Medicaid eligibility loss among dual-eligible beneficiaries before and during COVID-19 public health emergency

IMPORTANCE: Medicaid coverage loss can substantially compromise access to and affordability of health care for dual-eligible beneficiaries. The extent to which this population lost Medicaid coverage before and during the COVID-19 public health emergency (PHE) and the characteristics of beneficiaries more at risk for coverage loss are currently not well known. OBJECTIVE: To assess the loss of Medicaid coverage among dual-eligible beneficiaries before and during the first year of the PHE, and to examine beneficiary-level and plan-level factors associated with heightened likelihood of losing Medicaid. DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study used national Medicare data to estimate annual rates of Medicaid loss among dual-eligible beneficiaries before (2015 to 2019) and during the PHE (2020). Individuals who were dual eligible for Medicare and Medicaid at the beginning of a given year and who continuously received low-income subsidies for Medicare Part D prescription drug coverage were included in the sample. Multivariable regression models were used to examine beneficiary-level and plan-level factors associated with Medicaid loss. Data analyses were conducted between March 2023 and October 2023. EXPOSURE: Onset of PHE. MAIN OUTCOMES AND MEASURES: Loss of Medicaid for at least 1 month within a year. RESULTS: Sample included 56 172 736 dual-eligible beneficiary-years between 2015 and 2020. In 2020, most dual-eligible beneficiaries were aged over 65 years (5 984 420 [61.1%]), female (5 868 866 [59.9%]), non-Hispanic White (4 928 035 [50.3%]), full-benefit eligible (6 837 815 [69.8%]), and enrolled in traditional Medicare (5 343 537 [54.6%]). The adjusted proportion of dual-eligible beneficiaries losing Medicaid for at least 1 month increased from 6.6% in 2015 to 7.3% in 2019 and then dropped to 2.3% in 2020. Between 2015 and 2019, dual-eligible beneficiaries who were older (ages 55-64 years: -1.4%; 95% CI, -1.8% to -1.0%; ages 65-74 years: -2.0%; 95% CI, -2.5% to -1.5%; ages 75 and older: -4.5%; 95% CI, -5.0% to -4.0%), disabled (-0.8%; 95% CI, -1.1% to -0.6%), and in integrated care programs were less likely to lose Medicaid. In 2020, the disparities within each of these demographic groups narrowed significantly. Notably, while Black (0.6%; 95% CI, 0.2% to 0.9%) and Hispanic (0.7%; 95% CI, 0.3% to 1.2%) dual-eligible beneficiaries were more likely to lose Medicaid than their non-Hispanic White counterparts between 2015 and 2019, such gap was eliminated for Black beneficiaries and narrowed for Hispanic beneficiaries in 2020. CONCLUSIONS AND RELEVANCE: During the PHE, Medicaid coverage loss declined significantly among dual-eligible beneficiaries, and disparities were mitigated across subgroups. As the PHE unwinds, it is crucial for policymakers to implement strategies to minimize Medicaid coverage disruptions and racial and ethnic disparities, especially given that loss of Medicaid was slightly increasing over time before the PHE

Evaluating the Guiding Role of Elevated Pretreatment Serum Carcinoembryonic Antigen Levels for Adjuvant Chemotherapy in Stage IIA Colon Cancer: A Large Population-Based and Propensity Score-Matched Study

Objective: This study was to investigate guiding role of elevated pretreatment serum carcinoembryonic antigen (CEA) levels for ACT receipt in stage IIA colon cancer.Methods: Eligible patients diagnosed with stage IIA colon cancer (N = 21848) were identified from the Surveillance, Epidemiology, and End Results (SEER) database between January 2004 and December 2010. Pearson's chi-squared tests, Cox proportional hazards regression models, and Kaplan-Meier methods were performed. Propensity score matching (PSM) was used to decrease the risk of biased estimates of treatment effect.Results: Multivariate Cox analysis indicated that, in CEA-elevated group, receiving or not receiving ACT did not presented statistically CSS difference [hazard ratio (HR) = 0.940, 95% confidence interval (CI) = 0.804–1.097, P = 0.431]; in CEA-normal group, receiving or not receiving ACT also did not presented statistically CSS difference (HR = 0.911, 95% CI = 0.779–1.064, P = 0.239). After PSM, Kaplan-Meier analyses showed that there was no statistical CSS difference between receiving or not receiving ACT (P = 0.64).Conclusion: ACT did not show substantial survival benefit in stage IIA colon cancer with elevated pretreatment serum CEA levels. Stage IIA disease with elevated pretreatment serum CEA should not be treated with ACT

Do radioiodine-avid lymph nodes from differentiated thyroid cancer on the initial posttherapy scan need repeated 131I therapy?

BackgroundResidual/recurrent lymph node metastase (LNM) is often found after differentiated thyroid cancer (DTC) surgery. This study aimed to investigate whether patients complicated with radioiodine-avid (131I+) lymph nodes from DTC on the initial posttherapy scan (PTS) need repeated 131I therapy.MethodsFrom June 2013 to August 2022, DTC patients with 131I+ lymph nodes on the initial PTS who received at least two cycles of 131I therapy were retrospectively enrolled. They were divided into a complete response (CR) group and an incomplete response (IR) group according to their response to the initial 131I therapy based on the 2015 American Thyroid Association (ATA) guidelines.ResultsA total of 170 DTC patients with 131I+ lymph nodes on the initial PTS were included; 42/170 (24.7%) patients were classified into the CR group and 128/170 (75.9%) were classified into the IR group according to their response to the initial 131I therapy. None of the 42 CR patients had disease progression at the subsequent follow-up, and 37/170 (21.8%) IR patients improved after repeated therapy. Univariate analysis showed that N stage (P=0.002), stimulated thyroglobulin (sTg) level before initial 131I therapy (P<0.001), LNM size (P<0.001), number of total residual/recurrent LNM (P=0.021), radioiodine-nonavid (131I-) LNM (P=0.002) and ultrasound features (P<0.001) were related to the initial treatment response. On multivariate analysis, sTg level (OR=1.186, P<0.001) and LNM size (OR=1.533, P=0.004) were independent risk factors for IR after initial 131I therapy. The optimal sTg level and LNM size cutoff value for predicting the treatment response after initial 131I therapy were 18.2 µg/l and 5mm.ConclusionThis study suggested that approximately one-quarter of patients with 131I+ lymph nodes on initial PTS, especially those with N0 or N1a stage, lower sTg level, smaller LNM size, ≤2 residual/recurrent LNMs, negative ultrasound features and no 131I- LNM, remain stable after one cycle of 131I therapy and do not need repeated therapy

Upregulation of AT1 Receptor Mediates a Pressor Effect Through ROS-SAPK/JNK Signaling in Glutamatergic Neurons of Rostral Ventrolateral Medulla in Rats With Stress-Induced Hypertension

The present study examined whether angiotensin II (Ang II) mediates the pressor effect through nicotinamide adenine dinucleotide phosphate (NADPH) oxidase-derived reactive oxygen species (ROS)-mitogen-activated protein kinase (MAPK) signaling in the glutamatergic neurons of the rostral ventrolateral medulla (RVLM) in stress-induced hypertensive rats (SIHR). The SIHR model was established using electric foot-shocks combined with noises for 15 days. We observed that Ang II type 1 receptor (AT1R) and the glutamatergic neurons co-localized in the RVLM of SIHR. Furthermore, glutamate levels in the intermediolateral column of the spinal cord were higher in SIHR than in controls. Microinjection of Ang II into the RVLM of SIHR activated stress-activated protein kinase/Jun N-terminal kinase (SAPK/JNK), extracellular signal-regulated protein kinase (ERK) 1/2, and p38MAPK. Compared with controls, the activation of SAPK/JNK, ERK1/2, p38MAPK, and ROS in the RVLM were higher in SIHR, an effect that was blocked by an NADPH oxidase inhibitor (apocynin) and an AT1R antagonist (candesartan). RVLM microinjection of apocynin or a SAPK/JNK inhibitor (SP600125), but not an ERK1/2 inhibitor (U0126) or a p38MAPK inhibitor (SB203580), decreased AT1R mRNA and mean arterial blood pressure (MABP) in SIHR. The increase of AT1R protein expression and MABP was inhibited by intracerebroventricular infusion (ICV), for 14 days, of SP600125, but not U0126 or SB203580 in SIHR. We conclude that Ang II modulates the pressor effect through AT1R-dependent ROS-SAPK/JNK signaling in glutamatergic neurons in the RVLM of SIHR

Fine-Grained Modeling and Optimization for Intelligent Resource Management in Big Data Processing

International audienceBig data processing at the production scale presents a highly complex environment for resource optimization (RO), a problem crucial for meeting performance goals and budgetary constraints of analytical users. The RO problem is challenging because it involves a set of decisions (the partition count, placement of parallel instances on machines, and resource allocation to each instance), requires multi-objective optimization (MOO), and is compounded by the scale and complexity of big data systems while having to meet stringent time constraints for scheduling. This paper presents a MaxCompute based integrated system to support multi-objective resource optimization via ne-grained instance-level modeling and optimization. We propose a new architecture that breaks RO into a series of simpler problems, new ne-grained predictive models, and novel optimization methods that exploit these models to make effective instance-level RO decisions well under a second. Evaluation using production workloads shows that our new RO system could reduce 37-72% latency and 43-78% cost at the same time, compared to the current optimizer and scheduler, while running in 0.02-0.23s

Global incidence trends of early-onset colorectal cancer and related exposures in early-life: an ecological analysis based on the GBD 2019

BackgroundThe incidence of early-onset colorectal cancer (EOCRC) is increasing globally. This study aims to describe the temporal trends of incidence and explore related risk exposures in early-life at the country level based on the GBD 2019.MethodsData on the incidence and attributable risk factors of EOCRC were obtained from the GBD 2019. Temporal trends of age-standardized incidence were evaluated by average annual percentage change (AAPC). Early-life exposures were indicated as summary exposure values (SEV) of selected factors, SDI and GDP per capita in previous decades and at ages 0–4, 5–9, 10–14 and 15–19 years. Weighted linear or non-linear regressions were applied to evaluate the ecological aggregate associations of the exposures with incidences of EOCRC.ResultsThe global age-standardized incidence of EOCRC increased from 3.05 (3.03, 3.07) to 3.85 (3.83, 3.86) per 100,000 during 1990 and 2019. The incidence was higher in countries with high socioeconomic levels, and increased drastically in countries in East Asia and Caribbean, particularly Jamaica, Saudi Arabia and Vietnam. The GDP per capita, SDI, and SEVs of iron deficiency, alcohol use, high body-mass index, and child growth failure in earlier years were more closely related with the incidences of EOCRC in 2019. Exposures at ages 0–4, 5–9, 10–14 and 15–19 years were also associated with the incidences, particularly for the exposures at ages 15–19 years.ConclusionThe global incidence of EOCRC increased during past three decades. The large variations at regional and national level may be related with the distribution of risk exposures in early life

Ascorbate Biosynthesis during Early Fruit Development Is the Main Reason for Its Accumulation in Kiwi

Background: Ascorbic acid (AsA) is a unique antioxidant as well as an enzyme cofactor. Although it has multiple roles in plants, it is unclear how its accumulation is controlled at the expression level, especially in sink tissues. Kiwifruit (Actinidia) is well-known for its high ascorbate content. Our objective was to determine whether AsA accumulates in the fruits primarily through biosynthesis or because it is imported from the foliage. Methodology/Principal Findings: We systematically investigated AsA levels, biosynthetic capacity, and mRNA expression of genes involved in AsA biosynthesis in kiwi (A. deliciosa cv. Qinmei). Recycling and AsA localization were also monitored during fruit development and among different tissue types. Over time, the amount of AsA, with its capacity for higher biosynthesis and lower recycling, peaked at 30 days after anthesis (DAA), and then decreased markedly up to 60 DAA before declining more slowly. Expression of key genes showed similar patterns of change, except for L-galactono-1,4-lactone dehydrogenase and L-galactose-1-phosphate phosphatase (GPP). However, GPP had good correlation with the rate of AsA accumulation. The expression of these genes could be detected in phloem of stem as well as petiole of leaf and fruit. Additionally, fruit petioles had greater ascorbate amounts, although that was the site of lowest expression by most genes. Fruit microtubule tissues also had higher AsA. However, exogenous applications of AsA to those petioles did not lead to its transport into fruits, and distribution of ascorbate was cell-specific in the fruits, with more accumulation occurring in large

Suppressive Effects on the Immune Response and Protective Immunity to a JEV DNA Vaccine by Co-administration of a GM-CSF-Expressing Plasmid in Mice

As a potential cytokine adjuvant of DNA vaccines, granulocyte-macrophage colony–stimulating factor (GM-CSF) has received considerable attention due to its essential role in the recruitment of antigen-presenting cells, differentiation and maturation of dendritic cells. However, in our recent study of a Japanese encephalitis virus (JEV) DNA vaccine, co-inoculation of a GM-CSF plasmid dramatically suppressed the specific IgG response and resulted in decreased protection against JEV challenge. It is known that GM-CSF has been used in clinic to treat neutropenia for repopulating myeloid cells, and as an adjuvant in vaccine studies; it has shown various effects on the immune response. Therefore, in this study, we characterized the suppressive effects on the immune response to a JEV DNA vaccine by the co-administration of the GM-CSF-expressing plasmid and clarified the underlying mechanisms of the suppression in mice. Our results demonstrated that co-immunization with GM-CSF caused a substantial dampening of the vaccine-induced antibody responses. The suppressive effect was dose- and timing-dependent and likely related to the immunogenicity of the antigen. The suppression was associated with the induction of immature dendritic cells and the expansion of regulatory T cells but not myeloid-derived suppressor cells. Collectively, our findings not only provide valuable information for the application of GM-CSF in clinic and using as a vaccine adjuvant but also offer further insight into the understanding of the complex roles of GM-CSF

Essays On Policy Dynamics Under Political Frictions

The successful design and implementation of macroeconomic and public policies has an important political dimension. This dissertation, which lies at the intersection of macroeconomics and political economy, focuses on understanding the dynamic fiscal and regulatory policies in the context of political conflicts and special interests. The first essay, Curse or Blessing? On the Welfare Consequences of Divided Government and Policy Gridlock, studies the welfare consequences of divided government by analyzing a dynamic legislative bargaining model with endogenous status quo. By comparing a unified government where the opponent's approval is not needed with a divided government where unanimity rule applies, I show that with divided government tax policy is less responsive due to gridlock and is distorted due to dynamic strategic considerations. However, the welfare consequences of such a policy are mixed because gridlock also reduces policy fluctuations created by political turnover. In the simulated economy, I find that divided government can Pareto dominate unified government. While this phenomenon prevails at various levels of inequality and political polarization, the set of initial status quo tax rates allowing for it shrinks as inequality and political polarization rises. Moreover, as income inequality rises, on average divided government benefits the poor while hurting the rich. This is because households at different income levels trade off potential gains and losses from policy gridlock differently. The second essay, Political-Driven Financial Regulatory Cycle, develops a positive theory of political-driven financial regulatory cycle. The key feature of the model is that the regulatory policy is determined through the interaction of financial sector special interest group, politicians competing for office, and households with time-varying attention on financial regulation. I find that in absence of the special interest group, politicians maximize the utility of households and implement stringent regulation. Once the special interest group is introduced, the politicians are induced to behave as if they were maximizing the weighted sum of utilities of the financial industry and strategic households. In symmetric equilibrium, politicians' policies converge and they choose the regulation such that the electoral loss due to weakened support from households equals the electoral gain created by campaign contribution. Moreover, the equilibrium financial regulation turns out to be pro-cyclical. During financial market expansions, the financial regulation remains largely ignored by the general public. Hence the policymaker cater to the financial interest group and promote loose regulation. Once financial crisis takes place, the public attention on regulation is brought up. For fear of upsetting the voters, the politician is forced to tighten the regulation. The third essay, Evaluating Durable Public Good Provision using Housing Prices, is collaborated work with professor Stephen Coate. Recent empirical work in public finance uses the housing price response to public investments to assess the efficiency of local durable public good provision. This paper investigates the theoretical foundations for this technique. In the context of a novel theoretical model developed to study the issue, it shows that there is limited justification for the technique when a budget-maximizing bureaucrat interacts with rational, forward-looking citizens. A special case in which the bureaucrat faces no vot- ing uncertainty is solved in closed form to show why the technique can falsely predict under-provision. In the generalized model which involves randomness of voting outcomes, we show numerically that the technique may falsely predict both under-provision and over-provision of local durable public good. The technique is valid, however, when citizens have adaptive expectations, believing that whatever provision level that currently prevails will be maintained indefinitely