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1.  Medicaid Expansion under the Affordable Care Act. Implications for Insurance-related Disparities in Pulmonary, Critical Care, and Sleep 
The Affordable Care Act was intended to address systematic health inequalities for millions of Americans who lacked health insurance. Expansion of Medicaid was a key component of the legislation, as it was expected to provide coverage to low-income individuals, a population at greater risk for disparities in access to the health care system and in health outcomes. Several studies suggest that expansion of Medicaid can reduce insurance-related disparities, creating optimism surrounding the potential impact of the Affordable Care Act on the health of the poor. However, several impediments to the implementation of Medicaid’s expansion and inadequacies within the Medicaid program itself will lessen its initial impact. In particular, the Supreme Court’s decision to void the Affordable Care Act’s mandate requiring all states to accept the Medicaid expansion allowed half of the states to forego coverage expansion, leaving millions of low-income individuals without insurance. Moreover, relative to many private plans, Medicaid is an imperfect program suffering from lower reimbursement rates, fewer covered services, and incomplete acceptance by preventive and specialty care providers. These constraints will reduce the potential impact of the expansion for patients with respiratory and sleep conditions or critical illness. Despite its imperfections, the more than 10 million low-income individuals who gain insurance as a result of Medicaid expansion will likely have increased access to health care, reduced out-of-pocket health care spending, and ultimately improvements in their overall health.
PMCID: PMC4225799  PMID: 24708065
Patient Protection and Affordable Care Act; Medicaid; health policy; insurance, health
2.  The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients 
Rationale: Lack of health insurance may be an independent risk factor for mortality and differential treatment in critical illness.
Objectives: To determine whether uninsured critically ill patients had differences in 30-day mortality and critical care service use compared with those with private insurance and to determine if outcome variability could be attributed to patient-level or hospital-level effects.
Methods: Retrospective cohort study using Pennsylvania hospital discharge data with detailed clinical risk adjustment, from fiscal years 2005 and 2006, consisting of 167 general acute care hospitals, with 138,720 critically ill adult patients 64 years of age or younger.
Measurements and Main Results: Measurements were 30-day mortality and receipt of five critical care procedures. Uninsured patients had an absolute 30-day mortality of 5.7%, compared with 4.6% for those with private insurance and 6.4% for those with Medicaid. Increased 30-day mortality among uninsured patients persisted after adjustment for patient characteristics (odds ratio [OR], 1.25 for uninsured vs. insured; 95% confidence interval [CI], 1.04–1.50) and hospital-level effects (OR, 1.26; 95% CI, 1.05–1.51). Compared with insured patients, uninsured patients had decreased risk-adjusted odds of receiving a central venous catheter (OR, 0.84; 95% CI, 0.72–0.97), acute hemodialysis (OR, 0.59; 95% CI, 0.39–0.91), and tracheostomy (OR, 0.43; 95% CI, 0.29–0.64).
Conclusions: Lack of health insurance is associated with increased 30-day mortality and decreased use of common procedures for the critically ill in Pennsylvania. Differences were not attributable to hospital-level effects, suggesting that the uninsured have a higher mortality and receive fewer procedures when compared with privately insured patients treated at the same hospitals.
PMCID: PMC3208649  PMID: 21700910
insurance; intensive care unit; critical care; mortality
3.  Twelve-hour days in the brain and behavior of split hamsters 
The European journal of neuroscience  2012;36(4):2556-2566.
Hamsters will spontaneously ‘split’ and exhibit two rest–activity cycles each day when housed in constant light (LL). The suprachiasmatic nucleus (SCN) is the locus of a brain clock organizing circadian rhythmicity. In split hamsters, the right and left SCN oscillate 12 h out of phase with each other, and the twice-daily locomotor bouts alternately correspond to one or the other. This unique configuration of the circadian system is useful for investigation of SCN communication to efferent targets. To track phase and period in the SCN and its targets, we measured wheel-running and FOS expression in the brains of split and unsplit hamsters housed in LL or light–dark cycles. The amount and duration of activity before splitting were correlated with latency to split, suggesting behavioral feedback to circadian organization. LL induced a robust rhythm in the SCN core, regardless of splitting. Whereas the split hamsters’ SCNs exhibited 24-h rhythms of FOS that cycled in antiphase between left and right and between core and shell subregions, the medial preoptic area, paraventricular nucleus of the hypothalamus, dorsomedial hypothalamus and orexin-A neurons all exhibited 12-h rhythms of FOS expression, in-phase between hemispheres, but with detectable right–left differences in amplitude. Importantly, in all conditions studied, the onset of FOS expression in targets occurred at a common phase reference point of the SCN oscillation, suggesting that each SCN may signal these targets once daily. Finally, the transduction of 24-h SCN rhythms to 12-h extra-SCN rhythms indicates that each SCN signals both ipsilateral and contralateral targets.
PMCID: PMC4014115  PMID: 22703520
entrainment; locomotor activity; orexin; oscillator; suprachiasmatic nucleus

Results 1-3 (3)