Public Views on Medicaid Work Requirements and Mandatory Premiums in Kentucky.

Importance: Federal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements. Objective: To identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums. Design, Setting, and Participant: A cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023. Main Outcomes and Measures: Agreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an internet panel to recruit residents aged 18 years or older. Findings were weighted to reflect state demographics. Of 39 110 landlines called, 209 reached an eligible person (of whom 150 participated), 8654 were of unknown eligibility, and 30 247 were ineligible. Of 55 305 cell phone lines called, 617 reached an eligible person (of whom 451 participated), 29 951 were of unknown eligibility, and 24 737 were ineligible. Internet recruitment (602 participants) used a panel of adult Kentucky residents maintained by an external data collector. Results: Percentages were weighted to resemble the adult population of Kentucky residents. Of the participants in the study, 52% (95% CI, 48%-55%) were women, 80% (95% CI, 77%-82%) were younger than 65 years, 41% (95% CI, 38%-45%) were enrolled in Medicaid, 36% (95% CI, 32%-39%) were Republican voters, 32% (95% CI, 29%-36%) were Democratic voters, 14% (95% CI, 11%-16%) were members of racial and ethnic minority groups (including but not limited to American Indian or Alaska Native, Asian, Black, Hispanic or Latinx, and Native Hawaiian or Pacific Islander), and 48% (95% CI, 44%-52%) were employed. Most participants supported work requirements generally (69% [95% CI, 66%-72%]) but did not support terminating benefits due to noncompliance (43% [95% CI, 39%-46%]) or requiring quotas of 20 or more hours per week (34% [95% CI, 31%-38%]). Support for monthly premiums (34% [95% CI, 31%-38%]) and exclusion penalties for premium nonpayment (22% [95% CI, 19%-25%]) was limited. Medicaid enrollees were significantly less supportive of these policies than nonenrollees. For instance, regarding work requirements, agreement was lower (64% [95% CI, 59%-69%] vs 72% [95% CI, 68%-77%]) and disagreement higher (26% [95% CI, 21%-31%] vs 20% [95% CI, 16%-24%]) among current Medicaid enrollees compared with nonenrollees (P = .04). Among Medicaid enrollees, some beliefs about work requirements varied significantly by employment status but not by political affiliation. Among nonenrollees, beliefs about work requirements, premiums, and Medicaid varied significantly by political affiliation but not by employment. Conclusions and Relevance: This study suggests that even when public constituencies express general support for Medicaid work requirements or premiums, they may oppose central design features, such as quotas and termination of benefits. Program participants may also hold significantly different beliefs than nonparticipants, which should be understood before policies are changed.

Impact of Privacy Messaging on COVID-19 Exposure Notification App Downloads: Evidence From a Randomized Experiment.

Introduction: Digital contact-tracing smartphone apps have the potential to slow the spread of disease but are not widely used. We tested whether messages describing how a COVID-19 digital contact-tracing app protects users' privacy led to increased or decreased intentions to download the app by either calming privacy concerns or increasing their saliency. Design: Randomized controlled trial. Setting/participants: We recruited adult smartphone owners in the U.S. (oversampled for younger adults aged 18-34 years) in November 2020 through an online panel. Intervention: Survey software randomly assigned 860 participants to 1 of 2 parallel messaging conditions (n=430 privacy assured, n=430 no privacy described). Main outcome measures: 4-point scale of intention to use the app "if public health officials released a COVID Exposure Notification app in their state" that averaged likelihood to (1) download and install the app on their phone; (2) keep the app active on their phone; and (3) keep Bluetooth active on their phone (needed for the app to work). Results: After removing incompletes, those who failed the manipulation checks, or those who had already downloaded a COVID-19 digital contact-tracing app, we analyzed 671 participants (n=330 privacy, n=341 no privacy) in 2021. There was no relationship between privacy condition and download intention (meanprivacy=2.69, meannoprivacy=2.69, b=0.01, 95% CI= -0.13, 0.15, p=0.922) but also no evidence that describing the app's security increased context-dependent privacy concerns (measured 3 ways). Instead, we found increased endorsement of data security in the privacy condition using a scale of beliefs about the app keeping privacy secure (meanprivacy=2.74, meannoprivacy=2.58, b=0.16, 95% CI=0.04, 0.28, p=0.009, small effect ω2=0.009). Conclusions: This study provides some evidence that people developing contact-tracing messaging campaigns do not need to worry that describing a digital contact-tracing app's privacy protections will backfire. Future mixed methods testing of messages about who has access to information-and for how long-may uncover new communication strategies to increase public trust in contact-tracing apps. Trial registration: This study is registered with AsPredicted#51826.

COVID-19 contact tracing app reviews reveal concerns and motivations around adoption.

BACKGROUND: Google and Apple's Exposure Notifications System (ENS) was developed early in the COVID-19 pandemic to complement existing contact tracing efforts while protecting user privacy. An analysis by the Associated Press released in December 2020 estimated approximately 1 in 14 people had downloaded apps in states one was available. In this study, we assessed the motivation and experience of individuals who downloaded ENS apps from the Google Play and Apple App Stores. METHODS: We collected review text, star rating, and date of rating for all the reviews on ENS apps in the Google Play and Apple App stores. We extracted the relative frequency of single words and phrases from reviews and created an open vocabulary language, with themes categorized by the research team, to study the salient themes around reviews with high (3-5 stars), neutral (3 stars), and negative (1-2 stars) ratings using logistic regression. RESULTS: Of 7622 reviews obtained from 26 states between 04/07/2020 to 03/31/2021, 6364 were from Google Play Store, and 1258 were from Apple App Store. We obtained reviews for a total of 38 apps, with 25 apps from the Google Play Store and 13 apps from the Apple Play Store. 78% of the reviews are either 1 star or 5 stars. Positive reviews were driven by ease of use, support for the state government in creating the app, and encouragement for others to download, as well as engage in other COVID-19 precautions. Negative and neutral reviews focused on issues with app functionality (i.e., installation and tracking errors). CONCLUSIONS: Uptake was the largest barrier to success for ENS apps, but states can use insight from app store reviews to better position themselves if they choose to develop further public health apps.

Oral health and oral health care use among able-bodied adults enrolled in Medicaid in Kentucky after Medicaid expansion: A mixed methods study.

BACKGROUND: Oral health care use remains low among adult Medicaid recipients, despite the Patient Protection and Affordable Care Act's expansion increasing access to care in many states. It remains unclear the extent to which low use reflects either low demand for care or barriers to accessing care. The authors aimed to examine factors associated with low oral health care use among adults enrolled in Medicaid. METHODS: The authors conducted a survey from May through September 2018 among able-bodied (n = 9,363) Medicaid recipients who were aged 19 through 65 years and nondisabled childless adults in Kentucky. The survey included questions on perceived oral health care use. Semistructured interviews were also conducted from May through November 2018 among a subset of participants (n = 127). RESULTS: More than one-third (37.8%) of respondents reported fair or poor oral health, compared with 26.2% who reported fair or poor physical health. Although 47.6% of respondents indicated needing oral health care in the past 6 months, only one-half of this group reported receiving all of the care they needed. Self-reported barriers included lack of coverage for needed services and lack of access to care (for example, low provider availability and transportation difficulties). CONCLUSIONS: Low rates of oral health care use can be attributed to a subset of the study population having low demand and another subset facing barriers to accessing care. Although Medicaid-covered services might be adequate for beneficiaries with good oral health, those with advanced dental diseases and a history of irregular care might benefit from coverage for more extensive restorative services. PRACTICAL IMPLICATIONS: These results can inform dentists and policy makers about how to design effective interventions and policies to improve oral health care use and oral health outcomes.

The design of a randomized controlled trial to evaluate multi-dimensional effects of a section 1115 Medicaid demonstration waiver with community engagement requirements.

Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization - the gold standard for assessing causality - has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of beneficiaries deemed able-bodied to maintain eligibility for benefits. Beneficiaries were randomized 9:1 to the new waiver program or a control group who would retain their current benefits as part of the existing Medicaid expansion program. To address potential bias from differential attrition from the Medicaid program that would accrue from solely analyzing administrative data, our team designed a rich, prospective, longitudinal survey to collect primary and secondary outcomes from six categories of interest to policymakers: insurance coverage, health care utilization and quality, health behaviors, socioeconomic measures, personal finances, and health outcomes. At baseline, a subset of survey participants was invited to participate in the collection of biometric samples via in-person follow-up visits, and a cross-section were also invited to participate in qualitative interviews. While the demonstration waiver was terminated before the program began, our study design illustrates that it is possible for other researchers and state agencies seeking to evaluate Medicaid demonstration waivers and other demonstration policies to work together to implement high quality randomized trials - even for controversial policies.

Assessment of Medicaid Beneficiaries Included in Community Engagement Requirements in Kentucky.

Importance: States are pursuing Section 1115 Medicaid demonstration waiver authority to apply community engagement (CE) requirements (eg, participation in work, volunteer activities, or training) to beneficiaries deemed able-bodied as a condition of coverage. Understanding the size and characteristics of the populations included in these requirements can help inform policy initiatives and anticipate effects. Objective: To estimate the number and characteristics of Kentucky Medicaid beneficiaries who would have to meet CE requirements. Design, Setting, and Participants: Cross-sectional study in which administrative records for the entire population of Medicaid beneficiaries in Kentucky as of February 2018 and original survey data, based on responses from 9396 Medicaid beneficiaries included in the waiver program, were analyzed. Exposures: Eligibility for Kentucky's Medicaid demonstration waiver as of the originally planned implementation date (July 2018). Main Outcomes and Measures: Number of beneficiaries included in CE requirements, including those already meeting vs not meeting hour quotas and those who may qualify for medical frailty exemptions. Results: Among the 9396 individuals included in the Section 1115 waiver program who participated in the survey, the mean weighted (SD) age was 36.1 (11.9) years; a weighted 47.2% of respondents were female, and most beneficiaries (weighted percentage, 78.2%) were non-Hispanic white participants. We estimated that 132 790 (95% CI, 129 132-136 449) beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver. Of this group, 25 422 (95% CI, 23 135-27 710) beneficiaries may have qualified for a medical frailty exemption either by self-attestation (after confirmation by their Medicaid insurer) or by being identified as eligible by physicians or their insurer. Another 58 943 (95% CI, 55 687-62 196) beneficiaries likely would have met CE hour requirements and been required to report compliance. Ultimately, 48 427 (95% CI, 45 281-51 574) individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver. Beneficiaries in the potentially medically frail group reported worse socioeconomic status, poorer health outcomes, and higher rates of hospital admission and emergency department use than those meeting CE requirements. Similarly, the group currently not meeting and not exempt from CE hour requirements reported worse socioeconomic status than those meeting the CE requirements, although magnitudes of the differences were smaller. Conclusions and Relevance: Findings suggest that most beneficiaries who would be included in CE programs either already meet activity requirements, which they will be required to proactively report, or may qualify for a medical frailty exemption. Consequently, the outcomes of CE programs will depend on states' processes for addressing health-related, socioeconomic, and administrative barriers to participating in and reporting CE activities and identifying medical frailty.

Kitaoka's Tomato: Two Simple Explanations Based on Information in the Stimulus.

Kitaoka's Tomato is a color illusion in which a semitransparent blue-green field is placed on top of a red object (a tomato). The tomato appears red even though the pixels would appear green if viewed in isolation. We show that this phenomenon can be explained by a high-pass filter and by histogram equalization. The results suggest that this illusion does not require complex inferences about color constancy; rather, the tomato's red is available in the physical stimulus at the appropriate spatial scale and dynamic range.

Challenges and Opportunities in Adapting Clinical Trial Design for Immunotherapies.

Immunotherapy adds an exciting new dimension to the treatment of cancer, joining other approaches as a key pillar in the oncotherapeutics armamentarium. Immuno-oncology agents harbor unique mechanisms of antitumor activity by leveraging the host immune system, which may result in response patterns, resistance kinetics, and toxicity profiles that differ from other systemic therapies. These features have led to many discussions on ways to optimally integrate immunotherapy into cancer clinical trials. This overview provides an introduction to the four CCR Focus articles that ensue, with special thoughts paid to clinical trial endpoints, biomarker development and validation, combination strategies, and limitations that arise with increasing use of these agents. In addition, this overview examines design concepts that may be applied to invigorate clinical trials and to maximize their impact in the immuno-oncology era.

Immuno-oncology Clinical Trial Design: Limitations, Challenges, and Opportunities.

Recent advances in immuno-oncology and regulatory approvals have been rapid and paradigm shifting in many difficult-to-treat malignancies. Despite immune checkpoint inhibitor therapy becoming the standard of care across multiple tumor types, there are many unanswered questions that need to be addressed before this therapeutic modality can be fully harnessed. Areas of limitations include treatment of patients not sufficiently represented in clinical trials, uncertainty of the optimal treatment dosing and duration, and lack of understanding regarding long-term immune related toxicities and atypical tumor responses. Patients such as those with autoimmune disease, chronic viral infections, limited performance status, and brain metastases were often excluded from initial trials due to concerns of safety. However, limited data suggest that some of these patients can benefit from therapy with manageable toxicities; thus, future studies should incorporate these patients to clearly define safety and efficacy. There are still controversies regarding the optimal dosing strategy that can vary from weight-based to flat dosing, with undefined treatment duration. Further elucidation of the optimal dosing approach and evaluation of predictive biomarkers should be incorporated in the design of future trials. Finally, there are long-term immune-mediated toxicities, atypical tumor responses such as pseudoprogression and endpoints unique to immuno-oncology that are not adequately captured by traditional trial designs; thus, novel study designs are needed. In this article, we discuss in detail the above challenges and propose needed areas of research for exploration and incorporation in the next generation of immuno-oncology clinical trials.

Spatial filtering, color constancy, and the color-changing dress.

The color-changing dress is a 2015 Internet phenomenon in which the colors in a picture of a dress are reported as blue-black by some observers and white-gold by others. The standard explanation is that observers make different inferences about the lighting (is the dress in shadow or bright yellow light?); based on these inferences, observers make a best guess about the reflectance of the dress. The assumption underlying this explanation is that reflectance is the key to color constancy because reflectance alone remains invariant under changes in lighting conditions. Here, we demonstrate an alternative type of invariance across illumination conditions: An object that appears to vary in color under blue, white, or yellow illumination does not change color in the high spatial frequency region. A first approximation to color constancy can therefore be accomplished by a high-pass filter that retains enough low spatial frequency content so as to not to completely desaturate the object. We demonstrate the implications of this idea on the Rubik's cube illusion; on a shirt placed under white, yellow, and blue illuminants; and on spatially filtered images of the dress. We hypothesize that observer perceptions of the dress's color vary because of individual differences in how the visual system extracts high and low spatial frequency color content from the environment, and we demonstrate cross-group differences in average sensitivity to low spatial frequency patterns.

Feature- and Face-Exchange illusions: new insights and applications for the study of the binding problem.

THE BINDING PROBLEM IS A LONGSTANDING ISSUE IN VISION SCIENCE: i.e., how are humans able to maintain a relatively stable representation of objects and features even though the visual system processes many aspects of the world separately and in parallel? We previously investigated this issue with a variant of the bounce-pass paradigm, which consists of two rectangular bars moving in opposite directions; if the bars are identical and never overlap, the motion could equally be interpreted as bouncing or passing. Although bars of different colors should be seen as passing each other (since the colors provide more information about the bars' paths), we found "Feature Exchange": observers reported the paradoxical perception that the bars appear to bounce off of each other and exchange colors. Here we extend our previous findings with three demonstrations. "Peripheral Feature-Exchange" consists of two colored bars that physically bounce (they continually meet in the middle of the monitor and return to the sides). When viewed in the periphery, the bars appear to stream past each other even though this percept relies on the exchange of features and contradicts the information provided by the color of the bars. In "Face-Exchange" two different faces physically pass each other. When fixating centrally, observers typically report the perception of bouncing faces that swap features, indicating that the Feature Exchange effect can occur even with complex objects. In "Face-Go-Round," one face repeatedly moves from left to right on the top of the monitor, and the other from right to left at the bottom of the monitor. Observers typically perceive the faces moving in a circle-a percept that contradicts information provided by the identity of the faces. We suggest that Feature Exchange and the paradigms used to elicit it can be useful for the investigation of the binding problem as well as other contemporary issues of interest to vision science.

Paradoxical effect of spatially homogenous transparent fields on simultaneous contrast illusions.

In simultaneous brightness contrast (SBC) demonstrations, identical mid-luminance disks appear different from each other when one is placed on a black background while the other is placed on a white background. The strength of SBC effects can be enhanced by placing a semi-transparent layer on top of the display (Meyer's effect). Here, we try to separate the causes of Meyer's effect by placing a spatially homogenous transparent layer over a standard SBC display, and systematically varying the transmission level (alpha=0, clear; alpha=1, opaque) and color (black, gray, white) of the semi-transparent layer. Spatially homogenous transparent layers, which lack spatial cues, cannot be unambiguously interpreted as transparent fields. We measure SBC strength with both matching and ranking procedures. Paradoxically, with black layers, increasing alpha level weakens SBC when measured with a ranking procedure (no Meyer's effect) and strengthens SBC when measured with a matching procedure (Meyer's effect). With white and gray layers, neither procedure produces Meyer's effect. We account for the differences between white and black layers by positing that the visual system separates luminance from contrast. The results suggest that observers attend to different information in the matching and ranking procedures.

Scale-invariance in brightness illusions implicates object-level visual processing.

Brightness illusions demonstrate that an object's perceived brightness depends on its visual context, leading to theoretical explanations ranging from simple lateral inhibition to those based on the influence of knowledge of and experience with the world. We measure the relative brightness of mid-luminance test disks embedded in gray-scale images, and show that rankings of test disk brightness are independent of viewing distance, implying that the rankings depend on the physical object size, not the size of disks subtended on the retina. A single filter that removes low spatial frequency content, adjusted to the diameters of the test disks, can account for the relative brightness of the disks. We note that the removal of low spatial frequency content is a principle common to many different approaches to brightness/lightness phenomena; furthermore, object-size representations--as opposed to retinal-size representations--inherently remove low spatial frequency content, therefore, any process that creates object representations should also produce brightness illusions.

Clinical features of young children referred for impairing temper outbursts.

OBJECTIVE: In light of the current controversy about whether severe temper outbursts are diagnostic of mania in young children, we conducted a study to characterize such children, focusing on mania and other mood disorders, emotion regulation, and parental psychiatric history. METHODS: Study participants included 51 5-9-year-old children with frequent, impairing outbursts (probands) and 24 non-referred controls without outbursts. Parents completed a lifetime clinical interview about their child, and rated their child's current mood and behavior. Teachers completed a behavior rating scale. To assess emotion regulation, children were administered the Balloons Game, which assesses emotion expressivity in response to frustration, under demands of high and low regulation. Parental lifetime diagnoses were ascertained in blind clinical interviews. RESULTS: No child had bipolar disorder, bipolar disorder not otherwise specified (NOS), or major depression (MDD). The most prevalent disorder was oppositional defiant disorder (88.2%), followed by attention-deficit/hyperactivity disorder (74.5%), anxiety disorders (49.0%), and non-MDD depressive disorders (33.3%). Eleven probands (21.6%) met criteria for severe mood dysregulation. During the Balloons Game, when there were no demands for self-regulation, children with severe outbursts showed reduced positive expressivity, and also showed significant deficits in controlling negative facial expressions when asked to do so. Anxiety disorders were the only diagnoses significantly elevated in probands' mothers. CONCLUSIONS: Overall, young children with severe temper outbursts do not present with bipolar disorder. Rather, disruptive behavior disorders with anxiety and depressive mood are common. In children with severe outbursts, deficits in regulating emotional facial expressions may reflect deficits controlling negative affect. This work represents a first step towards elucidating mechanisms underlying severe outbursts in young children.