Improving Opportunities for Working People With Disabilities

In the late 1990's Congress recognized that federal policy not only established low expectations for people with disabilities to live and work independently, but also that the Medicaid program created disincentives for those with disabilities who wished to work. Congress, along with the Clinton administration, enacted laws creating two optional Medicaid eligibility groups through section 4733 of the Balanced Budget Act (BBA) of 1997 and Section 201 of the Ticket to Work and Work Incentives Improvement Act (TWWIA) of 1999.While Medicaid is the primary source of health insurance for people with disabilities, the program provides much more than health care services. Medicaid allows individuals with disabilities to live independently in the community. In addition to health services, Medicaid covers case management services, transportation, specialized medical equipment and supplies, and home and community-based services—including personal care assistant services—among other services not covered by Medicare or private health insurance. BBA and TWWIIA provided additional flexibility for states to offer Medicaid coverage to higher income working individuals with disabilities who—excluding income—meet the Social Security definition of disability. Together, these programs are referred to as Medicaid Buy-in (MBI) for Workers with Disabilities. Separate and distinct from recently implemented Medicaid Community Engagement Demonstrations with work-requirements, the Medicaid Buy-in eligibility option allows workers with disabilities access to Medicaid community-based services not available through other insurers.Over the last year, the Bipartisan Policy Center has identified recommendations to improve availability of the MBI for workers with disabilities. As part of that effort, BPC reached out to stakeholders and hosted public and private discussions with experts on the topic. Participants included current and former state and federal officials, consumers, and other experts. Based on those discussions, BPC developed recommendations to improve Medicaid Buy-in programs for working people with disabilities

Increasing the reflection efficiency of the Sedaconda ACD-S by heating and cooling the anaesthetic reflector: a bench study using a test lung

Background As volatile anaesthetic gases contribute to global warming, improving the efciency of their delivery can reduce their environmental impact. This can be achieved by rebreathing from a circle system, but also by anaesthetic refection with an open intensive care ventilator. We investigated whether the efciency of such a refection system could be increased by warming the refector during inspiration and cooling it during expiration (thermocycling). Methods The Sedaconda-ACD-S (Sedana Medical, Danderyd, Sweden) was connected between an intensive care ventilator and a test lung. Liquid isofurane was infused into the device at 0.5, 1.0, 2.0 and 5.0 mL/h; ventilator settings were 500 mL tidal volume, 12 bpm, 21% oxygen. Isofurane concentrations were measured inside the test lung after equilibration. Thermocycling was achieved by heating the breathing gas in the inspiratory hose to 37 °C via a heated humidifer without water. Breathing gas expired from the test lung was cooled to 14 °C before reaching the ACD-S. In the test lung, body temperature pressure saturated conditions prevailed. Isofurane concentrations and refective efciency were compared between thermocycling and control conditions. Results With thermocycling higher isofurane concentrations in the test lung were measured for all infusion rates studied. Interpolation of data showed that for achieving 0.4 (0.6) Vol% isofurane, the infusion rate can be reduced from 1.2 to 0.7 (2.0 to 1.2) mL/h or else to 56% (58%) of control. Conclusion Thermocycling of the anaesthetic gas considerably increases the efciency of the anaesthetic refector and reduces anaesthetic consumption by almost half in a test lung model. Given that cooling can be miniaturized, this method carries a potential for further saving anaesthetics in clinical practice in the operating theatre as well as for inhaled sedation in the ICU

Next Steps: Improving the Medicaid Buy-in for Workers with Disabilities

The Bipartisan Policy Center's Health Program is building on its previous report, Improving Opportunities for Working People with Disabilities (January 2021), to address barriers to employment for Medicaid beneficiaries with disabilities who often rely on Medicaid's unique services, such as home and community-based services (HCBS), to live independently in the community and work.The Medicaid Buy-In (MBI) for Workers with Disabilities refers to three eligibility groups within Medicaid that allow states to cover working individuals with disabilities who, excluding earned income, generally meet Social Security's definition of disability. The MBI for Workers with Disabilities therefore allows individuals with disabilities to work and retain their Medicaid coverage, or to use their Medicaid coverage to access wraparound services that are not covered under employer-sponsored insurance or Medicare. Enrollment in the MBI for Workers with Disabilities eligibility groups is associated with increased employment and earnings, while also having a positive impact on the economy, state Medicaid agencies, employers, and state and federal governments.In this report, BPC identifies federal policy reforms that will encourage more states to cover or optimize their coverage of the MBI for Workers with Disabilities eligibility groups. These reforms will improve access to the MBI for Workers with Disabilities programs and, thus, allow more Medicaid beneficiaries with disabilities to work and achieve their employment potential. More specifically, BPC has identified a set of federal policy recommendations that Congress and the administration should advance. These federal policy reforms will clarify existing flexibilities that states can adopt when designing their MBI for Workers with Disabilities programs while also strengthening outreach, data, and interagency coordination.

The Spatial Distribution of Benefits Resulting from REDD+ and FSC Implementation in Southeastern Tanzania

Forest loss and land use changes associated with agricultural expansion, urban development and bioenergy production are key concerns for many governments and forest-dependent communities around the world. Several strategies exist to address forest loss, including market-based mechanisms that promote good forest governance such as the Reducing Emissions from Deforestation and forest Degradation program that includes enhancements in biodiversity and livelihoods (REDD+) and the Forest Stewardship Council (FSC) certification. Many positive outcomes result from forest governance programs like REDD+ and FSC, including payments, increased stakeholder participation, and dissemination of knowledge among forest dependent communities. However, the distribution of and satisfaction with these outcomes is highly contextualized and variable at the community level. The objective of this paper is to analyze and understand the ways in which REDD+ and FSC program design and implementation impact the distribution of, and satisfaction with, program benefits at the community level. Specifically, this paper analyzes three study sites in Southeastern Tanzania implementing these programs. Our study finds that forest conservation programs have the opportunity to either exacerbate or ameliorate underlying disparity caused by spatial asymmetry in rural communities in Southeastern Tanzania. Different benefit-sharing and implementation mechanisms are shown to exhibit varying levels of success in overcoming baseline inequalities, and appear to be more important in determining community level benefits, participation, and knowledge sharing than inherent programmatic differences between REDD+ and FSC.Master of ScienceNatural Resources and EnvironmentUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/106561/1/Spatial Distribution of Benefits - REDD+ and FSC in Tanzania.pd

Effect of Cardiogenic Shock Hospital Volume on Mortality in Patients With Cardiogenic Shock

Background: Cardiogenic shock (CS) is associated with significant morbidity, and mortality rates approach 40% to 60%. Treatment for CS requires an aggressive, sophisticated, complex, goal‐oriented, therapeutic regimen focused on early revascularization and adjunctive supportive therapies, suggesting that hospitals with greater CS volume may provide better care. The association between CS hospital volume and inpatient mortality for CS is unclear. Methods and Results: We used the Nationwide Inpatient Sample to examine 533 179 weighted patient discharges from 2675 hospitals with CS from 2004 to 2011 and divided them into quartiles of mean annual hospital CS case volume. The primary outcome was in‐hospital mortality. Multivariate adjustments were performed to account for severity of illness, relevant comorbidities, hospital characteristics, and differences in treatment. Compared with the highest volume quartile, the adjusted odds ratio for inpatient mortality for persons admitted to hospitals in the lowest‐volume quartile (≤27 weighted cases per year) was 1.27 (95% CI 1.15 to 1.40), whereas for admission to hospitals in the low‐volume and medium‐volume quartiles, the odds ratios were 1.20 (95% CI 1.08 to 1.32) and 1.12 (95% CI 1.01 to 1.24), respectively. Similarly, improved survival was observed across quartiles, with an adjusted inpatient mortality incidence of 41.97% (95% CI 40.87 to 43.08) for hospitals with the lowest volume of CS cases and a drop to 37.01% (95% CI 35.11 to 38.96) for hospitals with the highest volume of CS cases. Analysis of treatments offered between hospital quartiles revealed that the centers with volumes in the highest quartile demonstrated significantly higher numbers of patients undergoing coronary artery bypass grafting, percutaneous coronary intervention, or intra‐aortic balloon pump counterpulsation. A similar relationship was demonstrated with the use of mechanical circulatory support (ventricular assist devices and extracorporeal membrane oxygenation), for which there was significantly higher use in the higher volume quartiles. Conclusions: We demonstrated an association between lower CS case volume and higher mortality. There is more frequent use of both standard supportive and revascularization techniques at the higher volume centers. Future directions may include examining whether early stabilization and transfer improve outcomes of patients with CS who are admitted to lower volume centers

Inhaled Sedation in Patients with COVID-19-Related Acute Respiratory Distress Syndrome: An International Retrospective Study

Background and objectives: The coronavirus disease 2019 (COVID-19) pandemic and the shortage of intravenous sedatives has led to renewed interest in inhaled sedation for patients with acute respiratory distress syndrome (ARDS). We hypothesized that inhaled sedation would be associated with improved clinical outcomes in COVID-19 ARDS patients. Methods: Retrospective international study including mechanically ventilated patients with COVID-19 ARDS who required sedation and were admitted to 10 European and US intensive care units. The primary endpoint of ventilator-free days through day 28 was analyzed using zero-inflated negative binomial regression, before and after adjustment for site, clinically relevant covariates determined according to the univariate results, and propensity score matching. Results: A total of 196 patients were enrolled, 78 of whom died within 28 days. The number of ventilator-free days through day 28 did not differ significantly between the patients who received inhaled sedation for at least 24 h (n = 111) and those who received intravenous sedation only (n = 85), with medians of 0 (interquartile range [IQR] 0–8) and 0 (IQR 0–17), respectively (odds ratio for having zero ventilator-free days through day 28, 1.63, 95% confidence interval [CI], 0.91–2.92, p = 0.10). The incidence rate ratio for the number of ventilator-free days through day 28 if not 0 was 1.13 (95% CI, 0.84–1.52, p = 0.40). Similar results were found after multivariable adjustment and propensity matching. Conclusion: The use of inhaled sedation in COVID-19 ARDS was not associated with the number of ventilator-free days through day 28. Keywords: coronavirus disease 2019; acute respiratory distress syndrome; inhaled sedation; sevoflurane; isofluran