Trends in Methadone Dispensing for Opioid Use Disorder After Medicare Payment Policy Changes.

Importance: A significant proportion of Medicare beneficiaries have a diagnosed opioid use disorder (OUD). Methadone and buprenorphine are both effective medications for the treatment of OUD (MOUDs); however, Medicare did not cover methadone until 2020. Objective: To examine trends in methadone and buprenorphine dispensing among Medicare Advantage (MA) enrollees after 2 policy changes in 2020 related to methadone access. Design, Setting, and Participants: This cross-sectional analysis of temporal trends in methadone and buprenorphine treatment dispensing assessed MA beneficiary claims from January 1, 2019, through March 31, 2022, captured by Optum's Clinformatics Data Mart. Of 9 870 791 MA enrollees included in the database, 39 252 had at least 1 claim for methadone, buprenorphine, or both during the study period. All available MA enrollees were included. Subanalyses by age and dual eligibility for Medicare and Medicaid status were conducted. Exposures: Study exposures were (1) the Centers for Medicare & Medicaid Services (CMS) Medicare bundled payment reimbursement policy for OUD treatment and (2) the Substance Abuse and Mental Health Administration and CMS Medicare policies designed to facilitate access to treatment for OUD, specifically during the COVID-19 pandemic. Main Outcomes and Measures: Study outcomes were trends in methadone and buprenorphine dispensing by beneficiary characteristics. National methadone and buprenorphine dispensing rates were calculated as claims-based dispensing rates per 1000 MA enrollees. Results: Among the 39 252 MA enrollees with at least 1 MOUD dispensing claim (mean age, 58.6 [95% CI, 58.57-58.62] years; 45.9% female), 195 196 methadone claims and 540 564 buprenorphine pharmacy claims were identified, for a total of 735 760 dispensing claims. The methadone dispensing rate for MA enrollees was 0 in 2019 because the policy did not allow any payment until 2020. Claims rates per 1000 MA enrollees were low initially, increasing from 0.98 in the first quarter of 2020 to 4.71 in the first quarter of 2022. Increases were primarily associated with dually eligible beneficiaries and beneficiaries younger than 65 years. National buprenorphine dispensing rates were 4.64 per 1000 enrollees in quarter 1 of 2019, increasing to 7.45 per 1000 enrollees in quarter 1 of 2022. Conclusions and Relevance: This cross-sectional study found that methadone dispensing increased among Medicare beneficiaries after the policy changes. Rates of buprenorphine dispensing did not provide evidence that beneficiaries substituted buprenorphine for methadone. The 2 new CMS policies represent an important first step in increasing access to MOUD treatment for Medicare beneficiaries.

Does paid sick leave encourage staying at home? Evidence from the United States during a pandemic.

We study the impact of a temporary U.S. paid sick leave mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. We study this policy using generalized difference-in-differences methods, leveraging pre-policy county-level heterogeneity in the share of workers likely eligible for paid sick leave benefits. We find that the policy leads to increased self-quarantining as proxied by staying home. We also find that COVID-19 confirmed cases decline post-policy.

Perceived COVID-19 vaccine attributes associated with early adoption among adults in rural Indiana.

2019 Novel coronavirus (COVID-19) vaccination rates in the United States have plateaued in specific populations, including rural areas. To improve COVID-19 vaccination rates and to encourage early vaccine uptake in future pandemics, this study aimed to examine vaccine attributes associated with early adoption. Data are from an anonymous online survey of adults using targeted Facebook pages of rural southern Indiana towns in January and February 2021 (n = 286). The diffusion of innovation theory states that the rate of adoption of a product in a specific population is explained by five perceived attributes: relative advantage, compatibility, observability, complexity and trialability. Binary logistic regression analyses were used to examine the association of Diffusion of Innovation theory attributes of the COVID-19 vaccine on early adoption. Results indicated that trialability [odds ratio (OR) = 3.307; 95% confidence interval (CI) = 1.964-5.571; P < 0.001], relative advantage (OR = 2.890; 95% CI = 1.789-4.667; P < 0.001) and compatibility (OR = 2.606; 95% CI = 1.476-4.601; P < 0.001) showed significant independent associations with early adoption. Furthermore, age and political ideology were significant moderators of complexity and relative advantage, respectfully. Health education strategies for early vaccine uptake should focus on building trust in vaccine safety, increasing short-term benefits of vaccination and promoting relatability to personal values.

Effects of social distancing policy on labor market outcomes

US workers receive unemployment benefits if they lose their job, but not for reduced working hours. In alignment with the benefits incentives, we find that the labor market responded to COVID-19 and related closure-policies mostly on the extensive (12 pp outright job loss) margin. Exploiting timing variation in state closure-policies, difference-in-differences (DiD) estimates show, between March 12 and April 12, 2020, employment rate fell by 1.7 pp for every 10 extra days of state stay-at-home orders (SAH), with little effect on hours worked/earnings among those employed. Forty percentage of the unemployment was due to a nationwide shock, rest due to social-distancing policies, particularly among "non-essential" workers.

College openings in the United States increase mobility and COVID-19 incidence.

School and college reopening-closure policies are considered one of the most promising non-pharmaceutical interventions for mitigating infectious diseases. Nonetheless, the effectiveness of these policies is still debated, largely due to the lack of empirical evidence on behavior during implementation. We examined U.S. college reopenings' association with changes in human mobility within campuses and in COVID-19 incidence in the counties of the campuses over a twenty-week period around college reopenings in the Fall of 2020. We used an integrative framework, with a difference-in-differences design comparing areas with a college campus, before and after reopening, to areas without a campus and a Bayesian approach to estimate the daily reproductive number (Rt). We found that college reopenings were associated with increased campus mobility, and increased COVID-19 incidence by 4.9 cases per 100,000 (95% confidence interval [CI]: 2.9-6.9), or a 37% increase relative to the pre-period mean. This reflected our estimate of increased transmission locally after reopening. A greater increase in county COVID-19 incidence resulted from campuses that drew students from counties with high COVID-19 incidence in the weeks before reopening (χ2(2) = 8.9, p = 0.012) and those with a greater share of college students, relative to population (χ2(2) = 98.83, p < 0.001). Even by Fall of 2022, large shares of populations remained unvaccinated, increasing the relevance of understanding non-pharmaceutical decisions over an extended period of a pandemic. Our study sheds light on movement and social mixing patterns during the closure-reopening of colleges during a public health threat, and offers strategic instruments for benefit-cost analyses of school reopening/closure policies.

COVID-19 booster uptake among US adults: Assessing the impact of vaccine attributes, incentives, and context in a choice-based experiment.

OBJECTIVE: Evidence shows that booster shots offer strong protection against the Omicron variant of COVID-19. However, we know little about why individuals would receive a booster compared to the initial decision to vaccinate. We investigate and assess the factors that affect individuals' reported willingness to receive the COVID-19 vaccine booster. This information can aid in tailoring public health messaging to communicate attributes that are associated with individuals' attitudes toward the COVID-19 booster. RATIONALE: Existing research provides little insight into whether the same factors that affect Americans' likelihood of accepting initial vaccination against COVID-19 also affect booster uptake. Our experiment also examines the influence of contextual information about a novel variant on willingness to receive a booster. METHODS: We administered a conjoint experiment (N = 2740 trials) in a survey of fully vaccinated US adults that had not yet received a COVID-19 booster (N = 548) to assess the impact of varied vaccine attributes on willingness to receive a booster. RESULTS: The most important factors associated with higher willingness to receive a booster were efficacy, manufacturer, and the size of a financial incentive. Protection duration and protection against future variants vs. only current variants had modest influence. A contextual prime reporting that some public health experts believe the Omicron variant is more contagious, but less lethal than those previously seen, significantly increased favorability toward boosters. This provides potential motivation and guidance for vaccination campaigns to emphasize these variant-specific traits. CONCLUSION: With several vaccines with varying degrees of efficacy available to consumers, emphasizing boosters with a high efficacy would likely improve attitudes toward boosters. Financial incentives and predispositions toward manufacturers also matter. Concerns about more contagious variants may spur uptake, even if such variants are less lethal.

Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic.

Importance: COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown. Objective: To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type. Design, Setting, and Participants: This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022. Main Outcomes and Measures: Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients. Results: A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups. Conclusions and Relevance: This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types.

Determinants of Disparities in Early COVID-19 Job Losses.

This study examines the sociodemographic divide in early labor market responses to the U.S. COVID-19 epidemic and associated policies, benchmarked against two previous recessions. Monthly Current Population Survey (CPS) data show greater declines in employment in April and May 2020 (relative to February) for Hispanic individuals, younger workers, and those with a high school diploma or some college. Between April and May, the demographic subgroups considered regained some employment. Reemployment in May was broadly proportional to the employment drop that occurred through April, except for Black individuals, who experienced a smaller rebound. Compared to the 2001 recession and the Great Recession, employment losses in the early COVID-19 recession were smaller for groups with low or high (vs. medium) education. We show that job loss was greater in occupations that require more interpersonal contact and that cannot be performed remotely, and that pre-COVID-19 sorting of workers into occupations and industries along demographic lines can explain a sizable portion of the demographic gaps in new unemployment. For example, while women suffered more job losses than men, their disproportionate pre-epidemic sorting into occupations compatible with remote work shielded them from even larger employment losses. However, substantial gaps in employment losses across groups cannot be explained by socioeconomic differences. We consider policy lessons and future research needs regarding the early labor market implications of the COVID-19 crisis.

US Health Care Workforce Changes During the First and Second Years of the COVID-19 Pandemic.

This article quantifies changes in employment and average wages of employees of 6 key health care organizations during the COVID-19 pandemic.

US Health Care Workforce Changes During the First and Second Years of the COVID-19 Pandemic

This article quantifies changes in employment and average wages of employees of 6 key health care organizations during the COVID-19 pandemic.

US Trends in COVID-19–Associated Hospitalization and Mortality Rates Before and After Reopening Economies

Key Points Question Did the trends in COVID-19–related hospitalizations and deaths change after states reopened their economies? Findings In this cross-sectional study of COVID-19–related hospitalizations and deaths across 47 US states between April 16 and July 31, 2020, the daily trend of hospitalizations after state reopenings was higher by 1.607 per 100 000 population. The change in the mortality rate trend was not significant. Meaning These findings suggest that data on COVID-19–related hospitalizations and mortality trends can be used to guide health policy as states make decisions to open or close activities in response to this and future pandemics. Importance After abrupt closures of businesses and public gatherings in the US in late spring 2020 due to the COVID-19 pandemic, by mid-May 2020, most states reopened their economies. Owing in part to a lack of earlier data, there was little evidence on whether state reopening policies influenced important pandemic outcomes—COVID-19–related hospitalizations and mortality—to guide future decision-making in the remainder of this and future pandemics. Objective To investigate changes in COVID-19–related hospitalizations and mortality trends after reopening of US state economies. Design, Setting, and Participants Using an interrupted time series approach, this cross-sectional study examined trends in per-capita COVID-19–related hospitalizations and deaths before and after state reopenings between April 16 and July 31, 2020. Daily state-level data from the University of Minnesota COVID-19 Hospitalization Tracking Project on COVID-19–related hospitalizations and deaths across 47 states were used in the analysis. Exposures Dates that states reopened their economies. Main Outcomes and Measures State-day observations of COVID-19–related hospitalizations and COVID-19–related new deaths per 100 000 people. Results The study included 3686 state-day observations of hospitalizations and 3945 state-day observations of deaths. On the day of reopening, the mean number of hospitalizations per 100 000 people was 17.69 (95% CI, 12.54-22.84) and the mean number of daily new deaths per 100 000 people was 0.395 (95% CI, 0.255-0.536). Both outcomes displayed flat trends before reopening, but they started trending upward thereafter. Relative to the hospitalizations trend in the period before state reopenings, the postperiod trend was higher by 1.607 per 100 000 people (95% CI, 0.203-3.011;P = .03). This estimate implied that nationwide reopenings were associated with 5319 additional people hospitalized for COVID-19 each day. The trend in new deaths after reopening was also positive (0.0376 per 100 000 people;95% CI, 0.0038-0.0715;P = .03), but the change in mortality trend was not significant (0.0443;95% CI, −0.0048 to 0.0933;P = .08). Conclusions and Relevance In this cross-sectional study conducted over a 3.5-month period across 47 US states, data on the association of hospitalizations and mortality with state reopening policies may provide input to state projections of the pandemic as policy makers continue to balance public health protections with sustaining economic activity. This cross-sectional study evaluates trends in hospitalization and death rates related to COVID-19 in US states between closures and reopenings of businesses and public gatherings in 2020.

Is Healthcare Employment Resilient and "Recession Proof"?

Conventional wisdom often holds that the healthcare sector fares better than other sectors during economic downturns. However, little research has examined the relationship between local economic conditions and healthcare employment. Understanding how the healthcare sector responds to economic conditions is important for policymakers seeking to ensure an adequate supply of healthcare workers, as well as for those directing displaced workers into new jobs. We examine the impact of macroeconomic conditions on both the healthcare labor market and the pipeline of healthcare workers receiving healthcare degrees during 2005-2017 (the pre-COVID era). Our results indicate that the healthcare sector is stable across past business cycles. If anything, when areas experience more severe local economic downturns, healthcare employment increases. Much remains unknown about how the healthcare sector will fare during the current recession. Our study represents an important backdrop as policymakers consider ways to sustain the healthcare sector during current economic and public health turbulence.

Tracking Public and Private Responses to the COVID-19 Epidemic: Evidence from State and Local Government Actions

This paper examines the determinants of social distancing during the COVID-19 epidemic. We classify state and local government actions, and we study multiple proxies for social distancing based on data from smart devices. Mobility fell substantially in all states, even ones that have not adopted major distancing mandates. There is little evidence, for example, that stay-at-home mandates induced distancing. In contrast, early and information-focused actions have had bigger effects. Event studies show that first case announcements, emergency declarations, and school closures reduced mobility by 1-5% after 5 days and 7-45% after 20 days. Between March 1 and April 11, average time spent at home grew from 9.1 hours to 13.9 hours. We find, for example, that without state emergency declarations, event study estimates imply that hours at home would have been 11.3 hours in April, suggesting that 55% of the growth comes from emergency declarations and 45% comes from secular (non-policy) trends. State and local government actions induced changes in mobility on top of a large response across all states to the prevailing knowledge of public health risks. Early state policies conveyed information about the epidemic, suggesting that even the policy response mainly operates through a voluntary channel.

Paid sick-leave and physical mobility: Evidence from the United States during a pandemic

We study the effects of a massive temporary U.S. paid sick leave (PSL) mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. Such behaviors are critical for containment of infectious diseases. The national PSL policy was implemented in response to the COVID-19 global pandemic and mandated two weeks of fully compensated paid leave. We study the impact of this policy using difference-in-differences methods, leveraging pre-policy county-level differences in the share of ‘nonessential’ workers likely eligible for paid sick leave benefits. We find robust evidence that the policy increased the average number of hours at home and reduced the share of the individuals likely at work. Comparing the county with the lowest to highest policy exposure, we find that the average hours per day not at home, and at work decreased by 8.9% and 6.9% post-policy.

Mandated and Voluntary Social Distancing During The COVID-19 Epidemic: A Review

For much of 2020, the COVID-19 epidemic upended social and economic life globally. In an effort to reduce COVID-19 risks in the U.S., state and local governments issued many recommendations and regulations to induce social distancing, adding to voluntary reductions in interpersonal contact. The responses to the epidemic helped contain spread, but also lead to high unintended societal costs. In the summer months, states took steps to revive the economy and lift social distancing regulations. However, as many epidemiologists expected, the scale of the epidemic has expanded very rapidly in the fall. In the week of October 14, the US generated around 57,000 new COVID-19 cases and 700 deaths each day. By November 15, the country was generating about 151,000 new cases and 1,200 deaths per day. These rapid increases in cases and deaths raise concerns about the capacity of local healthcare systems around the country. State governments are once again facing difficult choices about whether and how to use policies to address the spread of the virus. The incoming Biden-Harris administration faces an important challenge in trying to manage the epidemic as well as a large scale vaccination campaign. Although the epidemic is less than a year old, it has generated a huge volume of research by economists, epidemiologists, and others. This body of work may help inform policy decisions facing society in the coming months. In this paper, we make five broad contributions. First, we provide a concise review of economic and social science research on mobility patterns, labor market outcomes, consumer behavior, and population health during the first phase of the epidemic. Second, we sketch a simple microeconomic model that may be useful considering the determinants of social distancing and the role of different policy instruments in promoting distancing. Third, we present a simple typology of the policies that were used at the state and county levels during the closure and re-opening phases of the epidemic in the U.S.. Fourth, we review a collection of new data sources that have played an important role in monitoring and analyzing population behavior this year. Fifth, we present results from event study regressions that try to disentangle private vs. policy-induced changes in mobility patterns during the early part of the epidemic.

Is the Cure Worse than the Problem Itself? Immediate Labor Market Effects of COVID-19 Case Rates and School Closures in the U.S

The relationship between population health and measures of economic well-being and economic activity is a long standing topic in health economics (Preston, 1975;Cutler, Deaton, and Lleras-Muney, 2006;Ruhm, 2000). The conceptual issues in analyzing the complicated link between health and economic well-being are central to understanding the implications of the COVID-19 epidemic in the United States The public health shock of the epidemic has direct economic impacts, but the mitigation policies governments are using to control the spread of the virus may also damage economic activity. We estimate how state job market conditions respond to state COVID-19 infections and school closures, which are the earliest of the major mitigation policies. Mitigation policies and local epidemiological conditions explain some of the variation in unemployment patterns. However, the historically unprecedented increase in new UI claims during the weeks of March 15-21 and March 22-28 was largely across-the-board and occurred in all states. This suggests most of the economic disruption was driven by the health shock itself. Put differently, it appears that the labor market slowdown was due primarily to a nationwide response to evolving epidemiological conditions and that individual state policies and own epidemiologic situations have had a comparatively modest effect.

Is Healthcare Employment Resilient and “Recession Proof”?

Conventional wisdom often holds that the healthcare sector fares better than other sectors during economic downturns. However, little research has examined the relationship between local economic conditions and healthcare employment. Understanding how the healthcare sector responds to economic conditions is important for policy makers seeking to ensure an adequate supply of healthcare workers, as well as for those directing displaced workers into new jobs. We examine the impact of macroeconomic conditions on both the healthcare labor market and the pipeline of healthcare workers receiving healthcare degrees during a pre-COVID time period, 2005-2017. Our results indicate that the healthcare sector is stable across past business cycles. If anything, when areas experience more severe local economic downturns, healthcare employment increases. Much remains unknown about the adjustments and lasting impacts for the healthcare sector associated with the COVID era. Our study represents an important backdrop as policy makers consider ways to sustain the healthcare sector during economic and public health turbulence.

Impacts of State Reopening Policy on Human Mobility

This study quantifies the effect of state reopening policies on daily mobility, travel, and mixing behavior during the COVID-19 pandemic. We harness cell device signal data to examine the effects of the timing and pace of reopening plans in different states. We quantify the increase in mobility patterns during the reopening phase by a broad range of cell-device-based metrics. Soon (four days) after reopening, we observe a 6% to 8% mobility increase. In addition, we find that temperature and precipitation are strongly associated with increased mobility across counties. The mobility measures that reflect visits to a greater variety of locations responds the most to reopening policies, while total time in vs. outside the house remains unchanged. The largest increases in mobility occur in states that were late adopters of closure measures, suggesting that closure policies may have represented more of a binding constraint in those states. Together, these four observations provide an assessment of the extent to which people in the U.S. are resuming movement and physical proximity as the COVID-19 pandemic continues.

The Great Unequalizer: Initial Health Effects of COVID-19 in the United States

We measure inequities from the COVID-19 pandemic on mortality and hospitalizations in the United States during the early months of the outbreak. We discuss challenges in measuring health outcomes and health inequality, some of which are specific to COVID-19 and others that complicate attribution during most large health shocks. As in past epidemics, pre-existing biological and social vulnerabilities profoundly influenced the distribution of disease. In addition to the elderly, Hispanic, Black and Native American communities were disproportionately affected by the virus, particularly when assessed using the years of potential life lost metric. For example, Hispanic and Black Americans in 2020 saw 39.5 and 25 percent increases in excess mortality relative to trend, compared to a less than 15 percent increase for Whites;we find losses in potential years of life three to four times larger among Hispanic and Black compared to White Americans. Individual-level data from a commercially insured population show that otherwise similar Black and Hispanic enrollees were hospitalized due to COVID-19 at a higher rate than White enrollees. We provide a conceptual framework and initial empirical analysis which seek to shed light on contributors to pandemic-related health inequality, and suggest areas for future research.

Effects of State COVID-19 Closure Policy on NON-COVID-19 Health Care Utilization

The U.S. health care system has experienced great pressure since early March 2020 as it pivoted to providing necessary care for COVID-19 patients. But there are signs that non-COVID-19 care use declined during this time period. We examine near real time data from a nationwide electronic healthcare records system that covers over 35 million patients to provide new evidence of how non-COVID-19 acute care and preventive/primary care have been affected during the epidemic. Using event study and difference-in-difference models we find that state closure policies (stay-at-home or non-essential business closures) are associated with large declines in ambulatory visits, with effects differing by type of care. State closure policies reduced overall outpatient visits by about 15-16 percent within two weeks. Outpatient visits for health check-ups and well care experience very large declines during the epidemic, with substantial effects from state closure policies. In contrast, mental health outpatient visits declined less than other care, and appear less affected by state closure policies. We find substitution to telehealth modalities may have played an important role in mitigating the decline in mental health care utilization. Aggregate trends in outpatient visits show a 40% decline after the first week of March 2020, only a portion of which is attributed to state policy. A rebound starts around mid April that does not appear to be explained by state reopening policy. Despite this rebound, care visits still remain below the pre-epidemic levels in most cases.