is a serious adverse drug reaction after adenoviral SARS-CoV-2 vaccinations. CVST-TTS patients may need decompressive surgery to avoid fatal brain herniation, but despite this intervention, many CVST-TTS patients die during the initial hospital admission. Here, we describe the characteristics and outcomes of CVST-TTS patients who underwent decompressive surgery and explore predictors of mortality in CVST-TTS patients. Methods: We used data from an ongoing international registry collecting data from patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March and 9 December 2021. TTS was defined in accordance with the Brighton Collaboration case definition. Results: Out of 97 CVST-TTS patients, 29 (30%) underwent decompressive surgery. All operated patients had an intracerebral haemorrhage before the surgery. In-hospital mortality was 19/29 (66%) in the operated and 23/68 (34%) in the non-operated group. In the operated group, the highest mortality rate was among patients who were in coma before the surgery (14/15, 93% vs 4/12, 33% in those not in coma), had bilateral absence of the pupillary response (7/7, 100% vs 8/16, 50% in patients with uni/bilateral pupillary response) and platelet count <50 x103/μL (11/14, 79% vs 6/12, 50% in cases with a platelet count ≥50 x103/μL). Conclusion: Mortality rate of CVST-TTS patients who underwent decompressive surgery is extremely high. Among the operated patients, coma before the surgery, bilateral absence of the pupillary response, and platelet count <50 x103/μL were the predictors of mortality.

Changes in Employment Status and Access to Care During COVID-19 Pandemic Among Low-Income Adults in 4 Southern States.

BACKGROUND: While the impact of the COVID-19 recession on the economy is clear, there is limited evidence on how the COVID-19 pandemic-related job losses among low-income people may have affected their access to health care. OBJECTIVE: To determine the association of job loss during the pandemic with insurance coverage and access to and affordability of health care among low-income adults. DESIGN: Using a random digit dialing telephone survey from October 2020 to December 2020 of low-income adults in 4 states-Arkansas, Kentucky, Louisiana, and Texas-we conducted a series of multivariable logistic regression analyses, adjusting for demographics, chronic conditions, and state of residence. PARTICIPANTS: US citizens aged 19-64 with a family income less than 138% of the federal poverty line who became newly unemployed during pandemic, remained employed during pandemic, or were chronically unemployed before and during the pandemic. MAIN MEASURES: Rates of insurance, type of insurance coverage, measures of access to/affordability of care, and food/housing security KEY RESULTS: Of 1,794 respondents, 14.5% were newly unemployed, 49.6% were chronically unemployed, and 35.7% were employed. The newly unemployed were slightly younger and more likely Black or Latino. The newly unemployed were more likely to report uninsurance compared to the employed (+16.4 percentage points, 95% CI 6.0-26.9), and the chronically unemployed (+26.4 percentage points, 95% CI 16.2-36.6), mostly driven by Texas' populations. The newly unemployed also reported lower rates of access to care and higher rates of financial barriers to care. They were also more likely to report food and housing insecurity compared to others. CONCLUSIONS: In a survey of 4 Southern States during pandemic, the newly unemployed had higher rates of uninsurance and worse access to care-largely due to financial barriers-and reported more housing and food insecurity than other groups. Our study highlights the vulnerability of low-income populations who experienced a job loss, especially in Texas, which did not expand Medicaid.

Marketplace Health Insurance Ratings: Most Potential Enrollees Have Access To Plans Of Medium Or High Quality.

The Affordable Care Act (ACA) Marketplace plays a critical role in providing affordable health insurance for the nongroup market, yet the accessibility of plans from insurers with high quality ratings has not been investigated. Our analysis of recently released insurer quality star ratings for plan year 2020 found substantial variation in access to high rated plans in the federally facilitated ACA Marketplace. In most participating counties (1,390 of 2,265, or 61.4 percent), the highest-rated ACA Marketplace insurer had a three-star rating. Fewer than one-third of counties (703, or 31.0 percent) had access to four- or five-star-rated insurers. Fewer than 10 percent (172, or 7.6 percent) had access to only one- or two-star-rated insurers. In plan-based analyses, each one-point increase in star rating was associated with a $28 increase in the average monthly plan premium. Counties with the highest proportion of residents obtaining individual coverage through the ACA Marketplace and counties with more insurers were the most likely to have access to plans from high-rated insurers. We found no systematic racial or ethnic disparities in access to plans from high-rated insurers. Policy makers should continue to monitor the quality of available health plans.

Age stratified risk of cerebral venous sinus thrombosis after SARS-CoV-2 vaccination

Introduction: Cerebral Venous Sinus Thrombosis (CVST) as a part of the thrombosis and thrombocytopenia syndrome is a rare adverse drug reaction of SARS-CoV-2 vaccination. The estimated background rate of CVST in adults is around 1 case per million per month, and CVST with thrombocytopenia accounts for 8% of all CVST. We assessed the age-stratified risk of CVST with and without thrombocytopenia after SARS-CoV-2 vaccination. Methods: We estimated the absolute risk of any CVST, CVST with thrombocytopenia, and CVST without thrombocytopenia, within 28 days of first dose SARS-CoV-2 vaccination, using data from the European Medicines Agency's EudraVigilance database (until 13 June 2021). As a denominator, we used data on vaccine delivery from 31 European countries. For 22.8 million adults from 25 countries we estimated the absolute risk of CVST after the first dose of ChAdOx1 nCov-19 per age category. Results: The absolute risk of CVST within 28 days of first dose vaccination was 7.5 (95%CI 6.9- 8.3), 0.7 (95%CI 0.2-2.4), 0.6 (95%CI 0.5-0.7) and 0.6 (95%CI 0.3-1.1) per million of first doses of ChAdOx1 nCov-19, Ad26.COV2.S, BNT162b2 and mRNA-1273, respectively. The absolute risk of CVST with thrombocytopenia within 28 days of first dose vaccination was 4.4 (95%CI 3.9-4.9), 0.7 (95%CI 0.2-2.4), 0.0 (95%CI 0.0-0.1) and 0.0 (95%CI 0.0-0.2) per million of first doses of ChAdOx1 nCov-19, Ad26.COV2.S, BNT162b2 and mRNA-1273, respectively. In recipients of ChAdOx1 nCov-19, the risk of CVST, both with and without thrombocytopenia, was the highest in the 18-24 years age group (7.3 per million, 95%CI 2.8-18.8 and 3.7, 95%CI 1.0-13.3, respectively). The risk of CVST with thrombocytopenia was the lowest in ChAdOx1 nCov-19 recipients ≥70 years (0.2, 95%CI 0.0- 1.3). Age <60 compared to ≥60 was a predictor for CVST with thrombocytopenia (incidence rate ratio 5.79;95%CI 2.98-11.24, p<0.001). Discussion: The risk of CVST with thrombocytopenia within 28 days of first dose vaccination with ChAdOx1 nCov-19 was higher in younger age groups. The risk of CVST with thrombocytopenia was slightly increased in patients receiving Ad26.COV2.S, comparing with the estimated background risk. The risk of CVST with thrombocytopenia was not increased in recipients of mRNA vaccines for SARS-CoV-2.

Critical Teaching-Learning Situations in Higher Education and Vocational Education – A Qualitative Analysis of the Use of Digital Approaches and Tools in Virtual Collaborative Learning Environment

Due to internal and external events, such as the current Covid 19 pandemic, there are multiple changes in almost all life situations, thus also in pedagogical contexts of the education sector. In this context, concepts of learning guidance and learning support are of outstanding importance for development in higher education and vocational training. In particular, the immediate challenge is to transfer the tasks of learning guidance and learning support to virtual teaching and learning spaces in higher education and vocational training [1, 2]. For this purpose, the open-source online learning platform ILIAS™ and the web meeting software Adobe Connect™ were investigated in order to analyze critical teaching-learning situations in online learning and to derive recommendations for action. The results shown suggest that the development towards virtual teaching scenarios, which has become a necessity under the enforced conditions caused by the COVID-19 blocks, will also have an enormous impact on teaching and learning processes in the future in terms of didactics tailored to different learning groups and needs in and outside the classroom. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Ischemic stroke in consecutive patients with COVID-19: A case-control study of clinical features, mechanisms and outcome in the swiss stroke registry

Background and Aims: Most case series of patients with ischemic stroke (IS) and COVID-19 are limited to random centers or lack 3-month outcome. The aim of this study is to describe prevalence, clinical, radiological and pathophysiological features and long-term outcome of COVID-19-related IS in a nationwide stroke registry. Methods: From the Swiss Stroke Registry (SSR), we included all consecutive IS patients aged ≥18 years who were admitted to stroke units during the first wave of COVID-19 (25.02.-08.06.2020). We compared baseline features, stroke etiology and 3-month outcome (modified Rankin shift) of COVID PCR+ IS patients with COVID PCR-and/or asymptomatic non-tested IS patients. Results: Of the 2376 IS patients entered in the SSR during the study period, 36 (1.5%) had confirmed COVID-19 infection (details in Figure 1). In multivariate analysis, COVID+ patients had lower admission blood pressure (p=0.004) and more frequently lesions in multiple vascular territories (p=0.09). Stroke seemed more often related to several defined etiologies (p=0.07), and less often to large artery atherosclerotic (p=0.07) and cryptogenic mechanisms (p=0.03). There was a strong trend towards worse outcome in COVID+ patients across the entire Rankin-spectrum (Figure 2) despite adjustment for age, stroke severity and revascularization treatments (OR 1.97, 95%CI 0.92-4.21, p=0.08). Conclusions: In this nationwide analysis of consecutive ischemic strokes, concomitant COVID-19 was relatively rare. COVID+ patients more often had multiple territory involvement and multiple stroke mechanisms, and their 3-month outcome was worse across the entire Rankin spectrum. (Table Presented).

COVID-19-Related Insurance Coverage Changes and Disparities in Access to Care Among Low-Income US Adults in 4 Southern States.

Importance: It is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid. Objective: To determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status. Design Setting and Participants: This random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020. Using a difference-in-differences design, we estimated changes in outcomes by Medicaid expansion status overall and by race and ethnicity in 2020 (n = 1804) compared with 2018 to 2019 (n = 5710). We also explored barriers to health care and use of telehealth by race and ethnicity. Data analysis was conducted from January 2021 to March 2021. Exposures: COVID-19 pandemic and prior Medicaid expansion status. Main Outcomes and Measures: Primary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access. Results: Of 7514 respondents (11% response rate; 3889 White non-Latinx [51.8%], 1881 Black non-Latinx [25.0%], and 1156 Latinx individuals [15.4%]; 4161 women [55.4%]), 5815 (77.4%) were in the states with previous expansion and 1699 (22.6%) were in Texas (nonexpansion state). Respondents in the expansion states were older, more likely White, and less likely to have attended college compared with respondents in Texas. Uninsurance rate in 2020 rose by 7.4 percentage points in Texas (95% CI, 2.2-12.6; P = .01) and 2.5 percentage points in expansion states (95% CI, -1.9 to 7.0; P = .27), with a difference-in-differences estimate for Medicaid expansion of -4.9% (95% CI, -11.3 to 1.6; P = .14). Among Black and Latinx individuals, Medicaid expansion was associated with protection against a rise in the uninsured rate (difference-in-differences, -9.5%; 95% CI, -19.0 to -0.1; P = .048). Measures of access, including having a personal physician and regular care for chronic conditions, worsened significantly in 2020 in all 4 states, with no significant difference by Medicaid expansion status. Conclusions and Relevance: In this survey of US adults, uninsured rates increased among low-income adults in 4 Southern states during the COVID-19 pandemic, but Medicaid expansion states, that association was diminished among Black and Latinx individuals. Nonfinancial barriers to care because of the pandemic were common in all states.