Patient Disposition

Kevin Lewis

March 04, 2024

US state vaccine mandates did not influence COVID-19 vaccination rates but reduced uptake of COVID-19 boosters and flu vaccines compared to bans on vaccine restrictions
Stephen Rains & Adam Richards
Proceedings of the National Academy of Sciences, 20 February 2024

During the COVID-19 pandemic, some US states mandated vaccination for certain citizens. We used state-level data from the CDC to test whether vaccine mandates predicted changes in COVID-19 vaccine uptake, as well as related voluntary behaviors involving COVID-19 boosters and seasonal influenza vaccines. Results showed that COVID-19 vaccine adoption did not significantly change in the weeks before and after states implemented vaccine mandates, suggesting that mandates did not directly impact COVID-19 vaccination. Compared to states that banned vaccine restrictions, however, states with mandates had lower levels of COVID-19 booster adoption as well as adult and child flu vaccination, especially when residents initially were less likely to vaccinate for COVID-19. This research supports the notion that governmental restrictions in the form of vaccination mandates can have unintended negative consequences, not necessarily by reducing uptake of the mandated vaccine, but by reducing adoption of other voluntary vaccines.

The value of improving insurance quality: Evidence from long-run Medicaid attrition
Ajin Lee & Boris Vabson
Journal of Health Economics, March 2024

The US government increasingly provides public health insurance coverage through private firms. We examine associated welfare implications for beneficiaries, using a ‘revealed preference’ framework based on beneficiaries’ program attrition rates. Focusing on the Medicaid program in New York State, we exploit quasi-random variation in the initial assignment at birth to public versus private Medicaid based on birth weight. We find that infants assigned to private Medicaid at birth are less likely to subsequently leave Medicaid. We provide suggestive evidence that reduced attrition reflects beneficiary responses to improved program quality, rather than alternative mechanisms such as private Medicaid plans reducing re-enrollment barriers.

Antidepressant Dispensing to US Adolescents and Young Adults: 2016–2022
Kao-Ping Chua et al.
Pediatrics, February 2024

Methods: We identified antidepressant prescriptions dispensed to US individuals aged 12 to 25 years from 2016 to 2022 using the IQVIA Longitudinal Prescription Database, an all-payer national database. The outcome was the monthly antidepressant dispensing rate, defined as the monthly number of individuals with ≥1 dispensed antidepressant prescription per 100 000 people. We fitted linear segmented regression models assessing for level or slope changes during March 2020 and conducted subgroup analyses by sex and age group.

Results: Between January 2016 and December 2022, the monthly antidepressant dispensing rate increased 66.3%, from 2575.9 to 4284.8. Before March 2020, this rate increased by 17.0 per month (95% confidence interval: 15.2 to 18.8). The COVID-19 outbreak was not associated with a level change but was associated with a slope increase of 10.8 per month (95% confidence interval: 4.9 to 16.7). The monthly antidepressant dispensing rate increased 63.5% faster from March 2020 onwards compared with beforehand. In subgroup analyses, this rate increased 129.6% and 56.5% faster from March 2020 onwards compared with beforehand among females aged 12 to 17 years and 18 to 25 years, respectively. In contrast, the outbreak was associated with a level decrease among males aged 12 to 17 years and was not associated with a level or slope change among males aged 18 to 25 years.

In the Shadow of Antitrust Enforcement: Price Effects of Hospital Mergers from 2009 to 2016
Keith Brand, Chris Garmon & Ted Rosenbaum
Journal of Law and Economics, November 2023, Pages 639–669

We examine 558 hospital mergers during a period of increased antitrust enforcement. Using US data on commercially insured patients from 2009 to 2016, we estimate an average price effect of roughly 5 percent, with a smaller effect for mergers later in the sample period. Mergers between hospitals that were substitutes for patients, were in unconcentrated insurance markets, and were less likely to lead to efficiencies had higher price increases. Using administrative data on merger investigations, we estimate higher-than-average price increases for mergers selected for more detailed investigation and find no evidence of higher-than-average price increases for nonreportable mergers.

Complementing Public Care with Private: Evidence from Veterans Choice Act
Hiroki Saruya, Todd Wagner & Diana Zhu
Yale Working Paper, October 2023

We study the effect of complementing public health care with private care. Leveraging a policy at the Veterans Health Administration that generates discontinuity in private care access, we find that expanding coverage to private care increases private outpatient care by $53 (SE: 5) and decreases VA outpatient care by $20 (SE: 7), with no impact on inpatient care. The policy led to a marginally significant 0.1 p.p. (2.8%, SE: 0.04) decrease in one-year mortality, possibly because of decreased wait times and increased access to certain specialty care. Given our estimates, the benefit of access expansion significantly outweighs the increased costs.

Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial
Michael Hollifield et al.
JAMA Psychiatry, forthcoming

Objective: To compare verum acupuncture with sham acupuncture (minimal needling) on clinical and physiological outcomes.

Design, Setting, and Participants: This was a 2-arm, parallel-group, prospective blinded randomized clinical trial hypothesizing superiority of verum to sham acupuncture. The study was conducted at a single outpatient-based site, the Tibor Rubin VA Medical Center in Long Beach, California, with recruitment from April 2018 to May 2022, followed by a 15-week treatment period. Following exclusion for characteristics that are known PTSD treatment confounds, might affect biological assessment, indicate past nonadherence or treatment resistance, or indicate risk of harm, 93 treatment-seeking combat veterans with PTSD aged 18 to 55 years were allocated to group by adaptive randomization and 71 participants completed the intervention protocols.

Results: A total of 85 male and 8 female veterans (mean [SD] age, 39.2 [8.5] years) were randomized. There was a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean [SD] Δ, 7.1 [11.8]; t90 = 2.87, d, 0.63; P = .005) in the intention-to-treat analysis. The effect pattern was similar in the treatment-completed analysis: verum d, 1.53; sham d, 0.86; between-group mean (SD) Δ, 7.4 (11.7); t69 = 2.64; d, 0.63; P = .01). There was a significant pretreatment to posttreatment reduction of fear-potentiated startle during extinction (ie, better fear extinction) in the verum but not the sham group and a significant correlation (r = 0.31) between symptom reduction and fear extinction. Withdrawal rates were low.

How a dedicated postdischarge unit can reduce hospital congestion and costs
Maryam Khatami, Jon Stauffer & Mark Lawley
Decision Sciences, forthcoming

Depending on the patient's condition, up to 60% of inpatients are discharged to post–acute care facilities (PACFs). These patients may experience several days of nonmedical inpatient stay until the hospital finds a facility that fits their needs, contributing to overcrowding in upstream units. This article studies the feasibility of creating a “postdischarge unit” (PDU) for medically ready-for-discharge patients who experience transfer delays, to improve access to inpatient beds. We use a multistage stochastic program, solved with a dual dynamic programming algorithm, to address the PDU size and capacity question. The random variable is the number of bed requests from upstream units (e.g., emergency department). Our numerical analysis, using data from a large hospital, shows that a PDU can reduce costs and significantly reduce the number of patients waiting for transfer to PACFs that are occupying inpatient beds, as long as the percentage of these patients in the hospital is more than 4%. Compared to current practice in our partner hospital, a PDU could increase access to inpatient beds by up to 13% and result in 2%–21% cost savings. Results show that PDU capacity in hospitals with a larger number of patients waiting for transfer is more sensitive to variation in PDU renovation and operational costs. In addition to using fewer medical staff, a PDU can improve discharge transitions to lower levels of care and more efficiently utilize social workers and physical therapists assisting these patients.

Technology Regulation Reconsidered: The Effects of Certificate of Need Policies on the Quantity and Quality of Diagnostic Imaging
Jill Horwitz et al.
NBER Working Paper, February 2024

Estimates of the impact of Certificate of Need laws on medical care have been inconsistent, possibly because not all CON laws apply to all services. Using an original dataset identifying imaging-related CON laws, we estimate the effects of CON on CT and MRI, using regression discontinuities at state borders. Medicare beneficiaries in regulated states are slightly less likely to receive any image and considerably less likely to receive low-value imaging than beneficiaries in non-regulated states. High-value imaging is either unaffected or declines much less. Overall, CON reduces low value care and largely leaves high value care unaffected.

The impact of Medicaid expansion and travel distance on access to transplantation
Bethany Lemont
Journal of Health Economics, March 2024

Most transplant centers require candidates be insured before they can join the waitlist for a deceased donor organ. After the Affordable Care Act, many uninsured Americans gained improved access to Medicaid. I examine the effect of this increase in access to insurance and find that Medicaid expansions significantly increase Medicaid-insured waitlist registrations by 39% and deceased donor transplants received by 44%, but the increase in registrations is larger for candidates who live closer to a transplant center. Additionally I show that most of these registrations would have been privately insured otherwise but provide suggestive evidence that this is better explained by improved access to subsidized private coverage due to other ACA reforms than from candidates with private coverage before the ACA switching to Medicaid coverage after expansion. This suggests that although the ACA improved access to the transplantation system, access is still limited for candidates who live far from centers.


from the


A weekly newsletter with free essays from past issues of National Affairs and The Public Interest that shed light on the week's pressing issues.


to your National Affairs subscriber account.

Already a subscriber? Activate your account.


Unlimited access to intelligent essays on the nation’s affairs.

Subscribe to National Affairs.