The effect of losing federal coverage through the Affordable Care Act on ear tube placements at an urban children's hospital.

PURPOSE: 15-31% of the population in a large Mid-western city is between 100 and 400% of the Federal Poverty Level, thus qualifying for health care coverage under the Affordable Care Act (ACA). Coverage for their children would potentially be available under Children's Health Insurance Program (CHIP) or Medicaid programs. Loss of funding for these programs could be devastating for this community. METHODS: We retrospectively reviewed 1162 charts of pediatric patients with tympanostomy tube (TT) placement pre-ACA from November 2012 to December 2013 and 1606 charts post-ACA from January 2014 to July 2015. We filtered demographics by health insurance (Medicaid/CHIP/Other), residential zip codes, identified race/ethnicity within those zip codes as well as gender and age of patients getting TT during these periods. RESULTS: Bivariate analysis of these demographics between the two periods showed statistical significance (p = 0.0098) between White Hispanic/Latino children receiving ear tubes (pre-ACA = 3.8%, post-ACA = 6.4%). However, there was no statistical significance for insurance enrollment (Medicaid or non-Medicaid) and other races (White-not Hispanic/Latino (nHL), African American, Other/Unknown/Refused) with respect to TT placement. Using pre-ACA period and White nHL females as arbitrary reference, a multivariate logistic regression showed that patients requiring TT surgery were equally likely to be covered on Medicaid either before or after ACA. CONCLUSION: We demonstrated that the pre and post ACA Medicaid coverage for TT surgery did not change. Underserved children did not obtain other forms of insurance during this time. This demonstrates a potentially catastrophic loss of coverage for children should Medicaid/CHIP benefits be lost to sole coverage under the ACA.

Assessing Photoreceptor Structure in Retinitis Pigmentosa and Usher Syndrome.

PURPOSE: The purpose of this study was to examine cone photoreceptor structure in retinitis pigmentosa (RP) and Usher syndrome using confocal and nonconfocal split-detector adaptive optics scanning light ophthalmoscopy (AOSLO). METHODS: Nineteen subjects (11 RP, 8 Usher syndrome) underwent ophthalmic and genetic testing, spectral-domain optical coherence tomography (SD-OCT), and AOSLO imaging. Split-detector images obtained in 11 subjects (7 RP, 4 Usher syndrome) were used to assess remnant cone structure in areas of altered cone reflectivity on confocal AOSLO. RESULTS: Despite normal interdigitation zone and ellipsoid zone appearance on OCT, foveal and parafoveal cone densities derived from confocal AOSLO images were significantly lower in Usher syndrome compared with RP. This was due in large part to an increased prevalence of non-waveguiding cones in the Usher syndrome retina. Although significantly correlated to best-corrected visual acuity and foveal sensitivity, cone density can decrease by nearly 38% before visual acuity becomes abnormal. Aberrantly waveguiding cones were noted within the transition zone of all eyes and corresponded to intact inner segment structures. These remnant cones decreased in density and increased in diameter across the transition zone and disappeared with external limiting membrane collapse. CONCLUSIONS: Foveal cone density can be decreased in RP and Usher syndrome before visible changes on OCT or a decline in visual function. Thus, AOSLO imaging may allow more sensitive monitoring of disease than current methods. However, confocal AOSLO is limited by dependence on cone waveguiding, whereas split-detector AOSLO offers unambiguous and quantifiable visualization of remnant cone inner segment structure. Confocal and split-detector thus offer complementary insights into retinal pathology.