key: cord-0874011-5c1coxqr authors: Hussein, M. R.; Morsi, I.; Awad, E. A.; Fayed, D.; AlSulaiman, T.; Habib, M. F.; Herbold, J. R. title: The differential impact of the COVID-19 epidemic on Medicaid expansion and non-expansion states date: 2021-02-25 journal: nan DOI: 10.1101/2021.02.23.21252296 sha: b2ca881f798185a6f57d3faf76ad43759b05ceed doc_id: 874011 cord_uid: 5c1coxqr Medicaid expansion is a federally-funded program to expand health care access and coverage to economically challenged populations by increasing eligibility to Medicaid enrollment and investing in public health preventive services in the individual states. Yet, when the COVID-19 epidemic plagued the country, fourteen states were practicing their chosen decision not to enact the Medicaid expansion policy. We examined the consequences of this nationwide split in Medicaid design on the spread of the COVID-19 epidemic between the expansion and non-expansion states. Our study shows that, on average, the expansion states had 217.56 fewer confirmed COVID-19 cases per 100,000 residents than the non-expansion states [-210.41; 95%CI (-411.131) - (-2.05); P<0.05]. Also, the doubling time of COVID-19 cases in Medicaid expansion states was longer than that of non-expansion states by an average of 1.68 days [1.6826; 95%CI 0.4035-2.9617; P<0.05]. These findings suggest that proactive investment in public health preparedness was an effective protective policy measure in this crisis, unsurpassed by the benefits of COVID-19 emergency plans and funds. The study findings could be relevant to policymakers and healthcare strategists in non-expansion states considering their states' preparations for such public health crises. examined the consequences of this nationwide split in Medicaid design on the spread of the COVID-19 epidemic between the expansion and nonexpansion states. Our study shows that, on average, the expansion states had 217.56 fewer confirmed COVID-19 cases per 100,000 residents than the non-expansion states [-210.41 ; 95%CI (-411.131) -(-2.05); P<0.05]. Also, the doubling time of COVID-19 cases in Medicaid expansion states was longer than that of non-expansion states by an average of 1.68 days [1.6826; 95%CI 0.4035-2.9617; P<0.05]. These findings suggest that proactive investment in public health preparedness was an effective protective policy measure in this crisis, unsurpassed by the benefits of COVID-19 emergency plans and funds. The study findings could be relevant to policymakers and healthcare strategists in non-expansion states considering their states' preparations for such public health crises. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint their share in the population in ten of the fourteen non-expansion states. 5, 6 Most studies found that Medicaid expansion had positive associations with health care equity, access, service utilization, and selfreported health, along with reducing all-cause mortality. 7 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Covariates: We added information on the at-risk adults as a share of all adults ages 18 and older. We preferred to use this measure rather than the total population size in light of the literature's current consensus that not all age groups are equally vulnerable to COVID-19 14, 15, 16, 17 . We included the number of community health centers' delivery sites as a proxy of the state's primary care capacity to the underserved populations. 17 We also had information on the length of active stayhome orders as a proxy of the respective state's epidemic containment policies' stringency. Finally, we controlled for the proportion of surveyed population always wearing masks. We obtained this data from the New York Times survey in July 2020. 18, 19 Methods: We applied a multi-step model to investigate the research hypothesis. First, we used a Generalized Estimating Equation model to examine the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. Descriptive statistics: The public health layout differed in the non-expansion states from that in the expansion states. On average, the non-expansion states had a relatively higher ratio of the hospital and ICU beds to their population than the Medicaid expansion states. Yet, the non-expansion states also had a larger uninsured population and fewer primary care Community Health Centers delivery sites than the expansion states. Compared to the expansion states, the non-expansion states mandated stay-home orders for a shorter average period. Also, non-expansion states' residents' compliance to wearing masks was not as substantial as residents in the expansion states. (Table 2 ) The demographic profile of the two groups of states was comparable but slightly different. In 2019, non-white racial minorities in non-expansion states made 33.6% of the population, compared to 32% in expansion states. The largest minority in non-expansion states was African Americans, 15%, followed by Hispanics, 11%; while the largest minority in expansion states was Hispanics, 12.6%, followed by African Americans, 9.2%. The study models' results confirm, with statistical significance, that Medicaid expansion states had a lower caseload of COVID-19 cases than the non-expansion states by an average of 210.4 cases per 100,000 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The findings present an opportunity for the U.S. to improve its health care system, building on the ongoing efforts to ensure accuracy of its COVID-19 counting; an advantage not available in many other countries. 20 The results show that COVID-19 epidemic spread at a significantly slower rate in the expansion states than the non- . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint In conclusion, this study confirms that Medicaid expansion states were in a better public health position for crises like the COVID-19 epidemic. While after-the-fact federal assistance could have helped many uninsured, its benefit was not a full replacement to public health preparedness in terms of expanded insurance coverage. Further scientific inquiry will be needed to investigate further the Medicaid expansion elements that most helped the expansion states collectively outperform their non-expansion counterparts. This study has several limitations. First, widespread COVID-19 screening was not evenly available through the study period. It is possible that the case records early in the epidemic are not entirely indicative of COVID-19 spread. Second, we included some, but not all, of the epidemic containment state policies, and we did not add a measure of the stringency of enforcement of these local measures in the respective states. Third, we included one measure of primary care capacity, the number of community health centers' delivery sites. Still, there are other capacity elements like the number of primary care offices and registered general practitioners. Fourth, the analyses did not include the states' financial standings that could play into a state's decision of embracing Medicaid Expansion or not. Finally, the study is descriptive and did not divulge into the causality underlying the findings. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint 1 0 Tables Table 1: COVID-19 cases Doubling Time through the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint 1 2 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint 1 4 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint Unemployment Rates During the COVID-19 Pandemic: In Brief Kaiser Family Foundation / LA Times Survey Of Adults With Employer-Sponsored Health Insurance Covid-19 and the Need for Health Care Reform The United States can reduce socioeconomic disparities by focusing on chronic diseases The Atlantic. 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Certain Medical Conditions and Risk for Severe COVID-19 Illness Resources on Vulnerable Populations for Consumers and Patients COVID-19-Resources/COVID-19-Resources-For-Consumers-And-Patients COVID-19 advice -High risk groups Kaiser Foundation. State COVID-19 Data and Policy Actions Detailed Map of Who Is Wearing Masks in the The New York Times. Mask-Wearing Survey Data. The New York Times the author/funder, who has granted medRxiv a license to display the preprint in perpetuity The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252296 doi: medRxiv preprint